JANUARY 2015

IBD on the rise in Asia,

most cases reported
in China

FORUM
Alcohol
in all policies

CONFERENCE
Fracture risk
in diabetics
underestimated

CONFERENCE
Novel therapeutic
interventions
for gastroparesis

CONFERENCE
Involve family
physicians in
community
palliative care,
say experts

JA N UA RY 2 01 5

IBD on the rise in Asia, most cases

reported in China
ELVIRA MANZANO

here has been a progressive increase in

the incidence and prevalence of inflamma-

tory bowel disease (IBD) in Asia, characterized

by complicated disease behavior and significant morbidity, says an expert at the recent Asia
Pacific Digestive Week conference held in Bali,
Indonesia.
IBD has been traditionally known as a dis-

or perianal disease] was more common in Asia

than in the West, said Ng.

ease of the West and is relatively rare in Asia.

In Hong Kong, for example, a study showed

However, time trend studies from Japan, Korea

the rate of perianal disease was 29.2 percent com-

and Hong Kong have collectively shown a two-

pared with 15.8 percent in Australia (p=0.001). [J

to-three fold increase in the incidence and preva-

Gastroenterol Hepatol 2012; 27:1266-1280]

lence of IBD in the past 10 years, said Professor

These changes may have been due to our

Siew Chien Ng from the Department of Medicine

increased contact with the West, westernization

and Therapeutics, Chinese University of Hong

of diet, improved hygiene, increasing antibiotic

Kong in Hong Kong.

use, immune dysregulation and changes in the

In the first large scale population-based

gut microbiota, Ng said. Asian patients with

study of IBD involving seven countries in Asia

CD have altered microbiota compared with their

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

Caucasian counterparts. Mucosa-associated mi-

sia, Singapore, Sri Lanka) and Australia, the

crobiota in IBD may also differ geographically.

incidence of IBD varied from 0.54 to 3.44 per

In a more recent population-based case-con-

100,000 individuals. China had the highest in-

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

cidence of IBD at 3.44 per 100,000. Ulcerative

vestigator, breastfeeding, having pets and better

colitis (UC) was more prevalent than Crohns

sanitary conditions were shown to be protective

disease (CD), although the incidence of CD was

of IBD, suggesting that childhood environment

rapidly increasing in certain areas. [Gastroen-

plays an important role in modulating disease

terol 2013;145:158-165]

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

Although family history of IBD was less com-

doi: 10.1136/gutjnl-2014-307410]

mon in Asia as were extra-intestinal manifesta-

The results, Ng said, highlight the importance

tions complicated CD [penetrating, stricturing

of childhood immunological, hygiene and dietary

JA N UA RY 2 01 5

factors in the pathogenesis of IBD, suggesting

CD in Asians, but TNF-SF15 polymorphisms are

that markers of altered intestinal microbiota may

strongly associated with CD.

modulate risk of IBD later in life.

Understanding of the genetic variation and

There are also differences in the genetic

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

mutations of IBD between Asians and Cauca-

logical pathways causing the disease and to

sians, which may impact the development of

discover better drugs for patients. More stud-

IBD, added Ng. NOD2 and autophagy variants

ies are warranted to determine the critical etio-

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

logic factors for IBD, Ng said.

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JA N UA RY 2 01 5

Linagliptin plus metformin combo

safe and effective in Asian patients
with newly diagnosed T2DM
RADHA CHITALE

ombined oral antidiabetic therapy with lin-

apy was 3 percent compared with 1.84 percent

in the monotherapy group (p<0.0001).

agliptin plus metformin was well tolerated

Patients on combination therapy demonstrat-

and successfully brought down HbA1c levels

ed early saturation of greater glycemic levels

in newly diagnosed Asian patients with type 2

such that by week 6 there was a significant differ-

diabetes mellitus (T2DM) with very high blood

ence in glucose levels between the study arms.

sugar levels.

Patients with greater hyperglycemia (9.5

Linagliptin is a dipeptidyl peptidase (DPP)-4

percent) experienced greater HbA1c reductions

inhibitor, a class of drug which has been shown

by the end of the trial compared with those with

to lead to less weight gain and a lower risk of

lower baseline HbA1c (<9.5 percent).

hypoglycemia compared with insulin treatment.

Sixty-percent of patients on combination thera-

A recent multinational trial of patients with

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

untreated T2DM for less than a year includ-

pared with 21 percent in the monotherapy arm. Pa-

ed patients with HbA1c between 8.5-12 per-

tients on linagliptin alone gained about 1.3 kg while

cent who were randomized to linagliptin plus

those on combination therapy lost 0.45 kg.

metformin (n=159) or to linagliptin mono-

There was a fairly low percentage of cases

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

of hypoglycemia, including severe hypogly-

doi:10.1111/dom.12399]

cemia. There were some gastrointestinal dis-

A subgroup of patients recruited from five

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

orders reported, but none leading to discontinuation in either arm.

ippines, Thailand) had baseline characteristics

The combination of linagliptin plus metfor-

among the linagliptin plus metformin (n=62)

min led to clinically important HbA1c reduc-

and linagliptin monotherapy (n=63) groups

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

of median age about 48 years, median HbA1c

ald Ma of the Chinese University of Hong Kong.

about 10 percent, and median fasting plasma

This suggests that early combination [thera-

glucose of 188 mg/dL in the combination arm

py] may be a useful strategy in Asian patients.

and 195 mg/dL in the monotherapy arm. There

He noted that the results represent a post-

was some microvascular disease in both arms.

After 24 weeks, among the Asian patients,
mean reduction in HbA1c with combination ther-

hoc analysis of a small subgroup and that the

findings should benefit from the results of ongoing larger-scale trials.

JA N UA RY 2 01 5

FORUM

Alcohol in all policies

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

hree years ago, I wrote an article for the Malay Mail mourning the loss of a friend and

colleague to an alcohol-induced heart attack. He

was 41 years old and left behind two teenagers
and a toddler. On his final night alive he had been
at one of our fundraising events, and even though
he was already drunk, slurring, stumbling, he
kept drinking. Too inebriated to drive home, he
fell asleep in his car that night and never again
woke up. It was bizarre to walk into the office the
weeks after and know that he was no longer there
bizarre that I knew that simple public health regulations could have prevented his death. Public
health laws could have easily required that all alcohol servers not serve alcohol to persons who
are already drunk, or that free water be provided
at all venues where alcohol is served.

M
 any harm reductionists think
it is great if someone can be
abstinent, but if they cant, then

As a harm reductionist rather than a prohibitionist, I was intrigued to receive an email inviting me to do a keynote speech at the IOGT
World Congress on Alcohol in All Policies in Cha
Am, Thailand, in late October 2014. IOGT, or the
International Organisation of Good Templars, is

it is also great if they are stable

a very old organization believing in temperance

on medications, functioning

and, in many cases, complete abstinence from

in society with a stable job,

substances. A harm reductionist, on the other

and receiving counselling

and support they need 

hand, understands that despite prevention and

education programs, the wide availability of intoxicating substances (both licit and illicit) mean

JA N UA RY 2 01 5

FORUM

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

can be abstinent, but if they cant, then it is also

sures must be taken to reduce harm to individ-

great if they are stable on medications, function-

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

ing in society with a stable job, and receiving

without necessarily enforcing abstinence. While

counselling and support they need. An anti-

I knew that there were ideological differences

harm reduction stance is one that is harmful to

between IOGT and myself in terms of some drug

public health.

and alcohol policies, the keynote request was in

Interestingly, in terms of alcohol use, there

relation to Alcohol Regulation and Trade Agree-

was a clear difference in opinion among del-

ments, on which we shared a common interest

egates about language used at the WHO in

and agreement. I agreed to give the speech and

terms of alcohol regulation. The main WHO

travelled to Cha Am on 26 October 2014.

strategy for alcohol control and regulation is

Day 1 of the academic program began with a

titled the Global Strategy to Reduce the Harm-

session on the upcoming United Nations Gen-

ful Use of Alcohol. Pubudu Sumanasekara,

eral Assembly Special Session on Drugs in 2016

executive director of the Alcohol and Drug In-

(hereinafter the UNGASS2016). The Special

formation Centre (ADIC) in Sri Lanka, stated

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

that the terminology harmful use of alcohol

worldwide consensus that the War on Drugs,

as opposed to use of alcohol was one of the

a senseless war rooted in fear-mongering, rac-

successes of the alcohol industry in infiltrat-

ism, and punitive rhetoric, has completely failed.

ing public health policy. ystein Bakke, senior

To quote Dr. Alex Wodak, former director of the

advisor of Forut Norway, an organization work-

Drug and Alcohol Service at St Vincents Hos-

ing in alcohol policy, drugs and development,

pital in Sydney, Australia, and president of the

and women and childrens rights, disagreed,

Australian Drug Law Reform Foundation, it has

and said: the distinction may be losing a little

been an expensive way of making a bad prob-

bit of its value, and that enforcing the distinc-

lem worse. It concerned me greatly that IOGT

tion could alienate people that you would want

members considered harm reduction and hu-

to outreach to. Earlier, Bakke had pointed out

man rights arguments to be a threat to IOGT

that contrary to the perception that alcohol de-

objectives. Harm reduction, of which needle-

pendence and harmful use of alcohol was a

and-syringe exchange, condom provision, and

lifestyle disease particular to wealthy coun-

methadone maintenance therapy is a part, has

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

been proven to successfully reduce HIV infec-

cable disease deaths were in low- and middle-

tion, increase referrals to drug treatment due to

income countries.

increased interactions between drug users and

On the third day of the conference, I presented

health workers, reduce overdose deaths, and

on the impact of provisions in free trade agree-

improve quality of life and general health. Many

ments on alcohol regulation. New generation

harm reductionists think it is great if someone

trade agreements, like the Trans-Pacific Partner-

JA N UA RY 2 01 5

ship Agreement (TPPA) between the US and Ma-

gested that what is needed is enhanced label-

laysia, Singapore, Vietnam, and Brunei, among

ing with clear health warnings and nutritional

information printed on alcohol products. Such

I n terms of alcohol use,

there was a clear difference
in opinion among delegates
about language used at the

a policy, under both the TPPA and TTIP, could

constitute a technical barrier to trade and be
deemed an expropriation of the value of investments. In laymans terms, enhanced labeling would reduce profits, and so the company

WHO in terms of alcohol

would be able to sue governments at interna-

regulation 

tional tribunals. These tribunals have traditionally been pro-investor, and award unlimited

others, and the Transatlantic Trade and Invest-

damages based on expected profits of the

ment Partnership (TTIP) between the US and Eu-

company.

ropean Union, contain provisions that will restrict

Margaret Chan, executive-director of the

the ability of states to make public health policy,

WHO, rightly said that these trade agreements

including alcohol regulations. The Wine and Spir-

are being used to handcuff governments when

its Annex of the TPPA, for example, would make

acting to protect the health of its citizens. And

it difficult to place health warnings directly on the

while technical, the basic premise is simple: that

labels of alcohol products. Governments may

trade agreements should not venture into public

have to settle for a supplementary label.

health, and that civil society, academics, physi-

Martin-Moreno et al. in their 2013 article in

the European Journal of Public Health sug-

cians, and allied health professionals must rise

up against them.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

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

Involve family physicians in community

palliative care, say experts
CHRISTINA LAU

amily physicians should be involved in the

provision of palliative care, particularly in the

patient-desired community setting, said experts.

More than 90 percent of patients spend the
majority of their last year of life and receive palliative care at home, said Professor Rodger
Charlton of the Division of Primary Care, The
University of Nottingham, UK. This places GPs
and family physicians at the heart of palliative
care provision. Indeed, they value this aspect of
their work greatly.
In Hong Kong, although ambulatory palliative care is available for the terminally ill, primary
care physicians have not been involved in the

In fact, 96.8 percent of local family physi-

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

cians indicated in a survey that they should be

Specialist in Family Medicine at the Hong Kong

involved in the provision of palliative care, and

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

77.7 percent wished to provide palliative care in

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

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

113; Tse MWD, Hospital Authority Convention

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

The survey, to which 48.1 percent of members of the Hong Kong College of Family Physi-

Family physicians in Hong Kong are equipped

cians responded, also showed that 58.2 percent

and ready to provide palliative care, Hong ar-

of family physicians were currently providing

gued. Through family medicine training, they

some form of palliative care in their practice.

have acquired the concept and skills of a holistic

However, only 14 percent were providing home

approach to care, especially in the psychosocial

visits.

aspect, which is the essence of palliative care,

he said.

Barriers to family physicians provision of

community palliative care include cultural con-

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

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

is restricted and ward staff is unable to dedi-

ration networks with palliative care specialists

cate time to offer a good death experience to

and the multidisciplinary team, and knowledge

patients or assist with bereavement. [Asian J

gaps, said Hong.

Gerontol Geriatr 2011;6:103-106]

Further enhancement of primary healthcare

For GPs with an interest in providing pallia-

systems, social and medical support, and ed-

tive care, the question of whether they would be

ucation are needed to enable the provision of

surprised if a patient with advanced cancer died

continuity of care by teams involving family phy-

in the following year was shown to provide an

sicians, he continued.

accurate survival prognosis. According to researchers, this surprise question can be used

D
 ying naturally with dignity is
besieged by bureaucracy in both
Hong Kong and the UK
As for patients, 81.8 percent of those with
terminal cancer in a palliative care unit of a
public hospital in Hong Kong indicated they

to help identify patients who may need end-oflife care planning. [Palliat Med 2014;28:959-964]

T
 here is a need for doctors to stop
seeing death as the enemy because
death is not a failure of medicine

wished to have home visits by healthcare pro-

Having identified these patients, the next

fessionals when needed. Thirty-seven percent

step is to talk to them and their family members

wished to stay at home during the pre-termi-

about death, about their fears and concerns,

nal period, while 19 percent wished to die at

said Charlton.

home. [Hong TC, et al, Hospital Authority Convention 2010]

There is a need for doctors to stop seeing

death as the enemy because death is not a fail-

Two important elements of a good death

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

are to have choice and control over where death

emphasized. However, we sometimes try to keep

occurs, and who is present and shares the end.

people alive longer than we should.

However, dying naturally with dignity is be-

There is a growing movement of feeling that

sieged by bureaucracy in both Hong Kong and

we should be aiming for a good death and not

the UK, said Charlton.

a prolonged one, he continued. We should

As a result, inappropriate hospital admis-

focus on building a healthcare system that will

sions are common in Hong Kong, he contin-

help dying patients achieve what is important to

ued. Almost all elderly patients with terminal or

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

irreversible chronic illnesses die in an unfamiliar

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

acute hospital environment, where visiting time

life care provision.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

10

19th Congress of Asian Pacific Society of Respirology (APSR), November

13-16, Bali, Indonesia

Attitude determines outcome,

treatment strategy in asthma
PANK JIT SIN

asthma patients through personalized solutions

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

he findings of the Recognise Asthma and

Wang went on to describe each clusters

Link to Symptoms and Experience (RE-

character profile, with the Well Adjusted ones

ALISE) survey reveals that asthma patients

being able to cope well with their asthma and

can be segmented into distinct and action-

being minimally impacted in their daily lives,

able groups based on their attitude towards

both emotionally and functionally. Additionally,

asthma.

they are happy to go along with their doctors

Dr. Aileen David-Wang, clinical associate pro-

advice and have no problem using their inhaler

fessor, University of the Philippines Philippine

a reflection of their carefree attitude and lower

General Hospital, said the survey was aimed at

stress levels.

identifying distinct and explicit patient clusters

The Rejectors are patients who have to come

in Asia, defined by their differing attitudes, ad-

to terms with the emotional burden of living with

herence, educational needs and other important

asthma, and their asthma is generally well con-

attributes.

trolled. The refusal to accept their disease state

The survey assigned patients into one of five

is reflected in their tendency to deprioritize their

clusters Well Adjusted; Rejector; Lost; Endur-

health. This cluster is also particularly conscious

er; and Worrier. The attitudes of patients could

about using the inhaler in public.

confidently determine their asthma control

Those in the Lost cluster generally have a high

based on the Global Initiative for Asthma (GINA)-

level of stress and anxiety about their poorly con-

defined criteria. The Well Adjusted and Rejector

trolled asthma. This leads to a rejection of their

clusters typically had a high level of asthma con-

asthma status, their doctor and their inhaler, said

trol. The Lost and Endurer clusters experienced

Wang. The Lost tend to be evasive and avoid

low asthma control, while the Worriers had the

thinking about their health problems (asthma),

lowest control of asthma. Wang said each clus-

despite being emotionally and functionally af-

ter has different information needs and requires

fected by it. However, they frequently seek infor-

a tailored management approach.

mation regarding asthma, suggesting that they

Through proper matching of patients attitudinal cluster, doctors can optimally manage

have unanswered questions and are at a loss for

answers.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

11

Meanwhile, the Endurers are those who have

The cluster most troubled by their asthma

resigned themselves to the fact that they have

are the Worriers. To them, asthma is a constant

asthma and that they have no control over the

bother and always on their mind. Worriers are

disease. Even though their level of confidence

able to come to terms with being labeled as

in managing their asthma is low, the situation

asthmatic and acknowledge the seriousness of

doesnt impact their daily life, emotionally or func-

asthma, but live with a high level of stress and

tionally. The Endurers are fine with using their in-

anxiety over the disease. This is reflected in the

haler (in public) and are less interested in finding

high level of concern they have regarding their

out more about asthma compared to other poorly

asthma and the high frequency of information

controlled clusters.

seeking, noted Wang.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

12

19th Congress of Asian Pacific Society of Respirology (APSR), November

13-16, Bali, Indonesia

Harm from man-made fibers unclear

PANK JIT SIN

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

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

an-made fibers are defined as those

mono81.pdf Accessed on 9 December]

whose chemical composition, structure

Faisal noted that cancer is now a leading

and properties are significantly modified during

cause of death, with 12.7 million new cases and

the manufacturing process. These are spun and

7.6 million deaths in 2008. The World Health

woven into a number of consumer and industrial

Organization (WHO) attributes 19 percent of all

products such as rayon, nylon and dacron. On

cancers as being caused by the environment,

the other hand, natural fibers are composed of

including at work, with about 1.3 million deaths

biologically produced compounds such as cel-

each year.

lulose and protein. Such fibers emerge from the

Of this number, one in 10 lung cancer deaths

manufacturing process in a relatively unaltered

are closely related to risks in the workplace. Ac-

state, for example, silk and cotton.

cording to the WHO, lung cancer, mesothelioma

Speaking on the topic of man-made fibers and

and bladder cancer are among the most com-

the relationship with cancer, Professor Faisal Yu-

mon types of occupational cancers. For cancers

nus, senior lecturer, Department of Pulmonology

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

and Respiratory Medicine, Faculty of Medicine,

haust and chromium compounds are linked to

University of Indonesia, said the fibers studied were

carcinogenicity in humans. Additionally, crystal-

made from various components and largely used

line silica dust, soot, tobacco smoke and outdoor

in the electrical and insulation industry, especially

particulates are also proven lung carcinogens.

wool and filament types.

However, there is insufficient evidence from

The International Agency for Research on Can-

both animal and human studies for carcino-

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

genicity of fibers such as continuous glass

dence of carcinogenic effects of glass wool, con-

filament, alkaline earth silicate wool, high-

tinuous glass filament rock wool, slag wool and

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

refractory ceramic fibers in humans. However,

mal studies indicating that man-made vitreous

experimental evidence abounds for carcinogenic-

fibers are potentially carcinogenic are also

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

inconclusive.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

13

19th Congress of Asian Pacific Society of Respirology (APSR), November

13-16, Bali, Indonesia

Air pollution a leading preventable

cause of death worldwide
CHUAH SU PING

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

significant as it led to increased public aware-

ir pollution is one of the major causes of

ness, government regulation and environmental

mortality globally.

research, he said. The level of pollution noted

Ambient air pollution was estimated to have

in the 1952 smog in London, can now be seen

caused an excess of 3.7 million premature

in key cities in China, in particular Beijing, and

deaths in 2012, with 88 percent of these excess

India.

deaths having occurred in low- and middle-in-

Indoor air pollution is also a major concern.

come countries, said Professor Emeritus Nor-

Up to 3 billion people rely on the burning of

bert Berend, head of Respiratory Research at

biomass fuels indoors as a source of heating

the George Institute for Global Health, Sydney,

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

Australia. He noted that the causes include rapid

mately 4.3 million deaths yearly. Of that figure,

industrialization, increased motor vehicle traffic

1.69 million deaths are from Southeast Asia,

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

and 1.62 million are from the Western Pacific

The many effects of air pollution can be di-

region, said Berend. Worldwide, he noted, the

vided into acute and chronic effects. Acute ef-

use of biomass fuels is especially high in ur-

fects include respiratory symptoms, cardiovas-

ban slum populations.

cular events, hospitalizations and mortality, and

As healthcare practitioners, what we need

these are more pronounced in people with un-

to do now is to continue to advocate for lung

derlying respiratory or cardiovascular diseases.

health to the public, government health depart-

Chronic effects range from reduction of lung

ments as well as international agencies. Whilst

growth in children and adolescents, reduced

it is important that we continue the anti-smok-

lung function in adults and lung cancer, said

ing lobby, we must also demand an upgrading

Berend.

of international air quality standards as well as

Berend highlighted the Great Smog of 1952,

adherence to these standards. We also need

which was a severe air-pollution event that af-

to push for increased research funding from

fected London from December 5-8 in 1952. The

individuals, national and international respira-

Great Smog is known to be the worst air pollu-

tory societies to improve the field of respiratory

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

health.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

14

19th Congress of Asian Pacific Society of Respirology (APSR), November

13-16, Bali, Indonesia

Natural disasters can affect lung health

RADHA CHITALE

eases, about 180,000, occurred within the first 12

weeks following the disaster.

atural disasters have significant direct and

Large natural disasters can cause existing

indirect effects on lung health and can

healthcare services to break down resulting in a

have long-term repercussions, particularly in

lack of medical care for routine pulmonary events.

the Asia-Pacific region, where 80 percent of the

Healthcare workers are also at risk for physical

worlds natural disasters in the 20th and 21st

injury, infection, and may be worried about the

centuries have occurred.

safety of their own families.

Earthquakes, tsunamis, volcano eruptions

Patients with existing pulmonary disease are

and typhoons can be violent and dirty, exposing

at risk during natural disasters if there are disrup-

people in the area to harmful particulate matter

tions to power for oxygen delivery, routine medi-

and microbes. Efforts to gather people together

cines for asthma or chronic obstructive pulmo-

for care immediately after a disaster can lead to

nary disorder, or if there is no physiotherapy or

further harm.

other services for people with chronic diseases

Respiratory infectious diseases are the main

like cystic fibrosis.

problem, said Dr. Bruce Robinson of the Univer-

To be prepared, Robinson recommended

sity of Western Australia and director of the Na-

backup power sources, medication stores,

tional Centre for Asbestos Diseases Research in

and adequate transport plans to move patients

Perth, Australia.

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

Following a tsunami, for example, there is water everywhere creating lots of places for mosquitoes the disease vectors to breed.

395]
There are four main direct effects of disasters
on the lungs.

Crowding following a disaster can lead to

Small particles of smoke or toxic gases from

rapid infection spread due to exposure. Diseases

fires or volcanic emissions can be inhaled, and

such as measles, acute lower respiratory tract

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

infection, and tuberculosis all of which can be

and be poisoned by carbon monoxide.

fatal without prompt, appropriate treatment can

spread quickly.

The 1997 haze fires in Indonesia caused over

500 haze-related deaths in 3 months as well as

Following the 2004 earthquake and tsunami

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

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

chitis, and 1.5 million respiratory infections, Rob-

cent) of the consultations for communicable dis-

inson said.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

15

Aspirating water can introduce water-borne

As a chest physician, its important to engage

pathogens to the lungs. Direct trauma to the chest

with the psychological trauma after a disaster...

when buildings fall down can result in rib fractures

What Ive found is that its very important to talk

or diaphragm rupture.

to the patients because no one else is talking to

Psychological trauma following a natural di-

them, he said. Particularly when a mass group is

saster can also result in physical manifestations

affected, it becomes important for the doctor to

that need to be managed, Robinson said.

engage.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

16

IOF Regionals, 5th Asia-Pacific Osteoporosis Meeting 2014, November

14-16, Taipei, Taiwan Chuah Su Ping reports

Fracture risk in diabetics

underestimated

he potential for fracture in patients with diabetes may be underestimated, as some of

the major fracture assessment tools that are

available do not take into account diabetes as
a risk factor.
Fractures are a common complication of
diabetes, with common fracture sites including
the hip, wrist and spine, said Dr. Jung Fu Chen
of the Division of Endocrinology and Metabolism (Osteoporosis Clinic) at Chang Gung Me-

underestimated observed major osteoporot-

morial Hospital, Kaohsiung, Taipei. However,

ic and hip fracture risk in diabetics (adjusted

despite the metabolic abnormalities of diabe-

for competing mortality), thus suggesting that

tes which do affect bone metabolism, structure

diabetes might be considered for inclusion in

and bone mineral density (BMD), the associa-

future iterations of FRAX. However, more re-

tion between increased fracture risk in individu-

search is required in collecting new population

als with type 1 and 2 diabetes continues to be

cohorts worldwide before this risk factor can be

debated.

included in the FRAX, Chen opined.

Chen noted that the current algorithm of the

More recently, a Taiwanese study evaluat-

WHO fracture risk assessment tool (FRAX )

ed fracture risk and post-fracture mortality in

does not include diabetes as a risk factor. In

patients with diabetes. Using data obtained

2012, researchers reported that diabetes was

from Taiwans National Health Insurance Da-

a significant predictor of subsequent major

tabase, they identified 32,471 adults with

osteoporotic fracture after controlling for age,

newly diagnosed diabetes from 2000-2003;

sex, medication use and FRAX risk factors in-

and fracture events from 2000-2008 from

cluding BMD. Diabetes, they reported, was

medical claims.

also associated with significantly higher risk

Based on 652,530 person-years of follow-

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

up, they noted that the incidences of fracture

2012;27:301-308]

for people with and without diabetes were 24.2

The investigators concluded that the FRAX

and 17.1 per 1,000 person-years, respectively

JA N UA RY 2 01 5

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17

(p<0.0001). Compared with people without

pendently associated with an increased risk of

diabetes, diabetics face a higher risk of frac-

fracture. The ARIC study supports recommen-

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

dations from the American Diabetes Associa-

also found that the odds ratios of post-fracture

tion for assessment of fracture risk and imple-

deep wound infection, septicemia, and mortal-

mentation of prevention strategies in persons

ity associated with diabetes were 1.34 (95% CI,

with diabetes, particularly those with poor glu-

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

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

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

1158]

[Diabetes Care 2014;37:2246-2252]

With the ever-growing population of diabet-

Similarly, investigators from the Atheroscle-

ics in Asia, coupled with an increasing aging

rosis Risk in Communities (ARIC) Study a

population, a multidisciplinary team approach

US-based study with patients recruited from

which includes bone care is very crucial for the

four US communities had reported that di-

integrated management of diabetic patients,

agnosed diabetes was significantly and inde-

concluded Chen.

JA N UA RY 2 01 5

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18

IOF Regionals, 5th Asia-Pacific Osteoporosis Meeting 2014, November

14-16, Taipei, Taiwan Chuah Su Ping reports

Osteoporotic fractures in men

highlights from the MrOS study

ractures resulting from osteoporosis are a

major healthcare challenge in men, yet the

rate of detection and management of male osteoporosis lags well behind that in women, according to an expert.
The residual lifetime risk of experiencing an
osteoporotic fracture in men 50 years old and
above is estimated to be approximately 27 percent. [Osteoporosis Int 2001;12:124-130] In
comparison, the risk of developing prostate cancer in men over the age of 50 has been calculated at around 11 percent. [Cancer Epidemiol
Biomarkers Prev 1997;6:763-768]
The Osteoporotic Fractures in Men (MrOS)
Study is a prospective cohort study designed

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

to examine the extent to which fracture risk

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

is related to bone mass, bone geometry, life-

More recently, another paper from the MrOS

style,

neuromuscular

study noted that men with accelerated femoral

measures, and fall propensity, as well as to

neck BMD loss had an increased risk of hip and

determine how fractures affect quality of life

other non-spine fractures. [J Bone Miner Res

in men, said Dr. Eric Orwoll, professor of

2012;27:2179-2188]

anthropometric

and

Medicine and director of the Bone and Mineral

While the MrOS study has provided fur-

Clinic at Oregon Health and Science Universi-

ther understanding of osteoporosis fractures in

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

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

2005;26:569-585]

for example, raised the question of whether or

To date, the MrOS study has helped estab-

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

lish that although women have a higher risk of

range requiring treatment) should have a repeat

fracture, the association between bone mineral

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

density (BMD) and fracture risk is clearly evi-

er or not to treat men with the greatest rate of

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

19

bone loss earlier, said Orwoll. The researchers

twice the risk of radiographic vertebral frac-

concluded that further research was still need-

tures over time compared with men who did

ed in order to determine if repeat BMD testing

not perform poorly on any test, said Orwoll. [J

and subsequent treatment in such a popula-

Bone Miner Res 2014;29:2101-2108]

tion would be cost effective. [J Bone Miner Res

2012;27:2179-2188]

The MrOS study is still ongoing, and next

phase aims to provide further understanding

Orwoll also highlighted a MrOS substudy

of the trajectories of change in musculoskel-

which showed an association between poor

etal health, and how they affect important

physical performance and the likelihood of in-

outcomes such as fracture, and physical dis-

cident vertebral fractures. The investigators

ability, said Orwoll. Using high resolution mi-

concluded that men who performed poorly on

cro-computed tomographic imaging, our goal

several tests chair stand, walking speed, leg

is to further assess the relationship between

power, narrow walk and grip strength had

bone microstructure and fracture risk.

JA N UA RY 2 01 5

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20

IOF Regionals, 5th Asia-Pacific Osteoporosis Meeting 2014, November

14-16, Taipei, Taiwan Chuah Su Ping reports

Soy isoflavones and carotenoids

have gender-specific protective
roles against hip fractures

oy food intake is associated with a reduced

questionnaire (which all participants were re-

risk of osteoporotic hip fractures in women

quired to complete) and the summation of the

but not in men, according to research from the

[isoflavone] content of all the seven soy foods

Duke-NUS Graduate Medical School, Singa-

in the Singapore Food Composition Database,

pore. More recent data from the same study, the

she said.

Singapore Chinese Health Study, also suggest

This is the first study to compare the effects

that adequate intake of carotenoids may reduce

of soy on hip fracture between men and wom-

the risk of osteoporotic fractures among elderly

en in a cohort study, noted Koh. Our study

men, but not in women.

revealed a significant reduction in hip fracture

The incidence of hip fractures is rising in

in women with moderate intakes of soy isofla-

Asia, in part due to the rapidly aging popula-

vones. Conversely, no protective association

tion, however there is still a paucity of studies

was found in men with similar intakes. [Am J

among Asian populations on the dietary factors

Epidemiol 2009;170:901-909]

of osteoporosis, said Duke-NUS researcher

Koh noted that this is consistent with previ-

Associate Professor Koh Woon Puay. Koh and

ous animal studies which showed that expo-

her team prospectively examined the associa-

sure to the isoflavone genistein was linked to

tions of dietary intakes of soy isoflavones and

increased bone marrow density in the femurs of

carotenoids with hip fracture risk among elderly

adult female mice but not in male mice. [Pediatr

Chinese in the Singapore Chinese Health Study,

Res 2007;61:48-53]

a prospective cohort of 63,257 men and women

45-74 years of age.

With regards to carotenoid intake and hip fracture risk, Koh noted that among men, consump-

In their paper, Koh and colleagues noted that

tion of vegetables the main source of carotenoid

soy food products, such as plain tofu, taupok,

intake in this population was associated with

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

lower hip fracture risk. Similarly, dietary intake

drink, are common in the Singapore Chinese diet.

of total carotenoids and specific carotenoids

Total soy isoflavone intake for a given sub-

-carotene, -carotene, and lutein/zeaxanthin

ject was computed based on the food frequency

were inversely associated with hip fracture risk.

When stratified by body mass index (BMI),

JA N UA RY 2 01 5

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21

Res 2014;29:408-417]

the greatest protective effects of total vegetables

Koh concluded that, based on the hypothe-

and carotenoids were found in lean men (BMI

ses attained from these two studies, future inter-

<20 kg/m ), said Koh. There was no associa-

ventional studies should target different mecha-

tion between dietary carotenoids or vegetables/

nisms in osteoporotic fractures.

fruits, and hip fracture risk among women. The

High resolution micro-computed tomograph-

authors postulated that the antioxidant effects of

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

carotenoids may counteract the mechanism of

tionship between bone microstructure and frac-

osteoporosis related to leanness. [J Bone Miner

ture risk.

Odanacatib promising therapy

for osteoporosis in men

danacatib, a selective inhibitor of cathepsin K, has demonstrated promising po-

tential for the treatment of osteoporosis in men,

according to new results from the Long-Term
Odanacatib Fracture Trial (LOFT), which were
presented at the 5th Asia-Pacific Osteoporosis
Meeting held in Taipei, Taiwan. [Osteoporos Int
2014;25:571(OC1)]
In a phase II study in postmenopausal wom-

hip fracture. Following the promising results of

en, treatment with odanacatib 50 mg once week-

the phase II study in postmenopausal women,

ly resulted in increases in bone mineral density

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

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

trolled 24-month study to evaluate the safety

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

and efficacy of odanacatib for the treatment

sor Eric Orwoll, director of the Bone and Mineral

of men with osteoporosis, said Orwoll. This

Clinic, and of the Bone Density Lab at Oregon

is the first study of odanacatib in men with

Health and Science University, Portland, US. [J

osteoporosis.

Bone Miner Res 2012;27:2251-2258]

The primary objectives of their study were to

Men with osteoporosis represent between

assess the effect of odanacatib 50 mg weekly

20 and 25 percent of all osteoporotic patients

versus placebo on lumbar spine BMD over 24

and men are at greater risk of death following a

months; and to assess the safety and tolerability

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

22

of odanacatib 50 mg weekly compared with pla-

tion initially decreased [in the odanacatib group],

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

these were then noted to return toward levels

idiopathic osteoporosis or osteoporosis associ-

similar to that observed in the placebo group by

ated with hypogonadism (total serum testoster-

month 24, said Orwoll. The investigators noted

one 250 ng/dL). Participants were randomized

that the adverse events and overall safety profile

to either the study drug or placebo once weekly,

were similar between both study groups.

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

These data indicate that odanacatib therapy

calcium supplements (total intake approximate-

is effective in increasing spine and hip BMD in

ly 1,200 mg daily), noted Orwoll.

men with osteoporosis. Changes in bone turn-

Compared with placebo, treatment with odan-

over markers suggest that odanacatib treatment

acatib 50 mg weekly for 24 months increased

decreases bone resorption while producing rela-

lumbar spine, total hip, femoral neck and trochan-

tively small decreases in bone formation. Thus,

teric BMD. We noted decreased levels of mark-

this cathepsin K inhibitor may be a promising po-

ers of bone resorption in the odanacatib group

tential therapy for the treatment of osteoporosis

versus placebo. While markers of bone forma-

in men, Orwoll concluded.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

23

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

Elvira Manzano reports

Challenges in the management

of acute severe ulcerative colitis

cute severe ulcerative colitis remains a

challenging condition to manage even in

the era of biologic therapy, says an expert.

Ulcerative colitis is a chronic, idiopathic
inflammatory disorder with significant morbidity and mortality, said Associate Professor Ida Hilmi, a consultant in gastroenterology, University of Malaya, Kuala Lumpur,
Malaysia. The clinical course of the disease typically manifests with remissions

performed as part of the initial assessment,

and exacerbations characterized by rectal

as well as a test for Clostridium difficile in-

bleeding and diarrhea. Medical therapy can

fection. This is because pseudomembra-

only ameliorate the inflammatory process

nous colitis can complicate or mimic severe

and control most symptomatic flares but

ulcerative colitis. Plain abdominal radio-

provides no definitive treatment for the dis-

graphs are also important to look for toxic

ease.

megacolon or to rule out perforation.

Acute severe ulcerative colitis is usually

For patients who meet the clinical criteria

defined according to the original criteria

for severe ulcerative colitis, sigmoidoscopy

set forth by Truelove and Witts frequent

and a biopsy may be required to look for

loose bloody stools (6 per day) with evi-

cytomegalovirus (CMV), the presence of

dence of systemic toxicity as demonstrated

which may result in treatment failure. En-

by fever (37.8C), tachycardia (heart rate

doscopic scoring system (eg, the modified

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

Baron score) may be used to assess for dis-

an elevated erythrocyte sedimentation rate

ease severity. Some patients, however, may

(HR) >30 mm/h.

have severe ulcerative colitis at endoscopy,

Clinicians should be able to rule out

precipitating or other causes and assess

despite not fulfilling the clinical criteria for

severity, said Hilmi.

the need for emergent surgery, Hilmi said.

Intravenous corticosteroids (hydrocor-

Stool microscopy and culture should be

tisone 100 mg four times daily or meth-

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

24

ylprednisolone 60 mg daily) remain the

tive than intravenous cyclosporine in pa-

mainstay of treatment for severe ulcerative

tients with acute severe ulcerative colitis

colitis. Careful monitoring of stool frequen-

refractory to intravenous steroids. [Lancet

cy and vital symptoms, as well as abdomi-

2012;380:1909-195]

nal examination, is necessary to assess the

Well-timed rescue medical therapy is

patients response to therapy. The use of

generally safe when administered by ex-

antibiotics may be justified in those with co-

perienced physicians, and is effective in

existing sepsis, she added.

the majority of cases, said Hilmi. Close

For patients with steroid-refractory coli-

liaison with the surgeon is essential as the

tis, rescue therapy with cyclosporine or inf-

window for timely surgery is narrow and de-

liximab must be commenced. In one study,

layed surgery, when it is required, can lead

intravenous infliximab was no more effec-

to significant complications.

JA N UA RY 2 01 5

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25

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

Elvira Manzano reports

Serologic and fecal biomarkers in

IBD: Can they replace endoscopy?
There is a need for simple tests to assist the
accurate diagnosis and prognostic assessment
of patients with inflammatory bowel disease
(IBD), says an expert.
Serological antibodies are helpful in this
setting, but with major limitations, said Professor Michael A. Kamm from St. Vincents
Hospital and the University of Melbourne in
Melbourne, Australia. Most of the described
antibodies found in IBD are autoantibodies directed against enteric microbial epitopes and
are thought to arise secondary to the disease

Western populations. [World J Gastroenterol

process but are not thought to play a patho-

2013;19:6207-6213]

genic role.

Of note, none of the currently available se-

Perinuclear antineutrophil cytoplasmic an-

rological markers for IBD can be used as a

tibodies (pANCA) and anti-Saccharomyces

stand-alone diagnostic in clinical practice and

cerevisiae antibodies [ASCA], for example,

can only serve as an adjunct to endoscopy,

may have diagnostic value and are helpful in

which is quite invasive.

distinguishing Crohns disease (CD) from ul-

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

cerative colitis (UC) and intestinal tuberculo-

been the typical laboratory marker used for

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

differentiating IBD from functional and other

tic value, said Kamm. There is the presence

bowel disorders. CRP is an objective marker

of a large number of detectable antibodies

of inflammation and correlates well with dis-

[in the serum] that are associated with worse

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

long-term prognosis.

ideal, said Kamm.

Clinicians should also keep in mind that

It is nonspecific ... measures inflammation

antibody incidence in IBD is affected by spe-

but it does not tell us where the inflammation is

cific disease, geography and ethnicity. Hence,

occurring. There is also remarkable heterogene-

serologic responses differ between Asian and

ity in the CRP response between CD and UC.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

26

Recently, several fecal biomarkers have

functional symptoms and in monitoring dis-

been developed that are sensitive indicators

ease recurrence. Fecal testing of calprotectin

of active intestinal inflammation and may pro-

can also in some circumstances replace en-

vide a convenient method to assist in the di-

doscopy.

agnosis and prognosis of patients with IBD.

Fecal calprotectin is easy to measure, and

The best proven biomarker is calprotectin, a

is reproducible. The test is also inexpensive.

neutrophil-derived protein which is stable in

Fecal calprotectin is likely to play an increas-

feces and can be quantitatively measured in

ingly important role in the management of

stool. It is useful in distinguishing IBD from

IBD, Kamm said.

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

27

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

Radha Chitale reports

Improving CRC risk stratification

through simple criteria scores

isk stratification in colorectal cancer (CRC)

patients with the Asia-Pacific CRC Screening

(APCS) score can help reduce the risk of morbidity and mortality from CRC, but barriers remain
against screening uptake.
We anticipate [APCS] will be easier to use in
clinics by GPs for assessing the risk of CRC, be a
more efficient use of the resources and manpower, and improve public awareness via self-assessment of CRC risk, said Clinical Associate Profes-

weight, are significant contributors to higher CRC

sor Han-Mo Chiu of the National Taiwan University

risk. Metabolic syndrome increases the risk of

and Hospital and the Asia-Pacific Working Group

proximal and synchronous neoplasms, Chiu said,

on Colorectal Cancer.

as well as advanced neoplasm occurrence.

The APCS score is a simple set of criteria that

Increasing physical activity, reducing waist

classifies patients into average, moderate and high

circumference, smoking and alcohol intake, and

CRC risk based on age, gender, family history of

improving diet can reduce the risk of CRC by 23

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

percent. [BMJ 2010;341:c5504]

The Asia Pacific region has a low rate of screen-

Coupling primary prevention via lifestyle chang-

ing, ranging from about 33 to 40 percent across

es with increased early screening has the potential

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

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

lia. Low public awareness is part of the problem,

ticularly in the Asia Pacific region. US data from

but physicians play a key role in recommending

1975 to 2006 has shown that screening and early

screening.

treatment contributed to half of the CRC incidence

Current international guidelines recommend

reduction (26 percent) during that period. Re-

screenings about every 10 years if a colonoscopy

duced mortality was attributed in significant part to

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

risk factor modification (35 percent) and screening

ery 3 years if there are more than three adenomas

(53 percent) and only partially to advances in CRC

or one advanced neoplasm.

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

Lifestyle factors, particularly smoking and

573]

JA N UA RY 2 01 5

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28

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

Radha Chitale reports

Early surgery may benefit Crohns

disease patients

he incidence of Crohns disease is increasing

Surgery, in addition to medication and nutritional

in Asia and besides medical treatment and di-

therapy, is recommended for severe Crohns dis-

etary changes, earlier surgery may be an appropriate treatment option, research shows.

ease. [MHLW Research Group Report 2013]

For people whose Crohns disease is localized

Crohns disease, a type of inflammatory bowel

in the distal ileum, surgery may be an appropri-

disease that can affect the entire gastrointestinal

ate early intervention, Sugano said, with beneficial

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

long-term recurrence rates.

cluding Hong Kong, Korea, and Japan, according

In one study of 55 patients with Crohns disease

to Dr. Kentaro Sugano of Jichi Medical University in

who underwent resection surgery, over a median

Shimotsuke, Tochigi, Japan.

6.7 years of follow up, 32 patients remained relapse-

In general, international guidelines suggest be-

free. Five patients required resection for recurrent

ginning with anti-inflammatory medications and in-

disease but body image and comesis scores im-

corporating digestible nutrients into an elemental

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

diet composed of easily digestible liquid amino

Taking into account the benefits and risks of

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

medical treatment and surgery, the risk of recur-

tients with mild to moderate Crohns disease.

rence after surgery, individual preferences and any

This may be followed by more medications (an-

personal or cultural considerations... surgery can

tibiotics, immunosuppressants, corticosteroids),

be less expensive and may have a better long-term

nutritional therapy, and granulocyte aphoresis.

outcome, Sugano said.

JA N UA RY 2 01 5

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29

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

When should physicians stop HBV

therapy?
RADHA CHITALE

new schema for when to stop hepatitis B

virus (HBV) therapy that stratifies patients

by viral genotype could provide a roadmap for

hepatologists in the Asia Pacific region for im-

monitoring, or they may need to switch to or add

proving patient outcomes, said Dr. Muhammad

an alternative therapy and receive extremely

Umar of the Centre for Liver and Digestive Dis-

close monitoring if they have inadequate viral

eases at the Holy Family Hospital in Rawalpindi,

response.

Pakistan.

However, seroconversion, which is wide-

Globally, about 2 billion people have or

ly accepted as the primary endpoint for HBV

have had an HBV infection. Up to 40 percent

treatment, is not useful for certain types of

develop liver failure or hepatocellular carci-

less responsive HBV patients those who

noma (HCC) and about 1 million people die

are HBV e antigen (HbeAg)-negative mu-

each year from HBV-associated liver disease.

tants in the precore and core promoter re-

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

gions.

1997;337:1733-1745]
HBV patients can be categorized into three

For these patients relapse is common after stopping oral therapy.

groups: complete viral response (viral load <60

Therapy is usually administered long-

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

term, Umar said. But several years of un-

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

detectable HBV DNA may decrease the re-

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

lapse rate.

patients are assessed for primary non-response

By comparison, in HBeAg-positive pa-

after starting treatment at week 12 and again for

tients, who are the wild type, seroconver-

early predictors of efficacy via viral load at week

sion can be used to measure whether the

24. [Keeffe EB et al. Clin Gastroenterol Hepatol.

HBV viral load has reduced and, when it be-

In press.]

comes low or undetectable, therapy may be

Based on the viral response, patients may

discontinued 6-12 months after seroconver-

have no change in treatment and broadened

sion. However, Umar said the durability of

monitoring, no change in treatment and close

response would be about 80 percent.

JA N UA RY 2 01 5

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30

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

Novel therapeutic interventions

for gastroparesis
ELVIRA MANZANO

he treatment of gastroparesis delayed

gastric emptying in the absence of mechan-

ical obstruction is targeted at symptom control

and correcting the precipitating cause of gastric
stasis, says an expert.
In patients with diabetes, gastroparesis
and the associated disturbance in the delivery
of nutrients into the duodenum may affect the
ability to properly control glucose, said Pro-

peridone, cisapride, prucalopride, or itopride.

fessor Gerald Holtmann from the Department

Inhibiting acetylcholinesterase activity to im-

of Gastroenterology and Hepatology, Prin-

prove gastric motility and emptying is also an-

cess Alexandra Hospital and the University of

other therapeutic approach, said Holtmann.

Queensland in Brisbane, Australia. Gastropa-

Erythromycin derivatives devoid of antibiotic

resis is also thought to play an important role

properties are also considered promising candi-

in the manifestation of symptoms in patients

dates for the treatment of gastroparesis. Eryth-

with functional dyspepsia. Thus, normalization

romycin given at low doses stimulates gastro-

of gastric emptying may be targeted to relieve

intestinal motility and substantially accelerates

symptoms in patients with functional dyspep-

gastric emptying, he added.

sia or to control glucose in those with diabetic

gastroparesis.

Interestingly, normalization or improvement

of gastric emptying in response to prokinetics is

Apart from diabetes, common causes are

not linked to improvement in symptoms. In one

idiopathic and post-surgical as a consequence

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

of vagal nerve injury following upper abdominal

erythromycin derivative, was no more effective

surgery, resulting in reduced pyloric relaxation

than placebo in relieving symptoms in patients

and impaired antral contraction.

with or without delayed gastric emptying. Upper

Pharmacologic management include medi-

abdominal discomfort severity scores were simi-

cations targeting dopaminergic or serotoniner-

lar between the two groups at 4 weeks. [Aliment

gic pathways such as metoclopramide, dom-

Pharmacol Ther 2000;14:1653-1661]

JA N UA RY 2 01 5

CO N F E R E N C E COV E R AG E

31

For patients with refractory gastroparesis,

tomies] have been used to treat gastroparesis,

gastric electrical stimulation has been shown to

transpyloric stents have been trialled in selected

reduce symptoms, particularly nausea and vom-

cases. Symptom control appears successful,

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

but there is questionable effect with regard to

intrapyloric injection of botulinum toxin has been

other outcome parameters, said Holtmann.

successfully trialled in small group of patients.

While traditionally more invasive surgical interventions [pyloro-myotomies, gastro-jejunos-

For refractory patients who have failed other

measures, a gastrectomy may be the only option.

JA N UA RY 2 01 5

DR U G P R O F I L E

32

MAS064D: A new non-steroidal

topical treatment for mild-tomoderate seborrheic dermatitis
Seborrheic dermatitis is a condition that affects approximately 1-3 percent of healthy
adults, occurring more frequently in men than women. A number of mainstream
medications typically used for seborrheic dermatitis include antifungals, topical
corticosteroids and keratolytics. Antihistamines may also be used to relieve itching.
MAS064D (SEBCLAIR Cream, Sinclair Pharmaceuticals) is a topical seborrheic
dermatitis treatment approved in the European Union (EU) and the United States.
Ee Lyn Tan, PhD

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

Ingredients

Seborrheic dermatitis
Seborrheic dermatitis (SD) is a common,
chronic and recurrent inflammatory dermatological condition typically characterized by
erythema, scaling and itchiness. [Clin Dermatol 2013;31:343-351] Typically, SD involves the
areas with a high density of sebaceous glands.
The scalp, face, upper chest, shoulders, flexures
and pubis are often involved. [J Eur Acad Dermatol Venereol 2008;22:290-296] In infants, SD
typically occurs on the scalp (referred to as cradle cap) causing a thick, yellowish crust along

Concentration (%)

Activity

Active ingredients
Isohexadecane

Emollient

Shea butter

Emollient
Anti-inflammatory

Bisabolol

1.2

Piroctone olamine

Antimycotic

Alglycera

Anti-inflammatory & keratolytic

Vitamin E

Anti-inflammatory & antioxidant

Allatoin

0.35

Keratolytic

V. vinifera

0.1

Antioxidant

Telmesteine

0.01

Anti-inflammatory & antioxidant

Vehicle

Aqua

Moisturizer

Ethylhexylpalmitate

Emollient

Isohexadecane

Emollient

Cera alba

Emollient

Butylene glycol

Moisturizer

Propyl gallate

Antioxidant

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

the hairline. Infant SD is usually self-limiting and

treatments are seldom required. However, SD in

genetic, environmental and general health factors

adults can last from weeks to years and topical

contribute to this disorder. [Am Fam Physician

treatments are often required.

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

SD is more common and more severe in im-

Although SD is frequently seen in clinical

munocompromised patients, particularly patients

practice, much controversy remains regarding

infected with the human immunodeficiency virus

its pathogenesis. Much of this controversy may

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

be related to its classification in a spectrum of

philic yeasts of the Malassezia genus, as well as

cutaneous conditions from dermatitis, fungal

infection and inflammatory disease. [Clin Der-

JA N UA RY 2 01 5

DR U G P R O F I L E

33

MAS064D (Sebclair Cream)

matol 2013;31:343-351] For this reason, a va-

Indicated for the management of itching,

riety of treatments from topical corticosteroids

burning, scaling and pain associated with SD,

to topical antifungals and antimicrobials have

MAS064D cream is a steroid- and immunomod-

been used.

ulator-free topical treatment containing multiple

active ingredients (Table 1). [J Eur Acad Derma-

Treatment and management

tol Venereol 2008;22:290-296]

SD is characterized by the cycle of remission

and flare. Treatment and management strate-

Efficacy

gies aim to relieve acute symptoms and provide

MAS064D demonstrated good antifungal ac-

long-term prophylaxis to decrease the frequen-

tivity in animal studies. Using guinea pigs infect-

cy and severity of recurrences. [Clin Dermatol

ed with Malassezia furfur, MAS064D was tested

2009;27:S48-53]

against ciclopirox olamine 0.77 percent cream

Regular skin cleansing to remove oils from

and a control group (no treatment). Erythema

sebaceous areas can improve the symptoms

and edema were not visually observed in any

of SD. Outdoor recreation will also improve

of the infected animals at the end of the study.

seborrhea, although sunscreen should be

In the animals treated with MAS064D and ci-

used to avoid sun damage. [Am Fam Physician

clopirox, Malassezia furfur counts were reduced

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

to below the limit of quantitation. [Clin Dermatol

Pharmacological treatments for SD include

2009;27:S41-43]

antifungal preparations that decrease coloniza-

A multinational pilot study was conducted to

tion with Malassezia spp. yeast (eg, selenium

evaluate the efficacy and safety of MAS064D in

sulfide, azole agents, topical terbinafine) and

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

anti-inflammatory agents (eg, topical cortico-

this randomized, double-blind, controlled study,

steroids). For severe SD, keratolytics such as

60 patients with SD were randomized to receive

salicylic acid or coal tar preparations may be

either MAS064D (n=40) or a matching vehicle

used in conjunction with topical corticosteroids.

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

Scales can be removed by applying any of a va-

a higher percentage of treatment success (ac-

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

cording to investigators global assessment) in

night application softens the scale and coal tar

the MAS064D than the control group (68 versus

shampoo may be used subsequently.

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

In patients with refractory disease, sebosup-

were also significantly better than those of the

pressive agents such as isotretinoin may be

control vehicle for investigator-assessed erythe-

used as a last resort to reduce sebaceous gland

ma and scaling, and patient-assessed pruritus

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

and global response to MAS064D (p0.01). [J

2713-2704]

Eur Acad Dermatol Venereol 2008;22:290-296]

JA N UA RY 2 01 5

DR U G P R O F I L E

34

An open label, single-center, bilateral pi-

MAS064D group required rescue medication

lot study assessed the antifungal activity of

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

MAS064D cream against Malassezia spp, which

tients (two each in the MAS064D and control

is commonly associated with SD. Only 10 healthy

groups, respectively) reported a total of six mild

volunteers were involved in this pilot study. The

adverse events. [J Eur Acad Dermatol Venereol

study found that MAS064D reduced the number

2008;22:290-296]

of Malassezia spp colony-forming units (94 ver-

Further, nine out of 10 participants of the

sus 49 percent on treated and untreated areas,

Elewski study rated the safety of MAS064D as

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

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

nonsteroidal topical cream has antifungal activities. [Clin Dermatol 2009;27:S44-47]

In another investigator-blinded, randomized,
parallel-group, multicentre pilot study conducted

Dosing
MAS064D cream should be applied three times
a day to the areas of the skin affected by SD.

to compare the safety and efficacy of MAS064D

Summary and conclusions

and desonide 0.05 percent cream for the treat-

SD is a chronic, relapsing inflammatory der-

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

matological condition commonly encountered in

patients were randomized to receive either

clinical practice. Multiple factors may contribute to

MAS064D or desonide cream for up to 28 days.

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

This study showed that both treatments were

between sebaceous activity, presence of Malasse-

as effective in reducing disease severity, with

zia spp and immune status. [J Eur Acad Dermatol

approximately 90 percent of participants clear-

Venereol 2008;22:290-296] Topical and oral anti-

ing or almost clear during the study. Both treat-

fungals, topical corticosteroids and immunomod-

ments demonstrated significant reductions in

ulating agents are cornerstones of SD treatments.

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

However, there are safety concerns with many of

ther, patients treated with MAS064D who cleared

these primary treatment options for SD.

after 14 days of treatment were more likely to

MAS064D cream is a novel prescription non-

remain clear than those using desonide cream

steroidal medical device approved by the US

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

Food and Drug Administration and for use in the

EU. The cream has antifungal and anti-inflamma-

Safety
MAS064D topical cream is generally well tolerated.
In the Veraldi pilot study, a 7-day course of

tory actions. Emollients are important to relieve dry

skin and facilitate healing. The efficacy and safety
of MAS064D has been shown through animal trials and randomized controlled studies.

desonide 0.05 percent cream was available

This new treatment option is another addition

for patients who experienced a flare during

to the pharmaceutical armamentarium for patients

the study period. None of the patients in the

with mild-to-moderate SD.


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JA N UA RY 2 01 5

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C A L E N DA R

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JA N UA RY 2 01 5

HUMOR

I finally received your test results dear,

but before l let you read it,
l would like you to sign something for me!

Theres nothing wrong in trying to blend in,

but why must you always mimic the behavior of
others?

Any previous experience?

With medical students, the only way for them to

learn, is to let them make their own mistakes!

As far as l know he didnt

die of anything. He was a
hypochondriac!

Have you been putting

on weight?

Yes Doctor Manolete,

youre right.
Its probably the full moon!

36

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