Cost of treatment should always be considered while prescribing drugs-Prof. Yakoob Ahmedani

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PIMA Symposium on Cardio Metabolic Syndrome at JPMC

Cost of treatment should always be considered
while prescribing drugs-Prof. Yakoob Ahmedani

Muslim countries should have their own guidelines
on Fasting by Diabetics - Dr. M. A. Ebrahim

Foot care and good glycaemic control can prevent most
of the complications - Dr. Qaiser Jamal

KARACHI: Pakistan Islamic Medical Association (PIMA) organized a symposium on cardio metabolic syndrome at JPMC on June 9th 2013. The scientific programme was spread over two session, the first was devoted to diabetes while the second one to cardiovascular diseases. Speaking in the brief inaugural session Dr. Misbahul Aziz President PIMA said that PIMA has eighty six local units, four thousand doctors are its members in addition to three hundred five female physicians. It has two main hospitals at Muzzafar Abad in Azad Kashmir and one in Mansehra. So far over forty thousand eye surgeries have been performed at camps, hospitals by PIMA. It also runs an undergraduate medical college i.e. Peshawar Medial College in Khyber PK wherein the students have to write five mandatory research papers during their studies.
PIMA is a member of Federation of Islamic Medical Associations which has branches in thirty Muslim countries. During the Year 2013 we intend to implant five thousand IOLs during eye surgery. He also mentioned the PIMA medical relief activities within the country and overseas.
During the first scientific session which was moderated by Dr. M. A. Ebrahim a noted dialectologist, Dr. Qamar Masood from AKU was the first speaker who discussed emerging therapies in management of Type 2 diabetes mellitus. He pointed out that usually most of the diabetics die less than sixty years of age. Any patient having AIC of more than 6.5% from a standard laboratory could be diabetic. He then referred to various trials i.e. UKPDS, DCCT, ACCORD, ADVANCE and VADT which all have showed that diabetics suffer from macro vascular and micro vascular complications which account for increased morbidity. One should aim at HBAIc of less than 7%; young healthy adults should have an HBAIc of between 6-6.5. For elderly HBAIc of between 7.5 to 8% is acceptable. It must be ensured that these diabetics avoid hypoglycemia. The most commonly used oral agents include metformin, sulfonylurea’s, GLP-I receptors etc. He also discussed their mechanism of action and added that metformin is the most cost effective oral agent. TZDs have high cost and they also result in weight gain, heart failure edema. Bromocriptine can lead to bone fractures. He then talked about the rationale of SGLT2 inhibitors. In some cases one may have to use combination of one, two or even three drugs to control diabetes, he remarked. Dr. Ebrahim remarked that it must be remembered that diabetes control will prevent the complications later.
Dr. Qaiser Jamal discussed early screening and preventing complications. He laid emphasis on individualizing the treatment for each and every patient. The common complications are micro and macro vascular complications, neuropathy and infections. Macro vascular complications have two to six times’ higher risk in diabetics. Life expectancy is seven to ten years low in diabetics as compared to non-diabetics. Studies have shown that almost 50% of diabetics will have hypertension, 30% will have dyslipidemia. Glycaemic control reduces CAD. Treatment of hypertension in diabetics reduces not only disability and stroke but also death. Diabetics should have a blood pressure of 130/85 or less. Diabetic neuropathy is a common complication which results in lot of morbidity and mortality and fungal infections. Foot care and good glycaemic control can prevent most of the complications. Dr. Ebrahim added that all diabetics should have a detailed examination including eye check up and cardiovascular assessment.
Dr. M.A. Ebrahim was the next speaker who talked about Ramadan Fasting and Diabetes. He pointed out that there was no evidence based medicine in this regard and whatever he was presenting was based on expert’s opinion. He was of the view that before the start of Ramadan all diabetics must have counseling and therapy considerations must be discussed in detail. There is likelihood of change in the dose of certain anti-diabetics including insulin dosage. We need to conduct Research on Diabetes during Ramadan but since every year Ramadan comes week to ten days earlier, hence it requires many years of research to find out its effects in different environments and climate, weather in different countries. Some of the common complications encountered by the diabetics are hypo and hyperglycemias, DKA, dehydration and thrombosis. As a general principle Type-I diabetics should not fast. Those who use insulin pumps, it is also a contraindication. Similarly type 2 diabetics who have recent DKA, those with nephropathy, active peptic ulcer disease, bronchial asthma, and cancer should be careful before deciding to fast. He was of the view that Islamic countries should come out with its own guidelines on Ramadan and fasting.
Continuing he stated that diabetics need compulsory education during Ramadan on how to manage their diabetes, use of healthy balanced diet. They should be advised to take slow energy release foods, consume foods with high fiber contents which should be included in Sehar and Iftar. It is advisable to decide about medications in consultation with dietitians. Regular moderate exercise is safe in type 2 diabetics. He emphasized that good history, patient counseling on blood glucose monitoring before Ramadan is quite useful. If blood glucose is low, fast should be broken and similarly if it is more than 300, fast must be broken. Patients and their family members must be aware of the warning symptoms like dehydration, hypoglycemia. Blood sugar of 160-180 is acceptable during Ramadan and one should not go for tight blood glucose control. Those who take insulin twice a day should reduce the dose by 50% at Sehari and those who take once a day they should take Insulin after Iftar. He concluded his presentation by stating that for diabetics fasting during Ramadan is safe but needs good scientific approach.
Dr. Shamsul Arfeen talked about life style in Islamic perspective and emphasized the need to use more fruits and salad, red pepper is good anti oxidant. One should eat slowly and eat less which will ensure a healthy life. Fasting has many benefits as it helps reduce fat, un-necessary weight which is some of the health benefits of fasting. He suggested that one should avoid buffet lunch and dinner as one tends to eat much at buffet.
Dr. Salma Badaruddin a noted Dietitian spoke on Diet in Fasting. She pointed out that most diabetics fast and almost 50% do not change their diet. Some diabetics even gain weight during Ramadan due to use of oily dishes and too much use of fats besides over nutrition. She also laid emphasis on individualized instructions and treatment plan for every diabetic. Diabetics and even general population should be advised to use whole fruit rather than fruit juices. They should include vegetables in foods prepared for Iftar. The idea is to empower patients to fast safely.
Replying to a question regarding use of Anti TB drugs during Ramadan, Prof. Sohail Akhtar said that he advised his patients to take these medications after Iftar. Answering a question regarding use of ant platelets Prof. Khawar Kazmi said that we always advise patients to take ant platelet therapy after meals. Regarding the use of Jaman, it was stated that it can be used as a fruit but not as a substitute for medications. There have been some studies suggesting benefits of Jaman seeds in diabetics in India and not Jaman as a fruit.
Prof. Yakoob Ahmedani from BIDE, Baqai Medical University who was chairing this session in his conceding remarks said that physicians must always take into consideration cost of treatment while prescribing drugs. He also suggested that we must keep record of our patients in a database and see whether we are preventing the known complications among our diabetics. Patient education is extremely important and diabetics should be taught how to do blood glucose monitoring at home which plays an important role in management of diabetes, he added.
Prof. Azhar M.A. Farooqui former Executive Director of NICVD chaired the session devoted to cardiovascular diseases which was moderated by Dr. Fawad. Prof. Khawar Kazmi from AKU was the first speaker who discussed prevention of CAD in diabetics. He discussed in detail the assessment of cardiac status of the diabetics, preventive strategies and supplemented it with different case scenarios. No drugs, he said, are needed in low risk patients but those who are at high risk will require medications after ECG and Stress Test. Aspirin, Statins, ACEIs, ARBs are all good for blood pressure control in diabetics. Aspirin in primary prevention is good for those diabetics who are not at increased risk of bleeding. In young diabetics with no other risk factors, one should not use Aspirin but for secondary prevention Aspirin is very useful as it reduced and prevents MI, CAD but it should always be used with caution, he added. Statins use in primary prevention could result in musculoskeletal injuries and high dose of Statins can result in fractures. ACEIs and ARBs are the drugs of first choice in diabetic hypertensives.
Dr. Syed Imran Ahmad form Ziauddin Medical University talked about new trends in hypertension management. He pointed out that hypertension is a significant cardiovascular risk factor. A reduction of 2MMHg in blood pressure can result in 7-10% reduction in IHD mortality. First line anti hypertensive drugs includes diuretics, beta blockers, CCBs, ACEIs. Patient’s evaluation, he opined, is most important. One must take into account the patient life style and other risk factors and look at individualized causes of hypertension. One should assess the presence or absence of target organ damage. Inappropriate activation of RASS will lead to hypertension, diabetes, obesity, heart failure and renal disease. Valsartan improves endothelial function. State of pre diabetes should also be considered while treating hypertension. New Onset Diabetes should also be kept in mind. LVH is a common occurrence. ARBs provide renal protection to diabetics and controlling blood pressure is something good one can do in diabetics. He concluded his presentation by stating that control of blood pressure with medications is the most cost effective method of reducing premature cardiovascular morbidity and mortality.

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