Tag Archives: Diabetes mellitus

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Nonetheless, the previous inhaled insulin Exubera had been withdrawn from the market before because of poor sales.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.

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!

Tom Hanks has Type 2 Diabetes

Tom Hanks 2009

Photo credit: Wikipedia

I love Tom Hanks. From Forrest Gump to Angels & Demons, I have always enjoyed watching him perform. He is professional, willing to gain or lose 20kg just to fit into the look of a role.

He has just declared that he has developed type 2 diabetes mellitus at age 57. Also, he has been having “high sugars” (likely prediabetes) from age 36.

Type 2 Diabetes mellitus is a disease of high blood sugar, when the body cannot make enough insulin to bring the sugar down in the blood. It happens especially in people who are overweight and obese, because when they gain fat tissue, their body becomes resistant to the effect of insulin. At first, the pancreas makes more insulin to overcome this resistance and their blood sugar is still normal. Over time, however, the pancreas becomes weak and blood sugar starts to rise a bit (prediabetes) and then a lot (frank diabetes).

8.3% of Americans have diabetes, and 11.3% of Singaporeans have diabetes. The high blood sugar wreaks havoc in the body, getting attached to everything in the body, preventing their normal function. If uncontrolled, diabetes can lead to blindness, kidney failure, amputations of the lower limbs, heart attacks and strokes. Fortunately, good control of diabetes can prevent all these complications.

The most important thing is through lifestyle modifications. The most important thing is to control the amount of carbohydrate intake and exercise regularly. Tom Hanks has said that he would not be taking on roles that require weight gain any more. Well he is someone that can lose 26 pounds (12kg) just through sheer determination, so I think he can do it.

Indeed, Tom Hanks has had quite a good run with his prediabetes. He only “graduated” from prediabetes to diabetes after 21 years! In Singapore, a study done by Prof ES Tai showed that 35% of patients with prediabetes develop diabetes in 8 years. So Mr Hanks have largely avoided developing diabetes at a much earlier age, and should be congratulated.

It is also very encouraging to know that celebrities like Tom Hanks would openly admit their chronic medical condition. It can lead to better recognition of the illness by the public, and lead to healthy discussion by patients at risk and their doctors. Well done Mr Hanks!

Exercise versus Medicine

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Children love to exercise. Every day I am reminded by my kids how much exercise they naturally do every day. When we grow older, however, we become more and more sedentary.

Now a study has shown that exercise is as good as medication for the management of chronic disease: http://www.latimes.com/science/sciencenow/la-sn-exercise-drugs-20131002,0,2582449.story

The researchers had gone over 300 studies and compared exercise versus medicine in the prevention of diabetes, heart disease, strokes etc. Guess what? Good ol’ Exercise is just as good!

In my field, it has been shown actually long ago that exercise was better than the medication metformin in the prevention of diabetes. However, knowing that a lot of people would not be able to do exercise, the American Diabetes Association still allows for metformin to be used in the prevention of diabetes.

Should doctors prescribe exercise? Of course! I do not know any doctor who would not prescribe it! So what’s the point of this study?

The key is this: this study looks at structured exercise that is monitored by physical therapists/ certified instructors. In good quality research, that is often undertaken so that the research actually knows that the patients do their exercise. Self-reported exercise just won’t cut it…

Unfortunately, structured exercise is expensive. For diabetes, generic metformin in Singapore costs less than S$6 a month at the government-run polyclinics. A lesson with a certified gym instructor would cost S$90 a session!

Nonetheless we should all do exercise ourselves, most of the days!