Hope for Thalassaemics

In the NST,

Hope for thalassaemic patients Ranjeetha Pakiam and Farish Shahrir KUALA LUMPUR, May 12: The painful injection that thalassaemic patient Mohd Zanel Ibrahim, 18, endures daily will become a thing of the past soon. Advances in the medical field have brought substitute medication in the form of pills and syrup which can be taken orally. A new drug called ICL670 removes excess iron from the thalassaemic patient's body caused by frequent blood transfusions. The transfusions are needed since those suffering from the genetic disease experience rapid break-up of red blood cells, leading to anaemia (low haemoglobin levels). This drug, so far, is said to have no side-effects. ................

This is a heartening advance. Thalassaemics especially those of the beta-type, usually require repeated blood transfusions. This will increase their iron level in their body over time leading to a condition termed haemasiderosis. This can affect the heart, nerves and endocrine tissues. Most thalassaemics had a short life span due to this unwanted accumulation of iron.

Then iron chelation with desferoxamine was found. Iron chelation means binding to excess iron for excretion from the body. However, the patients were inconvenienced by the fact that this drug could only be given by a intramuscular route. Thus the quest for an oral drug began.

There is currently another oral agent, desferiprone. It however is far less effective than desferoxamine and had potential suppressive effects on white blood cells. This latest oral drug of ICL 670 is so far been promising. In actual fact at a dose of 20mg/kg/day, it surpasses the chelating effects of desferoxamine. It is also a daily dosing drug thus it can be taken with ease. There has so far been no reported adverse side effects.

Despite still in Phase III trials, such promise augurs well for the thalassaamic community. Malaysia has a high number of thalassaemia patients and those with traits. One way to fight thalassaemia is effective family counselling. Partners who both have thalassaemia traits should be advised to not get married. Thus we can hopefully decrease the prevalence of this faulty gene.

We are still waiting for the day that gene therapy can cure all genetic diseases. We are still a long way from it but current research is on-going. Due to a high number of thalassaemic patients here, it would be wise for the government to invest more money in research. Pharmaceutical companies can also play a role in establishing a research center here in Malaysia!

Docguide article
E-Thal

An Aging Population: Focus on Men's Health

Malaysia has an aging population. Soon we will join the ranks of developed countries in terms of its demographic characteristics. This was pointed out by Dato Dr Tan Hui Ming, a consultant urologist with SJMC, during the launch of Levitra(ED drug) recently. Interestingly, it is the men that is not coping well with aging, that is they are not aging healthily. Several contributors include the consumption of alcohol, smoking and their reluctance to seek early medical attention. This increases the incidences of cardiovascular morbidity, cancer, diabetes and hyperlipidemic states. All this contributes to the higher rate of mortality in a younger age group among men leading to their declining numbers as the age increases.

Even erectile dysfunction it appears is prevalent among our aging men. Nevertheless, not many seek medical attention and even less are taking treatments for erectile dysfunction(ED). The treatment of ED has revolutionised since the introduction of oral medications that is the PDE-5 inhibitors. Sildenafil(viagra) was the first of its kind. Levitra (vardenafil) can be considered as a second generation PDE-5 inhibitor.

Among the advantages of Levitra over Viagra is its specificity for the PDE-5 enzyme. This specificity reduces side effects associated with viagra especially blue-green color vision associated with inhibition of PDE-6 enzyme in the eye. Although Levitra also inhibits the PDE-11 enzyme, the function of this enzyme is unknown. Side effects from trials include benign conditions eg headaches , flushes, nasal congestion and an upset stomach. The onset of action(ie the time to achieving an erection) for Levitra could also be as early as 10-15 minutes with variations among patients.

According to the PROVEN study, Levitra was effective in about 46% of the men who were previously unsuccessful with Viagra. However, note that there are no head to head comparison studies to date.

Below is an article I wrote on MMR previously

Erectile Dysfunction(ED) : Sildenafil vs tadalafil vs vardenafil ED is an under-discussed problem between patients and their doctors. Unfortunately most doctors themselves are uncomfortable discussing about sexual problems with their patients. The prevalence of ED in Malaysia is not known but I would suspect little difference with other countries. In the United States, up to 26% of males are said to be suffering from moderate to severe forms of ED. The aetiology of ED is numerous from organic (eg vascular compromise due to smoking or diabetes) to psychogenic problems. Some have mixed aetiologies. The treatment of ED has revolutionised over the past decade with the introduction of Sildenafil (Viagra). Since its advent, second generation ED drugs have surfaced namely talalafil (Cialis) and Vardenafil(levitra). These are drugs that competitively inhibit the enzyme Phosphodiesterase (PDE), specifically PDE-5 which is mainly found in smooth muscle and vascular tissues. For the benefit of all, here is some physiology about erection. Upon sexual stimulation, the parasympathetic nerves release nitric oxide which then diffuses into smooth muscle cells before binding to enzyme guanylate cyclase there. Guanylate cyclase converts GTP to cGMP. cGMP then binds to Protein Kinase G which then causes smooth muscle cells to relax allowing blood to flow through the sinosoids of the corpus cavernosum producing an erection. PDE-5 causes the breakdown of cGMP. Therefore by inhibiting PDE-5, cGMP could produce its effects for a longer period of time. With the recent introduction of tadalafil(Cialis) in Malaysia, which would be a better choice? Viagra or Cialis? There are at this moment no comparator studies between the two. So no one can say one is better than the other. But doubleblind placebo controlled studies have shown both to be efficacious. Viagra has a shorter half life (4-6 hours) and its onset of action is approximately 30 minutes. Studies have shown and proven its safety , even in heart patients. But side effects are dose dependant ie the higher the prescribed dose, the greater its side effects. Because Viagra inhibits PDE-6(present in the eye) at high doses, it could produce colour visual disturbances. Other side effects, headaches, diarrhoea and flushing are similar with other groups of PDE inhibitors as well. It is contraindicated in patients using nitrates (also a vasodilator) and caution in patients with heart disease. Although data from some studies actually show a cardioprotective effect from Viagra! Vardenafil(Levitra) has a similar profile to sildenafil due to its slosely similar chemical structure. Cialis on the other hand,which has a slightly different chemical structure, has a longer half life, up to 24 hours. It is said to be more specific for PDE-5 although it is known to also inhibit PDE-11 which is found in the testes and heart. The effect of this is unknown pending post marketing studies. Due to its long half life, the chances of side effects from it is much higher. However the benefit of tadalafil is said to be that, it is not significantly affected by renal or liver impairment. The onset is also claimed to be as fast as 15 minutes in responsive patients!! The verdict? Personally, i would prefer a more well tested drug ie Viagra. The shorter half life is more comforting as compared to a longer one. Until further studies show a superior safety profile of Cialis, Viagra would be the preferred choice. Perhaps a head to head comparator study needs to be done, pitching Pfizer, Bayer and Lilly! That would certainly be the next big thing ... after Lord of the Rings!

With new information on Levitra, it probably holds an edge over Viagra in terms of its onset of action and its safety profile. Cialis is less enticing due to its long duration of action. However, all 3 drugs do work and it boils down to patient preferences. As pointed out, a good sexual life is not all just about achieving an erection!

Lastly, healthy aging involves a healthy and fulfilling sexual life! Levitra is certainly a welcomed addition to the armamentarium of ED treatment.

http://www.levitra.com

Pharmacists: Should they prescribe?

There is a current air of haziness as to the role of a pharmacist. Can they prescribe or should they just dispense? From a doctor's viewpoint, pharmacists are not trained to prescribe, as their training do not encompass making a proper diagnosis of a patient through their history, physical examination and investigation.

Let me illustrate. A hypertensive patient once told me that he could walk up to a pharmacist and request for loose tablets of hypertensive medication with no questions asked. No blood pressure readings were even taken. This is an unacceptable and unethical practice.

Pharmacist have an important role to play in healthcare. However, they are not ready to prescribe yet. Their history taking and physical examination skills need some brushing up if they are to take over the role of general practitioners. Even the prescription of simple medications may be tricky if proper procedures are not adhered to.

It is my opinion that the pharmacists should stick with dispensing for now. The regulation of the practices of pharmacists needs improvement as well. Perhaps if a pharmacist would like to prescribe, he/she should undergo 6 years of gruelling training that a medical student has to undergo. Even their examination formats will have to be revamped to accomodate such a change in responsibilities.

The bottomline is that a patient's healthcare should not be compromised.

The Threat of Diabetes

From Medscape

World Faces a "Devastating" Diabetes Epidemic--WHO By Richard Waddington GENEVA (Reuters) May 05 - The world faces a devastating diabetes epidemic, with the annual death toll already exceeding the three million killed by AIDS and set to rise, the World Health Organisation warned on Wednesday. Issuing a cry of alarm about the disease, the WHO and the International Diabetes Foundation said the number of diabetics worldwide would more than double to 366 million by 2030, from some 171 million at present. Although often thought a rich country risk, it is in poorer countries that diabetes is growing fastest, with cases seen rising 150% over the next 25 years. In India, for example, the number would leap from 32 million to 80 million. Furthermore, while in rich states diabetes affects mainly older people, in poorer countries incidence is surging among those still economically active, the two organisations said. "The number is increasing dramatically and has the potential to overwhelm countries' health systems," WHO director for chronic disease Dr Robert Beaglehole told a news conference. WHO and the Foundation said they were launching a campaign to raise awareness, because, unlike some other health threats, type 2 diabetes could be prevented by improved eating and exercise habits. "It is determined environmentally and therefore it can be reversed," Beaglehole said. LARGELY UNRECOGNIZED Some 3.2 million people died in 2000, the latest year for which figures were available, of ailments brought on by diabetes such as cardiovascular disease and kidney failure. This compares with three million deaths from AIDS. "The burden of premature death from diabetes is similar to that of HIV/AIDS, yet the problem is largely unrecognised," the two organisations said in a statement. Although it was not possible to predict accurately the future death rate, WHO officials said it would probably mirror the increase in overall cases. The per capita death toll was highest in the Middle East and parts of the Pacific, with more than one in four deaths in the 35-64 age range attributed to diabetes.

Diabetes mellitus is indeed on the rise. In Malaysia, we are not spared. Registration figures at diabetic clinics are rising and the age at the time of diagnosis is decreasing. Exact figures will probably not be availabe until the next Health and Morbidity Survey in 2006. The question is why is it increasing at such an alarming rate and why is it affecting a younger age group?

Genetics have been shouldering the blame. Although genetics do have a role in the pathogenesis of diabetes, there are environmental factors as well. Among them are a poor diet and a sedentary lifestyle. Diets high in sugar and carbohydrates appear unfriendly to cells producing insulin. Look around us, from "santans" and curries to Coffee Beans and Secret Recipes. The tantalizing view of delicious looking dishes tempts all. This puts stress on insulin-producing cells and studies have shown that such high sugar content in the bloodstream is toxic to these cells.

Lack of exercise and increasing waistlines are also culprits in this scourge of diabetes. Obesity rates are on the rise even among children. The habit of exercising needs to be inculcated in the young. More facilities are also needed for the public. Exclusive clubs and expensive membership fees to gymnasiums, especially in urban areas, are a move in the wrong direction.

There is increasing evidence that smoking is an independant risk factor for diabetes. Smoking is certainly on the rise despite the valiant efforts of the Government in stemming it. More young souls are delving into this practice of self destruction.

So the fight against diabetes has to be on several fronts. We need to treat the community even before diabetes strikes. For when diabetes strikes, there is no turning back. Diabetes can be prevented but we have to change the lifestyle that many others in the developed world are abandoning.

Are you at risk for diabetes? Perhaps you could take the Diabetes Risk Test


Smoking and Diabetes
National Diabetes Institute,Malaysia
Diabetes dan Anda
American Diabetes Association

HRT, PAP smear and Bedside manners

In the NST letter section,

Our hospitals need doctors with better bedside manners May 07: I AM a pensioner and I am under the care of a gynaecologist at a government-run hospital. For quite a while, I have been on hormone replacement therapy (HRT). With the recent controversy over HRT, I am apprehensive about its long-term effects especially when told that all hormone tablets are a form of synthetic steroids. So I voiced my concerns to the gynaecologist. I was appalled when she replied in no uncertain terms that if I wished to be taken off HRT, I would not qualify to seek treatment for my menopausal symptoms. Are we not given any other choice? Have the health authorities done enough research to warrant that all women of a certain age be put on HRT in government hospitals? I was also told that women over 60 years of age do not qualify for a pap test. She said that statistics show that only three per cent of women over 60 get cervical cancer. What if I am among the three per cent? How uncaring and high-handed can doctors be in government hospitals? Minister of Health Datuk Dr Chua Soi Lek said he was working towards cutting short the waiting time in government hospitals. That is commendable. What we government pensioners would like to see are specialists with better bedside manners. JANE WONG Subang Jaya

Hormonal Replacement Therapy remains a controversy ever since the Women's Health Initiative Study results were published. It used to be the wonder drug for post menopausal women. Despite its effectiveness in alleviating menopausal symptoms like hot flushes, new data have cautioned physicians especially gynecologists on potential side effects. The WHI study suggested a link between HRT and Coronary Heart Disease. It also suggests a possible link with breast and ovarian cancers. So doctors are now more apprehensive when treating for menopausal symptoms. It is no longer a knee jerk reflex in giving HRT to all menopausal symptoms.

Below is an article i wrote earlier on MMR:

Hormonal Replacement Therapy(HRT) : A continuing dilemma HRT which contains estrogen and progesterone in combination, has been widely prescribed to peri and post menopausal women until several years ago when fresh data (in particular the Women's Health Initiative study) suggests an increase in cardiovascular and stroke risk. HRT has been useful in alleviating disturbing menopausal symptoms, eg hot flushes and irritability. The increased risk of breast and endometrial cancer(if estrogen given alone) has also been noted. Thus it appears that the recent revelation has been the final nail in HRT's coffin. The recently concluded 11th World Congress of Gynecological Endocrinology held in Florence, Italy, discussed HRT at length. THe controversies surrounding the recently published studies remain. However, there is a trend to look for alternatives that are superior to conventional HRT. One alternative drug is the Selective Estrogen Receptor Modulators (SERMs) namely Raloxifene. It is a synthetic compound that binds to estrogen receptors at different sites and can be both pro or anti estrogen depending on the target tissue. In the bones, it prevents bone resorption, increases bone mineral density and decreases the incidence of spinal fractures as shown by the MORE study (Multiple Outcomes of Raloxifene trial). Most importantly, it has little effect on the endometrium or the breast. However , the effects on the cardiovascular system needs further evaluation. As SERMs do not alleviate menopausal symptoms, the drug may not be well received by patients. Perhaps for long term protection, SERMs may have its best advantage. Tibolone(livial) has long been available in Malaysia. Tibolone is a synthetic steroid that can display estrogenic, androgenic, or progesterone-like effects, depending on the target tissue. It alleviates vasomotor symptoms, improves BMD, and has no significant endometrial and breast effects. Its cardiovascular safety has not been established in large trials. Experiences of family members on Tibolone has been marred by elevated liver enzymes on routine investigations , thus discontinuation of this drug adn the return of liver enzymes to normal values. The combination of estradiol and drospirenone, a synthetic progestin, was also mentioned and is associated with favorable vasomotor, cardiovascular, skeletal, and quality-of-life effects.It is available in Malaysia as Yasmin tablet. Remifemin, a CIMICIFUGAE RHIZOMA EXTRACT is a traditional compound that has positive effects on menopausal symptoms.(see table below) Nevertheless it has no protective effects on the bone and heart and probably neutral effects on the breast and endometrium. However, experiences of my patients on Remifemin was not as dramatic as those on conventional hormonal replacement therapy. However, conventional HRT cannot be totally ignored. It will still serve its purpose and remains the best agent in alleviating menopausal symptoms. Its other previously stated benefits remain under the microscope. The best strategy may be to start early , even in the peri menopausal period and not exceed 10 years of therapy or discontinuation earlier if menopausal symptoms do not recur. There is no right or wrong in this scenario and only time will tell if we have been doing the right things for our patients. "God guide us!", we pray.

With regards to a PAP smear, there should be no age limit. Any woman with sexual exposure is at risk. Although some studies suggest a lower incidence of progression to dysplasia in menopausal women, these are just figures and each population will vary. So when the gynecologist in the above case mentioned that PAP smears are not for women above 60, it is utter rubbish.

It is important that doctors explain certain issues carefully to ensure that patients understand what they are being told. Perhaps there was a misunderstanding in the case above leading to more confusion and thus dissatisfaction and anger. I have to agree with Jane that some doctors will need some brushing up on bedside manners.

Womens Health Initiative

Levitra Launch

Levitra (Verdanafil) will be launched this Sunday at the Shangrila Hotel KL.