medical tribune january 2015 rg

IBD on the rise in Asia, most cases reported in China

FORUMAlcohol in all policies

CONFERENCENovel therapeutic interventions for gastroparesis

CONFERENCEFracture risk in diabetics underestimated

CONFERENCEInvolve family physicians in community palliative care, say experts

JANUARY 2015

JANUARY 2015 2

ELVIRA MANZANO

There has been a progressive increase in

the incidence and prevalence of inflamma-

tory bowel disease (IBD) in Asia, characterized

by complicated disease behavior and signifi-

cant morbidity, says an expert at the recent Asia

Pacific Digestive Week conference held in Bali,

Indonesia.

“IBD has been traditionally known as a dis-

ease of the West and is relatively rare in Asia.

However, time trend studies from Japan, Korea

and Hong Kong have collectively shown a two-

to-three fold increase in the incidence and preva-

lence of IBD in the past 10 years,” said Professor

Siew Chien Ng from the Department of Medicine

and Therapeutics, Chinese University of Hong

Kong in Hong Kong.

In the first large scale population-based

study of IBD involving seven countries in Asia

(China, Hong Kong, Macau, Thailand, Malay-

sia, Singapore, Sri Lanka) and Australia, the

incidence of IBD varied from 0.54 to 3.44 per

100,000 individuals. China had the highest in-

cidence of IBD at 3.44 per 100,000. Ulcerative

colitis (UC) was more prevalent than Crohn’s

disease (CD), although the incidence of CD was

rapidly increasing in certain areas. [Gastroen-terol 2013;145:158-165]

“Although family history of IBD was less com-

mon in Asia – as were extra-intestinal manifesta-

tions – complicated CD [penetrating, stricturing

IBD on the rise in Asia, most cases reported in China

or perianal disease] was more common in Asia

than in the West,” said Ng.

In Hong Kong, for example, a study showed

the rate of perianal disease was 29.2 percent com-

pared with 15.8 percent in Australia (p=0.001). [J Gastroenterol Hepatol 2012; 27:1266-1280]

“These changes may have been due to our

increased contact with the West, westernization

of diet, improved hygiene, increasing antibiotic

use, immune dysregulation and changes in the

gut microbiota,” Ng said. Asian patients with

CD have altered microbiota compared with their

Caucasian counterparts. Mucosa-associated mi-

crobiota in IBD may also differ geographically.

In a more recent population-based case-con-

trol study in Asia, where Ng was the principal in-

vestigator, breastfeeding, having pets and better

sanitary conditions were shown to be protective

of IBD, suggesting that childhood environment

plays an important role in modulating disease

development. [Gut 2014; pii: gutjnl-2014-307410.

doi: 10.1136/gutjnl-2014-307410]

The results, Ng said, highlight the importance

of childhood immunological, hygiene and dietary

JANUARY 2015 3

factors in the pathogenesis of IBD, suggesting

that markers of altered intestinal microbiota may

modulate risk of IBD later in life.

There are also differences in the genetic

mutations of IBD between Asians and Cauca-

sians, which may impact the development of

IBD, added Ng. NOD2 and autophagy variants

(ATG 16L1 and IL 23) are not associated with

CD in Asians, but TNF-SF15 polymorphisms are

strongly associated with CD.

“Understanding of the genetic variation and

mutations [of IBD] will help us to identify bio-

logical pathways causing the disease and to

discover better drugs for patients. More stud-

ies are warranted to determine the critical etio-

logic factors for IBD,” Ng said.

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JANUARY 2015 4

Linagliptin plus metformin combo safe and effective in Asian patients with newly diagnosed T2DMRADHA CHITALE

Combined oral antidiabetic therapy with lin-

agliptin plus metformin was well tolerated

and successfully brought down HbA1c levels

in newly diagnosed Asian patients with type 2

diabetes mellitus (T2DM) with very high blood

sugar levels.

Linagliptin is a dipeptidyl peptidase (DPP)-4

inhibitor, a class of drug which has been shown

to lead to less weight gain and a lower risk of

hypoglycemia compared with insulin treatment.

A recent multinational trial of patients with

untreated T2DM for less than a year includ-

ed patients with HbA1c between 8.5-12 per-

cent who were randomized to linagliptin plus

metformin (n=159) or to linagliptin mono-

therapy (n=157). [Diabetes Obes Metab 2014.

doi:10.1111/dom.12399]

A subgroup of patients recruited from five

Asian countries (India, Sri Lanka, Malaysia, Phil-

ippines, Thailand) had baseline characteristics

among the linagliptin plus metformin (n=62)

and linagliptin monotherapy (n=63) groups

of median age about 48 years, median HbA1c

about 10 percent, and median fasting plasma

glucose of 188 mg/dL in the combination arm

and 195 mg/dL in the monotherapy arm. There

was some microvascular disease in both arms.

After 24 weeks, among the Asian patients,

mean reduction in HbA1c with combination ther-

apy was 3 percent compared with 1.84 percent

in the monotherapy group (p<0.0001).

Patients on combination therapy demonstrat-

ed early saturation of greater glycemic levels

such that by week 6 there was a significant differ-

ence in glucose levels between the study arms.

Patients with greater hyperglycemia (≥9.5

percent) experienced greater HbA1c reductions

by the end of the trial compared with those with

lower baseline HbA1c (<9.5 percent).

Sixty-percent of patients on combination thera-

py achieved HbA1c of <7 percent at week 24 com-

pared with 21 percent in the monotherapy arm. Pa-

tients on linagliptin alone gained about 1.3 kg while

those on combination therapy lost 0.45 kg.

There was a fairly low percentage of cases

of hypoglycemia, including severe hypogly-

cemia. There were some gastrointestinal dis-

orders reported, but none leading to discon-

tinuation in either arm.

“The combination of linagliptin plus metfor-

min led to clinically important HbA1c reduc-

tions... within a 24-week period,” said Dr. Ron-

ald Ma of the Chinese University of Hong Kong.

“This suggests that early combination [thera-

py] may be a useful strategy in Asian patients.”

He noted that the results represent a post-

hoc analysis of a small subgroup and that the

findings should benefit from the results of on-

going larger-scale trials.

JANUARY 2015 FORUM 5

Alcohol in all policies

Three years ago, I wrote an article for the Ma-lay Mail mourning the loss of a friend and

colleague to an alcohol-induced heart attack. He

was 41 years old and left behind two teenagers

and a toddler. On his final night alive he had been

at one of our fundraising events, and even though

he was already drunk, slurring, stumbling, he

kept drinking. Too inebriated to drive home, he

fell asleep in his car that night and never again

woke up. It was bizarre to walk into the office the

weeks after and know that he was no longer there

– bizarre that I knew that simple public health reg-

ulations could have prevented his death. Public

health laws could have easily required that all al-

cohol servers not serve alcohol to persons who

are already drunk, or that free water be provided

at all venues where alcohol is served.

As a harm reductionist rather than a prohi-

bitionist, I was intrigued to receive an email in-

viting me to do a keynote speech at the IOGT

World Congress on Alcohol in All Policies in Cha

Am, Thailand, in late October 2014. IOGT, or the

International Organisation of Good Templars, is

a very old organization believing in temperance

and, in many cases, complete abstinence from

substances. A harm reductionist, on the other

hand, understands that despite prevention and

education programs, the wide availability of in-

toxicating substances (both licit and illicit) mean

Fifa RahmanLLB (Hons), MHL (Health Law) (Sydney)Policy Manager, European Union Asia Action and Community Action on Harm Reduction (CAHR) Projects

“ Many harm reductionists think

it is great if someone can be

abstinent, but if they can’t, then

it is also great if they are stable

on medications, functioning

in society with a stable job,

and receiving counselling

and support they need ”

JANUARY 2015 FORUM 6

that there will always be drug use, and that mea-

sures must be taken to reduce harm to individ-

ual users, their families, and society as a whole,

without necessarily enforcing abstinence. While

I knew that there were ideological differences

between IOGT and myself in terms of some drug

and alcohol policies, the keynote request was in

relation to Alcohol Regulation and Trade Agree-

ments, on which we shared a common interest

and agreement. I agreed to give the speech and

travelled to Cha Am on 26 October 2014.

Day 1 of the academic program began with a

session on the upcoming United Nations Gen-

eral Assembly Special Session on Drugs in 2016

(hereinafter the UNGASS2016). The Special

Session is to be held following more-or-less a

worldwide consensus that the ‘War on Drugs’,

a senseless war rooted in fear-mongering, rac-

ism, and punitive rhetoric, has completely failed.

To quote Dr. Alex Wodak, former director of the

Drug and Alcohol Service at St Vincent’s Hos-

pital in Sydney, Australia, and president of the

Australian Drug Law Reform Foundation, it has

been “an expensive way of making a bad prob-

lem worse”. It concerned me greatly that IOGT

members considered harm reduction and hu-

man rights arguments to be a threat to IOGT

objectives. Harm reduction, of which needle-

and-syringe exchange, condom provision, and

methadone maintenance therapy is a part, has

been proven to successfully reduce HIV infec-

tion, increase referrals to drug treatment due to

increased interactions between drug users and

health workers, reduce overdose deaths, and

improve quality of life and general health. Many

harm reductionists think it is great if someone

can be abstinent, but if they can’t, then it is also

great if they are stable on medications, function-

ing in society with a stable job, and receiving

counselling and support they need. An anti-

harm reduction stance is one that is harmful to

public health.

Interestingly, in terms of alcohol use, there

was a clear difference in opinion among del-

egates about language used at the WHO in

terms of alcohol regulation. The main WHO

strategy for alcohol control and regulation is

titled the ‘Global Strategy to Reduce the Harm-

ful Use of Alcohol’. Pubudu Sumanasekara,

executive director of the Alcohol and Drug In-

formation Centre (ADIC) in Sri Lanka, stated

that the terminology ‘harmful use of alcohol’

as opposed to ‘use of alcohol’ was ‘one of the

successes of the alcohol industry’ in infiltrat-

ing public health policy. Øystein Bakke, senior

advisor of Forut Norway, an organization work-

ing in alcohol policy, drugs and development,

and women and children’s rights, disagreed,

and said: “the distinction may be losing a little

bit of its value,” and that enforcing the distinc-

tion could alienate people that you would want

to outreach to. Earlier, Bakke had pointed out

that contrary to the perception that alcohol de-

pendence and harmful use of alcohol was a

‘lifestyle disease’ particular to wealthy coun-

tries, the fact that 80 percent of non-communi-

cable disease deaths were in low- and middle-

income countries.

On the third day of the conference, I presented

on the impact of provisions in free trade agree-

ments on alcohol regulation. New generation

trade agreements, like the Trans-Pacific Partner-

JANUARY 2015 7

ship Agreement (TPPA) between the US and Ma-

laysia, Singapore, Vietnam, and Brunei, among

others, and the Transatlantic Trade and Invest-

ment Partnership (TTIP) between the US and Eu-

ropean Union, contain provisions that will restrict

the ability of states to make public health policy,

including alcohol regulations. The Wine and Spir-

its Annex of the TPPA, for example, would make

it difficult to place health warnings directly on the

labels of alcohol products. Governments may

have to settle for a supplementary label.

Martin-Moreno et al. in their 2013 article in

the European Journal of Public Health sug-

gested that what is needed is enhanced label-

ing with clear health warnings and nutritional

information printed on alcohol products. Such

a policy, under both the TPPA and TTIP, could

constitute a ‘technical barrier to trade’ and be

deemed an ‘expropriation of the value of in-

vestments’. In layman’s terms, enhanced label-

ing would reduce profits, and so the company

would be able to sue governments at interna-

tional tribunals. These tribunals have tradition-

ally been pro-investor, and award unlimited

damages based on expected profits of the

company.

Margaret Chan, executive-director of the

WHO, rightly said that these trade agreements

are being used to ‘handcuff governments’ when

acting to protect the health of its citizens. And

while technical, the basic premise is simple: that

trade agreements should not venture into public

health, and that civil society, academics, physi-

cians, and allied health professionals must rise

up against them.

“ In terms of alcohol use,

there was a clear difference

in opinion among delegates

about language used at the

WHO in terms of alcohol

regulation ”

JANUARY 2015 CONFERENCE COVERAGE 8

CHRISTINA LAU

Family physicians should be involved in the

provision of palliative care, particularly in the

patient-desired community setting, said experts.

“More than 90 percent of patients spend the

majority of their last year of life and receive pal-

liative care at home,” said Professor Rodger

Charlton of the Division of Primary Care, The

University of Nottingham, UK. “This places GPs

and family physicians at the heart of palliative

care provision. Indeed, they value this aspect of

their work greatly.”

“In Hong Kong, although ambulatory pallia-

tive care is available for the terminally ill, primary

care physicians have not been involved in the

provision of such care,” said Dr. Tin-Chak Hong,

Specialist in Family Medicine at the Hong Kong

Sanatorium & Hospital. [HK Pract 2004;26:151-

155; Progress in Palliative Care 2011;19:109-

113; Tse MWD, Hospital Authority Convention

2012; HK Pract 2013;35:52-58]

Family physicians in Hong Kong are equipped

and ready to provide palliative care, Hong ar-

gued. “Through family medicine training, they

have acquired the concept and skills of a holistic

approach to care, especially in the psychosocial

aspect, which is the essence of palliative care,”

he said.

In fact, 96.8 percent of local family physi-

cians indicated in a survey that they should be

involved in the provision of palliative care, and

77.7 percent wished to provide palliative care in

their practice. [HK Pract 2013;35:36-51]

The survey, to which 48.1 percent of mem-

bers of the Hong Kong College of Family Physi-

cians responded, also showed that 58.2 percent

of family physicians were currently providing

some form of palliative care in their practice.

However, only 14 percent were providing home

visits.

“Barriers to family physicians’ provision of

community palliative care include cultural con-

Involve family physicians in community palliative care, say experts

21st Hong Kong International Cancer Congress, The University of Hong Kong, 21 November 2014


cerns, lack of time, lack of support and collabo-

ration networks with palliative care specialists

and the multidisciplinary team, and knowledge

gaps,” said Hong.

“Further enhancement of primary healthcare

systems, social and medical support, and ed-

ucation are needed to enable the provision of

continuity of care by teams involving family phy-

sicians,” he continued.

As for patients, 81.8 percent of those with

terminal cancer in a palliative care unit of a

public hospital in Hong Kong indicated they

wished to have home visits by healthcare pro-

fessionals when needed. Thirty-seven percent

wished to stay at home during the pre-termi-

nal period, while 19 percent wished to die at

home. [Hong TC, et al, Hospital Authority Con-

vention 2010]

“Two important elements of a ‘good death’

are to have choice and control over where death

occurs, and who is present and shares the end.

However, dying ‘naturally’ with dignity is be-

sieged by bureaucracy in both Hong Kong and

the UK,” said Charlton.

“As a result, inappropriate hospital admis-

sions are common in Hong Kong,” he contin-

ued. “Almost all elderly patients with terminal or

irreversible chronic illnesses die in an unfamiliar

acute hospital environment, where visiting time

is restricted and ward staff is unable to dedi-

cate time to offer a ‘good death’ experience to

patients or assist with bereavement.” [Asian J Gerontol Geriatr 2011;6:103-106]

For GPs with an interest in providing pallia-

tive care, the question of whether they would be

surprised if a patient with advanced cancer died

in the following year was shown to provide an

accurate survival prognosis. According to re-

searchers, this ‘surprise’ question can be used

to help identify patients who may need end-of-

life care planning. [Palliat Med 2014;28:959-964]

“Having identified these patients, the next

step is to talk to them and their family members

about death, about their fears and concerns,”

said Charlton.

“There is a need for doctors to stop seeing

death as the enemy because death is not a fail-

ure of medicine; it is the inevitable result of life,” he

emphasized. “However, we sometimes try to keep

people alive longer than we should.”

“There is a growing movement of feeling that

we should be aiming for a good death and not

a prolonged one,” he continued. “We should

focus on building a healthcare system that will

help dying patients achieve what is important to

them. To a great extent, the quality of a health-

care system is reflected in the quality of end-of-

life care provision.”

“ Dying ‘naturally’ with dignity is

besieged by bureaucracy in both

Hong Kong and the UK ”“ There is a need for doctors to stop

seeing death as the enemy because

death is not a failure of medicine”


PANK JIT SIN

The findings of the Recognise Asthma and

Link to Symptoms and Experience (RE-

ALISE) survey reveals that asthma patients

can be segmented into distinct and action-

able groups based on their attitude towards

asthma.

Dr. Aileen David-Wang, clinical associate pro-

fessor, University of the Philippines – Philippine

General Hospital, said the survey was aimed at

“identifying distinct and explicit patient clusters

in Asia, defined by their differing attitudes, ad-

herence, educational needs and other important

attributes.”

The survey assigned patients into one of five

clusters – Well Adjusted; Rejector; Lost; Endur-

er; and Worrier. The attitudes of patients could

confidently determine their asthma control

based on the Global Initiative for Asthma (GINA)-

defined criteria. The Well Adjusted and Rejector

clusters typically had a high level of asthma con-

trol. The Lost and Endurer clusters experienced

low asthma control, while the Worriers had the

lowest control of asthma. Wang said each clus-

ter has different information needs and requires

a tailored management approach.

Through proper matching of patients’ atti-

tudinal cluster, doctors can optimally manage

asthma patients through personalized solutions

instead of a one-size-fits-all approach.

Wang went on to describe each cluster’s

character profile, with the Well Adjusted ones

being able to cope well with their asthma and

being minimally impacted in their daily lives,

both emotionally and functionally. Additionally,

they are happy to go along with their doctor’s

advice and have no problem using their inhaler

– a reflection of their carefree attitude and lower

stress levels.

The Rejectors are patients who have to come

to terms with the emotional burden of living with

asthma, and their asthma is generally well con-

trolled. The refusal to accept their disease state

is reflected in their tendency to deprioritize their

health. This cluster is also particularly conscious

about using the inhaler in public.

Those in the Lost cluster generally have a high

level of stress and anxiety about their poorly con-

trolled asthma. This leads to a rejection of their

asthma status, their doctor and their inhaler, said

Wang. The Lost tend to be evasive and avoid

thinking about their health problems (asthma),

despite being emotionally and functionally af-

fected by it. However, they frequently seek infor-

mation regarding asthma, suggesting that they

have unanswered questions and are at a loss for

answers.

Attitude determines outcome, treatment strategy in asthma

19th Congress of Asian Pacific Society of Respirology (APSR), November 13-16, Bali, Indonesia


Meanwhile, the Endurers are those who have

resigned themselves to the fact that they have

asthma and that they have no control over the

disease. Even though their level of confidence

in managing their asthma is low, the situation

doesn’t impact their daily life, emotionally or func-

tionally. The Endurers are fine with using their in-

haler (in public) and are less interested in finding

out more about asthma compared to other poorly

controlled clusters.

The cluster most troubled by their asthma

are the Worriers. To them, asthma is a constant

bother and always on their mind. Worriers are

able to come to terms with being labeled as

asthmatic and acknowledge the seriousness of

asthma, but live with a high level of stress and

anxiety over the disease. This is reflected in the

high level of concern they have regarding their

asthma and the high frequency of information

seeking, noted Wang.


PANK JIT SIN

Man-made fibers are defined as those

whose chemical composition, structure

and properties are significantly modified during

the manufacturing process. These are spun and

woven into a number of consumer and industrial

products such as rayon, nylon and dacron. On

the other hand, natural fibers are composed of

biologically produced compounds such as cel-

lulose and protein. Such fibers emerge from the

manufacturing process in a relatively unaltered

state, for example, silk and cotton.

Speaking on the topic of man-made fibers and

the relationship with cancer, Professor Faisal Yu-

nus, senior lecturer, Department of Pulmonology

and Respiratory Medicine, Faculty of Medicine,

University of Indonesia, said the fibers studied were

made from various components and largely used

in the electrical and insulation industry, especially

wool and filament types.

The International Agency for Research on Can-

cer (IARC) has stated that there is inadequate evi-

dence of carcinogenic effects of glass wool, con-

tinuous glass filament rock wool, slag wool and

refractory ceramic fibers in humans. However,

experimental evidence abounds for carcinogenic-

ity of special-purpose glass fibers such as E-glass

and refractory ceramic fibers. [Available at http://

monographs.iarc.fr/ENG/Monographs/vol81/

mono81.pdf Accessed on 9 December]

Faisal noted that cancer is now a leading

cause of death, with 12.7 million new cases and

7.6 million deaths in 2008. The World Health

Organization (WHO) attributes 19 percent of all

cancers as being caused by the environment,

including at work, with about 1.3 million deaths

each year.

Of this number, one in 10 lung cancer deaths

are closely related to risks in the workplace. Ac-

cording to the WHO, lung cancer, mesothelioma

and bladder cancer are among the most com-

mon types of occupational cancers. For cancers

of the lung, arsenic, asbestos, coal, engine ex-

haust and chromium compounds are linked to

carcinogenicity in humans. Additionally, crystal-

line silica dust, soot, tobacco smoke and outdoor

particulates are also proven lung carcinogens.

However, there is insufficient evidence from

both animal and human studies for carcino-

genicity of fibers such as continuous glass

filament, alkaline earth silicate wool, high-

alumina, and low-silica wools. Data from ani-

mal studies indicating that man-made vitreous

fibers are potentially carcinogenic are also

inconclusive.

Harm from man-made fibers unclear



CHUAH SU PING

Air pollution is one of the major causes of

mortality globally.

“Ambient air pollution was estimated to have

caused an excess of 3.7 million premature

deaths in 2012, with 88 percent of these excess

deaths having occurred in low- and middle-in-

come countries,” said Professor Emeritus Nor-

bert Berend, head of Respiratory Research at

the George Institute for Global Health, Sydney,

Australia. He noted that the causes include rapid

industrialization, increased motor vehicle traffic

and the use of cheap coal as a source of power.

“The many effects of air pollution can be di-

vided into acute and chronic effects. Acute ef-

fects include respiratory symptoms, cardiovas-

cular events, hospitalizations and mortality, and

these are more pronounced in people with un-

derlying respiratory or cardiovascular diseases.

Chronic effects range from reduction of lung

growth in children and adolescents, reduced

lung function in adults and lung cancer,” said

Berend.

Berend highlighted the ‘Great Smog’ of 1952,

which was a severe air-pollution event that af-

fected London from December 5-8 in 1952. “The

Great Smog is known to be the worst air pollu-

tion to have ever occurred in the UK, and it is

Air pollution a leading preventable cause of death worldwide

linked to at least 12,000 deaths. This event was

significant as it led to increased public aware-

ness, government regulation and environmental

research,” he said. “The level of pollution noted

in the 1952 smog in London, can now be seen

in key cities in China, in particular Beijing, and

India.”

“Indoor air pollution is also a major concern.

Up to 3 billion people rely on the burning of

biomass fuels indoors as a source of heating

or to cook, and this has been linked to approxi-

mately 4.3 million deaths yearly. Of that figure,

1.69 million deaths are from Southeast Asia,

and 1.62 million are from the Western Pacific

region,” said Berend. Worldwide, he noted, the

use of biomass fuels is especially high in ur-

ban slum populations.

“As healthcare practitioners, what we need

to do now is to continue to advocate for lung

health to the public, government health depart-

ments as well as international agencies. Whilst

it is important that we continue the anti-smok-

ing lobby, we must also demand an upgrading

of international air quality standards as well as

adherence to these standards. We also need

to push for increased research funding from

individuals, national and international respira-

tory societies to improve the field of respiratory

health.”



RADHA CHITALE

Natural disasters have significant direct and

indirect effects on lung health and can

have long-term repercussions, particularly in

the Asia-Pacific region, where 80 percent of the

world’s natural disasters in the 20th and 21st

centuries have occurred.

Earthquakes, tsunamis, volcano eruptions

and typhoons can be violent and dirty, exposing

people in the area to harmful particulate matter

and microbes. Efforts to gather people together

for care immediately after a disaster can lead to

further harm.

“Respiratory infectious diseases are the main

problem,” said Dr. Bruce Robinson of the Univer-

sity of Western Australia and director of the Na-

tional Centre for Asbestos Diseases Research in

Perth, Australia.

Following a tsunami, for example, there is wa-

ter everywhere creating lots of places for mosqui-

toes – the disease vectors – to breed.

Crowding following a disaster can lead to

rapid infection spread due to exposure. Diseases

such as measles, acute lower respiratory tract

infection, and tuberculosis – all of which can be

fatal without prompt, appropriate treatment – can

spread quickly.

Following the 2004 earthquake and tsunami

that hit parts of Thailand, more than half (62 per-

cent) of the consultations for communicable dis-

Natural disasters can affect lung healtheases, about 180,000, occurred within the first 12

weeks following the disaster.

Large natural disasters can cause existing

healthcare services to break down resulting in a

lack of medical care for routine pulmonary events.

Healthcare workers are also at risk for physical

injury, infection, and may be worried about the

safety of their own families.

Patients with existing pulmonary disease are

at risk during natural disasters if there are disrup-

tions to power for oxygen delivery, routine medi-

cines for asthma or chronic obstructive pulmo-

nary disorder, or if there is no physiotherapy or

other services for people with chronic diseases

like cystic fibrosis.

To be prepared, Robinson recommended

backup power sources, medication stores,

and adequate transport plans to move patients

to better facilities. [Respirology 2011;16:386-

395]

There are four main direct effects of disasters

on the lungs.

Small particles of smoke or toxic gases from

fires or volcanic emissions can be inhaled, and

if they are hot the lungs can burn, become leaky,

and be poisoned by carbon monoxide.

The 1997 haze fires in Indonesia caused over

500 haze-related deaths in 3 months as well as

300,000 cases of asthma, 50,000 cases of bron-

chitis, and 1.5 million respiratory infections, Rob-

inson said.



Aspirating water can introduce water-borne

pathogens to the lungs. Direct trauma to the chest

when buildings fall down can result in rib fractures

or diaphragm rupture.

Psychological trauma following a natural di-

saster can also result in physical manifestations

that need to be managed, Robinson said.

“As a chest physician, it’s important to engage

with the psychological trauma after a disaster...

What I’ve found is that it’s very important to talk

to the patients because no one else is talking to

them,” he said. Particularly when a mass group is

affected, it becomes important for the doctor to

engage.


Fracture risk in diabetics underestimated

IOF Regionals, 5th Asia-Pacific Osteoporosis Meeting 2014, November 14-16, Taipei, Taiwan – Chuah Su Ping reports

The potential for fracture in patients with dia-

betes may be underestimated, as some of

the major fracture assessment tools that are

available do not take into account diabetes as

a risk factor.

“Fractures are a common complication of

diabetes, with common fracture sites including

the hip, wrist and spine,” said Dr. Jung Fu Chen

of the Division of Endocrinology and Metabo-

lism (Osteoporosis Clinic) at Chang Gung Me-

morial Hospital, Kaohsiung, Taipei. “However,

despite the metabolic abnormalities of diabe-

tes which do affect bone metabolism, structure

and bone mineral density (BMD), the associa-

tion between increased fracture risk in individu-

als with type 1 and 2 diabetes continues to be

debated.”

Chen noted that the current algorithm of the

WHO fracture risk assessment tool (FRAX®)

does not include diabetes as a risk factor. In

2012, researchers reported that diabetes was

a significant predictor of subsequent major

osteoporotic fracture after controlling for age,

sex, medication use and FRAX risk factors in-

cluding BMD. Diabetes, they reported, was

also associated with significantly higher risk

for hip fractures (p<0.001). [J Bone Miner Res

2012;27:301-308]

The investigators concluded that the FRAX

underestimated observed major osteoporot-

ic and hip fracture risk in diabetics (adjusted

for competing mortality), thus suggesting that

diabetes might be considered for inclusion in

future iterations of FRAX. “However, more re-

search is required in collecting new population

cohorts worldwide before this risk factor can be

included in the FRAX,” Chen opined.

More recently, a Taiwanese study evaluat-

ed fracture risk and post-fracture mortality in

patients with diabetes. Using data obtained

from Taiwan’s National Health Insurance Da-

tabase, they identified 32,471 adults with

newly diagnosed diabetes from 2000-2003;

and fracture events from 2000-2008 from

medical claims.

Based on 652,530 person-years of follow-

up, they noted that the incidences of fracture

for people with and without diabetes were 24.2

and 17.1 per 1,000 person-years, respectively


(p<0.0001). Compared with people without

diabetes, diabetics face a higher risk of frac-

ture (HR, 1.66, 95% CI, 1.60-1.72). “The study

also found that the odds ratios of post-fracture

deep wound infection, septicemia, and mortal-

ity associated with diabetes were 1.34 (95% CI,

1.06-1.71), 1.42 (95% CI, 1.23-1.64) and 1.27

(95% CI, 1.02-1.60), respectively,” said Chen.

[Diabetes Care 2014;37:2246-2252]

Similarly, investigators from the Atheroscle-

rosis Risk in Communities (ARIC) Study – a

US-based study with patients recruited from

four US communities – had reported that di-

agnosed diabetes was significantly and inde-

pendently associated with an increased risk of

fracture. The ARIC study supports recommen-

dations from the American Diabetes Associa-

tion for assessment of fracture risk and imple-

mentation of prevention strategies in persons

with diabetes, particularly those with poor glu-

cose control. [Diabetes Care 2013;36:1153-

1158]

“With the ever-growing population of diabet-

ics in Asia, coupled with an increasing aging

population, a multidisciplinary team approach

which includes bone care is very crucial for the

integrated management of diabetic patients,”

concluded Chen.


Osteoporotic fractures in men – highlights from the MrOS study


Fractures resulting from osteoporosis are a

major healthcare challenge in men, yet the

rate of detection and management of male os-

teoporosis lags well behind that in women, ac-

cording to an expert.

The residual lifetime risk of experiencing an

osteoporotic fracture in men 50 years old and

above is estimated to be approximately 27 per-

cent. [Osteoporosis Int 2001;12:124-130] In

comparison, the risk of developing prostate can-

cer in men over the age of 50 has been calcu-

lated at around 11 percent. [Cancer Epidemiol Biomarkers Prev 1997;6:763-768]

“The Osteoporotic Fractures in Men (MrOS)

Study is a prospective cohort study designed

to examine the extent to which fracture risk

is related to bone mass, bone geometry, life-

style, anthropometric and neuromuscular

measures, and fall propensity, as well as to

determine how fractures affect quality of life

in men,” said Dr. Eric Orwoll, professor of

Medicine and director of the Bone and Mineral

Clinic at Oregon Health and Science Universi-

ty, Portland, Oregon, US. [Contemp Clin Trials

2005;26:569-585]

“To date, the MrOS study has helped estab-

lish that although women have a higher risk of

fracture, the association between bone mineral

density (BMD) and fracture risk is clearly evi-

dent in men, and similar to that in women,” said

Orwoll. [J Bone Miner Res 2006;21:1550-1556]

More recently, another paper from the MrOS

study noted that men with accelerated femoral

neck BMD loss had an increased risk of hip and

other non-spine fractures. [J Bone Miner Res

2012;27:2179-2188]

“While the MrOS study has provided fur-

ther understanding of osteoporosis fractures in

men, it did also raise questions. [One] study,

for example, raised the question of whether or

not men with low-to-normal BMD (not yet in the

range requiring treatment) should have a repeat

[BMD] measurement in 2-to-3 years, and wheth-

er or not to treat men with the greatest rate of


bone loss earlier,” said Orwoll. The researchers

concluded that further research was still need-

ed in order to determine if repeat BMD testing

and subsequent treatment in such a popula-

tion would be cost effective. [J Bone Miner Res

2012;27:2179-2188]

Orwoll also highlighted a MrOS substudy

which showed an association between poor

physical performance and the likelihood of in-

cident vertebral fractures. “The investigators

concluded that men who performed poorly on

several tests – chair stand, walking speed, leg

power, narrow walk and grip strength – had

twice the risk of radiographic vertebral frac-

tures over time compared with men who did

not perform poorly on any test,” said Orwoll. [J Bone Miner Res 2014;29:2101-2108]

“The MrOS study is still ongoing, and next

phase aims to provide further understanding

of the trajectories of change in musculoskel-

etal health, and how they affect important

outcomes such as fracture, and physical dis-

ability,” said Orwoll. “Using high resolution mi-

cro-computed tomographic imaging, our goal

is to further assess the relationship between

bone microstructure and fracture risk.”


Soy food intake is associated with a reduced

risk of osteoporotic hip fractures in women

but not in men, according to research from the

Duke-NUS Graduate Medical School, Singa-

pore. More recent data from the same study, the

Singapore Chinese Health Study, also suggest

that adequate intake of carotenoids may reduce

the risk of osteoporotic fractures among elderly

men, but not in women.

“The incidence of hip fractures is rising in

Asia, in part due to the rapidly aging popula-

tion, however there is still a paucity of studies

among Asian populations on the dietary factors

of osteoporosis,” said Duke-NUS researcher

Associate Professor Koh Woon Puay. Koh and

her team prospectively examined the associa-

tions of dietary intakes of soy isoflavones and

carotenoids with hip fracture risk among elderly

Chinese in the Singapore Chinese Health Study,

a prospective cohort of 63,257 men and women

45-74 years of age.

In their paper, Koh and colleagues noted that

soy food products, such as plain tofu, taupok,

taukwa, foopei, foojook, tofu-far and soybean-

drink, are common in the Singapore Chinese diet.

“Total soy isoflavone intake for a given sub-

ject was computed based on the food frequency

questionnaire (which all participants were re-

quired to complete) and the summation of the

[isoflavone] content of all the seven soy foods

in the Singapore Food Composition Database,”

she said.

“This is the first study to compare the effects

of soy on hip fracture between men and wom-

en in a cohort study,” noted Koh. “Our study

revealed a significant reduction in hip fracture

in women with moderate intakes of soy isofla-

vones. Conversely, no protective association

was found in men with similar intakes.” [Am J Epidemiol 2009;170:901-909]

Koh noted that this is consistent with previ-

ous animal studies which showed that expo-

sure to the isoflavone genistein was linked to

increased bone marrow density in the femurs of

adult female mice but not in male mice. [Pediatr Res 2007;61:48-53]

With regards to carotenoid intake and hip frac-

ture risk, Koh noted that among men, consump-

tion of vegetables – the main source of carotenoid

intake in this population – was associated with

lower hip fracture risk. Similarly, dietary intake

of total carotenoids and specific carotenoids –

α-carotene, β-carotene, and lutein/zeaxanthin –

were inversely associated with hip fracture risk.

Soy isoflavones and carotenoids have gender-specific protective roles against hip fractures



“When stratified by body mass index (BMI),

the greatest protective effects of total vegetables

and carotenoids were found in lean men (BMI

<20 kg/m2),” said Koh. “There was no associa-

tion between dietary carotenoids or vegetables/

fruits, and hip fracture risk among women.” The

authors postulated that the antioxidant effects of

carotenoids may counteract the mechanism of

osteoporosis related to leanness. [J Bone Miner

Res 2014;29:408-417]

Koh concluded that, based on the hypothe-

ses attained from these two studies, future inter-

ventional studies should target different mecha-

nisms in osteoporotic fractures.

High resolution micro-computed tomograph-

ic imaging, our goal is to further assess the rela-

tionship between bone microstructure and frac-

ture risk.”

Odanacatib promising therapy for osteoporosis in men

Odanacatib, a selective inhibitor of cathep-

sin K, has demonstrated promising po-

tential for the treatment of osteoporosis in men,

according to new results from the Long-Term

Odanacatib Fracture Trial (LOFT), which were

presented at the 5th Asia-Pacific Osteoporosis

Meeting held in Taipei, Taiwan. [Osteoporos Int 2014;25:571(OC1)]

“In a phase II study in postmenopausal wom-

en, treatment with odanacatib 50 mg once week-

ly resulted in increases in bone mineral density

(BMD) at the lumbar spine (11.9 percent) and

total hip (8.5 percent) over 5 years,” said Profes-

sor Eric Orwoll, director of the Bone and Mineral

Clinic, and of the Bone Density Lab at Oregon

Health and Science University, Portland, US. [J Bone Miner Res 2012;27:2251-2258]

“Men with osteoporosis represent between

20 and 25 percent of all osteoporotic patients

and men are at greater risk of death following a

hip fracture. Following the promising results of

the phase II study in postmenopausal women,

we carried out a double-blind, placebo-con-

trolled 24-month study to evaluate the safety

and efficacy of odanacatib for the treatment

of men with osteoporosis,” said Orwoll. “This

is the first study of odanacatib in men with

osteoporosis.”

The primary objectives of their study were to

assess the effect of odanacatib 50 mg weekly

versus placebo on lumbar spine BMD over 24

months; and to assess the safety and tolerability


of odanacatib 50 mg weekly compared with pla-

cebo. “We enrolled men 40-95 years of age with

idiopathic osteoporosis or osteoporosis associ-

ated with hypogonadism (total serum testoster-

one ≤250 ng/dL). Participants were randomized

to either the study drug or placebo once weekly,

and all received vitamin D3 (5,600 IU/week) and

calcium supplements (total intake approximate-

ly 1,200 mg daily),” noted Orwoll.

Compared with placebo, treatment with odan-

acatib 50 mg weekly for 24 months increased

lumbar spine, total hip, femoral neck and trochan-

teric BMD. “We noted decreased levels of mark-

ers of bone resorption in the odanacatib group

versus placebo. While markers of bone forma-

tion initially decreased [in the odanacatib group],

these were then noted to return toward levels

similar to that observed in the placebo group by

month 24,” said Orwoll. The investigators noted

that the adverse events and overall safety profile

were similar between both study groups.

“These data indicate that odanacatib therapy

is effective in increasing spine and hip BMD in

men with osteoporosis. Changes in bone turn-

over markers suggest that odanacatib treatment

decreases bone resorption while producing rela-

tively small decreases in bone formation. Thus,

this cathepsin K inhibitor may be a promising po-

tential therapy for the treatment of osteoporosis

in men,” Orwoll concluded.


Acute severe ulcerative colitis remains a

challenging condition to manage even in

the era of biologic therapy, says an expert.

“Ulcerative colitis is a chronic, idiopathic

inflammatory disorder with significant mor-

bidity and mortality,” said Associate Profes-

sor Ida Hilmi, a consultant in gastroenter-

ology, University of Malaya, Kuala Lumpur,

Malaysia. “The clinical course of the dis-

ease typically manifests with remissions

and exacerbations characterized by rectal

bleeding and diarrhea. Medical therapy can

only ameliorate the inflammatory process

and control most symptomatic flares but

provides no definitive treatment for the dis-

ease.”

Acute severe ulcerative colitis is usually

defined according to the original criteria

set forth by Truelove and Witts – frequent

loose bloody stools (≥6 per day) with evi-

dence of systemic toxicity as demonstrated

by fever (≥37.8°C), tachycardia (heart rate

[HR] >90 bpm), anemia (Hb <10.5 g/dL) or

an elevated erythrocyte sedimentation rate

(HR) >30 mm/h.

“Clinicians should be able to rule out

precipitating or other causes and assess

the need for emergent surgery,” Hilmi said.

Stool microscopy and culture should be

performed as part of the initial assessment,

as well as a test for Clostridium difficile in-

fection. “This is because pseudomembra-

nous colitis can complicate or mimic severe

ulcerative colitis. Plain abdominal radio-

graphs are also important to look for toxic

megacolon or to rule out perforation.”

For patients who meet the clinical criteria

for severe ulcerative colitis, sigmoidoscopy

and a biopsy may be required to look for

cytomegalovirus (CMV), the presence of

which may result in treatment failure. En-

doscopic scoring system (eg, the modified

Baron score) may be used to assess for dis-

ease severity. Some patients, however, may

have severe ulcerative colitis at endoscopy,

despite not fulfilling the clinical criteria for

severity, said Hilmi.

Intravenous corticosteroids (hydrocor-

tisone 100 mg four times daily or meth-

Challenges in the management of acute severe ulcerative colitis

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia – Elvira Manzano reports


ylprednisolone 60 mg daily) remain the

mainstay of treatment for severe ulcerative

colitis. Careful monitoring of stool frequen-

cy and vital symptoms, as well as abdomi-

nal examination, is necessary to assess the

patient’s response to therapy. The use of

antibiotics may be justified in those with co-

existing sepsis, she added.

For patients with steroid-refractory coli-

tis, rescue therapy with cyclosporine or inf-

liximab must be commenced. In one study,

intravenous infliximab was no more effec-

tive than intravenous cyclosporine in pa-

tients with acute severe ulcerative colitis

refractory to intravenous steroids. [Lancet 2012;380:1909-195]

“Well-timed rescue medical therapy is

generally safe when administered by ex-

perienced physicians, and is effective in

the majority of cases,” said Hilmi. “Close

liaison with the surgeon is essential as the

window for timely surgery is narrow and de-

layed surgery, when it is required, can lead

to significant complications.”


There is a need for simple tests to assist the

accurate diagnosis and prognostic assessment

of patients with inflammatory bowel disease

(IBD), says an expert.

“Serological antibodies are helpful in this

setting, but with major limitations,” said Pro-

fessor Michael A. Kamm from St. Vincent’s

Hospital and the University of Melbourne in

Melbourne, Australia. “Most of the described

antibodies found in IBD are autoantibodies di-

rected against enteric microbial epitopes and

are thought to arise secondary to the disease

process but are not thought to play a patho-

genic role.”

Perinuclear antineutrophil cytoplasmic an-

tibodies (pANCA) and anti-Saccharomyces cerevisiae antibodies [ASCA], for example,

may have diagnostic value and are helpful in

distinguishing Crohn’s disease (CD) from ul-

cerative colitis (UC) and intestinal tuberculo-

sis (TB). However, they have limited prognos-

tic value,” said Kamm. “There is the presence

of a large number of detectable antibodies

[in the serum] that are associated with worse

long-term prognosis.”

Clinicians should also keep in mind that

antibody incidence in IBD is affected by spe-

cific disease, geography and ethnicity. Hence,

serologic responses differ between Asian and

Western populations. [World J Gastroenterol 2013;19:6207-6213]

Of note, none of the currently available se-

rological markers for IBD can be used as a

stand-alone diagnostic in clinical practice and

can only serve as an adjunct to endoscopy,

which is quite invasive.

As clinical aid, C-reactive protein (CRP) has

been the typical laboratory marker used for

differentiating IBD from functional and other

bowel disorders. CRP is an objective marker

of inflammation and correlates well with dis-

ease activity in CD. However, it is still far from

ideal, said Kamm.

“It is nonspecific ... measures inflammation

but it does not tell us where the inflammation is

occurring. There is also remarkable heterogene-

ity in the CRP response between CD and UC.”

Serologic and fecal biomarkers in IBD: Can they replace endoscopy?

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia – Elvira Manzano reports


Recently, several fecal biomarkers have

been developed that are sensitive indicators

of active intestinal inflammation and may pro-

vide a convenient method to assist in the di-

agnosis and prognosis of patients with IBD.

“The best proven biomarker is calprotectin, a

neutrophil-derived protein which is stable in

feces and can be quantitatively measured in

stool. It is useful in distinguishing IBD from

functional symptoms and in monitoring dis-

ease recurrence. Fecal testing of calprotectin

can also in some circumstances replace en-

doscopy.”

Fecal calprotectin is easy to measure, and

is reproducible. The test is also inexpensive.

“Fecal calprotectin is likely to play an increas-

ingly important role in the management of

IBD, Kamm said.


Improving CRC risk stratification through simple criteria scores

Risk stratification in colorectal cancer (CRC)

patients with the Asia-Pacific CRC Screening

(APCS) score can help reduce the risk of morbid-

ity and mortality from CRC, but barriers remain

against screening uptake.

“We anticipate [APCS] will be easier to use in

clinics by GPs for assessing the risk of CRC, be a

more efficient use of the resources and manpow-

er, and improve public awareness via self-assess-

ment of CRC risk,” said Clinical Associate Profes-

sor Han-Mo Chiu of the National Taiwan University

and Hospital and the Asia-Pacific Working Group

on Colorectal Cancer.

The APCS score is a simple set of criteria that

classifies patients into average, moderate and high

CRC risk based on age, gender, family history of

CRC and smoking status. [Gut 2011;60:1236-1241]

The Asia Pacific region has a low rate of screen-

ing, ranging from about 33 to 40 percent across

Taiwan, Japan, Korea and, at the high end, Austra-

lia. Low public awareness is part of the problem,

but physicians play a key role in recommending

screening.

Current international guidelines recommend

screenings about every 10 years if a colonoscopy

is normal or if there are small adenomas, and ev-

ery 3 years if there are more than three adenomas

or one advanced neoplasm.

Lifestyle factors, particularly smoking and

weight, are significant contributors to higher CRC

risk. Metabolic syndrome increases the risk of

proximal and synchronous neoplasms, Chiu said,

as well as advanced neoplasm occurrence.

Increasing physical activity, reducing waist

circumference, smoking and alcohol intake, and

improving diet can reduce the risk of CRC by 23

percent. [BMJ 2010;341:c5504]

Coupling primary prevention via lifestyle chang-

es with increased early screening has the potential

to reduce the risk of CRC in at-risk patients, par-

ticularly in the Asia Pacific region. US data from

1975 to 2006 has shown that screening and early

treatment contributed to half of the CRC incidence

reduction (26 percent) during that period. Re-

duced mortality was attributed in significant part to

risk factor modification (35 percent) and screening

(53 percent) and only partially to advances in CRC

treatment (12 percent). [Cancer 2010;116:544-

573]

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia – Radha Chitale reports


Early surgery may benefit Crohn’s disease patients

The incidence of Crohn’s disease is increasing

in Asia and besides medical treatment and di-

etary changes, earlier surgery may be an appropri-

ate treatment option, research shows.

Crohn’s disease, a type of inflammatory bowel

disease that can affect the entire gastrointestinal

tract, is on a steady upward trend in countries in-

cluding Hong Kong, Korea, and Japan, according

to Dr. Kentaro Sugano of Jichi Medical University in

Shimotsuke, Tochigi, Japan.

In general, international guidelines suggest be-

ginning with anti-inflammatory medications and in-

corporating digestible nutrients into an “elemental

diet” composed of easily digestible liquid amino

acids, fats, sugars, minerals and vitamins, in pa-

tients with mild to moderate Crohn’s disease.

This may be followed by more medications (an-

tibiotics, immunosuppressants, corticosteroids),

nutritional therapy, and granulocyte aphoresis.

Surgery, in addition to medication and nutritional

therapy, is recommended for severe Crohn’s dis-

ease. [MHLW Research Group Report 2013]

For people whose Crohn’s disease is localized

in the distal ileum, surgery may be an appropri-

ate early intervention, Sugano said, with beneficial

long-term recurrence rates.

In one study of 55 patients with Crohn’s disease

who underwent resection surgery, over a median

6.7 years of follow up, 32 patients remained relapse-

free. Five patients required resection for recurrent

disease but body image and comesis scores im-

proved overall. [Br J Surg 2010;97:563-568]

“Taking into account the benefits and risks of

medical treatment and surgery, the risk of recur-

rence after surgery, individual preferences and any

personal or cultural considerations... surgery can

be less expensive and may have a better long-term

outcome,” Sugano said.

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia – Radha Chitale reports


When should physicians stop HBV therapy?

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia

RADHA CHITALE

A new schema for when to stop hepatitis B

virus (HBV) therapy that stratifies patients

by viral genotype could provide a roadmap for

hepatologists in the Asia Pacific region for im-

proving patient outcomes, said Dr. Muhammad

Umar of the Centre for Liver and Digestive Dis-

eases at the Holy Family Hospital in Rawalpindi,

Pakistan.

Globally, about 2 billion people have or

have had an HBV infection. Up to 40 percent

develop liver failure or hepatocellular carci-

noma (HCC) and about 1 million people die

each year from HBV-associated liver disease.

[WHO Fact Sheets, www.who.int; N Engl J Med

1997;337:1733-1745]

HBV patients can be categorized into three

groups: complete viral response (viral load <60

IU/mL), partial or response (viral load >60 to

2,000 IU/mL), and inadequate response (viral

load ≥2,000 IU/mL). These are determined after

patients are assessed for primary non-response

after starting treatment at week 12 and again for

early predictors of efficacy via viral load at week

24. [Keeffe EB et al. Clin Gastroenterol Hepatol. In press.]

Based on the viral response, patients may

have no change in treatment and broadened

monitoring, no change in treatment and close

monitoring, or they may need to switch to or add

an alternative therapy and receive extremely

close monitoring if they have inadequate viral

response.

However, seroconversion, which is wide-

ly accepted as the primary endpoint for HBV

treatment, is not useful for certain types of

less responsive HBV patients – those who

are HBV e antigen (HbeAg)-negative mu-

tants in the precore and core promoter re-

gions.

For these patients relapse is common af-

ter stopping oral therapy.

“Therapy is usually administered long-

term,” Umar said. “But several years of un-

detectable HBV DNA may decrease the re-

lapse rate.”

By comparison, in HBeAg-positive pa-

tients, who are the wild type, seroconver-

sion can be used to measure whether the

HBV viral load has reduced and, when it be-

comes low or undetectable, therapy may be

discontinued 6-12 months after seroconver-

sion. However, Umar said the durability of

response would be about 80 percent.


Novel therapeutic interventions for gastroparesis

Asian Pacific Digestive Week 2014, November 22-25, Bali, Indonesia

ELVIRA MANZANO

The treatment of gastroparesis – delayed

gastric emptying in the absence of mechan-

ical obstruction – is targeted at symptom control

and correcting the precipitating cause of gastric

stasis, says an expert.

“In patients with diabetes, gastroparesis

and the associated disturbance in the delivery

of nutrients into the duodenum may affect the

ability to properly control glucose,” said Pro-

fessor Gerald Holtmann from the Department

of Gastroenterology and Hepatology, Prin-

cess Alexandra Hospital and the University of

Queensland in Brisbane, Australia. “Gastropa-

resis is also thought to play an important role

in the manifestation of symptoms in patients

with functional dyspepsia. Thus, normalization

of gastric emptying may be targeted to relieve

symptoms in patients with functional dyspep-

sia or to control glucose in those with diabetic

gastroparesis.”

Apart from diabetes, common causes are

idiopathic and post-surgical as a consequence

of vagal nerve injury following upper abdominal

surgery, resulting in reduced pyloric relaxation

and impaired antral contraction.

Pharmacologic management include medi-

cations targeting dopaminergic or serotoniner-

gic pathways such as metoclopramide, dom-

peridone, cisapride, prucalopride, or itopride.

Inhibiting acetylcholinesterase activity to im-

prove gastric motility and emptying is also an-

other therapeutic approach, said Holtmann.

“Erythromycin derivatives devoid of antibiotic

properties are also considered promising candi-

dates for the treatment of gastroparesis. Eryth-

romycin given at low doses stimulates gastro-

intestinal motility and substantially accelerates

gastric emptying,” he added.

Interestingly, normalization or improvement

of gastric emptying in response to prokinetics is

not linked to improvement in symptoms. In one

study, for example, treatment with ABT-229, an

erythromycin derivative, was no more effective

than placebo in relieving symptoms in patients

with or without delayed gastric emptying. Upper

abdominal discomfort severity scores were simi-

lar between the two groups at 4 weeks. [Aliment Pharmacol Ther 2000;14:1653-1661]


For patients with refractory gastroparesis,

gastric electrical stimulation has been shown to

reduce symptoms, particularly nausea and vom-

iting, in small open-label studies. More recently,

intrapyloric injection of botulinum toxin has been

successfully trialled in small group of patients.

“While traditionally more invasive surgical in-

terventions [pyloro-myotomies, gastro-jejunos-

tomies] have been used to treat gastroparesis,

transpyloric stents have been trialled in selected

cases. Symptom control appears successful,

but there is questionable effect with regard to

other outcome parameters,” said Holtmann.

For refractory patients who have failed other

measures, a gastrectomy may be the only op-

tion.

JANUARY 2015 DRUG PROFILE 32

MAS064D: A new non-steroidal topical treatment for mild-to-moderate seborrheic dermatitisSeborrheic dermatitis is a condition that affects approximately 1-3 percent of healthy

adults, occurring more frequently in men than women. A number of mainstream

medications typically used for seborrheic dermatitis include antifungals, topical

corticosteroids and keratolytics. Antihistamines may also be used to relieve itching.

MAS064D (SEBCLAIR® Cream, Sinclair Pharmaceuticals) is a topical seborrheic

dermatitis treatment approved in the European Union (EU) and the United States.

Ee Lyn Tan, PhD

Seborrheic dermatitisSeborrheic dermatitis (SD) is a common,

chronic and recurrent inflammatory derma-

tological condition typically characterized by

erythema, scaling and itchiness. [Clin Derma-tol 2013;31:343-351] Typically, SD involves the

areas with a high density of sebaceous glands.

The scalp, face, upper chest, shoulders, flexures

and pubis are often involved. [J Eur Acad Der-matol Venereol 2008;22:290-296] In infants, SD

typically occurs on the scalp (referred to as cra-

dle cap) causing a thick, yellowish ‘crust’ along

the hairline. Infant SD is usually self-limiting and

treatments are seldom required. However, SD in

adults can last from weeks to years and topical

treatments are often required.

SD is more common and more severe in im-

munocompromised patients, particularly patients

infected with the human immunodeficiency virus

(HIV). [N Engl J Med 2009;360:387-396] Lipo-

philic yeasts of the Malassezia genus, as well as

genetic, environmental and general health factors

contribute to this disorder. [Am Fam Physician

2000;61:2703-2710, 2713-2714]

Although SD is frequently seen in clinical

practice, much controversy remains regarding

its pathogenesis. Much of this controversy may

be related to its classification in a spectrum of

cutaneous conditions from dermatitis, fungal

Table 1: Constituents of MAS064D cream and their mechanisms of action

Ingredients Concentra-tion (%) Activity

Active ingredients

Isohexadecane 8 Emollient

Shea butter 6 Emollient

Bisabolol 1.2 Anti-inflammatory

Piroctone olamine 1 Antimycotic

Alglycera 1 Anti-inflammatory & keratolytic

Vitamin E 1 Anti-inflammatory & antioxidant

Allatoin 0.35 Keratolytic

V. vinifera 0.1 Antioxidant

Telmesteine 0.01 Anti-inflammatory & antioxidant

Vehicle

Aqua Moisturizer

Ethylhexylpalmitate Emollient

Isohexadecane Emollient

Cera alba Emollient

Butylene glycol Moisturizer

Propyl gallate Antioxidant

Adapted from J Eur Acad Dermatol Venereol 2008;22:290-296


infection and inflammatory disease. [Clin Der-matol 2013;31:343-351] For this reason, a va-

riety of treatments from topical corticosteroids

to topical antifungals and antimicrobials have

been used.

Treatment and managementSD is characterized by the cycle of remission

and flare. Treatment and management strate-

gies aim to relieve acute symptoms and provide

long-term prophylaxis to decrease the frequen-

cy and severity of recurrences. [Clin Dermatol 2009;27:S48-53]

Regular skin cleansing to remove oils from

sebaceous areas can improve the symptoms

of SD. Outdoor recreation will also improve

seborrhea, although sunscreen should be

used to avoid sun damage. [Am Fam Physician

2000;61:2703-2710, 2713-2704]

Pharmacological treatments for SD include

antifungal preparations that decrease coloniza-

tion with Malassezia spp. yeast (eg, selenium

sulfide, azole agents, topical terbinafine) and

anti-inflammatory agents (eg, topical cortico-

steroids). For severe SD, keratolytics such as

salicylic acid or coal tar preparations may be

used in conjunction with topical corticosteroids.

Scales can be removed by applying any of a va-

riety of oils (eg, peanut, olive or mineral). Over-

night application softens the scale and coal tar

shampoo may be used subsequently.

In patients with refractory disease, sebosup-

pressive agents such as isotretinoin may be

used as a last resort to reduce sebaceous gland

activity. [Am Fam Physician 2000;61:2703-2710,

2713-2704]

MAS064D (Sebclair® Cream)Indicated for the management of itching,

burning, scaling and pain associated with SD,

MAS064D cream is a steroid- and immunomod-

ulator-free topical treatment containing multiple

active ingredients (Table 1). [J Eur Acad Derma-tol Venereol 2008;22:290-296]

EfficacyMAS064D demonstrated good antifungal ac-

tivity in animal studies. Using guinea pigs infect-

ed with Malassezia furfur, MAS064D was tested

against ciclopirox olamine 0.77 percent cream

and a control group (no treatment). Erythema

and edema were not visually observed in any

of the infected animals at the end of the study.

In the animals treated with MAS064D and ci-

clopirox, Malassezia furfur counts were reduced

to below the limit of quantitation. [Clin Dermatol 2009;27:S41-43]

A multinational pilot study was conducted to

evaluate the efficacy and safety of MAS064D in

the treatment of mild-to-moderate facial SD. In

this randomized, double-blind, controlled study,

60 patients with SD were randomized to receive

either MAS064D (n=40) or a matching vehicle

(control; n=20). After 4 weeks, results showed

a higher percentage of treatment success (ac-

cording to investigators’ global assessment) in

the MAS064D than the control group (68 versus

11 percent, p<0.0001). The effects of MAS064D

were also significantly better than those of the

control vehicle for investigator-assessed erythe-

ma and scaling, and patient-assessed pruritus

and global response to MAS064D (p≤0.01). [J Eur Acad Dermatol Venereol 2008;22:290-296]


An open label, single-center, bilateral pi-

lot study assessed the antifungal activity of

MAS064D cream against Malassezia spp, which

is commonly associated with SD. Only 10 healthy

volunteers were involved in this pilot study. The

study found that MAS064D reduced the number

of Malassezia spp colony-forming units (94 ver-

sus 49 percent on treated and untreated areas,

respectively; p=0.03). This pilot study shows the

nonsteroidal topical cream has antifungal activi-

ties. [Clin Dermatol 2009;27:S44-47]

In another investigator-blinded, randomized,

parallel-group, multicentre pilot study conducted

to compare the safety and efficacy of MAS064D

and desonide 0.05 percent cream for the treat-

ment of mild-to-moderate SD of the face, 77

patients were randomized to receive either

MAS064D or desonide cream for up to 28 days.

This study showed that both treatments were

as effective in reducing disease severity, with

approximately 90 percent of participants clear-

ing or almost clear during the study. Both treat-

ments demonstrated significant reductions in

erythema, scaling, and pruritus (p<0.0001). Fur-

ther, patients treated with MAS064D who cleared

after 14 days of treatment were more likely to

remain clear than those using desonide cream

(p=0.0173). [Clin Dermatol 2009;27:S48-53]

SafetyMAS064D topical cream is generally well tol-

erated.

In the Veraldi pilot study, a 7-day course of

desonide 0.05 percent cream was available

for patients who experienced a flare during

the study period. None of the patients in the

MAS064D group required rescue medication

(versus 2 in the control group). In total, four pa-

tients (two each in the MAS064D and control

groups, respectively) reported a total of six mild

adverse events. [J Eur Acad Dermatol Venereol 2008;22:290-296]

Further, nine out of 10 participants of the

Elewski study rated the safety of MAS064D as

‘excellent.’ [Clin Dermatol 2009;27:S48-53]

DosingMAS064D cream should be applied three times

a day to the areas of the skin affected by SD.

Summary and conclusions

SD is a chronic, relapsing inflammatory der-

matological condition commonly encountered in

clinical practice. Multiple factors may contribute to

the etiology of SD, but it appears to be an interplay

between sebaceous activity, presence of Malasse-

zia spp and immune status. [J Eur Acad Dermatol Venereol 2008;22:290-296] Topical and oral anti-

fungals, topical corticosteroids and immunomod-

ulating agents are cornerstones of SD treatments.

However, there are safety concerns with many of

these primary treatment options for SD.

MAS064D cream is a novel prescription non-

steroidal medical device approved by the US

Food and Drug Administration and for use in the

EU. The cream has antifungal and anti-inflamma-

tory actions. Emollients are important to relieve dry

skin and facilitate healing. The efficacy and safety

of MAS064D has been shown through animal tri-

als and randomized controlled studies.

This new treatment option is another addition

to the pharmaceutical armamentarium for patients

with mild-to-moderate SD.

JANUARY 2015 CALENDAR 35

J A N U A R Y

International Conference on Infectious and Tropical Diseases 16/1/2015 to 18/1/2015 Phnom Penh, Cambodia Info: Govt. Gandhi Memorial Science College Email: [email protected] Website: http://10times.com/ictid

9th Asia Pacific Conference on Clinical Nutrition (APCCN) 26/1/2015 to 29/1/2015Kuala Lumpur, MalaysiaInfo: Congress Secretariat Tel: (603) 2162 0566 Fax: (603) 2161 6560 Email: [email protected] Website: www.apccn2015.org.my

U P C O M I N G

14th World Congress on Public Health 11/2/2015 to 15/2/2015 Kolkata, India Phone: (91) 124 463 6713Email: [email protected] Website: www.14wcph.org

24th Conference of the Asian Pacific Association for the Study of the Liver (APASL)12/3/2015 to 15/3/2015Istanbul, TurkeyInfo: APASL SecretariatTel: (90) 312 440 50 11Fax: (90) 312 441 45 63Email: [email protected]: www.apasl2015.org

World Congress of Nephrology (WCN) 201513/3/2015 to 17/3/2015Cape Town, South AfricaInfo: International Society of NephrologyTel: (32) 2 808 71 81Fax: (32) 2 808 4454Email: [email protected]: www.wcn2015.org

64th Annual Scientific Session of the American College of Cardiology (ACC)14/3/2015 to 16/3/2015San Diego, California, USInfo: ACC Registration and Housing CenterTel: (1) 703 449 6418Email: [email protected]: http://accscientificsession.cardiosource.org/ACC.aspx

6th Association of Southeast Asian Pain Societies (ASEAPS) Congress15/3/2015 to 17/3/2015Manila, PhilippinesInfo: ASEAPS SecretariatTel: (65) 6292 0732Fax: (65) 6292 4721Email: [email protected] Website: www.aseaps2015.org

16th World Congress on Human Reproduction 18/3/2015 to 21/3/2015Berlin, GermanyInfo: Biomedical Technologies srlTel: (39) 070340293Fax: (39) 070307727Email: [email protected]: www.humanrep2015.com

4th Global Congress for Consensus in Pediatrics and Child Health (CIP)19/3/2015 to 22/3/2015Marrakech, MoroccoInfo: Paragon GroupTel: (41) 22 5330948Fax: (41) 22 5802953Email: [email protected]: http://2015.cipediatrics.org/marrakesh/

World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (WCO-IOF)26/3/2015 to 29/3/2015Milan, ItalyInfo: Yolande Piette CommunicationTel: (32) 0 4 254 1225 Fax: (32) 0 4 254 1290 Email: [email protected]: www.wco-iof-esceo.or

7th Asian Oncology Summit10/4/2015 to 12/4/2015Shanghai, ChinaInfo: Elsevier ConferencesEmail: [email protected]: http://asianoncologysummit.com

Royal College of Obstetricians & Gynaecologists (RCOG) World Congress12/4/2015 to 15/4/2015Brisbane, AustraliaInfo: RCOG World Congress 2015, Joint RCOG / RANZCOG Event OfficeTel: (61) 3 9645 6311Fax: (61) 3 9645 6322Email: [email protected]: www.rcog2015.com

30th International Conference of Alzheimer’s Disease International (ADI)15/4/2015 to 18/4/2015Perth, AustraliaInfo: ADITel: (44) 845 1800 169Fax: (44) 1730 715 291Email: [email protected]: www.alzint.org/2015

25th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID)25/4/2015 to 28/4/2015Copenhagen, DenmarkInfo: Kenes International – RegistrationTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected] Website: www.eccmid.org

20th Asian Pacific Society of Cardiology (APSC) Congress29/4/2015 to 2/5/2015Abu Dhabi, UAE Info: APSC 2015 Organizing CommitteeEmail: [email protected]: www.apsc2015.com

JANUARY 2015 HUMOR 36

“Yes Doctor Manolete, you’re right.

It’s probably the full moon!”

“Have you been putting on weight?”

“As far as l know he didn’t die of anything. He was a

hypochondriac!”

“Any previous experience?”

“There’s nothing wrong in trying to blend in, but why must you always mimic the behavior of

others?”

“I finally received your test results dear, but before l let you read it,

l would like you to sign something for me!”

“With medical students, the only way for them to learn, is to let them make their own mistakes! ”

P U B L I S H E R

Ben Yeo

M A N A G I N G E D I T O R

Greg Town

C O N T R I B U T I N G E D I T O R S

Christina Lau, Jackey Suen, Jenny Ng (Hong Kong), Saras Ramiya, Pank Jit Sin, Joslyn Ngu Kathlin Ambrose (Malaysia), Dr Mel Beluan (Philippines), Radha Chitale, Elvira Manzano, Chuah Su Ping (Singapore)

P U B L I C A T I O N M A N A G E R

Marisa Lam

D E S I G N E R S

Razli Rahman, Anson Suen, Joseph Nacpil, Agnes Chieng, Ryan R.A. Baranda, Sam Shum

P R O D U C T I O N

Edwin Yu, Ho Wai Hung, Jasmine Chay

C I R C U L A T I O N E X E C U T I V E

Christine Chok

A C C O U N T I N G M A N A G E R

Minty Kwan

A D V E R T I S I N G C O - O R D I N A T O R

Jasmine Chay

P U B L I S H E D B Y

MIMS (Hong Kong) Limited 27th Floor, OTB Building, 160 Gloucester Road, Wanchai, Hong Kong Tel: (852) 2559 5888 Fax: (852) 2559 6910 Email: [email protected]

A D V E R T I S I N G E N Q U I R I E S :

C H I N A

Yang Xuan Tel: (8621) 6157 3888 Email: [email protected]

H O N G K O N G

Kristina Lo-Kurtz, Miranda Wong, Marisa Lam, Jacqueline Cheung Tel: (852) 2559 5888 Email: [email protected]

I N D I A

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K O R E A

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M A L A Y S I A

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P H I L I P P I N E S

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S I N G A P O R E

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T H A I L A N D

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Medical Tribune is published 12 times a year (23 times in Malaysia) by MIMS Pte Ltd. Medical Tribune is on controlled circulation publication to medical practitioners in Asia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Views expressed are not necessarily those of MIMS Pte Ltd. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

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ISSN 1608-5086

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