Speakers discuss various treatment modalities for managing Acromegaly


PES Mid-Summer Meeting at Bhurban
Speakers discuss various treatment
modalities for managing Acromegaly
Treatment of T1DM, T2DM, Gestational Diabetes and
Erectile dysfunctions also highlighted

From Dr. Musarrat Riaz

BHURBAN: Pakistan Endocrine Society recently organized its 7th Mid-Summer Endocrine Updates from 2nd to 4th July at Bhurban which attracted a large number of doctors. The event was attended by not only endocrinologists but internists, family physicians and other health care specialists. The conference started with pre-conference workshops on Treatment approaches to type 2 diabetes, Insulin management, Diabetes and pregnancy and diabetic foot.

Prof. Khursheed Ali Khan presenting Mementoes to Prof.A.H.Amar and
Prof. Abdul Basit during the PES conference held at Bhurban recently.

Prof. Khursheed Ali Khan, President PES in his address highlighted the various activities and projects that the society has been doing for the last two years. He specially highlighted the launch of T2DM and Metabesity guidelines in addition to series of webinars and online lecture series related to various Endocrine disorders from the platform of PES. Prof. Abdul Basit, Director BIDE presented the National Diabetes Prevention Program that has been initiated by PES. Elaborating the roadmap for achieving the desired goals of primary prevention of diabetes, prof. Basit highlighted various activities and initiatives that are already in progress by various stakeholders including public awareness campaigns, organizing walks, involving print and electronic media, targeting obesity and promoting healthy lifestyle choices. However, it is time to make certain policy decisions involving provincial and federal health ministries and ensuring its proper implementation that is needed urgently, he further emphasized.

Prof. Najmul Islam alongwith Prof. Imran Hassan Khan chairing one of
the scientific sessions during the PES conference at Bhurban.

Speaking at one of the session related to Acromegaly, Dr. John Ayuk from UK presented the global perspective as well as the management protocols for acromegaly in UK. He discussed various treatment modalities illustrating with the help of case presentation. Surgery is the mainstay of treatment followed by either LA somatostatin analogue or focused radiotherapy for residual tumor he stated, while in some cases repeat surgery maybe required. Treatment with Pegvisomant is very expensive even in UK and one has to make special recommendation to NHS in very refractory cases when there is no other option. Col. Dr. Shahid Ahmed gave an overview of managing acromegaly in Pakistan and discussed various limitations that one has to face in the local setup. He presented case series from his institute. Dr. Akbar Ali Khan neurosurgeon at Shifa Hospital Islamabad presented the neurosurgical aspect of managing acromegaly. He showed the videos of endoscopically performed pituitary surgeries for acromegaly with good results. Dedicated trained pituitary surgeons are very valuable for achieving good results, he opined.

During questions and answers session Prof. Najmul Islam from AKU said that Acromegaly should be managed by a multidisciplinary team approach. Surgery should be the first line of treatment where possible followed by radiotherapy. Somatostatin analogue are very expensive and patients cannot be put on these medications for in definite period and pegvisomant is not available in Pakistan so we have to refer these patients for Radiotherapy preferably cyber knife stereotactic surgery which is available with minimal side effects for residual tumor. Sharing his experience, Prof. Najmul Islam said that he always finds it very difficult to convince for second pituitary surgery if the first one fails to cure the disease. This initiated a very healthy discussion about pros and cons of various treatment modalities in the context of Pakistan.

Session for Primary
Care Physicians

During the conference a special session was arranged in collaboration with Society of Family Physicians targeting the primary care physicians. Approach to management of Type 1 diabetes (T1DM), type 2 diabetes (T2DM) and Gestational Diabetes (GDM0 were discussed in detail from family physician’s perspective. Dr. Ali Karamat from UK discussed in detail the diagnostic workup and protocols for the management of T1DM and highlighted the subtle differences between type 1 and type 2 diabetes.

Prescribing insulin for glycemic control is not the only goal for management but preventing acute and chronic complications should also be of prime importance. Psychosocial counselling is also an integral part of management of people with T1DM. Dr. Faisal Qureshi from Multan discussed the management of T2DM in detail focusing on its pathophysiology as well as the mode of action of currently available drugs. Referring particularly to the cardiovascular outcome trials he specifically emphasized the efficacy of SGLT2 inhibitors and GLP 1 analogue for managing type 2 diabetes.

Dr. Musarrat Riaz while discussing Gestational Diabetes Mellitus stated that unfortunately in Pakistan, we do not know the exact prevalence of GDM as proper epidemiologic studies have not been conducted. However it is estimated to be vey high keeping in view the rising prevalence of diabetes in Pakistan. Up till now there was no consensus regarding screening, diagnosis and management of GDM in Pakistan, however the situation has changed now as PES as part of South Asian Federation of Endocrine Societies (SAFES) has launched GDM guidelines in 2018 and now very recently Society of Gynecologists and Obstetricians (SOGP) also launched their guidelines. Both societies have joined hands through a joint GDM SERENDIP project for the dissemination of these guidelines. The good thing is that there are no major differences between these two guidelines and both emphasized on universal screening for GDM irrespective of risk factors in every pregnant female. The screening should be done at first booking visit and if negative should be repeated at 24-28 weeks gestation and again during post- partum period. The recommended screening test is 75 gms OGTT which should be done in fasting state and diagnosis should be made as per IADPSG criteria.

Emphasis on achieving glycemic targets (FBS <95 mg/dl and 2 hours post meal <120 mg/dl) should be strongly emphasized to the pregnant female in order to prevent fetal and maternal complications. Medical nutrition therapy with lifestyle modifications will be able to achieve the targets in majority of GDM women, however 10-15% women may require pharmacotherapy including Metformin and insulin. Glibenclamide is not recommended for the treatment of GDM by PES as well as SOGP due to lack of long-term safety data, she further stated. Post-partum screening is the most crucial step that is currently missing in our setup due to various reasons and we all should now be focusing primarily on this area as it provides a window of opportunity for primary prevention. Dr Tariq Mian in his concluding remarks said that we have got a very few endocrinologists in the country which alone cannot tackle this huge burden of diabetes, therefore family physicians are indispensable to tackle the rising prevalence of diabetes in Pakistan.

Prof.Khursheed Ali Khan alongwith Prof. M. Hafeezullah and Prof.Zaman Sheikh chairing one of
the scientific sessions during PES conference held at Bhurban recently.

Erectile dysfunctions are very common, however people tend to shy away from discussing these problems with their doctor resulting in majority of them consulting quacks with serious consequences. This was stated by Dr. Osama Ishtiaq from Shifa Hospital while making a presentation regarding assessment of a patient with erectile dysfunction. He described in detail regarding history, physical examination and relevant investigations in patients presenting with these problems. Drug history as well as history of co morbidities is very important as these conditions may play an important role in etiology. Organic causes should be differentiated from psychosocial problems, he further stated. Dr. Abdul Wahab Yousufzai consultant Psychiatrist discussed the psychosocial consequences of erectile dysfunction. He emphasized that doctors should be emphatic to the patients and judgmental statements should not be passed and personal opinions should not be given. If a patient is consulting you then he should be taken seriously and a thorough evaluation should be done to find out the root cause and appropriate treatment should be provided.

Earlier a session dedicated to women health included talks related to Psychological aspects of management of T1DM by Dr. Sadia Salman and preventing diabetes post GDM by Dr. Aisha Shaikh. Debate regarding best suitable 2nd line drug after metformin in T2DM in Pakistan was also part of the conference.