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Proteinuria and Hypertension with and and without type 2 diabetes mellitus: An Update

The Singapore Family Physician.2019;45(2):6-12.

In this update four related areas are reviewed. They are: (1) Blood Pressure (BP) definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 mmHg to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

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Insulin Therapy in Type 2 Diabetes Mellitus

Hwee Huan Tan ; Chee Fang Sum

The Singapore Family Physician.2019;45(2):13-15.

Initiation of insulin therapy is challenging in the primary care setting without nursing support. Doctors have to prepare their practices to deal with these challenges in order not to delay insulin therapy when needed.

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Obesity Updates: Understanding Obesity as a Disease and Intermittent Fasting

Lam Chih Chiang Benjamin Lam

The Singapore Family Physician.2019;45(2):16-19.

Obesity is now recognised as a chronic disease which needs chronic treatment to treat or prevent obesity related complications. This article discusses the biology of weight regulation as a basis to understanding obesity as a disease, and to appreciate the complex and multifactorial nature of the obesity problem. Finally, the article highlights the dietary approaches as part of the multi-pronged approach to treating obesity and gives a brief update on intermittent fasting.

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Initiation of Urate Lowering Therapy (ULT)

Richard Meng Kam Lee

The Singapore Family Physician.2019;45(2):20-23. doi:http://www.cfps.org.sg/publications/the-singapore-family-physician/article/1339_pdf

Mr Tan, 60, a smoker with diabetes mellitus (DM), hypertension and chronic kidney disease (CKD) Stage 3, and recurrent gout flares last five weeks of increasing intensity and duration. He assumes it is due to frequent travel and lack of exercise. He comes today for routine review of his chronic diseases. Current laboratory results are creatinine 106, eGFR 56, uric acid 490, HbA1c 7.3%, random hypocount 8.5 mmol/L. He is on glipizide 5mg bd, Metformin 250mg BD, Amlodipine 5mg OM. He complains of severe gout pain. He had always been reluctant to start definitive treatment which you had previously mentioned. What will you do next?

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Assessment and Management of Non-alcoholic Fatty Liver Disease

Desmond Chun Tao Wai

The Singapore Family Physician.2019;45(2):24-26.

Non-alcoholic fatty liver disease (NAFLD) has become the commonest chronic liver disease in the world. Overall improvement in public health, active screening of blood products, and universal vaccination of hepatitis B have led to a drop in incidence of hepatitis B and C worldwide. NAFLD is strongly associated with metabolic syndrome. With the rise in overweight status and obesity worldwide, it is not surprising that NAFLD is on the rise. Diagnosis of NAFLD requires confirmation of fatty infiltration in liver, as well as liver damage such as elevated liver enzymes and presence of fibrosis. Currently, the best treatment for NAFLD is weight loss, and the proven method would be dieting with regular exercises. Vitamin E and pioglitazoles are promising medications for treating NAFLD, but each medication has their shortcomings. Until more studies are conducted, lifestyle modification remains the only reliable way to treat NAFLD. Family physicians ought to look out for cardiovascular diseases, as well as being vigilant in cancer screening, as NAFLD is associated with higher risks of ischemic heart disease and cancer.

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Heart failure with normal and reduced ejection fraction - assessment and shared care management

Rohit Khurana

The Singapore Family Physician.2019;45(2):27-31.

Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders. HF due to left ventricular dysfunction is categorized into HF with reduced ejection fraction (with Left Ventricular Ejection Fraction (LVEF) ≤50 percent, known as HFrEF; also referred to as systolic HF) and HF with preserved ejection fraction (with LVEF >50 percent; known as HFpEF; also referred to as diastolic HF.1 A reduced LVEF in systolic heart failure is a powerful predictor of mortality. As many as 40 -50 percent of patients with heart failure have diastolic heart failure with preserved left ventricular function. Overall, there is no difference in survival between diastolic and systolic heart failure that cannot be attributed to ejection fraction. Patients with diastolic heart failure are more likely to be women, to be older, and to have hypertension, atrial fibrillation, and left ventricular hypertrophy, but no history of coronary artery disease.2,3 The pathogenesis of diastolic dysfunction involves abnormalities of active ventricular relaxation and passive ventricular compliance, which lead to ventricular stiffness and higher diastolic pressures. These pressures are transmitted through atrial and pulmonary venous systems, reducing lung compliance. A combination of decreased lung compliance and cardiac output leads to symptoms.

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Asthma and Inflammation

Adrian Chan

The Singapore Family Physician.2019;45(6):5-6. doi:https://doi.org/10.33591/sfp.45.6.u1

Asthma is a chronic inflammatory airway disease, for which the cornerstone of asthma therapy is inhaled corticosteroids. However, long term clinical outcomes are variable, and not all patients respond optimally to corticosteroids. Underpinning this observation is that asthma is a heterogeneous disease consisting of phenotypes that are driven by different inflammatory pathways. In this article, we will discuss the different inflammatory mechanisms of asthma to better define patient characteristics and help improve patient outcomes with newer specific-targeted asthma therapies.

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The Role of Airway Inflammation in Asthma

Hui Fang Lim

The Singapore Family Physician.2019;45(6):7-10. doi:https://doi.org/10.33591/sfp.45.6.u2

Uncontrolled airway inflammation contributes to persistent asthma symptoms and risks of exacerbations and airway remodelling. many asthma patients are non-adherent to inhaled corticosteroid (ICS) treatment and have a discordance between subjective symptom perception versus actual control of asthma, i.e. airway inflammation. Objective measurements of airway inflammation, e.g. fENO and sputum cell count quantification can aid clinical management. Nonetheless, there are many limitations in the tests’ availability and interpretation. Hence, these tests are used mainly for difficult-to-treat or severe airway diseases. In the 2019 Global Initiative for Asthma (GINA) strategy report, short-acting beta-agonist (SABA) monotherapy is no longer recommended in Step 1 and ICS is recommended across all asthma severity to emphasize the importance of controlling airway inflammation. Doctors should discuss and recommend the most appropriate ICS therapy (dosing regimen and inhaler device) that is acceptable to the patient, to promote adherence. Appropriate use of ICS is crucial in achieving the management targets of asthma: maintenance symptom control and prevention of asthma risks.

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Spirometry in Asthma

Esther Pang

The Singapore Family Physician.2019;45(6):11-14. doi:https://doi.org/10.33591/sfp.45.6.u3

Asthma is a common respiratory condition seen in primary care. It is characterised by common respiratory symptoms and variable expiratory airflow limitation due to underlying chronic airway inflammation. Diagnosis should be established promptly to prevent misdiagnosis and inappropriate management. Objective lung function assessment is therefore recommended to guide the primary care physician. This article describes the use of spirometry, its role in the diagnosis of asthma and assessment of asthma control. Barriers to the use of spirometry in primary care are also discussed with suggested interventions.

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A New Lease of Life - Living With Disability and Renal Dialysis

Rose Wai Ye Fok ; Sher Guan Luk Low ; Farhad Fakhrudin Vasanwala

The Singapore Family Physician.2019;45(6):25-28. doi:https://doi.org/10.33591/sfp.45.6.up1

Based on the National Health Survey in 2010, almost half a million Singaporeans have diabetes, higher than the global prevalence. Diabetes is associated with a host of complications including heart disease, stroke, kidney failure, blindness and amputation. In 2016, Singapore declared a ‘war on diabetes’ to decrease the incidence of diabetes and its complications. Beyond providing healthcare resources, tackling diabetes requires the shifting of mindsets and changing of habits. The case study illustrates how biopsychosocial factors play a role in the optimal care of a diabetic patient. Self-management, acceptance, empowerment and health literacy are essential components to good diabetic care. System and support factors, as well as excellent communication with healthcare providers, are advocated as strategies to optimise outcome.

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