Category Archives: Diabetes

FDA approved Inhaled Insulin Afrezza

Damion Edwards for Mannkind

The Food and Drug Administration (FDA) of America had just approved the new inhaled insulin Afrezza for patients with both types of diabetes. It can replace the short acting insulins but not the long acting ones, so patients with type 1 diabetes would still need to inject the basal insulin, but would then just need to inhale before meal times, effectively saving themselves 3 injections.

Afrezza, or technosphere insulin, has a short time to maximum blood concentration of 14 minutes, resulting in improved control of postprandial (after meal) blood sugars, less weight gain and lower risk of hypoglycemia (blood sugar level too low). Side effects include transient cough, and a small reversible reduction in forced expiratory volume in 1 second (FEV1) (a measure of a person’s ability to blow) by 37ml. An expected FEV1 calculated for a Chinese man measuring 174cm and 72kg was about 4 litres, making this a drop of less than 1%.

However, bronchospasm (airway narrowing) had occurred in patients with previous asthma and chronic lung disease, so Afrezza is contraindicated in those patients. FDA had also mandated post-marketing studies of the drug.

This is great news for patients who are currently injecting insulin multiple times a day, as inhaled insulin was much more acceptable to patients with type 2 diabetes.  This means that more patients with poorly controlled diabetes would be willing to be started on insulin, which no longer requires painful injections.

Nonetheless, the previous inhaled insulin Exubera had been withdrawn from the market before because of poor sales. The high price, and the huge size of the inhaler were cited as reasons of its failure.

Provided this is not priced too high, the fact that this inhaler is palm-sized should help Afrezza escape the fate of Exubera. Hopefully it will arrive in Singapore soon.

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A New Class of Diabetes Medication Arrives in Singapore

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Despite current treatment including insulin, only 40% of patients in Indonesia35% of patients in Singapore and 22% of patients in Malaysia have good diabetes control.

A new class of medication called the SGLT2 inhibitor has been approved in Singapore, the first one being Invokana (canagliflozin). It has a unique mode of action for the treatment of type 2 diabetes mellitus.

In the kidneys when blood is pushed through a glomerulus (the smallest operating unit in the kidney), glomerular filtrate (earliest urine) is formed. It contains glucose (sugar), different ions, water and waste products. The good stuff is retained through reabsorption. Glucose is reabsorbed through the SGLT2 channels.

SGLT2 inhibitors block the action of the SGLT2 channels, so glucose is lost in urine. Thus the blood glucose drops and diabetes control improves. Patients also lose weight as they are losing energy in the urine. The glucose in the urine also drags water with it and thus patients’ blood pressure drops.

The most important benefit is that it is not dependent on insulin secretion, so the risk of a dangerously low blood sugar (hypoglycemia) is prevented. With this extra class of oral medication, patients may be able to delay their use of insulin.

There are side effects though. First, the sugar in the urine increases the risk of a urine tract infection and fungal infection around the urethra. Second, patients can get dehydrated unless they replenish their fluids with an extra glass of water.

I am very glad that we now have another weapon in the treatment of diabetes.

Universal Screening of Gestational Diabetes Proposed

Pregnancy

Photo credit:  Stuart Miles/freedigitalphotos.net

The U.S. Preventive Services Task Force (USPSTF) has just recommended that all pregnant women be screened for gestational diabetes. For health care professionals, the document is here.

In pregnancy, the baby and the placenta induces a higher of sugar level in the mother, to ensure that the baby will have enough sugar for use and growth. Normally, the mother’s pancreas will work harder to overcome this by making more insulin. However, sometimes that fails and blood sugar starts to rise, causing gestational diabetes. The main problem of gestational diabetes is that the baby has too much sugar and so grows to too big a size, sometimes more than 4kg. This may make giving birth difficult.

Gestational Diabetes was last reported in Singapore to affect 13.8% of all pregnant mothers in 1988.

Fortunately, the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial cleared showed that proper treatment to normalize the blood sugar helps to prevent complications . For healthcare professionals, the paper is here.

Because effective treatment protects the mother and baby, all women in the US are now encouraged to have an oral glucose tolerance test (OGTT). In Singapore, women who are high risk are encouraged to have the OGTT. These risk factors are: obesity, family history of diabetes, previous gestational diabetes, and previous birth to a baby heavier than 4kg.

In pregnancy, diet and exercise is key to control the blood sugar. A lot of pregnant women can control their blood sugar with simple changes to their diet by decreasing refined carbohydrates such as white sugar, white rice, rice-based noodles (bee-hoon) and white bread.

However, in severe cases insulin will be needed. Oral medication are generally not advised for pregnant mothers.

To know more, here is a video shot by Leonny Atmadja from Our Channel.

The Latest ACC/AHA Cholesterol Guideline: A sea change

Cholesterol check

Photo Credit:  Stuart Miles/freedigitalphotos.net

The American College of Cardiology/American Heart Association published their latest cholesterol management guideline last month. It is a complete change of the prior American guidelines that aim at a particular cholesterol target.

First of all, it recommends treatment for the 4 groups of patients:

1. All who already have heart disease, stroke or peripheral blood vessel disease (“cardiovascular diseases”)

2. Everyone with diabetes between 40-75 years of age

3. Those with an LDL (bad) cholesterol of 190 mg/dl (5.0 mmol/l) or more

4. Those with a calculated 10-year risk of cardiovascular disease of 7.5% or more.

Secondly, they suggest using only statins, and no other cholesterol-lowering medication.

Thirdly, they recommend stopping the routine monitoring of cholesterol levels after treatment, because of the lack of evidence.

Lastly, they place far less emphasis on additional screening tests such as hsCRP, a mark of inflammation in the body and cardiovascular risk

Since then Dr Nancy Cook and Dr Paul Ridker had published an article in the New York Times that call into question the calculator used, unusally before their critique paper in the journal Lancet has been published. Cook and Ridker pointed out that the calculator overestimates the cardiovascular risk in their own data set of patient population. Dr David Goff, co-chair of the guideline committee, explained that the population set used by Cook and Ridker are more recent and those patients have reduced risk probably because they are volunteers, and might have already taken statins and so their risk became lower. Interestingly, Goff was also puzzled by Ridker’s lack of comment in 2012 when the guidelines were sent to Ridker, and revealed that Ridker’s suggestion to use hsCRP in the risk calculation was rejected. Ridker receives royalties as co-holder of patent on hsCRP, which is a blood test used for risk-stratification for cardiovascular risk.

Hmm. I had not seen a guideline critique being so personal before. Previously, lead authors exchange disagreements in the journals, in an usually courteous manner.

The American Association of Clinical Endocrinologists had just rejected the guideline. They disagree with removing the cholesterol targets, the out-dated risk calculator, and the omission of medication other than statins in lowering cardiovascular risk.

Do we doctors agree on anything now about cholesterol? Well there are:

1. High cholesterol is associated with blood vessel blockage (atherosclerosis), heart attacks and stroke.

2. Lowering cholesterol generally lowers that risk. Most studies were done on statins, but other studies on other medication, such as niacin,  fibrates and Vytorin, had also shown benefits before.

3. The relative benefits are rather constant. So patients with high risk benefit more. For example, if a patient has a 50% risk of having a heart attack in 10 years, lowering the cholesterol can reduce the risk to 25-30%. So 1 in 4 patients are saved. But for a low risk person with 1% risk of having a heart attack in 10 years, lowering the cholesterol reduce the risk by 0.4-0.5%. So 200 people needs to be treated before one is saved.

4. All cholesterol-lowering medication has a small risk of side effects. Muscle ache, increased liver enzymes, and diabetes are the commonest.

Ultimately, it is best that you discuss with your doctor whether you need treatment. You should ask about the benefits and the risks of taking the drug.

Avoid Glibenclamide for patients who are elderly or have renal failure

Finger prick meter

Photo credit:  Gualberto107/freedigitalphotos.net

Glibenclamdie (glyburide in America) is a common and useful drug for type 2 diabetes. It is effective and the blood sugar lowering effect long-lasting. However, the strength is also a weakness: it can sometimes be so powerful that the patient can suffer prolonged hypoglycemia (low blood sugar level).

The Health Sciences Authority of Singapore had looked at the data and found that in Singapore, patients who are above 60 or those with kidney failure have a much increased risk of severe and protracted hypoglycemia. They have now advised all doctors to avoid using glibenclamide in those patients.

There are many other alternative drugs in the same class such as gliclazide and they are also generics, available at a low price at our clinics.

If you are taking glibenclamide and had recently turned 60 or have renal failure, please do not stop your medicine immediately, but talk to your doctor about it.

3 Scientifically Proven Way to Prevent Diabetes: sleep, move, eat

Tsunami

Photocredit: Danilo Rizzuti/freedigitalphotos.net

My article on the Coming Tsunami of Diabetes: how to dodge it has just been published.

Diabetes is an extremely serious problem in Singapore. 1 in 9 adults have it and by 2030, 1 in 5 adults are going to get it.

I personally love the first scientifically proven way: sleeping. Not sleeping enough increases our stress hormones (adrenalin and cortisol) which raises our sugar, and increases our hunger hormone so we want to eat more.

The second is what all doctors say: exercise. I had previously written about the power of exercise.

The third is to eat healthy. Avoid artificially processed starch such as white bread,  white rice and juices. Whole grains should be taken instead. Yes even Michelle Obama supported it.

Remember: sleep, move, eat.

World Diabetes Day Singapore 2013

WDD 2013

Mark the day – 10 November 2013. As diabetes affects 11.3% of Singaporeans, the number of families with one or more members are becoming very high. This year the Diabetes Society of Singapore is going to have an event packed with activities at the Suntec Convention Centre. There are tons of free stuff there:

Free Hba1c test (cost $30)

Free eye photos (cost $30)

Free feet check (cost from $25 at least)

Free consultation with diabetic nurse educators, pharmacists, dieticians (cost from $25 each)

Total free stuff: $160 plus the goodie bag!

In fact since every year the DSS celebrates the World Diabetes Day, you can just get your eyes and feet checked free of charge over there, as they are supposed to be screened yearly as well.

Pravin, a patient with type 1 diabetes will also be there to share his experience. He was diagnosed to have type 1 diabetes at age 7, but had learnt to live with the illness, and is now an engineer. He also runs marathons, climb mountains and volunteers overseas to help other people with diabetes.

So just go to Suntec this Sunday!