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NEWS & INSIGHTS MALAYSIA

MALAYSIA • 15-31
• 1-15 APR MAY
2015 2017

Triple combo in single inhaler bests


tiotropium alone in COPD

MALAYSIA FOCUS MALAYSIA FOCUS


Heart failure on the BP Healthcare joins
rise, more awareness hands with Microsoft
needed to expand Doctor2U
services

CONFERENCE IN PRACTICE
Self-expanding TAVR Managing Helicobacter
noninferior to SAVR in pylori infection in
intermediate-risk AS primary care
15-31 MAY 2017 • 2

Triple combo in single inhaler bests


tiotropium alone in COPD
PEARL TOH national, active-controlled trial enrolled 2,691
COPD patients aged ≥40 years with postbron-

A n extrafine fixed triple therapy, compris- chodilator FEV1 <50 percent, ≥1 moderate-to-
ing the long-acting muscarinic antagonist severe COPD in the past 1 year, and a CAT**
(LAMA) glycopyrronium bromide (GB), the score ≥10. After a run-in period of receiving
long-acting β2-agonist (LABA) formoterol fuma- once-daily 18 µg tiotropium for 2 weeks, the
rate (FF), and the inhaled corticosteroid (ICS) patients were randomized at a 2:2:1 ratio to re-
beclometasone dipropionate (BDP), is supe- ceive either 18 µg tiotropium once daily, 100
rior to the LAMA tiotropium alone in reducing μg BDP/6 μg FF/12.5 μg GB (fixed triple) twice
exacerbations and improving lung function in daily in a single inhaler, or a free combination
patients with symptomatic chronic obstructive of 100 μg BDP/6 μg FF twice daily in one inhal-
pulmonary disease (COPD), according to the er plus 18 μg tiotropium once daily in another
TRINITY* trial. inhaler (open triple) for 52 weeks.
Compared with tiotropium alone, patients Similarly, the open triple group showed
receiving fixed triple therapy had a 20% re- significant reduction in moderate-to-severe
duced rate of moderate-to-severe exacerba- exacerbation rates (RR, 0.79; p=0.0095) and
tions (0.57 vs 0.46 per patient per year, ad- improvement in pre-dose FEV1 from baseline
justed rate ratio [RR], 0.80; p=0.0025). [Lancet (p<0.001) compared with the tiotropium group.
2017;doi:10.1016/S0140-6736(17)30188-5] Compared with open triple therapy, fixed
Furthermore, fixed triple therapy was superi- triple therapy was non-inferior in improving
or to tiotropium in improving lung function, with pre-dose FEV1 from baseline (adjusted mean
an additional improvement of 0.061 L in pre- difference, -0.003 L; p=0.85), which was con-
dose forced expiratory volume in 1 s (FEV1) firmed in per-protocol analysis.
from baseline in the triple therapy group over Subgroup analysis revealed that the reduc-
the tiotropium group at week 52 (pre-dose tion in exacerbation rates with the two triple
FEV1, 0.082 vs 0.021 L; p<0.0001). therapies was greater in patients with higher
“This consistent improvement in different eosinophil concentrations (by eosinophil count
disease domains suggests that stepping up a of ≥2%: RR, 0.70 for fixed triple and 0.69 for
patient from LAMA to triple therapy will have open triple, vs tiotropium or by eosinophil
a clinically meaningful impact,” said the re- count of ≥0.2×109 cells/L: RR, 0.64 for fixed
searchers. triple and 0.62 for open triple, vs tiotropium).
The double-blind, double-dummy, multi- There were no new safety signals, with simi-
15-31 MAY 2017 • 3

lar adverse event rates (55%, 58%, and 58% for


fixed triple, tiotropium, and open triple, respec-
tively) and pneumonia incidence (2% vs 1% vs
2%).
The researchers acknowledged the low
exacerbation rate as a major limitation, which
they attributed to improved care with regular
clinic visits during the interventional trial.
However, the limitation posed major impli-
cation for clinical practice, according to Drs tients currently defined as GOLD severity B (ie,
Leonardo Fabbri, Sara Roversi, and Bianca highly symptomatic but at low risk of exacerba-
Beghé of University of Modena Reggio Emilia tions, for whom current guidelines recommend
in Modena, Italy, who wrote in a separate com- LABA alone or in combination [with LAMA but
mentary that “[the] study provides [no] support not ICS],” they added. “In our view, this recom-
for the current recommendation of triple LABA/ mendation will have to be revisited in the 2018
LAMA/ICS therapy for patients with GOLD*** edition of GOLD.”
severity D, because only about 20% of the pa-
tients examined had had at least two exacerba- *TRINITY: Efficacy of fixed combination of be
tions or more than one hospitalization.” [Lan- clometasone+formoterol+glycopyrrolate in
cet 2017;doi:10.1016/S0140-6736(17)30567-6] chronic obstructive pulmonary disease **CAT:
“On the other hand, the [study provides] COPD Assessment Test ***GOLD: Global ini-
evidence for the efficacy of triple therapy in pa- tiative for chronic Obstructive Lung Disease
MD 1_3 CCM Pharma Corporate_Jan18.pdf 1 18/01/2017 9:39 AM
15-31 MAY 2017 • WO R L D A S T H M A DAY • 4

Low inhaler compliance in


secondary school children despite
poor asthma control
PEARL TOH scribed with an inhaled corticosteroid (ICS)
inhaler with or without long-acting β2-agonists

A lmost half of secondary school children


who had been diagnosed with asthma
had suboptimal asthma control, yet over half
(LABA), more than half (56.4%) reported not
using the inhaler according to prescription
“at least some of the time”, 19.2% did not use
of those surveyed did not use their inhalers as “most of the time”, and 9.5% “all of the time”.
prescribed, a recent study finds. The most common reason for noncompli-
“Young teenagers don’t always fully appreci- ance to ICS±LABA inhaler was “forgetfulness”,
ate the long-term consequences of not taking claiming “it was sometimes difficult to remem-
their medicine, and often reject medication be- ber to take their [inhalers] due to distractions
cause they want to be seen as normal like their including getting ready for school in the morn-
peers,” said Dr. Michael Lim, a consultant of the ings, homework, and extracurricular activities.”
Division of Paediatric Pulmonary and Sleep in Also, 41.7% of the students did not know
National University Hospital, Singapore, who is what an ICS±LABA inhaler was for, giving a
unaffiliated with the study. wrong answer for a multiple-choice question on
Among 689 asthmatic students in London, the inhaler. Over one third (42.4%) of students
342 (49.6%) reported suboptimal asthma con- with suboptimal control perceived their asthma
trol, defined as scoring ≤19 out of a maximum to be “well/completely controlled”.
of 25 in an asthma control test (ACT), while 39 Compared with those who had optimal
(5.7%) reported consistent condition without asthma control, more students with suboptimal
asthma symptoms (ACT score of 25). [J Asthma control felt “somewhat/hardly/not at all comfort-
2017;doi:10.1080/02770903.2017.1299757] able” using their SABA inhalers at school (29.1
Of the 528 students who needed a short- vs 52.7%; p<0.01) and forgot their ICS±LABA
acting β2-agonist (SABA) inhaler at school, inhaler (55.5 vs 57.0%; p<0.01).
224 (42.4%) claimed that they felt “somewhat/ Similarly in Singapore, only about a quarter
hardly/not at all comfortable” using their inhal- of patients were fully compliant to their asthma
ers at school. Almost one third of them (29.2%) therapy in a small survey of adolescent patients,
reported not using an inhaler even when they according to Lim, who observed that the rea-
needed it, “at least some of the time”. sons behind noncompliance among Singapore
For the 390 students who had been pre- adolescents include forgetfulness, perceived
15-31 MAY 2017 • WO R L D A S T H M A DAY • 5

wellness, and inconvenience.


“Ongoing patient education is important
about the long-term consequences of poor
asthma control, [including an] increased risk of
difficult-to-treat asthma when older, and a poor-
er quality of life and increased risk of severe
asthma attacks when older,” said Lim.
“Having a good doctor-patient relationship
reduces the chances of patients defaulting on
their clinic appointments. We maintain a so-
called ‘high-risk’ register of patients who have
bad asthma control, and actively get in touch
with the child and family whenever a clinic ap- compliance, and medications requiring fewer
pointment is missed,” he added, suggesting dosing may help increase patient’s compli-
that having an asthma diary can help monitor ance.
15-31 MAY 2017 • M E D I C A L B R I E F S • 6

Malaysia named destination of the year for medical


tourism

O ur country bags the title ‘Destination of


the Year’ for the 3rd consecutive year at
the International Medical Travel Journal (IMTJ)
Awards 2017, which was held in conjunction
with the IMTJ Medical Travel Summit in Croatia.
The criteria for selection was all-round ex-
cellence in promoting inbound medical tour-
ism; verified statistics of yearly growth in medi-
cal tourists served; evidence of high levels of
patient satisfaction and coordinated activities
that delivered an increase in medical tourism. medical or health tourism organizations and
Other recognitions given during the cer- enterprises under its umbrella.
emony included the title ‘Health and Medi- Several local hospitals were also given rec-
cal Tourism Cluster of the Year’ award which ognition. For example, the TMC Fertility Centre
went to the Malaysia Healthcare Travel Council won the title ‘International Fertility Clinic of the
(MHTC). The award was given to recognize the Year’ while Sunway Medical Centre received
efforts by a health or medical tourism cluster or the titles ‘International Hospital of the Year’,
association that showed recommendable qual- ‘Best Marketing Initiative’ and ‘Best Quality Ini-
ities in organizing, managing and stewarding tiative’.
15-31 MAY 2017 • M E D I C A L B R I E F S • 7

Ultrasound for paediatric arm fractures effective

A ssessment of distal forearm injuries in chil-


dren with point-of-care ultrasound (PO-
CUS) provides sufficiently high accuracy and
“Our findings suggest that POCUS is an ac-
curate tool to diagnose distal forearm fractures
in children that is associated with high care-
less pain compared to X-rays, according to a giver satisfaction and low levels of pain,” said
recent study. Dr. Naveen Poonai, lead author and associate
In a cross-sectional study of 169 children professor of paediatrics and internal medicine
aged 4 to 17 years with suspected non-angu- at Western University, Ontario, Canada.
lated distal forearm fractures, POCUS identified Study participants underwent both x-ray and
72 of the 76 patients with ultrasound-diagnosed POCUS assessment; primary outcome was
fractures (sensitivity 94.7%; 95% CI 89.7–99.8), sensitivity between POCUS and x-ray while
and was also associated with a significantly secondary outcomes included self-reported
lower median pain score compared to x-ray: 1 pain using the Faces Pain Scale–Revised,
(0–2) versus 2 (1–3), respectively. (median dif- caregiver satisfaction using a five-item Likert
ference = 0.5; 95% CI = 0.5–1; p<0.001) [Acad scale, and procedure duration.
Emerg Med 2016;doi:10.1111/acem.13146]
15-31 MAY 2017 • M A L AYS I A F O C U S • 9

Heart failure on the rise, more


awareness needed
PANK JIT SIN

H eart failure tends to occur at a much


younger age in Asian populations and is
characterized by more severe clinical symp-
toms corresponding to risk factors such as hy-
pertension, obesity and type 2 diabetes, reveal
experts.
According to Datuk Dr. Aizai Azan Abdul
Rahim, many people are unaware heart failure
is deadlier than some types of cancer in Ma-
laysia. “Malaysians mistakenly think it only af- [Management of Heart Failure CPG 2014] On
fects the older generation, but in fact, the mean top of that, half of the hospitalized heart failure
age of [heart failure in] Asians is strikingly low patients may die within 5 years. In the National
(at 59.6 years). [Heart failure] is an important Heart Institute, about 20% of non-elective ad-
cause of hospitalization, accounting for about missions are due to heart failure, noted Aizai.
six to 10% of all acute medical admissions in
Malaysia,” noted Aizai, who is chief clinical of- Heart failure more severe in Southeast Asia
ficer and senior consultant cardiologist at the Aizai said the disease’s increased prevalence
National Heart Institute Malaysia. [Euro J Heart in comparison with the UK and US was due to
Fail 2003;5(4);569–574, J of Cardiac Failure Southeast Asia’s high prevalence of hyperten-
1999:3(Suppl 1):64] sion, obesity, hyperglycaemia and smoking
Malaysia has the highest heart failure rate in rates. “These adverse lifestyle habits (smoking
the region, at around 6.7%. Singapore, China and unhealthy foods), coupled with physical in-
and Japan’s rates stand at 4.5%, 1.3% and activity particularly in Malaysia, may contribute
less than 1%, respectively. [ESC Heart Fail- to the high premature mortality from cardiovas-
ure 2014;1:4–25]Taking into consideration that cular diseases.”
more than 3 million hospital admissions are re- Through efforts such as media workshops,
corded each year, the number of heart failure Aizai hopes the awareness about heart fail-
patients can be as high as 300,000 per year. To ure will improve, subsequently resulting in im-
complicate matters further, up to 25% of these proved understanding, better disease recogni-
patients are re-hospitalized within 30 days. tion and management.
15-31 MAY 2017 • M A L AYS I A F O C U S • 10

Agreeing with Aizai, Dr. Carsten Tschöpe, or being unfit rather than being associated with
professor of Medicine and Cardiology, vice-di- the heart. Better recognition and understand-
rector of the Department of Cardiology, Chari- ing of the symptoms would prompt people to
té, CVK, Universitaetsmedizin, Berlin, Germany seek treatment at an earlier stage, leading to
said: “Serious misconceptions and knowledge more accurate diagnosis, decreasing the risk
gaps exist around heart failure and consequent- of hospitalization and improving survival rates.”
ly, a large number of premature deaths still When asked about the role GPs in the fight
occur. Heart failure has a crippling impact on against heart failure, Aizai said it was important
patients’ lives, as often they are not equipped for them to maintain a high index of suspicion
with the knowledge of the disease and proper when a patient comes to them with any of the
management of the condition. The most com- symptoms of early heart failure. He said they
mon symptoms—breathlessness, fatigue and are the gatekeepers and have an important role
swollen ankles—which can vary from person to to play to catch them early and prevent further
person, are often mistaken as signs of aging damage to their patients’ hearts.
A M I LE S T O N E I N C E L E B R EX ® H I S TORY

A landmark randomized controlled


trial to prospectively examine the
cardiovascular (CV) safety of CELEBREX®
in arthritis patients with, or at increased
risk for CV disease.1
ION
PRECIS

STUDY DESIGN T
INDEPENDEN
Randomization 1:1:1
Minimum follow-up
A randomized, double-blind, 18 months 1
GOVERNA
NC E

parallel-group study evaluating


CV preventive management INDEPENDENT
the CV safety of CELEBREX® vs. At baseline, approximately 46% of
prescription strength naproxen EXECUTIVE COMMITTEE
patients were taking low-dose aspirin PRECISION was governed by an
and ibuprofen in 24,081 subjects (≤325 mg/day) for cardioprotection1
executive committee composed
with osteoarthritis or rheumatoid Gastroprotection of cardiology, gastroenterology,
arthritis who required daily NSAID All patients received daily open-label treat- and rheumatology specialists.2
treatment to maintain their quality CELEBREX ®
Naproxen Ibuprofen ment with the proton pump
of life.1,2 100-200 mg BID 375-500 mg BID 600-800 mg TID inhibitor esomeprazole1 MEASURES TO ENSURE
ACADEMIC INTEGRITY
Members of the executive committee
agreed to not accept honoraria,
consulting fees, or other
CV SAFETY: CELEBREX® SHOWED SIMILAR INCIDENCE OF CV EVENTS compensation related to NSAIDs
PRIMARY ENDPOINT COMPARED TO NAPROXEN AND IBUPROFEN.1 during the course of the trial.2
Time to APTC event, intent-to-treat population Time to APTC event, on-treatment population All safety endpoints have been
First occurrence of the Antiplatelet independently
Time to serious adjudicated.
GI event, intent-to-treat population
2

Trialists Collaboration (APTC) 4


CELEBREX® vs. ibuprofen
HR (95% CI)
0.85 (0.70-1.04)
NI
p<0.001
4
CELEBREX® vs. ibuprofen
HR (95% CI)
0.81 (0.65-1.02)
NI
p<0.001
endpoint, which is a composite of:1 CELEBREX® vs. naproxen 0.93 (0.76-1.13) p<0.001 CELEBREX® vs. naproxen 0.90 (0.71-1.15) p<0.001 1.5 10 YEARSHR (95% CI)IN THE MAKING
CELEBREX® vs. ibuprofen
0.65 (0.50-0.85) p=0.002
Ibuprofen vs. naproxen 1.08 (0.90-1.31) p=0.02 Ibuprofen vs. naproxen 1.12 (0.89-1.40) p=0.025
PRECISION broadens our understanding
Patients with event (%)

• Death from cardiovascular causes, 3 3 CELEBREX® vs. naproxen


0.71 (0.54-0.93)
Ibuprofen vs. naproxen
p=0.01
1.08 (0.85-1.39) p=0.53
of the risks associated with the use of

Patients with event (%)


including hemorrhagic death 1.0
three commonly prescribed NSAIDs in
• Nonfatal myocardial infarction 2 2
arthritis patients with, or at increased
• Nonfatal stroke CELEBREX® CELEBREX® risk for CV disease.1,2
1 1 0.5
Naproxen Naproxen
Ibuprofen Ibuprofen
FUNDED BY PFIZER CELEBREX
®

Naproxen
0
0 6 12 18 24 30
0
0 6 12 18 24 30 36 42 Committed to improvingIbuprofen
patients’ lives.
0
Months since randomization Months since randomization 0 6Renowned
12 for innovation
18 24 and integrity.
30
Months since randomization

HR: hazard ratio; NI: non-inferiority Adapted from Nissen SE, et al.
Adapted from Nissen SE, et al.

GASTROINTESTINAL (GI) CELEBREX® SHOWED A SIGNIFICANTLY RENAL SAFETY: CELEBREX® SHOWED A SIGNIFICANTLY
SAFETY: COMPOSITE OF LOWER INCIDENCE OF SERIOUS GI TERTIARY ENDPOINT LOWER INCIDENCE OF RENAL EVENTS VS.
SECONDARY + TERTIARY EVENTS VS. NAPROXEN AND IBUPROFEN.1 Occurrence of clinically IBUPROFEN AND A SIMILAR INCIDENCE
ENDPOINTS significant renal events, TO NAPROXEN.1
Occurrence of serious GI events, Time to serious GI event, intent-to-treat population defined as development Time to renal event, intent-to-treat population
which is a composite of clinically of any of the following:1
1.5 HR (95% CI) 1.5 HR (95% CI)
significant iron deficiency anemia CELEBREX® vs. ibuprofen
CELEBREX® vs. naproxen
0.65 (0.50-0.85) p=0.002
0.71 (0.54-0.93) p=0.01
• Verified serum creatinine CELEBREX® vs. ibuprofen
CELEBREX® vs. naproxen
0.61 (0.44-0.85) p=0.004
0.79 (0.56-1.12) p=0.19
of GI origin and clinically significant Ibuprofen vs. naproxen 1.08 (0.85-1.39) p=0.53 level of ≥2.0 mg/dL and Ibuprofen vs. naproxen 1.29 (0.95-1.76) p=0.10
Patients with event (%)

Patients with event (%)

GI events, which includes:1 1.0 an increase of verified 1.0

• Symptomatic gastric serum creatinine level


or duodenal ulcer of ≥0.7 mg/dL from
0.5 baseline 0.5
• Gastroduodenal, small-bowel CELEBREX®
or large-bowel perforation
CELEBREX®
Naproxen
• Hospitalization for Naproxen

or hemorrhage Ibuprofen acute renal failure Ibuprofen


0 0
• Gastric outlet obstruction
0 6 12 18 24 30 • Initiation of hemodialysis 0 6 12 18 24 30
Months since randomization or peritoneal dialysis Months since randomization
• Acute GI hemorrhage of
unknown origin Adapted from Nissen SE, et al. Adapted from Nissen SE, et al.

CELEBREX® is now the only COX-2 selective NSAID to demonstrate similar


CV safety to naproxen and ibuprofen with significantly fewer serious GI events.1 Time to renal event, intent-to-treat population

1.5 HR (95% CI)


CELEBREX® vs. ibuprofen 0.61 (0.44-0.85) p=0.004
CELEBREX® vs. naproxen 0.79 (0.56-1.12) p=0.19
Abbreviated Prescribing Information1 Ibuprofen vs. naproxen 1.29 (0.95-1.76) p=0.10
Patients with event (%)

Composition: Celecoxib. Indications: For the management of acute pain in adults and for the treatment of primary dysmenorrhea. Relief of the acute and chronic pain and inflammation of rheumatoid arthritis and osteoartritis. Relief of signs and symptoms of ankylosing spondylitis. Management of low back pain (100mg and 200mg only) Recommended dosage: Management of
acute pain and for the treatment of primary dysmenorrhea. The recommended dose of Celecoxib1.0 is 400mg, initially,followed by an additional 200mg dose, if needed on the first day. On subsequent days, the recommended dose is 200mg twice daily, as needed. Ankylosing Spondylitis: 200mg to 400mg daily. Osteoarthritis - 200mg once daily. Rheumatoid arthritis - 200mg twice daily.
Low Back Pain (LBP): Usual dosage for adults is 100mg of Celecoxib orally twice daily, morning and evening after meal, or 200mg once daily. Use in the elderly: No dosage adjustment is necessary. However, for elderly patients with a lower than average body weight (<50kg), it is advisable to initiate therapy at the lowest recommended dose. Patients with severe hepatic impairment
have not been studied (Child-Pugh Class C). There is no clinical experience in severe liver impairment. No dosage adjustment is necessary in patients with mild or moderate renal impairment. There is no clinical experience in patients with severe renal impairment. Contraindications: Hypersensitivity to any ingredient of the product; known sulfonamide hypersensitivity, Patients who
have experienced asthma, urticaria or allergic-type reactions after taking ASA or other NSAIDs, including other COX-2, peri-operative from CABG surgery, established cardiovascular disease (ischaemic heart disease and stroke). Special warnings and precautions for use: Risk of GI ulceration, bleeding and perforation with NSAIDs. The lowest effective dose should be used for the
shortest duration possible. Cardiovascular effect: May increase risk of serious cardiovascular thrombotic events, myocardial infarction and stroke. The lowest effective dose should be used for the shortest duration possible. May lead to the onset of new hypertension or worsening of pre-existing hypertension and should be used with caution in patients with hypertension and monitor
BP closely. Used with caution in patients with compromised cardiac function, pre-existing edema, or other conditions predisposing to, or worsened by, fluid retention including those taking diuretic treatment or otherwise at risk of hypovolemia. Renal: Caution should be used in dehydrated patients. It is advisable to rehydrate patients before starting Celecoxib. Renal function should be
closely monitored in patients with advanced renal disease who are administered Celecoxib. 0.5Anaphylactoid Reactions refer to contraindication. Celecoxib should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity. Hepatic: In liver dysfunction, patients on Celecoxib should be monitored for evidence of a hepatic reaction. Celecoxib
should be used with caution when treating patients with moderate hepatic impairment (Child-Pugh Class B), and initiated at half the recommended dose. Patients with severe hepatic impairment (Child-Pugh Class C) have not been studied and Celecoxib is not recommended. Patient with symptoms and/or signs of liver dysfunction, or in whom an abnormal liver function test has
occurred, should be monitored carefully for evidence of the development of a more severe hepatic reaction while on therapy with Celecoxib. Anticoagulation/INR CELEBREX ®
should be monitored in patients taking a warfarin/coumarin-type anticoagulant after initiating treatment with Celecoxib or changing the dose. The concomitant use of Celecoxib and a non-aspirin NSAID should be avoided.
Common side effects: Bronchitis, sinusitis, upper respiratory tract infection, urinary tract infection, ear and fungal infection, insomnia, dizziness, hypertensionNaproxen
(including aggravated hypertension),cough,vomiting,abdominal pain, diarrhoea,dysphagia, irritable bowel syndrome, GERD, nausea, diverticulum, dyspepsia, flatulence, Pruritus (includes pruritus generalized), rash, oedema
Ibuprofen prostatic hyperplasia, blood creatinine increased, prostatic specific antigen increased, weight increased, Formulation and Preparation: 200 mg Capsules-Packs of 10, 30 & 100.400 mg Capsules-Packs of 10.
peripheral edema, myocardial infarction, angina pectoris, dyspnoea,hepatic enzyme increased, muscle spasms, nephrolithiasis, vaginal haemorrhage, prostatitis,benign
API-CELEBREX-0116 0
Reference: 1. Celebrex Malaysia Prescribing Information dated 13 January 2016 0 6 12 18 24 30
Pfizer does not promote the use of Celebrex in patients with established CVD. We believe the study results will enable physicians
sincetorandomization
make better informed decisions based on validated scientific research about treatment options for patients who require long term pain management.
WMACEL0416208 -17/11/2016

Months
NSAIDs: non-steroidal anti-inflammatory drugs

Adapted from Nissen SE, et al.

Pfizer (Malaysia) Sdn Bhd (040131-T) References: 1. Nissen SE, et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med. 2016.
Level 10 & 11, Wisma Averis, Tower 2, Avenue 5, Bangsar South, DOI: 10.1056/NEJMoa1611593. 2. Becker MC, et al. Rationale, design, and governance of Prospective Randomized Evaluation
8 Jalan Kerinchi, 59200 Kuala Lumpur of Celecoxib Integrated Safety versus Ibuprofen Or Naproxen (PRECISION), a cardiovascular end point trial of nonsteroidal
Tel: 603 2281 6000 | Fax: 603-2281 6388 | www.pfizer-malaysia.com antiinflammatory agents in patients with arthritis. Am Heart J. 2009;157(4):606-612.
© 2016 Pfizer Inc. All rights reserved.
02 2017
15-31 MAY 2017 • M A L AYS I A F O C U S • 13

BP Healthcare joins hands with


Microsoft to expand Doctor2U
services
SARAS RAMIYA

T he partnership of BP Healthcare Group


and Microsoft Malaysia is set to improve
the healthcare services provided through the
Doctor2U app.
“Doctor2U is very excited to be launching
this partnership with Microsoft. When Microsoft
first approached us about the partnership idea,
we were really blown away and thrilled about
the opportunity,” said Keegan Flynn, cofound-
er, Doctor2U.
“We’re using Microsoft Azure as WebRTC
(Web Real-Time Communication) service to al-
low our patients to see the real-time location of
the ambulance and have a more reliable ser-
vice,” said Flynn.
In addition, Azure gives the flexibility to ex-
L-R: Alberto Granados (VP of Sales Marketing and
pand regionally and add other services such as Operations for Microsoft APAC), K. Raman, Dato’ Beh
nursing and physiotherapy. Chun Chuan (Chairman, BP Healthcare), Keegan Flynn
and Garvy Beh (CEO, Doctor2U) exchanging the MoU at
“We’re proud because Doctor2U is built on Kuala Lumpur.
Azure—our trusted intelligent cloud-computing live chat feature to improve the quality for our
platform,” said K. Raman, managing director, customers,” said Flynn.
Microsoft Malaysia. Microsoft uses top-notch Doctor2U is a mobile health app that brings
security protocols, which give Doctor2U an a range of healthcare services to the patients’
added layer of trust and reliability. doorsteps. It was first launched in October
“[Additionally] we use Azure as our cloud- 2015 as a doctor house call app. “We have
computing platform for all our app services, da- over 1,000 doctors nationwide and coverage
tabase and storage needs. It also powers our in all major towns and cities throughout Malay-
Chatbot that we recently implemented for our sia. We’re currently offering four core features,
15-31 MAY 2017 • M A L AYS I A F O C U S • 14

which include doctor house calls, free live chat, long-term conditions are bedridden and immo-
video consultation and medication delivery,” bile and it can be extremely time consuming
he said. and costly to transport them to a clinic or hos-
“A big reason that Malaysian users use the pital,” he added.
app is to order on behalf of elderly parents and Flynn, Raman and Beh were speaking at a
grandparents. We saw a huge problem in the media briefing to announce the MoU between
community that these people who often have Microsoft and BP Healthcare.

Novel laparoscopic surgery book


now available
DR. JOSLYN NGU

A n expert has written and published a book


plus multiple videos on laparoscopic sur-
gery in gynaecology and common gynaeco-
logical conditions.
Concerned with the current lack of interest
and driven by the motivation to increase aware-
ness and knowledge on laparoscopic surgery
among the general population and medical fra-
ternity, consultant obstetrician and gynaecolo- There are many exciting advancements in
gist, Dr. S. Selva (Sevellaraja Supermaniam), the field of laparoscopic or keyhole surgery,
decided to try and improve the appeal of lapa- and Selva highlighted two: three-dimensional
roscopic surgery. He rationalized that if he can (3-D) laparoscopy and single incision lapa-
increase the general population’s awareness roscopy. Conventionally, laparoscopic surgery
and knowledge on the procedure, it will trans- was performed using a two-dimensional (2-D)
late into an increased demand from patients monitor. Advancements in the field have now
opting for laparoscopy over laparotomy. Hope- evolved to the use of 3-D, which makes surgery
fully, this will increase the number of doctors safer and less stressful, he said.
utilizing the laparoscopic method for suitable Being both a fertility specialist and a laparo-
surgeries. scopic surgeon, Selva noted that after a suc-
15-31 MAY 2017 • M A L AYS I A F O C U S • 15

cessful keyhole surgery, many patients with book will increase the appeal and practice of
conditions such as fibroid and endometriosis laparoscopy.
managed to conceive spontaneously without The book is divided into three parts: the first
having to undergo in vitro fertilization (IVF). section centres around common gynaecologi-
Even though laparoscopic surgery is an old- cal conditions, the second on procedures that
er technology compared to IVF, it is not as well can be performed via laparoscopy and the third
known as the latter among the general popula- focuses on hysteroscopy and hysteroscopic
tion. This is partly because in IVF, there is some- surgery.
thing—a baby—to show as the final outcome, There are also 62 videos—developed by the
whereas laparoscopic surgery does not have author—which accompanies the book. After
a visible product as its outcome, he explained. reading a chapter, one can easily scan the QR
As for gynaecologists, there is not much incen- codes in the book to access the videos.
tive to pick up laparoscopic surgery as it takes It took Selva 4 years to complete the writing
a long time to train as a laparoscopic surgeon. of the book. He expressed gratitude to a num-
Moreover, the remuneration is not very good; ber of influential people who have played a big
the payment a surgeon receives is the same part in his career and the writing of the book,
regardless if the surgery was done via laparot- particularly his mentor, Dato’ Dr. Alex Mathews,
omy or laparoscopy, Selva explained. for being a major source of motivation and his
It is undeniable that the laparoscopic meth- wife, Sarojini, for her role in making the book
od can be more beneficial to patients for par- an easier read for the lay public who are less fa-
ticular procedures, said Selva. He hopes his miliarwith technical medical terminologies.
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 17

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

Self-expanding TAVR noninferior to


SAVR in intermediate-risk AS
PEARL TOH

T ranscatheter aortic valve replacement


(TAVR) with a self-expanding prosthesis is
noninferior to surgical aortic valve replacement
(SAVR) in terms of death from any cause or dis-
abling stroke at 2 years in intermediate-risk pa-
tients with severe aortic stenosis (AS), accord-
ing to data from the SURTAVI* trial presented at
the ACC.17 Scientific Session held in Washing-
ton, DC, US. Professor Michael Reardon
“We know that in patients that are at high sur- NEJMoa1700456]
gical risk, TAVR with the self-expanding valve is At 24 months, the primary endpoint compris-
superior to surgery,” said lead author Professor ing a composite of disabling stroke or all-cause
Michael Reardon, of the Methodist DeBakey mortality occurred at a lower rate in patients
Heart and Vascular Center in Houston, Texas, who underwent TAVR than SAVR (12.6% vs
US. “What we don’t know yet is the compara- 14.0%), with a posterior probability of noninfe-
tive efficacy as we move down the risk scale to riority of >0.999, which according to Reardon,
lower surgical risk.” corresponds to a one-sided p<0.001.
The prospective multicentre study includ- “TAVR was just as good as surgery, but it was
ed 1,746 patients (mean age 79.8 years) with not statistically superior to it,” said Reardon, at-
symptomatic, severe AS at intermediate surgi- tributing the difficulty to meet superiority to the
cal risk, who were randomized to self-expand- low mortality rate in the surgical group, despite
ing TAVR (n=879) or SAVR (n=867). Patients TAVR having a favourable disabling stroke rate
were stratified by their need for revasculariza- over SAVR at 2 years (2.6% vs 4.5%).
tion in the analysis, unlike the previous PART- The two approaches showed different safety
NER** trial which stratified patients by the ac- and complication profiles, with the TAVR group
cess route of the catheter. [ACC.17, abstract having lower rates of acute kidney injury (stage
LB-16607; N Engl J Med 2017;doi:10.1056/ 2 or 3), atrial fibrillation, transfusion needs, and
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 18

superior quality of life than the SAVR group tin Fuster, who is also the editor-in-chief of the
at 30 days, but higher rates of major vascular Journal of the American College of Cardiology.
complication, residual aortic regurgitation and "While this study further supports the safety
pacemaker implantation, although the need and efficacy of TAVR in intermediate risk pa-
for new pacemaker was not associated with in- tients, demonstration of comparable long term
creased mortality. durability of TAVR compared to SAVR out to 10
In addition, TAVR resulted in significantly im- years and beyond is critical to decision making
proved aortic-valve (AV) haemodynamics with in younger individuals," said Professor Kim Ea-
lower mean gradients and larger AV areas than gle, director of the Frankel Cardiovascular Cen-
SAVR through 24 months follow-up. ter at the University of Michigan in Ann Arbor,
“These are outstanding data,” said Reardon. Michigan, US, who is also the editor-in-chief of
“The guidelines were just updated and for in- ACC.org.
termediate-risk, TAVR is now a 2a, but with this Following the presentation, the FDA has ap-
data it will need updating and [should even get] proved the CoreValve Evolut Pro device used
a class 1 indication.” for TAVR in 16% of the study patients.
Nonetheless, cardiologists should not con-
fuse the favourable results for intermediate-risk *SURTAVI: SUrgical Replacement and Trans-
group as an “OK” to treat patients younger and catheter Aortic Valve Implantation **PARTNER:
earlier in life, cautioned session chair Dr. Valen- Placement of AoRtic TraNscathetER valves
Multidisciplinary Musculoskeletal Ultrasound Congress
on Pain Management (MSK US PM) 2017
19 – 21 May 2017 • Hong Kong
www.miamsk.org

International Faculty
Cadaveric Sonoanatomy Workshop
Professor Rainer Freynhagen (Germany) Dr. Sasikaan Nimmaanrat (Thailand)
Dr. Peter Hebbard (Australia) Dr. Philip Peng (Canada)
Dr. Jackie Ho (Singapore) Dr. Nicholas Romanov (USA)
Dr. Sang-hoon Lee (Korea) Mr. Severin Romanov (USA) Masterclass Hands-on Workshop with
Dr. Philip Lim (Australia) Dr. Maria Dolma Santos (Philippines) Head to Toe Scan on Pathologies
Dr. Sean Lin (Taiwan) Dr. Rajesh Singh (Malaysia)
Dr. James Linklater (Australia) Dr. Carla Stecco (Italy)
Dr. Philippe MaCaire (Dubai) Dr. Suwimon Tangwiwat (Thailand)
Dr. Dong-eon Moon (Korea) Dr. Shibata Yasuyuki (Japan)
Clinical Pearls Sharing
Dr. Samer Narouze (USA) Dr. Alex Yeo (Singapore)

Local Faculty Mixed Pain Cases Discussions


Dr. Lap-ki Chan (Hong Kong) Dr. Gavin Lee (Hong Kong)
Dr. Wing-sang Chan (Hong Kong) Dr. Carina Li (Hong Kong)
Dr. Kwong-yuen Chiu (Hong Kong) Dr. Koon-man Sieh (Hong Kong) MSK Pain Assessment Guidelines
Dr. Carmen Ho (Hong Kong) Dr. Andrew Wai (Hong Kong)
Dr. Tai-pang Ip (Hong Kong) Dr. Carrel Yu (Hong Kong)
Dr. Wing-hon Kwok (Hong Kong) Professor Patrick Yung (Hong Kong) Town Hall Debate on OA Knee
Dr. Sheung-wai Law (Hong Kong)
Many more distinguished speakers to follow…

Congress Venue
Hong Kong Convention and Exhibition Centre
r e gi s te r
n o w!
1 Expo Drive, Wanchai, Hong Kong

Enquiry
Congress Secretariat
MIMS (Hong Kong) Limited Early-bird Registration Deadline 10 April 2017
Tel: (852) 2155 8557 or 2116 4348
E-mail: meeting.hk@mims.com Abstract Submission Deadline 10 April 2017

Cutting edge clinical pearls congress for Anaesthesiologists, Pain / Rehabilitation Physicians,
Surgeons, Rheumatologists, Neurologists, Orthopaedic Surgeons,
Sports Physicians & Allied Health Professionals

Organizer: Supporting Organizations:


15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 21

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

Rivaroxaban trumps aspirin in


reducing VTE recurrence
PEARL TOH

E xtended therapy with rivaroxaban was


more effective than aspirin in reducing
the risk of recurrent venous thromboembolism
(VTE) with no significant increase in bleed-
ing risk, according to data from the EINSTEIN
CHOICE* study presented at the ACC.17 Sci-
entific Session in Washington, DC, US.
"Although extended anticoagulation ther- Dr. Philip Wells
apy prevents recurrent VTE, concerns about Moa1700518]
bleeding often lead to reluctance to continue After following up for a median of 351 days,
treatment beyond 6 to 12 months," said Dr recurrent VTE (symptomatic fatal or nonfatal)
Philip Wells of the University of Ottawa in On- occurred less commonly in rivaroxaban-treat-
tario, Canada. "Our findings show that it’s [a ed patients than aspirin-treated patients (1.5%
safe option] and ... that practitioners can safely and 1.2% respectively for rivaroxaban 20 and
prescribe rivaroxaban for patients at risk for a 10 mg vs 4.4% for aspirin, hazard ratio [HR],
recurrent VTE without being concerned that 0.34 and 0.26 for each respective comparison;
doing so will increase risk for bleeding side ef- p<0.001 for both).
fects.” The secondary efficacy endpoint com-
The multicentre, double-blind, phase III prising a composite of recurrent VTE-related
randomized trial enrolled 3,396 patients (mean deaths or all-cause mortality was also signifi-
age 59, 55% male) with VTE, who had previ- cantly lower with rivaroxaban compared with
ously completed 6–12 months of anticoagu- aspirin (2.1% and 1.3% vs 4.9%; p<0.001).
lant therapy and were uncertain whether to Similarly, the combined rates of recurrent VTE/
continue with longer-term therapy. They were myocardial infarction/systemic embolism/isch-
randomized to receive rivaroxaban (10 or 20 aemic stroke were significantly reduced in pa-
mg once-daily) or aspirin 100 mg for up to 12 tients receiving rivaroxaban than aspirin (2.0%
months. [N Engl J Med 2017;doi:10.1056/NEJ- and 1.9% vs 5.6%; p<0.001).
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 22

There were no significant differences in ma-


jor bleeding rates (0.5% and 0.4%, respectively
for 20 and 10 mg rivaroxaban, vs 0.3% for as-
pirin) and clinically relevant nonmajor bleeding
rates (2.7% and 2.0% vs 1.8%) between the
three groups.
"Rivaroxaban 10 mg once daily provides
an additional option for extended VTE treat-
ment," said Wells, although he noted that pa-
tients requiring full-dose anticoagulant therapy, in other patient populations, and whether
such as rivaroxaban 20 mg, were excluded in treatment should be continued beyond 12
the current study, which was also not powered months require further study, he added.
to detect noninferiority of the 10 mg vs 20 mg
treatment regimen. *EINSTEIN CHOICE: Reduced-dosed rivarox-
Whether low-dose rivaroxaban is as ef- aban in the long-term prevention of recurrent
fective as the established therapeutic dose symptomatic venous thromboembolism
ASIAN PACIFIC
DIGESTIVE WEEK
23 – 26 SEP TEMBER 20 1 7
H O N G KO N G

W W W. A P D W 2 0 1 7. O R G

THE FUTURE IN DIGESTIVE DISEASES

Early Bird Registration Deadline: 30 June 2017

PROGRAMME HIGHLIGHTS
• Latest advances and updates on Gastrointestinal, Liver, Endoscopy and Surgery topics
• Young Investigator’s Awards and Travel Grants according to the quality of abstracts will be offered!
• JGHF Marshall & Warren Lecture
• JGHF Okuda Lecture
• JGHF Emerging Leaders Lectures
• IDD Forum Named Lectures & YIA
• Multi-disciplinary Symposia
• Live Endoscopy Demonstrations APDW 2017 SECRETARIAT
MIMS (Hong Kong) Limited
• Debates and Controversies 27/F., OTB Building
160 Gloucester Road
• Pre-congress Symposia / Workshops Wanchai, Hong Kong
• Postgraduate Course Tel: (852) 2155 8557
Fax: (852) 2559 6910
• Nurses Program Email: info@apdw2017.org
MIMS DOCTOR MALAYSIA
REVEALS NEW LOOK!
Promising a more pleasurable reader experience

MIMS Doctor Malaysia Edition Previously a newspaper, the redesign now features a magazine to
is unveiling a new look from its July issue onwards, following represent a progressive path and an innovative approach to
an earlier launch in Singapore and Hong Kong this year. medical publications in Asia, alongside evolving media trends.

The new look is grounded in months of intensive research The new look incorporates design as well as content updates,
and development, which delivered a clear understanding and, whilst innovative and moving with the HCPs’ need for
of today’s discerning physicians and their expectations change, remains very true to the MIMS brand.
of a medical magazine.

Since its launch in 1983, MIMS Doctor has grown to be a


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and credibility in the medical community.

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15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 25

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

No adverse cognitive effects with


evolocumab added to statins in
EBBINGHAUS trial
ELVIRA MANZANO

A dding the proprotein convertase subtilisin/


kexin type 9 (PCSK9) inhibitor evolocum-
ab to statin therapy to further lower bad cho-
lesterol does not cause memory loss or other
cognitive issues in patients with known cardio-
vascular disease (CVD), the EBBINGHAUS*
trial has shown, giving clinicians some sense
of reassurance.
There were no significant differences be- Dr. Robert Giugliano
tween patients receiving evolocumab and pla- being affected,” said lead investigator Dr. Rob-
cebo on any of the four measures of cognitive ert P. Giugliano, of the Brigham and Women’s
functioning (spatial working memory index of Hospital in Boston, US, who presented the
executive function, spatial working memory findings.
between errors, paired associates learning, There had been some potential signals for
and reaction time), patient questionnaires, or adverse cognitive effects with statins in previ-
physician-reported adverse cognitive events. ous trials, prompting the US Food and Drug
Cognitive function was also similar among Administration to include a safety alert to statin
patients who achieved very low LDL-c levels labeling in 2012. However, analyses from large-
(<25mg/dL) and those with higher LDL-c val- scale randomized controlled trials (RCTs) do
ues (≥40mg/dL). [ACC.2017, abstract 17-LB- not support these findings. In 2014, the Statin
16161-AC] Cognitive Safety Task Force concluded that
“The findings make physicians feel more se- statins are not associated with cognitive side
cure about adding evolocumab to statin ther- effects. [J Clin Lipidol 2014;8(3 Suppl):S5–16]
apy to achieve very low LDL-c levels without The current data from the EBBINGHAUS
worrying about patients’ cognitive functioning trial reinforced the Task Force’s findings.
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 26

EBBINGHAUS was a cognitive study of


1,974 patients with atherosclerotic CVD en-
rolled in the FOURIER Outcomes trial. FOU-
RIER has shown that aside from significantly
lowering LDL-c, evolocumab injections (140
mg every other week or 420 mg monthly) on
top of statins reduced the risk for the compos-
ite primary endpoint of MI, stroke, hospitaliza-
tion for unstable angina or coronary revascular-
ization, and CV death at 22 months vs placebo well below the upper bounds of the noninferior-
(p<0.001). In addition, there was a 20% reduc- ity boundary,” said Giugliano.
tion in the risk for the key secondary endpoint Evidence from EBBINGHAUS and FOURIER
of MI, stroke, or CV death with evolocumab trials suggests that in a secondary-prevention
(p<0.001). [N Engl J Med 2017; doi:10.1056/ population (average age 63) with atheroscle-
NEJMoa1615664] rotic CVD, lowering LDL-c below the current
For EBBINGHAUS, the primary endpoint was targets with evolocumab and a statin does not
a change from baseline on the spatial working adversely affect cognitive function and may
memory strategy index (SWMsi) of executive help improve cardiovascular outcomes
function. Secondary endpoints included work- Whether these benefits persist beyond 2
ing memory, memory function, and psychomo- years is the subject of an ongoing long-term
tor speed, assessed using an electronic tablet. follow-up in a subset of patients in the EBBING-
Mean duration of follow-up was 19.8 months. HAUS trial.
Raw scores on the SWMsi did not differ be-
tween evolocumab and placebo at baseline *EBBINGHAUS: Evaluating PCSK9 Binding
(17.8 for each) or at study end (17.5 vs 17.6, Antibody Influence On Cognitive Health in High
respectively). “The treatment differences were Risk Cardiovascular Risk Subjects
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15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 28

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

Fewer major bleeding events with


dabigatran over warfarin during AF
catheter ablation
ROSHINI CLAIRE ANTHONY

T he use of uninterrupted dabigatran be-


fore, during, and after catheter ablation in
patients with atrial fibrillation (AF) resulted in
fewer major bleeding complications than unin-
terrupted warfarin, according to results of the
RE-CIRCUIT* trial.
“The results of the RE-CIRCUIT study dem-
onstrate that performance of AF ablation on
uninterrupted dabigatran is a better anticoagu- coagulation was initiated 4 to 8 weeks prior to
lation strategy as compared with performance ablation and was continued during and up to 8
of AF ablation on uninterrupted warfarin,” said weeks postprocedure.
lead author Professor Hugh Calkins from Johns There were fewer major bleeding events
Hopkins Hospital, Baltimore, Maryland, US, among patients on uninterrupted dabigatran
who presented the findings at the American compared with uninterrupted warfarin during
College of Cardiology (ACC) 66 Scientific Ses-
th
and up to 8 weeks after ablation (1.6% [n=5]
sion in Washington DC, US. vs 6.9% [n=22], absolute risk difference,
In this open-label, multicentre (104 sites -5.3%, 95% confidence interval [CI], -8.4 to
in 11 countries), controlled trial, 704 patients -2.2; p<0.001), with a relative risk reduction of
scheduled to undergo catheter ablation for par- 77.2%. [N Engl J Med 2017;doi:10.1056/NEJ-
oxysmal or persistent AF were randomized to Moa1701005]
receive either dabigatran (150 mg twice daily) The incidence of minor bleeding events was
or warfarin (target international normalized ra- comparable between groups (18.6% [n=59] vs
tio, 2.0–3.0). Of these, 635 (mean age, 59 years) 17.0% [n=54] in the dabigatran and warfarin
were included in the final analysis (317 and 318 groups, respectively), while there was no inci-
on dabigatran and warfarin, respectively). Anti- dence of stroke or systolic embolism among
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 29

the participants, and just one incident of a tran- ablation to enable continuous anticoagulation
sient ischaemic attack in a patient on warfarin. during the procedure. They are then reverted
Four patients in the dabigatran group and 21 to non-VKAs 1 to 2 months after ablation, said
in the warfarin group had major bleeding events the researchers. “The practice of switching an-
that required medical attention; the dabigatran- ticoagulants is cumbersome ... and the grow-
reversal agent idarucizumab was not needed ing use of [non-VKAs] has made this approach
to treat patients on dabigatran whose major impractical,” they said.
bleeding events required medical attention. According to the researchers, the more spe-
Severe adverse events occurred in 18.6% cific mechanism of action and shorter half-life
and 22.2% of patients in the dabigatran and of dabigatran may be behind the lower num-
warfarin groups, respectively, with no death oc- bers of major bleeding events. Normal levels
curring in either group. of factor VII and a stable anticoagulation effect
“Thromboembolic and bleeding events ... may also play a role, they said.
are some of the most feared complications of
AF ablation,” said Calkins. *RE-CIRCUIT: Randomized Evaluation of Dabi-
High-risk patients on non-vitamin K antago- gatran Etexilate Compared to Warfarin in Pul-
nists (non-VKAs) are often put on VKAs before monary Vein Ablation
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 30

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

Durable LDL-C reduction with novel


anti-PCSK9
PEARL TOH

T reatment with inclisiran, a siRNA for


PCSK9* knockdown, delivers significant
and sustained LDL-c lowering in a dose-de-
pendent manner over 6 to 9 months in patients
with high cardiovascular risk, according to the
ORION-1** study presented at the ACC.17 Sci-
entific Session held in Washington, DC, US.
Unlike PCSK9 antibody-based therapy
which requires 12 to 26 injections per year,
inclisiran requires less frequent injection at a Dr. Kaushik Ray
starting regimen of twice every 90 days and neous doses of placebo or 100, 200, or 300 mg
may be feasible at Q6M thereafter. This could of inclisiran on days 1 and 90. At the start of
help circumvent the issue of poor adherence to the study, 73% of the patients were on statins
therapy, which has been associated with poor and 31% were on ezetimibe. [N Engl J Med
outcomes and an issue most relevant in high- 2017;doi:10.1056/NEJMoa1615758]
risk patients with high LDL-c, according to lead Compared with the baseline, LDL-c de-
investigator Dr. Kaushik Ray, of the Imperial creased by 27.9–41.9% at day 180 after a single
Centre for Cardiovascular Disease Prevention inclisiran dose vs an increase by 2.1% for pla-
at Imperial College London in UK. cebo (p<0.001). For patients who received two
The multicentre double-blind phase II study doses of inclisiran, LDL-c fell by 35.5–52.6% at
randomized 501 patients (mean age 63 years, day 180 from baseline compared with a 1.8%
35% female) with elevated LDL-c levels (mean increase with placebo (p<0.001).
LDL-c, 125.2–133.0 mg/dL) who were at high At 240 days, LDL-c declined by 28.2–36.6%
risk for atherosclerotic cardiovascular disease from baseline after a single inclisiran dose and
to receive one of the eight treatments: a single 26.7–47.2% after two doses of inclisiran.
subcutaneous dose of placebo or 200, 300, or LDL-c levels remained lower than baseline at
500 mg of inclisiran on day 1; or two subcuta- day 270 across all studied doses of inclisiran
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 31

be it a single- or double-dose regimen. There were no safety concerns with incli-


“The greatest reduction (52.6%) in LDL-c lev- siran seeing that the incidence of treatment-
els was observed in association with the two- emergent adverse events, including transient
dose 300-mg regimen of inclisiran, a reduc- increase in transaminase, was similar to pla-
tion that is in a range similar to that achieved cebo, except injection site reaction which oc-
with monoclonal antibodies designed to target curred in 5% of the inclisiran-treated patients,
PCSK9,” according to Ray, who noted that 48% according to Ray. Also, no neutralizing antibod-
of patients in this regimen group achieved LDL- ies were detected.
c levels of <50 mg/dL at day 180. Study on CV outcomes with inclisiran in
“The optimal dose of 300 mg given twice as high-risk primary and secondary prevention pa-
a starting regimen appears to allow for a subse- tients with elevated LDL-c of about 130 mg/dL
quent 6-month dosing interval,” he added. will be pursued in the ORION-4 study, informed
The researchers also showed that PCSK9 Ray.
levels decreased by 53.2% to 69.1% (p<0.001)
from baseline at 180 days after a two-dose incli- *PCSK9: Proprotein Convertase Subtilisin–
siran regimen, which remained >40% reduced Kexin type 9 **ORION-1: Trial to evaluate the
from baseline at 240 days. effect of ALN-PCSSC treatment on LDL-C
Diagnostic Musculoskeletal Ultrasound &
Injection Technique Workshop
18 – 20 August 2017 | Hong Kong

Hands-on Course
Focusing on Musculoskeletal Sonoanatomy of the Extremities,
Hip & Spine using Live Models and Porcine Cadavers

Nerve and Spine Track Available

Programme
The programme includes scanning on Live Models and practicing ultrasound 1:4 Faculty to Attendees Ratio
guided injection on Porcine Cadavers. 90% of all sessions are hands-on.

Course Faculty
Thomas B Clark Mark WW Lai
DC, RVT, RMSK MBBS(HK), MScSM&HS(CUHK)
MSKUS, Course Chair Hong Kong Institute of Musculoskeletal Medicine

Keith Hansen Stanley KH Lam


DC, RMSK MBBS(HK), MScSEM(Bath)
Advanced Rheumatology Hong Kong Institute of Musculoskeletal Medicine

Andrew KK Ip Ricky WK Wu
MBBS(HK), MScSEM(Bath) MBBS(HK), PGDipMSM(Otago)
Hong Kong Institute of Musculoskeletal Medicine Hong Kong Institute of Musculoskeletal Medicine

Who Should Attend?


• Family Physicians
• Musculoskeletal Physicians
• Rehabilitation and Pain Physicians
• Sports Physicians

Venue
Function Rooms, 3/F., South Tower, The Salisbury – YMCA of Hong Kong
41 Salisbury Road, Tsimshatsui, Kowloon, Hong Kong

Registration
The Registration fee is HK$24,900 / US$3,250
Please register at www.hkimm.hk

Further Information
Please visit www.hkimm.hk or contact the meeting secretariat at
(852) 2155 8557 / 3153 4374 or e-mail to meeting.hk@mims.com
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 33

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

FFR-guided revascularization
reduces risk of cardiovascular
events
AUDREY ABELLA

F ractional flow reserve (FFR)-guided com-


plete revascularization of non-infarct-re-
lated arteries in acute primary percutaneous
coronary intervention (PCI) reduced the risk
of cardiovascular outcomes compared with
treatment of infarct-related arteries (IRA) alone,
according to the COMPARE-ACUTE* trial pre-
sented at the American College of Cardiology’s
(ACC) 66th Annual Scientific Session held in
Washington, DC, US. Dr. Pieter Smits
In this prospective, multicentre study, re- Compared with participants in the IRA-only
searchers randomized 885 patients with group, patients who underwent FFR-guided
ST-segment elevation myocardial infarction evaluation were less likely to experience the
(STEMI) and multivessel disease who had primary outcome at 1-year follow-up (haz-
undergone primary PCI of an IRA to undergo ard ratio [HR], 0.35, 95% confidence inter-
FFR-guided complete revascularization of non- val [CI], 0.22–0.55; p<0.001). [N Engl J Med
IRA lesions (n=295) or IRA-only treatment plus 2017;doi:10.1056/NEJMoa1701067]
blinded FFR of non-IRA lesions (n=590). The When broken up by component, the re-
patients had a mean age of 62, and 79% were duced risk was only noted for revascularization
male. The primary outcome (composite of all- (HR, 0.32, 95% CI, 0.20–0.54; p<0.001).
cause mortality, nonfatal myocardial infarction, “The use of an FFR-guided strategy for com-
revascularization, and cerebrovascular events plete revascularization during STEMI has the
at 12 months) was observed in 7.8% (n=23) of potential to substantially decrease the number
the non-IRA group and 20.5% (n=121) of the of unnecessary interventions during primary
IRA-only group. PCI and the number of subsequent revascular-
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 34

izations,” said Dr. Pieter Smits, lead author and warrant further attention. The FFR-guided ap-
cardiologist at Maasstad Hospital, Rotterdam, proach fine tunes the process by offering a
the Netherlands. more precise assessment that could enable
It is a tremendous advantage for patients as clinicians to immediately identify and address
they will not need rehospitalization for invasive other blockages after initial PCI, leading to op-
procedures and other diagnostic tests, said timized patient outcomes, noted the research-
Smits, who underscored the reduced risk for ers.
subsequent invasive intervention as well as the In a related editorial, Dr. Lars Kober from the
potential economic benefits of an FFR-guided University of Copenhagen, Denmark said com-
approach. plete revascularization in all patients with STE-
While FFR-guided PCI is not commonly used MI and multivessel disease may be safe but
in cases of acute coronary syndrome, the find- may not be necessary in all patients. [N Engl
ings tie in with a previous study that validates J Med 2017;doi:10.1056/NEJMe1702825]
the reliability of FFR evaluation in non-IRA cas-
es. [JACC Cardiovasc Interv 2010;3:1274–81] *COMPARE-ACUTE: Comparison between
Current medical guidelines suggest treat- FFR-guided revascularization versus conven-
ment be directed to the specific blockage only tional strategy in acute STEMI patients with
and other arteries treated once symptoms MVD
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 35

The American College of Cardiology 66th Annual Scientific Session (ACC),


March 17 to 19, US

Higher target lesion failure rates at


2 years with Absorb BVS vs Xience
stents
PEARL TOH

T he everolimus-eluting bioresorbable vascu-


lar scaffold (BVS), Absorb, was noninferior
to the Xience metal stent for target lesion failure
(TLF) by 1 year, and between 1 and 2 years,
but was associated with significantly higher cu-
mulative TLF rates by 25 months, according to
the ABSORB III trial presented at the ACC.17 in
Washington, DC, US.
The researchers attributed the difference in
TLF rates at 25 months to the placement of Ab-
sorb in vessels with a reference vessel diame- Dr. Stephen Ellis
ter (RVD) of <2.25 mm in some patients, which years) with stable ischaemic heart disease or
is smaller than the recommended size of 2.5 to stabilized acute coronary syndrome, who had
3.75 mm. significant plaque buildup in up to two areas
“A key take-home is that this device shouldn’t of separate vessels, to receive Absorb BVS
be used in very small vessels,” said lead au- (n=1,322) or Xience stent (n=686). [ACC.17,
thor Dr. Stephen Ellis, of the Cleveland Clinic LB-16265]
in Cleveland, Ohio, US. “This isn’t necessarily At 1 year, Absorb was noninferior to Xience
surprising because the Absorb BVS is consid- for TLF, comprising a composite of target-ves-
erably larger than the Xience stent, but it would sel myocardial infarction (TV-MI), cardiac death,
have been preferable to have more consistency or ischaemia-driven target lesion revasculariza-
with regard to the vessel sizing and utilization tion (ID-TLR) (7.8% vs 6.1%, hazard ratio [HR],
of the device in the study.” 1.3; p=0.15).
The multicentre, prospective, single-blind Similarly, between 1 and 2 years, TLF rates
study randomized 2,008 patients (mean age 63 were comparable between the two groups
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 36

(3.7% vs 2.5%, HR, 1.45; p=0.19), with a scaf-


fold thrombosis rate of 0.3% (number needed
to harm, 317) for Absorb.
However, the cumulative TLF rates by 25
months were significantly higher among pa-
tients receiving Absorb (11.0% vs 7.9%, HR,
1.42; p=0.03), driven mainly by a significantly
higher rate of TV-MI in the Absorb group (7.3%
vs 4.9%; p<0.04).
Noting that an increased risk was associ-
ated with treating vessels with RVD <2.5 mm procedural techniques,” said Ellis, adding that
in a post hoc subgroup analysis, and that 19% BVS is a first generation device and was used
of the ABSORB III cohort had stents placed in for the first time by most operators within this
vessels <2.25 mm (as this correlates with a vi- trial, and that the optimal implantation tech-
sual estimate of about 2.5 mm when vessels nique was still evolving during the initiation and
were assessed by coronary angiogram), Ellis enrolment of the study.
and co-authors excluded patients with vessels “Superiority of Absorb BVS is not likely to
<2.25mm (by quantitative coronary analysis) in emerge before the bioresorption process is
a separate subanalysis. complete (approximately 3 years),” he sug-
Subanalysis of only vessels of ≥2.25 mm gested. “Longer-term data from the ABSORB
showed a smaller and nonsignificant difference III/IV program will determine whether better pa-
in TLF rates between Absorb and Xience (9.4% tient selection and technique improves short-
vs 7%, HR, 1.35; p=0.11). term outcomes.”
“These results show that this device is gen- Following the presentation, the FDA pub-
erally comparable with the drug-eluting metal lished a letter sent to healthcare providers to
stent when the device is placed in appropriate- caution them on the increased risk with Absorb
ly-sized vessels and placed using appropriate and to avoid using it in very small vessels.
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15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 39

The Endocrine Society Annual Meeting (ENDO 2017), April 1 to 4, US

Novel drug offers hope for


menopausal hot flushes
PEARL TOH

A novel treatment targeting the neurokinin 3


receptor (NK3R) pathway with MLE4901, a
NK3R antagonist, significantly reduces the fre-
quency and severity of menopausal hot flushes,
as well as the impact on daily life of menopaus-
al women compared with placebo, according to
a study presented at The Endocrine Society An-
nual Meeting (ENDO 2017) in Orlando, Florida,
US. MLE4901 than with placebo (mean score, 3.27
“[Treatment with MLE4901] could be prac- vs 5.70; p<0.0001).
tice-changing as it safely and effectively re- In addition, women taking MLE4901 experi-
lieves hot flush symptoms without the need for enced 45% less bothersome hot flushes (mean
oestrogen exposure,” said lead author Dr. Julia score, 2.92 vs 5.56; p<0.0001) and 58% less
Prague, of the Imperial College London, UK. interference from hot flushes, as rated with the
At baseline, the study participants reported Hot Flash Related Daily Interference Scale (7.94
about 13 hot flushes per day and 85 events per vs 26.48; p<0.0001).
week. After 4 weeks of treatment, the frequen- The effects of menopausal symptoms on
cy of hot flushes was significantly reduced by overall life quality, scored using the Menopause-
45% to 19 events during the final week in the Specific Quality of Life questionnaire, improved
MLE4901 group vs 49 events in the placebo significantly with MLE4901 in terms of vasomo-
group (p<0.0001). [Lancet 2017;doi:10.1016/ tor symptoms (2.05 vs 3.98; p<0.0001), physi-
S0140-6736(17)30823-1] cal (2.42 vs 2.93; p=0.0002), and psychosocial
Objective assessment of hot flushes using a domains (2.18 vs 2.58; p=0.0083).
skin conductance monitor further confirmed the Treatment was well tolerated with no seri-
findings from participants’ subjective reporting, ous adverse events. By day 28 following treat-
which corresponds to a 43% decrease (mean ment with MLE4901, three women developed
weekly frequency, 16.22 vs 26.91; p<0.0001). elevated liver enzyme (alanine aminotransfer-
Hot flushes were also 41% less severe with ase reached 4.5 to 5.9-fold the upper limit of
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 40

normal) although bilirubin level was normal, ing hot flushes using hormone replacement
and the elevation eventually normalized within therapy is effective, it is contraindicated in
3 months. some women and comes with long-term safety
The phase II, single-centre, crossover trial concerns, the researchers noted.
randomized 37 menopausal women with ≥7 “NKB antagonists are an exciting develop-
hot flushes per day to oral MLE4901 40 mg ment … Larger trials of clinically relevant dura-
twice daily or placebo for 4 weeks followed by tion examining benefits relative to established
a 2-week washout period before switching over treatments are needed and might lead to a
to the opposite treatment. much needed addition to a very small toolbox
Due to the small number of participants and of treatments for hot flushes,” according to
short duration of treatment, Prague acknowl- Drs. Jenifer Sassarini and Richard Anderson,
edged that “a larger and longer trial is needed of the University of Glasgow and MRC Centre
to establish whether the treatment effect is long for Reproductive Health in Edinburgh, UK, re-
lasting in a greater number of individuals.” spectively in a separate commentary. [Lancet
Although the current gold standard for treat- 2017;doi:10.1016/S0140-6736(17)30886-3]

‘Yo-yoing’ weight predicts CV risk in


CHD
ELVIRA MANZANO The wider the weight fluctuation, the greater
the risk. “For every 1.5- to 2-pound change in

‘Y o-yoing’ weight or repeated weight


swings in overweight patients with cor-
onary heart disease (CHD) is independently
weight fluctuation, the risk of any coronary or
CV event was increased by 4%,” said lead in-
vestigator Dr. Sripal Bangalore, an intervention-
associated with higher risks of cardiovascular al cardiologist at New York University School of
(CV) events and death, a study shows. Medicine, New York City, US. “Our results may
Each increase of one standard deviation be a motivational factor to not only lose weight
(SD) in weight variability was associated with but to try to maintain any weight loss that the
an increased risk of any coronary event (haz- patient experiences.”
ard ratio [HR], 1.04; p=0.01), CV event (1.04; Bangalore and colleagues conducted a post
p<0.001), and death (1.09; p<0.001). [N Engl hoc analysis of data from Treating to New Tar-
J Med 2017;376:1332–1340] gets (TNT) trial, which looked at the efficacy
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 41

and safety of lowering LDL-C in patients with


CHD. The analysis involved 9,509 patients who
had a median of 12 weight measurements. The
primary endpoint was any coronary event (a
composite of death from coronary heart dis-
ease, non-fatal myocardial infarction (MI), re-
suscitated cardiac arrest, revascularization or
angina); secondary endpoints were any CV
event (a composite of any coronary event, a
cerebrovascular event, peripheral vascular
disease, or heart failure), death, MI, or stroke.
Change in body weight was measured at 3, 6, tend to develop diabetes. We know that diabe-
9, and 12 months and every 6 months thereaf- tes itself is a risk factor for CVD events,” said
ter for 4 years. Bangalore, who reported their findings at the
Heart attack, stroke, and death were more recent ENDO 2017 meeting in Orlando, Florida,
common in patients who had weight fluc- US.
tuations of 8 to 10 lbs than those with weight Overweight patients with CHD often fall into
changes of 2 to 4 lbs. Patients with the greatest a rhythmic pattern of cyclical loss and gain of
weight fluctuation (average 8.5 lbs) had a 64% weight, which may not be a good strategy ac-
higher risk of coronary event, 85% higher risk cording to the investigators. Still, overweight
of CV event, a 117% higher risk of MI, a 136% patients with CHD should aim to drop excess
higher risk of stroke, and 124% higher risk of pounds and maintain ideal weight in the long
death vs those with the lowest weight fluctua- term to improve their health.
tion (≤2 lbs). “The findings should not deter anyone from
Similarly, weight fluctuation was linked to losing weight,” said Bangalore. “There is more
new-onset diabetes (HR, 1.08). Patients with the reason to say that once you’ve done the hard
highest variability had a 78% higher risk than work of losing weight, it’s really important to
those with lowest-weight variability. “[They] keep the pounds off for a long period.”
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 42

The Endocrine Society Annual Meeting (ENDO 2017), April 1 to 4, US

Abaloparatide increases forearm


BMD, lowers wrist fracture risk
PEARL TOH teriparatide, and placebo). Although the differ-
ence between the abaloparatide and the pla-

A baloparatide increases bone mineral den- cebo arms was not significant (p=0.19), the
sity (BMD) at the ultradistal radius along decrease was significantly greater in the terip-
with lower risk of wrist fracture compared with aratide arm when compared with abalopara-
placebo and teriparatide in postmenopausal tide (p<0.001) and with placebo (p<0.0001).
women with osteoporosis, according to a Compared with the abaloparatide arm (sev-
study presented at The Endocrine Society An- en women [1.0% by Kaplan-Meier estimate]),
nual Meeting (ENDO 2017) in Orlando, Florida, there were more women who reported wrist
US. fractures in both the teriparatide (17 [2.3%])
The analysis was on a subset of 982 post- and the placebo arms (15 [2.2%]). This trans-
menopausal women from a total cohort of lates to a lower wrist fracture risk in the abalo-
2,463 women enrolled in the global, double- paratide group compared with the teriparatide
blind, phase III ACTIVE* trial who were ran- group (hazard ratio, 0.43; p=0.052), although
domized to subcutaneous abaloparatide 80 µg the reduction was not statistically significant.
(n=321), open-label teriparatide 20 µg daily “These data are also consistent with the
(n=327), or placebo (n=334) for 18 months. reduction in nonvertebral fractures, sites rich
[ENDO 2017, abstract LB SUN 46] in cortical bone, with [subcutaneous abalo-
At the ultradistal radius, an anatomical paratide] compared with placebo treatment
site considered relevant to wrist fractures, observed during ACTIVE,” said lead author Dr.
BMD significantly increased from baseline Nelson Watts, of the Mercy Health Osteopo-
with abaloparatide (mean percent change, rosis and Bone Health Services in Cincinnati,
+1.0%) compared with a decrease with pla- Ohio, US.
cebo (-1.2%; p<0.0001) and with teriparatide Abaloparatide is an osteoanabolic agent
(-0.5%; p<0.001) after 18 months. currently under development for treating post-
Measurements at the 1/3 radius, which is menopausal osteoporosis by selectively bind-
constituted of a substantial proportion of cor- ing to and activating the parathyroid 1 recep-
tical bone, showed an overall BMD decrease tor. The ACTIVE trial has previously shown
from baseline in all three arms (-1.0%, -2.3%, significantly decreased risk of vertebral (VF)
and -0.6%, respectively for abaloparatide, and nonvertebral fractures (NVF) compared
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 43

with placebo, and lower risk of major osteopo- According to Dr. Michael McClung of Oregon
rotic fractures (MOF) compared with teripara- Osteoporosis Center in Portland, Oregon, US,
tide. [JAMA 2016;316:722–733] who presented the subanalysis, the protective
Also presented was a separate subanalysis effects of abaloparatide are likely to be clinically
of the ACTIVE cohort, which suggests that the meaningful for patients who are at a very high
beneficial effects of abaloparatide on reducing risk for NVF, but probably less so for lower-risk
the risks of VF, NVF, and MOF were consistent patients, for whom anabolic drug are also less
across different geographic subgroups (in- likely to be considered.
cluding Europe, North America, South Amer-
ica, and Asia) compared with placebo. [ENDO *ACTIVE: Abaloparatide Comparator Trial In
2017, abstract OR08-7] Vertebral Endpoints

Triple drug therapy improves fertility


in girls with PCOS
ELVIRA MANZANO group, but not in the oral contraceptive group.
[ENDO 2017, abstract OR32-1]

E arly treatment with a triple-drug combi- “Normalizing the amount of abdominal vis-
nation of low-dose spironolactone, pio- ceral and liver fat restores ovulation, besides
glitazone, and metformin (SPIOMET) helps normalizing the symptoms of androgen excess
improve fertility and overall health in adoles- in adolescent girls with PCOS,” said lead inves-
cents with polycystic ovary syndrome (PCOS), tigator Dr. Lourdes Ibáñez, professor of paedi-
a small study shows. atrics and director of the fellowship programme
After treatment, there was a two-and-a-half in paediatric endocrinology at the University of
fold higher ovulation rate and a sixfold higher Barcelona in Barcelona, Spain. “These find-
prevalence of normovulation among adoles- ings corroborate the notion that PCOS is not
cent girls on SPIOMET vs those on oral con- an ovarian disease but rather a pseudo-ovarian
traceptive ethinylestradiol-levonorgestrel (p< central obesity sequence.”
0.001 for both). Oligo-anovulation risk after “Refocusing PCOS treatment toward early
SPIOMET was 65% lower than after ethinyl- reduction of ectopic fat may prevent part of
estradiol-levonorgestrel treatment. Visceral fat subsequent oligo-anovulatory subfertility,” she
and insulinaemia normalized in the SPIOMET added.
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 44

The study included 36 girls with PCOS


(mean age 16 years, BMI 23.5 kg/m2, with no
sexual activity) who were randomized to low-
dose SPIOMET (spironolactone 50 mg/day,
pioglitazone 7.5 mg/day, and metformin 850
mg/day) or ethinylestradiol plus levonorgestrel
given 21/28 days for 1 year. They were then
followed for another year off treatment. The
primary outcome was posttreatment ovulation
rate, inferred from menstrual diaries and sali-
vary progesterone; the secondary outcomes
included body composition, abdominal fat, in- cover why SPIOMET has sustained benefits
sulinaemia, and androgenaemia. Only 34 girls even after discontinuation, she said.
completed the trial. Women with PCOS have a higher risk of
Treatment with SPIOMET resulted in greater pregnancy complications, including gestation-
reductions in C-reactive protein, insulin produc- al diabetes, hypertension, preeclampsia, and
tion, and adiponectin. It also led to normaliza- miscarriage. The risk is even higher in those
tion of visceral and hepatic fat. There were no who are obese.
further effects on body weight, BMI, lean mass Currently, there is not one treatment that
or subcutaneous fat with either treatment. reverses the hormonal disturbances of PCOS.
At 24 months, girls who lost more hepatic fat Management is mainly targeted at individual
had more ovulations, said Ibáñez. symptoms such as hirsutism, obesity, and in-
Understanding the interactions between the fertility. Further studies with SPIOMET in larger
components of this combination and other fac- populations are needed to asses its clinical
tors, for example, epigenetic factors, may un- utility.
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 45

World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal


Diseases 2017, March 23 to 26, Italy

Bisphosphonate holiday ups


fracture risk in postmenopausal
osteoporosis
ELVIRA MANZANO

W omen with postmenopausal osteopo-


rosis who take a drug holiday from
bisphosphonate are at increased risk for frac-
tures, according to a retrospective analysis.
The rate of new clinical fractures was 16.1%
in patients who discontinued bisphosphonate
vs 11.9% in those who continued treatment. The
hazard ratio of new clinical fractures among pa-
tients who discontinued bisphosphonate was
also higher at 1.40 (p=0.0095). Older age (71.2 sis. However, the optimal treatment duration
years; p=0.002) was the lone risk factor for new remains unclear. Concerns have also emerged
clinical fractures after first-line bisphosphonate about rare but adverse events related to
therapy in this patient group. [WCO 2017, ab- bisphosphonates’ long-term use such as os-
stract P489] teonecrosis of the jaw, atypical femur fractures,
“The results suggest that discontinuing and atrial fibrillation. Clinicians, therefore, con-
bisphosphonate therapy may have important sider drug holiday as a reasonable approach to
implications on fracture risk in postmenopaus- managing bisphosphonate risk.
al women,” said investigators. They sought to In this study, the investigators retrieved re-
compare the incidence of new clinical fractures cords of 1,894 patients from the Lille Universi-
in 898 women with postmenopausal osteopo- ty Hospital Bone Clinic in Lille, France; 898 of
rosis who had taken a drug holiday after first- whom were identified to have postmenopausal
line bisphosphonate therapy for 3 to 5 years vs osteoporosis. Of this number, 183 had under-
those who continued treatment. gone treatment with bisphosphonates, specifi-
Bisphosphonates have been the mainstay cally alendronate (n=81), risedronate (n=73),
of treatment for postmenopausal osteoporo- zoledronic acid (n=20), and ibandronate (n=9)
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 46

for 3 to 5 years. vival rates without new clinical fractures.


Of the full cohort, 166 were included in the “After first-line bisphosphonate therapy in
analysis. Follow-up duration was from 6 to 36 postmenopausal women with osteoporosis, the
months with a mean duration of 31.8 months. risk of new clinical fractures was 40% higher in
Thirty-one patients had discontinued bisphos- patients who took a bisphosphonate drug holi-
phonate while 135 had taken a drug holiday. day,” the investigators said.
Cox proportional hazards models were used The study comes with several caveats, one
to assess the relationship between stopping of which is its retrospective nature, which de-
treatment and clinical fracture risk and Kaplan- spite controlling for confounding factors leaves
Meier curves and log-rank tests to analyse sur- residual confounding.

Novel point-of-care device


measures BTMs in osteoporosis
ELVIRA MANZANO ECLIA and Osteokit were 4.6% and 3.7% for
Oc, and 6.4% and 7.7% for CTX. “There was

A new point-of-care device, Osteokit, ap- also a high correlation between the sensor re-
pears effective in measuring serum levels sults and that of ECLIA,” they added.
of bone turnover markers (BTMs) in osteoporo- Most techniques to detect BTMs are based
sis, according to a new study. on electrochemiluminescence (ECLIA) and the
Researchers sought to evaluate the feasibil- enzyme-linked immunosorbent assay (ELISA)
ity and specificity of Osteokit device in assay- which can be time-consuming, expensive, and
ing serum BTMs using osteocalcin (Oc) and C- require staining procedure and fluorescence
terminal telopeptide of type 1 collagen (CTX), measurement.
which are markers of bone formation and re- “Osteokit could someday be used as an al-
sorption, respectively. The detection limit of ternative to ELISA/ECLIA particularly in devel-
Oc was 1.94 ng/mL and CTX was 2.77 pg/mL. oping countries and resource-poor areas,” said
[WCO-IOF-ESCEO 2017, abstract OCs 23] the researchers. “This microfluidic proteomic
“The sensitivity of the device was compa- platform can easily be translated into an in-
rable with ECLIA [electrochemiluminescence office biomarker diagnostic tool for clinicians
assay] in human serum samples,” said the re- managing osteoporosis patients.”
searchers. The coefficients of variation for the Bone mineral density (BMD) of the spine and
15-31 MAY 2017 • CO N F E R E N C E COV E R AG E • 47

proximal femur measured by DXA (dual-energy


x-ray absorptiometry) is currently the most use-
ful diagnostic tool for diagnosis of osteoporo-
sis. Although they help guide decision to start
treatment, subsequent changes in BMD may
not be a good indicator of treatment efficacy.
There is good evidence for monitoring treat-
ment efficacy with BTMs, especially with com-
monly used antiresorptive agents bisphospho- nology with electrochemical sensing to mea-
nates and denosumab. sure serum levels of different biomarkers with
“It would be useful to have a novel point-of- comparable accuracy to ECLIA and ELISA, but
care and in-office device that can quantitate in a shorter time, and is probably cheaper.”
several BTMs rapidly at a relatively low cost The device can be used to monitor osteopo-
without the need for a highly skilled operator for rosis treatment more efficiently and help iden-
patient check-up and screening,” the research- tify high turnover patients in an earlier phase,
ers said. “Osteokit integrates microfluidic tech- they concluded.
15-31 MAY 2017 • I N T E R N AT I O N A L • 48

Intensive alveolar recruitment


strategy reduces pulmonary
complications
ELVIRA MANZANO

A dding 10 cm H2O to positive end-expira-


tory volume (PEEP) during mechanical
ventilation significantly reduces the severity
and occurrence of pulmonary complications in
hospitalized patients who developed hypoxae-
mia after cardiac surgery, according to a ran-
domized controlled trial, putting a premium on
intensive recruitment strategy in this high-risk
population.
Intensive alveolar recruitment strategy yield- “This is especially noteworthy considering
ed a median pulmonary complications score that the control group was also receiving pro-
of 1.7 (interquartile range, 1.0-2.0) vs 2.0 (IQR, tective lung ventilation with low [tidal volume]
1.5-3.0) in patients who underwent ventilation and moderate PEEP levels,” Costa Leme said.
with a PEEP of 20 cm H2O, said lead investiga- “The major difference between the two groups
tor Dr. Alcino Costa Leme, of the Department was the intensity of lung recruitment.”
of Anaesthesia and Intensive Care, Heart In- The study involved 320 adult patients (me-
stitute in São Paulo, Brazil. “There was a sig- dian age 62) who developed hypoxaemia after
nificant effect of lung recruitment manoeuvres undergoing elective cardiac surgery. None had
on clinical outcomes, which resulted in modest a history of pulmonary disease at baseline. Pul-
reductions in intensive case unit [ICU] and hos- monary complications were assessed (grade
pital length of stay.” [JAMA 2017;doi:10.1001/ 0=no symptoms; grade 5=death).
jama.2017.2297] The intensive alveolar recruitment strategy
Patients who were managed intensively had consisted of three 60-second cycles of lung
shorter hospital days (mean 10.9 vs 12.4 days, inflation with a PEEP of 30 cm H2O, pressure-
absolute difference -1.5 days; p=0.04) and ICU controlled ventilation, driving pressure of 15 cm
days (mean 3.8 vs 4.8 days, absolute differ- H2O, respiratory rate of 15/min, inspiratory time
ence-1.0 day; p=0.01) vs those managed mod- of 1.5 seconds, and fraction of inspired oxygen
erately. (FIO2) of 0.40.
15-31 MAY 2017 • I N T E R N AT I O N A L • 49

Patients received assist-controlled or pres- Intensive alveolar recruitment nearly dou-


sure-controlled ventilation between and after bled the odds of a lower pulmonary complica-
inflations, with driving pressures set to achieve tions score (common odds ratio, 1.9; p=0.003).
a tidal volume of 6 mL/kg of predicted body “Intensive alveolar recruitment strategy com-
weight, an inspiratory time of 1 second, PEEP pared with a moderate recruitment strategy re-
of 13 cm H2O, and minimum respiratory rate to sulted in less severe pulmonary complications
maintain partial pressure of arterial carbon di- during patients’ hospital stay,” the investigators
oxide (PaCO2) between 35 and 45 mm Hg. said. Similarly, intensive management was as-
Moderate strategy consisted of three 30-sec- sociated with lower rates of hospital deaths and
ond inflations under continuous positive airway barotrauma (injury caused by rapid changes in
pressure (CPAP) mode at 20 cm H2O and FIO2 air pressure). However, the differences did not
of 0.60. Between and after inflations, patients reach statistical significance.
received assist or control volume-controlled Compared with previous investigations, the
ventilation (decelerating-flow waveform), tidal lung-rescue procedure in the current study was
volume of 6 mL/kg of predicted body weight, performed during the postoperative phase and
inspiratory time of 1 second, PEEP of 8 cm H2O, not intraoperatively, which offers “a good com-
and FIO2 of 0.60, at a minimum respiratory rate promise between safety and efficacy,” conclud-
that maintained PaCO2 at 35 to 45 mm Hg. ed the investigators.
15-31 MAY 2017 • I N P R AC T I C E • 50

Managing Helicobacter pylori


infection in primary care
Helicobacter pylori (H. pylori) infection is associated with conditions such as gastri-
tis, peptic ulcer, gastric cancer, and certain types of lymphoma. A common present-
ing complaint among all these H. pylori-related illnesses is dyspepsia. MIMS Doctor
speaks to Dr. Desmond Wai from the Desmond Wai Liver and Gastrointestinal Dis-
eases Centre, Mount Elizabeth Novena Specialist Centre, Singapore, on the impor-
tant role GPs play in recognizing, diagnosing, and treating H. pylori.

ROSHINI CLAIRE ANTHONY

Introduction

T he prevalence of H. pylori infection is re-


lated to the socioeconomic status and hy-
giene level of a country. In countries such as In-
dia, Bangladesh, and Vietnam, the prevalence
exceeds 70%, while in countries such as China,
Korea, Hong Kong, and Taiwan, the prevalence
is 50% to 70%.
Singapore is considered a low prevalent Dr. Desmond Wai
country with a prevalence of about 31%. How- laboratories and most hospitals. In suitable
ever, Singapore is also a regional medical hub patients, for example, young patients with dys-
where patients come from all over Asia. Fur- peptic symptoms, it is reasonable for GPs to
thermore, many foreigners from neighbouring use the 'Test and Treat' strategy and refer the
countries live in Singapore for work and study patients to gastroenterologists should they fail
purposes, enabling most doctors in Singapore this strategy.
to have exposure to patients with H. pylori in- According to the 2007 guidelines from the
fection. American College of Gastroenterology, general
population screening for H. pylori infection is
Diagnosing H. pylori generally not recommended. Screening for H.
A diagnosis of H. pylori can be made by non- pylori should only be performed when treat-
invasive investigations such as serology or a ment is considered. Screening for H. pylori
urea breath test which are available in many should be performed in patients with dyspep-
15-31 MAY 2017 • I N P R AC T I C E • 51

sia, history of peptic ulcer, or gastric cancer, as


well as those on nonsteroidal anti-inflammatory
drugs (NSAIDs) or antiplatelet agents. This is
because the presence of H. pylori infection in
patients on antiplatelet agents or NSAIDs would
increase their risk of peptic complications.
Screening of family members for H. pylori
infection is controversial. On one hand, re-in-
fection of H. pylori may occur if family mem-
bers are also infected. However, studies have
shown that intra-familial transmission of H. py-
lori is more related to socioeconomic status of
the families involved. referred to gastroenterologists.
Another challenge is treatment-related com-
Challenges in diagnosing H. pylori plications, mainly diarrhoea and abdominal dis-
Most GPs are well-versed with the latest guide- comfort. These are common and are observed
lines on H. pylori infection as well as many oth- in up to 50% of patients undergoing treatment.
er common gastrointestinal conditions. This is This leads to poor compliance to treatment,
due to the wide availability of continuing medi- which may eventually lead to higher resistance
cal education (CME) talks, as well as the avail- to antibiotics.
ability of most treatment guidelines online.
A major challenge is reimbursement. Cur- Treating H. pylori
rently, most insurance policies do not cover Generally speaking, treatment consists of a
investigation and treatment of H. pylori infec- proton pump inhibitor plus two antibiotics, for
tion at the primary care setting. Integrated 7 to 14 days. With the rise in prevalence of an-
shield plans only cover medical care leading tibiotic resistance for H. pylori infection in the
to and after admission. H. pylori infection is of- region, the treatment is often extended to 2
ten diagnosed with gastroscopy examination, weeks. Knowing the background resistance of
which is a day-surgical admission. Therefore, H. pylori to various antibiotics enables the use
treatment at specialist level after endoscopy of antibiotics with less resistance.
is reimbursed, whereas treatment at primary An important aspect in treating this condition
care level is self-paid. This is really not ideal as is the management of patients’ expectation. Up
it unnecessarily increases the overall medical to 50% of patients may experience adverse ef-
cost. Good treatment at the primary care level fects during treatment yet it is paramount that
could help reduce overall medical cost as only they complete treatment in order to achieve a
patients with difficult-to-treat cases need to be 90% cure rate.
15-31 MAY 2017 • I N P R AC T I C E • 52

When should patients be referred to a spe- terology which was published in 2016.
cialist?
H. pylori infection and gastrointestinal diseases Conclusion
are two separate entities. While most H. pylori- H. pylori infection is relatively common in Sin-
related diseases such as gastritis and peptic gapore and it is associated with many digestive
ulcers heal upon H. pylori eradication, patients diseases. The eradication of the condition will
with gastric or hepatobiliary cancer can also help reduce gastrointestinal complications in
have concomitant H. pylori infection and pres- patients taking antiplatelet agents and NSAIDs;
ent with upper abdominal pain. Patients who therefore, screening of suitable patients is ad-
have persistent symptoms after H. pylori treat- visable.
ment and those who present with 'alarm' symp-
toms should be referred to gastroenterologists
for endoscopy and further examination. Online Resources:

Practice guidelines American College of Gastroenterology

The Singapore Ministry of Health (MOH) last is- https://gi.org/guideline/management-of-he-

sued treatment guidelines on H. pylori manage- licobacter-pylori-infection/

ment in 2004. GPs can also follow guidelines


from the Asia Pacific Digestive Week, American Canadian Association of Gastroenterol-

College of Gastroenterologists, and the Ameri- ogy

can Gastroenterology Association. The latest https://www.cag-acg.org/images/publica-

set of guidelines is the Toronto Consensus writ- tions/Hp_Toronto_Consensus_2016.pdf

ten by the Canadian Association of Gastroen-


15-31 MAY 2017 • F O R SA L E • 53

DOCTOR (LOCUM)
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15-31 MAY 2017 • F O R SA L E • 54

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15-31 MAY 2017 • C A L E N DA R • 55

ANNOUNCEMENT

12th Liver Update 2017


20/7 to 23/7; Kuala Lumpur
Info : Malaysian Liver Foundation
Email : enquiries@liver.org.my, kanchana@liver.org.my

Specialist Medical Module in Hypnoanaesthesia and Hypnosedation –


JULY 2017 Open for Registration
22/7; University of Malaya, Kuala Lumpur
Tel : (03) 7960 6449 / (011) 2662 4623
Email : info@hypnosis-malaysia.com
www.lcch.asia

National Dengue and Arboviruses Infection Conference 2017 www.diabetesexpo.com/


12/8 to 13/8; Kuala Lumpur asiapacific/
Info : Secretariat
Malaysian Thoracic Society
Tel : (017) 914 9704 Congress 2017
Email : anum.udin@gmail.com 20/7 to 23/7; Petaling Jaya
Info : Malaysian Thoracic
The 5th Scientific Meeting of the Asian Federation of Osteoporosis Society Secretariat
Societies 2017 (5th AFOS 2017) Tel/Fax : (03) 2856 9539
Email : m.thoracicsociety@
6/10 to 8/10; Kuala Lumpur
gmail.com /
Tel : (03) 2242 0902 secretariat@mts.org.my
Email : secretariat@afos2017malaysia.com www.mts.org.my
www.afos2017malaysia.com
12th Malaysian Liver Foundation
(MLF) Update
20/7 to 23/7; Kuala Lumpur
JUNE UPCOMING Info : Nor Shahidah Khairullah
Tel : (03) 7842-6101
40th Annual Macula Society 33rd Annual Meeting of the Fax : (03) 7842-6107
Meeting European Society of Human Email : secretariat@
7/6 to 10/6; Singapore Reproduction and Embryology loveyourliver.org.my
Info : The Macula Society (ESHRE) www.loveyourliver.org.my
Tel : 216 839 4949 2/7 to 5/7; Geneva, Switzerland
Email : maculasociety@aol.com Info : ESHRE Central Office APHM International
www.maculasociety.org/ Email : eshre2017@eshre.eu Healthcare Conference and
meetingsprograms www.eshre.eu/ Exhibition 2017
25/7 to 27/7; Kuala Lumpur
77th Scientific Sessions of the ISPP 2017 - 11th International Info : Secretariat
American Diabetes Association Symposium on Pediatric Pain Tel : (017) 882 1680
(ADA) 6/7 to 9/7; Kuala Lumpur Email : majmin8@gmail.com
9/6 to 13/6; San Diego, California Info : Secretariat www.aphmconferences.org
Tel : (415) 268 2086 Tel : (012) 302 9898
http://professional.diabetes.org/ Email : secretariat@ispp2017.org Medical CBT: Ten-minute
www.ispp2017.org Techniques for Real Doctors
25th Asian & Ocenic Congress (Cognitive Behavior Therapy)
of Obstetrics and Gynaecology 19th Asia Pacific Diabetes 3/8 to 12/8; Tokyo, Japan
(AOCOG) Conference Info : Greg Dubord
15/6 to 18/6; Hong Kong 20/7 to 22/7; Melbourne, Australia Tel : 877 466 8228
Email : enquiry@aocog2017.com Email : diabetesasiapacific@ Email : info@cbt.ca
www.aocog2017.com endocrineconferences.com http://cbt.ca/locations/cbt-japan/
15-31 MAY 2017 • C A L E N DA R • 56

47th World Congress of Surgery 2017 European Society of 18th Congress of the ASEAN
13/8 to 17/8; Basel, Switzerland Cardiology (ESC) Congress Association of Radiology
Info : Congress Secretariat , 26/8 to 30/8; Barcelona, Spain 28/9 to 30/9; Kuala Lumpur
MCI Geneva Office Info : ESC Info : College of Radiology,
Tel : 011 41 22 339 9500 Tel : 011 33 4 9294 7600 Academy of Medicine
Email : wcs@mci-group.com www.escardio.org/Congresses-&- of Malaysia, Medical
www.wcs2017.org/ Events/ESC-Congress Conference Partners
Tel : (03) 2242 0902
17th International Conference on 6th World Congress on Addiction Fax : (03) 6207 6795
Children’s Vaccines Disorder and Addiction Therapy Email : secretariat@aar2017.com
21/8 to 22/8; Birmingham, United 29/8 to 31/8; Prague, Czech Republic http://aar2017.com/
Kingdom Info : Brian Wilson
Info : Conference Series.com Email : addictioncongress2017@
Email : childrenvaccines@ gmail.com
conferenceseries.com/ https://goo.gl/obvCUW

International Forum on Quality Asian Pacific Digestive Week


and Safety in Healthcare (APDW) 2017
24/8 to 26/8; Kuala Lumpur 23/9 to 26/9, Hong Kong
Info : BMJ Events, Tel : +852 2155 8557
BMJ Publishing Group Email : meeting.hk@mims.com
Email : events@bmj.com www.apdw2017.org
http://internationalforum.bmj.com/
kuala-lumpur/
Go
Beyond
the
Clinic
Dear Doctors,
What do you do when you leave the clinic? Is there life beyond the clinic? Is
there a passion that keeps you sane throughout the day, and leaves you
raring to go the moment you complete your shift and step out of that door?

would like to invite you to share your passion


and obsession with the rest of the medical fraternity.

Do submit your stories and pictures to enquiry.my@mims.com.

Share your PASSION. –Ed.


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