1.Diabetes control- the legacy of a memory
Journal of University of Malaya Medical Centre 2009;12(2):47-56
Achieving and maintaining good glycaemic control remains an important goal in the management
of this common and prevalent disorder. Recent evidence from important megatrials, ACCORD,
ADVANCE, VADT, UKPDS-10 year follow-up as well as the STENO-2 follow-up study, have cleared
doubts concerning the benefits of targeting good glycaemic control. For the first time, we have
the reassurance that macrovascular benefits can be realised from good glycaemic control. The
legacy effect of prior good glucose control from the UKPDS-10 year follow-up, reinforces the
results seen from the DCCT-EDIC (for Type 1 diabetes). The Intervention Phase of the UKPDS
revealed benefits for reduction of microvascular complications, while it was only at the end of
the Post-Trial Monitoring Phase where significant improvements in both micro and macrovascular
outcomes were seen.
The other three Trials assessing the effect of glycaemic control on cardiovascular outcomes,
although largely negative for CV benefit, give valuable insight towards appropriate patient
characteristics for which aggressive glucose control can and should be instituted. Individualising
glycaemic targets, which has been the approach that many clinicians have been practising, has
received new impetus albeit with clearer details.
Getting to glycaemic goal early in the course of T2DM and Doing to Safely (Avoiding hypoglycaemia)
are the key ingredients to successful management. The legacy of the memory of initial good
metabolic/glycaemic control is investment in good health with benefits of reductions in both
micro and more importantly, macrovascular disease, years later.
Multifactorial interventions that include blood pressure, lipid lowering in addition to glucose
control in these individuals with the Metabolic Syndrome result in more immediate beneficial
additive effects on cardiovascular outcomes.
Diabetes Complications
2.Management of postmenopausal osteoporosis
Malaysian Family Physician 2013;8(2):36-40
3.Oncogenic osteomalacia, you say? better start looking then - a case report
Vijay AP ; Tan ATB ; Suhaida AM ; Chan SP
Journal of University of Malaya Medical Centre 2010;13(1):63-68
Tumour-induced or oncogenic osteomalacia (OOM) is a rare paraneoplastic syndrome characterized
by bone pain and muscle weakness. A biochemical profile consisting of normocalcaemia,
hypophosphataemia, phosphaturia, increased serum alkaline phosphatase and inappropriately
low serum levels of 1, 25-dihydroxyvitamin-D is diagnostic. OOM is usually caused by an osseous
or soft-tissue tumour of mesenchymal origin that secretes phosphaturic substances leading to
increased urinary phosphate wasting. These tumours are small and slow growing. The diagnosis
continues to be easily missed and when eventually made, localization of the tumour can be
difficult. We describe the case of a young man who presented with severe generalized pain
associated with muscle weakness. He was extensively investigated and eventually diagnosed to
have OOM 3 years after initial presentation. Specialized investigations were necessary to localize
the offending tumour.
4.Carbimazole-induced aplastic anaemia - a case report
Vijay AP ; Lim SS ; Tan ATB ; Rokiah P ; Chan SP
Journal of University of Malaya Medical Centre 2009;12(2):92-95
Antithyroid drugs have been used for more than 50 years for the management of hyperthyroidism.
Most patients tolerate treatment well, but some may develop rare life threatening side effects such
as agranulocytosis and aplastic anaemia. Clinical experience with the latter condition is extremely
limited. We report on a case of carbimazole-induced aplastic anaemia caused by hypocellular bone
marrow and associated plasmacytosis in a thyrotoxic patient chronically treated with carbimazole.
This resolved after substitution with propylthiouracil. The clinical course was complicated by
neutropaenic septicaemia and atrial fibrillation.
Thyrotoxicosis
5.Carbimazole-related agranulocytosis in pregnancy - A case report
Lim SS ; Shireene V ; Vijay A ; Tan TBA ; Rokiah P ; Chan SP
Journal of University of Malaya Medical Centre 2007;10(1):34-38
We report a 33-year-old Malay lady who presented with fever, tonsillitis and pharyngitis
a month after initiation of antithyroid therapy (carbimazole 15 mg tds) for thyrotoxicosis by her general
practitioner. She was still clinically and biochemically thyrotoxic but not in thyroid storm. At that
time, she was also confirmed to be four weeks pregnant. Her full blood count revealed neutropaenia
with an absolute neutrophil count of 0.036 × 109/L. Bone marrow aspirate and trephine were compatible
with carbimazole-related agranulocytosis. Carbimazole was discontinued and she was given broad
spectrum antibiotics and Granulocyte Colony Stimulating Factor (GCSF), to which she responded.
Verapamil was used for symptomatic heart rate control instead of beta-blockers as she had a history of
bronchial asthma. The patient subsequently opted for termination of pregnancy after which she was
given radioactive iodine I131 (10 mCi) for definitive therapy of her thyrotoxicosis. In conclusion,
carbimazole-related agranulocytosis is an important entity to recognise and treat early to prevent
morbidity and mortality. Termination of pregnancy was carried out as the treatment given during the
episode of agranulocytosis may have negative effects on foetal viability and growth.
6.Metabolic syndrome amongst patients with psoriasis in a tertiary dermatology centre, Malaysia
Lee YY ; Lim SS ; Lee CK ; Tan ATB ; Ananda V ; Rokiah P ; Chan SP
Malaysian Journal of Dermatology 2011;27(-):6-6
Background: Psoriasis has been shown to be associated with a higher risk of metabolic syndrome and cardiovascular disease.
Objective: To investigate the prevalence of metabolic syndrome among patients with psoriasis and study the association between psoriasis and cardiovascular risk factors.
Methods: This was a hospital based case-control study conducted at the Dermatology Clinic, University Malaya Medical Centre (UMMC) from May 2010 to March 2011. A total of 131 adult patients with psoriasis and 129 age-, gender- and race-matched controls were recruited. All subjects answered a standardised cardiovascular risks questionnaire and had anthropometric measurements recorded. Laboratory investigations included fasting glucose / lipid profile, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), urine microalbumin:creatinine ratio and an electrocardiogram. The diagnosis of metabolic
syndrome was made using the harmonised criteria for metabolic syndrome in South East Asians. Statistical analysis was performed using statistical processing software (SPSS-17).
Results: Metabolic syndrome was significantly higher among patients with psoriasis (64.9% versus 51.9%) (p = 0.034). The presence of metabolic syndrome was associated with low high density lipoprotein (HDL) (p=0.002) and high triglyceride (TG) levels (p = 0.014). The prevalence of diabetes mellitus was also significantly higher among patients with psoriasis (46.6% versus
27.1%) (p = 0.001). Hypertension, ischaemic heart disease, low density lipoprotein (LDL) levels, smoking and obesity were not significantly higher among patients with psoriasis.
Conclusion: Our results demonstrate an association between psoriasis and metabolic syndrome which was primarily due to diabetes mellitus and dyslipidaemia.
8.Cost-effectiveness of olaparib versus routine surveillance in the maintenance setting for patients with BRCA-mutated advanced ovarian cancer after response to first-line platinum-based chemotherapy in Singapore
David SP TAN ; Jack Junjie CHAN ; Robert HETTLE ; Wrik GHOSH ; Amrita VISWAMBARAM ; Cindy Chen YU
Journal of Gynecologic Oncology 2021;32(2):e27-
Objective:
To evaluate the cost-effectiveness of olaparib as a maintenance treatment versus routine surveillance (RS) in patients with BRCA mutated (BRCAm) advanced ovarian cancer (OC) following response to first-line platinum-based chemotherapy in Singapore.
Methods:
A 4-health state partitioned survival model was developed to simulate the lifetime (50 years) incremental cost-effectiveness ratio (ICER) of olaparib versus RS from a healthcare payer perspective. Progression-free survival, time to second disease progression, and overall survival were estimated using SOLO-1 data and extrapolated beyond the trial period using parametric survival models. Any patient who remained progression-free at year 7 was assumed to be no longer at risk of progression. Mortality rates were based on all-cause mortality, adjusted based on BRCA1/2 mutation. Health state utilities and adverse event frequencies were from SOLO-1. Drug costs were from local public healthcare institutions. Healthcare resource usage and costs were from local clinician input and publications. A 3% discount rate was applied to costs and outcomes. Deterministic and probabilistic sensitivity analyses (PSA) were performed to assess the robustness of results.
Results:
The base-case analysis of olaparib maintenance therapy versus RS resulted in an ICER of Singapore dollar (SGD) 19,822 per quality-adjusted life-year (QALY) gained. The ICER was most sensitive to variations in the discount rate. PSA demonstrated that olaparib had an 87% probability of being cost-effective versus RS at a willingness-to-pay of SGD 60,000 per QALY gained.
Conclusion
Olaparib has a high potential of being a cost-effective maintenance treatment versus RS for patients with BRCA1/2m advanced OC after response to first-line chemotherapy in Singapore.