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Objective@#This study aims to report the demographic features of patients with acromegaly the disease burden, and the corresponding treatment patterns and outcomes in Malaysia.@*Methodology@#This is a retrospective study that included patients from the Malaysian Acromegaly registry who were diagnosed with acromegaly from 1970 onwards. Data collected included patient demographics, clinical manifestations of acromegaly, biochemical results and imaging findings. Information regarding treatment modalities and their outcomes was also obtained.@*Results@#Registry data was collected from 2013 to 2016 and included 140 patients with acromegaly from 12 participating hospitals. Median disease duration was 5.5 years (range 1.0 – 41.0 years). Most patients had macroadenoma (67%), while 15% were diagnosed with microadenoma. Hypertension (49.3%), diabetes (37.1%) and hypopituitarism (27.9%) were the most common co-morbidities for patients with acromegaly. Majority of patients had surgical intervention as primary treatment (65.9%) while 20.7% were treated medically, mainly with dopamine agonists (18.5%). Most patients had inadequate disease control after first-line treatment regardless of treatment modality (79.4%).@*Conclusion@#This registry study provides epidemiological data on patients with acromegaly in Malaysia and serves as an initial step for further population-based studies.
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AcromegaliaRESUMO
Objectives@#Insulin degludec (IDeg)/insulin aspart (IAsp; IDegAsp) is a co-formulation of 70% IDeg and 30% IAsp. According to several randomized controlled trials, IDegAsp is effective and safe for patients with type 2 diabetes mellitus (T2DM). A subgroup analysis of the ARISE study was conducted to explore the safety and efficacy of IDegAsp among Malaysian patients with T2DM in real-world settings.@*Methodology@#ARISE, an open-label, multicenter, non-interventional, prospective study was conducted between August 2019 and December 2020. Adult Malaysian patients with T2DM who were enrolled from 14 sites received IDegAsp as per the local label for 26 weeks. The primary endpoint was change in glycated hemoglobin (HbA1c) levels from baseline to end of study (EOS).@*Results@#Of the 182 patients included in the full analysis set, 159 (87.4%) completed the study. From baseline to EOS, HbA1c (estimated difference [ED]: –1.3% [95% CI: –1.61 to –0.90]) and fasting plasma glucose levels (ED: –1.8 mmol/L [95% CI: –2.49 to –1.13]) were significantly reduced (p<0.0001). The patient-reported reduced hypoglycemic episodes (overall and nocturnal) during treatment. Overall, 37 adverse events were observed in 23 (12.6%) patients.@*Conclusion@#Switching or initiating IDegAsp treatment resulted in significant improvements in glycemic control and a reduction in hypoglycemic episodes.
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@#Thyroid hormone plays an important role in cardiovascular function. Pericardial effusions are commonly seen in cases of severe hypothyroidism. However, large to massive pericardial effusions with cardiac tamponade are exceptionally rare. Herein, we present two cases of severe hypothyroidism with massive pericardial effusion. Our first case demonstrates that a patient with large pericardial effusion can be managed conservatively with aggressive thyroid hormone replacement therapy. In our second case, pericardiocentesis was performed in addition to thyroid hormone replacement therapy as the underlying aetiology of effusion could not be reasonably limited to hypothyroidism. These two cases served to highlight and demonstrate rapid normalisation of thyroid function test by using aggressive oral thyroid hormone replacement therapy using liothyronine, in combination with levothyroxine, which led to resolution of pericardial effusion and prevent its re-accumulation.
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Derrame Pericárdico , Tiroxina , Tri-IodotironinaRESUMO
@#Giant parathyroid adenoma (GPA) is defined as adenoma larger than 3.5 g. Twenty-one cases of parathyroid mass >3.5 g in patients with primary hyperparathyroidism who underwent parathyroidectomy in Hospital Putrajaya, Malaysia were identified. Most cases presented with nephrolithiasis. Two cases are reported as parathyroid cancer. GPA has significantly higher serum calcium and iPTH levels and can be asymptomatic. Parathyroid carcinoma patients are frequently symptomatic, with large tumors. Differentiating GPA from parathyroid cancer is important as it determines the subsequent surgical intervention.
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Hiperparatireoidismo , Neoplasias das Paratireoides , Paratireoidectomia , Cálcio , AdenomaRESUMO
@#Cushing’s syndrome due to ectopic adrenocorticotrophic hormone (ACTH) secretion is uncommon, accounting for 9 to 18% of cases; approximately 10% of ACTH producing tumours are caused by thymic carcinomas.1 We describe a young lady who presented with Cushing’s syndrome secondary to a primary neuroendocrine tumour (NET) arising from the thymus. She had surgical resection of her primary tumour with remission of her Cushing’s syndrome however subsequently went on to have locoregional recurrence followed by distant metastases to her bilateral ovaries. She underwent 6 surgeries including bilateral adrenalectomy and had 3 cycles of chemotherapy over the course of the 8 years since her diagnosis. Due to the rarity and highly aggressive nature of this disease, we highlight the need for a multidisciplinary team approach and use of multiple modalities in the management of our patient. Timely use of bilateral adrenalectomy particularly in young patients is important to prevent further complications and facilitate other treatment modalities.
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Adrenalectomia , Síndrome de ACTH EctópicoRESUMO
@#Introduction: Prediabetes, typically defined as blood glucose levels above normal but below diabetes thresholds, denotes a risk state that confers a high chance of developing diabetes. Asians, particularly the Southeast Asian population, may have a higher genetic predisposition to diabetes and increased exposure to environmental and social risk factors. Malaysia alone was home to 3.4 million people with diabetes in 2017; the figure is estimated to reach 6.1 million by 2045. Developing strategies for early interventions to treat prediabetes and preventing the development of overt diabetes and subsequent cardiovascular and microvascular complications are therefore important. Methods: An expert panel comprising regional experts was convened in Kuala Lumpur, for a one-day meeting, to develop a document on prediabetes management in Malaysia. The expert panel comprised renowned subject-matter experts and specialists in diabetes and endocrinology, primary-care physicians, as well as academicians with relevant expertise. Results: Fifteen key clinical statements were proposed. The expert panel reached agreements on several important issues related to the management of prediabetes providing recommendations on the screening, diagnosis, lifestyle and pharmacological management of prediabetes. The expert panel also proposed changes in forthcoming clinical practice guidelines and suggested that the government should advocate early screening, detection, and intensive management of prediabetes. Conclusion: This document provides a comprehensive approach to the management of prediabetes in Malaysia in their daily activities and offer help in improving government policies and the decision-making process.
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@#Introduction: Biosimilar insulins have the potential to increase access to treatment among patients with diabetes mellitus (DM), reduce treatment costs, and expand market competition. There are no published studies evaluating the performance of biosimilar insulins in routine clinical practice in Asia. This study assessed the safety and effectiveness of biphasic isophane insulin injection in Malaysian DM patients. Materials and Methods: In this open label, single-arm, observational, post marketing study, patients received biphasic isophane insulin injection as per the Prescribing Information; and were assessed for safety (adverse events including hypoglycaemia), effectiveness (glycosylated haemoglobin [HbA1c]; fasting blood sugar, [FBS]; and patient’s condition by patient and physician) over a period of 24 weeks. Results: Adult male and female diabetes patients (N=119; type 2 DM, n=117) with a mean (SD) diabetes duration of 13 years were included. No new safety signals have been identified. Significant reduction in HbA1c was observed at weeks 12 and 24 (mean [SD] - baseline: 9.6% [1.9]; Week 12: 9.0% [1.7] and at Week 24: 9.1% [1.7]; p < 0.001). There were 10 serious and 9 non-serious adverse events reported in the study. Expected mild events included hypoglycaemia and injection site pruritus. However, the majority of the adverse events were non-study drug related events. No deaths were reported during the study. Discussion: Biphasic isophane insulin injection was well tolerated with no new safety concerns. It was found effective in post- marketing studies conducted in routine clinical settings when administered in DM patients in this study.
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Objectives@#The COVID-19 pandemic has made a major impact on hospital services globally, including the care of persons with diabetes and endocrine disorders. The aim of this study is to describe the epidemiology of COVID-19 in the ASEAN Federation of Endocrine Societies (AFES) member countries; to describe challenges, changes and opportunities in caring for patients with endocrine diseases, as well as in fellowship training programs, and endocrine-related research in the AFES countries.@*Methodology@#The AFES ASEAN Survey Of Needs in Endocrinology (AFES A.S.-O.N.E.) was an open-ended questionnaire that was sent to the presidents and representatives of the AFES member countries by email. Responses from Societies were collated and synthesized to obtain perspectives on the emergent issues in endocrinology in the Southeast Asian region during this pandemic.@*Results@#The burden of COVID-19 cases varied widely across the AFES member countries, with the least number of cases in Vietnam and Myanmar, and the greatest number of cases in either the most populous countries (Indonesia and the Philippines), or a country with the highest capability for testing (Singapore). The case fatality rate was also the highest for Indonesia and the Philippines at around 6%, and lowest for Vietnam at no fatalities. The percentage with diabetes among patients with COVID-19 ranged from 5% in Indonesia to 20% in Singapore, approximating the reported percentages in China and the United States. The major challenges in managing patients with endocrine diseases involved inaccessibility of health care providers, clinics and hospitals due to the implementation of lockdowns, community quarantines or movement control among the member countries. This led to disruptions in the continuity of care, testing and monitoring, and for some, provision of both preventive care and active management including surgery for thyroid cancer or pituitary and adrenal tumors, and radioactive iodine therapy. Major disruptions in the endocrine fellowship training programs were also noted across the region, so that some countries have had to freeze hiring of new trainees or to revise both program requirements and approaches to training due to the closure of outpatient endocrine clinics. The same observations are seen for endocrine-related researches, as most research papers have focused on the pandemic. Finally, the report ends by describing innovative approaches to fill in the gap in training and in improving patient access to endocrine services by Telemedicine.@*Conclusion@#The burden of COVID-19 cases and its case fatality rate varies across the AFES member countries but its impact is almost uniform: it has disrupted the provision of care for patients with endocrine diseases, and has also disrupted endocrine fellowship training and endocrine-related research across the region. Telemedicine and innovations in training have been operationalized across the AFES countries in an attempt to cope with the disruptions from COVID-19, but its over-all impact on the practice of endocrinology across the region will only become apparent once we conquer this pandemic.
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Inquéritos e Questionários , Sudeste Asiático , COVID-19 , SARS-CoV-2RESUMO
@#<p style="text-align: justify;">In Malaysia, acromegaly is under-recognised with only 10-15% of the expected number of cases from prevalence estimates, having been diagnosed and managed in established endocrine centres with access to multidisciplinary care. This is mainly due to lack of awareness and standardised approach in diagnosing this disease resulting in delay in diagnosis and management with suboptimal treatment outcomes. This first Malaysian consensus statement on the diagnosis and management of acromegaly addresses these issues and is based on current best practices and latest available evidence so as to reduce the disease burden on acromegaly patients managed in the Malaysian healthcare system.</p>
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Humanos , Acromegalia , Consenso , MalásiaRESUMO
Introduction: An economic analysis was performed to estimate the annual cost of diabetes mellitus to Malaysia. Methods: We combined published data and clinical pathways to estimate cost of follow-up and complications, then calculated the overall national cost. Costs consisted of diabetes follow-up and complications costs. Results: Patient follow-up was estimated at RM459 per year. Complications cost were RM42,362 per patient per year for nephropathy, RM4,817 for myocardial infarction, RM5,345 for stroke, RM3,880 for heart failure, RM5,519 for foot amputation, RM479 for retinopathy and RM4,812 for cataract extraction. Conclusion: Overall, we estimated the total cost of diabetes as RM2.04 billion per year for year 2011 (both public and private sector). Of this, RM1.40 billion per year was incurred by the government. Despite some limitations, we believe our study provides insight to the actual cost of diabetes to the country. The high cost to the nation highlights the importance of primary and secondary prevention.
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Diabetes Mellitus , Custos de Cuidados de Saúde , Gastos em SaúdeRESUMO
@#For ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), when surgery is not feasible, or in cases of severe biochemical disturbances, immunosuppression or mental instability, medical therapy with agents such as etomidate is indicated. We present our experience in using etomidate for a 41-year old female with EAS secondary to a malignant mediastinal paraganglioma. We were able to demonstrate that etomidate can be used effectively to control severe hypercortisolism in a lower dose than previously described.
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Etomidato , Síndrome de ACTH EctópicoRESUMO
Aims: The aim of the study was to re-evaluate the relationship between hospital based diabetes care delivery and prevention of complications. Methods: DiabCare is an observational, non-interventional, cross-sectional study of hospital-based outpatient diabetes care. Results: A total of 1668 patients participated in the study: mean age 57.8 ± 11.0 years, duration of diabetes 13.0 ± 8.6 years, and duration of insulin treatment 5.6 ± 5.5 years. Mean weight was 74.3 ± 16.6 kg (BMI 29.1 ± 5.8 kg/m2). The majority of patients were female (53.6%) and the largest ethnic group was Malay (51.3%), followed by Indian (21.9%) and Chinese (20.1%). The percentage of patients with HbA1c < 6.5% (< 42 mmol/mol) and < 7.0% (< 53 mmol/mol) was 12.2% and 23.8%, respectively (mean HbA1c 8.52 ± 2.01% [70 ± 22 mmol/mol]). The proportion of patients using insulin was 65% at a total daily dose of 60 ± 37 IU. One or more episodes of hypoglycaemia were reported by 39% (n=658) of patients within the previous three months. The risk of any hypoglycaemia was associated with the use of insulin (odds ratio [OR 3.26, 95% CI 2.59–4.09]), and total daily insulin dose (OR 1.04, 95% CI 1.01–1.07 per 10 IU increase). Mean HbA1c had not changed significantly between DiabCare cohorts 2008 and 2013 (p=0.08). Conclusions: Despite evidence of improving processes of diabetes care, glycaemic control and the prevalence of many diabetes related complications were unchanged.
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Diabetes Mellitus Tipo 2RESUMO
The risk of coronary heart disease (CHD) is dramatically increased in diabetic patients due to their atherogenic lipid profile. The severity of CHD in diabetic patients has been found to be directly associated with glycated haemoglobin (HbA1c). According to the Malaysian Clinical Practice Guidelines on diabetes mellitus (DM), HbA1c level less than 6.5% reduces the risk of microvascular and macrovascular complications. Hence, this study aimed to determine the relationship between dyslipidaemia and glycaemic status in patients with type 2 DM (T2DM) patients in Hospital Putrajaya, a tertiary endocrine centre in Malaysia. This was a cross sectional, retrospective study of 214 T2DM patients with dyslipidaemia who had visited the endocrine clinic between January 2009 and December 2012. Significant correlations were found between fasting blood glucose (FBG) and HbA1c with total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL), non-high density lipoprotein cholesterol (non-HDL), LDL/HDL ratio and TC/HDL ratio; greater correlation being with HbA1c than FBG. In patients with HbA1c ≥ 6.5%, TC, TG, non-HDL and TC/HDL ratio were significantly higher than in patients with HbA1c < 6.5%. Non-HDL, LDL/HDL ratio, TC/HDL ratio and HbA1c were significantly lower in patients on statin treatment than nontreated patients (p<0.05). This significant association between glycaemic status and dyslipidaemia emphasises the additional possible use of HbA1c as a biomarker for dyslipidaemia as well as a potential indirect predictor of cardiovascular disease (CVD) risk in T2DM patients.
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@#For ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), when surgery is not feasible, or in cases of severe biochemical disturbances, immunosuppression or mental instability, medical therapy with agents such as etomidate is indicated. We present our experience in using etomidate for a 41-year old female with EAS secondary to a malignant mediastinal paraganglioma. We were able to demonstrate that etomidate can be used effectively to control severe hypercortisolism in a lower dose than previously described.
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Etomidato , Síndrome de ACTH Ectópico , Síndrome de CushingRESUMO
The glycosylated haemoglobin (HbA1c) test is the most widely accepted laboratory test for evaluating long term glycaemic control. Patient’s understanding of HbA1c can lead to better glycaemic control. This study is aimed to determine the awareness and level of understanding of HbA1c among type 2 DM patients and its association with glycaemic control. A cross-sectional descriptive study among Type 2 DM patients undergoing routine follow up in an endocrine clinic of a tertiary centre in Malaysia. Patients were invited to answer a validated questionnaire which assessed their awareness and understanding of HbA1c. Their last HbA1c results were retrieved from the laboratory information system. A total of 92 participants were recruited. Fifty-six (60.9%) were aware of the term HbA1c. Fifty percent were categorised as having good HbA1c understanding, with age, monthly income and level of education being the factors associated with understanding. No significant association was noted between HbA1c understanding and glycaemic control, although more patients with good HbA1c understanding had achieved the target glycaemic control compared to those with poor understanding. The level of HbA1c awareness and understanding was acceptable. Factors associated with understanding were age, income and level of education. Continuing efforts however, must be made to improve patients understanding of their disease and clinical disease biomarkers.
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Diabetes Mellitus Tipo 2RESUMO
Patients with diabetes have an earlier onset and increased severity of anaemia compared to those with similar degree of renal impairment from other causes. Anaemia is associated with an increased risk of vascular complications. In this study, we determined the prevalence of anaemia in T2DM patients and its association with sociodemographic, clinical and laboratory parameters in an endocrine tertiary hospital in Malaysia. This was a cross-sectional study using retrospective electronic data from January 2011 to December 2013 of 165 T2DM patients in Hospital Putrajaya. Data was analysed using IBM SPSS Statistics version 21.0 for Windows. The prevalence of anaemia was 39.4% and majority had normocytic normochromic (80%), mild (58.5%) anaemia. Majority were Malays (73.9%), aged below 60 with comparable gender percentage and long-standing, poorly-controlled DM [median fasting blood sugar (FBS) 8mmol/L; glycated haemoglobin (HbA1c) 7.9%]. Using the KDIGO chronic kidney disease (CKD) staging system, 86% of these patients were in stages 3-5. Anaemic patients had a significantly higher serum urea, creatinine and a lower FBS, estimated glomerular filtration rate (eGFR) compared to non-anaemic patients. Anaemic patients with diabetic nephropathy had a significantly lower haemoglobin (Hb) compared to those without this complication (p=0.022). The sensitivity and specificity at a cut-off eGFR value of 38.3 ml/min/1.73 m2 (maximum Youden index = 0.462) was 66.7% and 79.5%, respectively to discriminate mild from moderate anaemia. This study shows that anaemia is already present in T2DM patients in Hospital Putrajaya at initial presentation to the specialist outpatient clinic and is significantly associated with CKD. Hence, it emphasises the obligatory need for routine and follow-up full blood count monitoring in T2DM patients in primary care as well as tertiary settings in Malaysia to enable early detection and aggressive correction of anaemia in preventing further complications.
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Diabetes Mellitus Tipo 2RESUMO
Introduction: Prolactin (PRL) exists in different forms in human serum. The predominant form is monomeric PRL (molecular mass 23 kDa) with smaller amounts of big PRL (molecular mass 50–60 kDa) and at times macroprolactin (molecular mass 150–170 kDa). Macroprolactin, generally considered to be biologically inactive, accounts for the major part of prolactin in some patients. Different immunoassays for prolactin differ in reactivity with this macromolecular complex. Aim: The present study was undertaken to assess the incidence of macroprolactinaemia in our cohort of hyperprolactinemic patients. Method: 204 samples with hyperprolactinemia were evaluated for macroprolactinemia by polyethylene glycol (PEG) precipitation and gel fi ltration chromatography (GFC). Recoveries 40% but 50%. The incidence of macroprolactinemia in our cohort of hyperprolactinaemic patients was noted to be 4.4%. Conclusion: Macroprolactin is a signifi cant cause of misdiagnosis, unnecessary investigation, and inappropriate treatment and hence it is useful to screen all patients with high PRL levels with PEG precipitation and to apply GFC to samples with recoveries <50%.