Use of SGLT-2 Inhibitors in Patients with Type 2 Diabetes Mellitus and Abdominal Obesity: An Asian Perspective and Expert Recommendations

Wayne Huey-Herng Sheu,Siew Pheng Chan,Bien J. Matawaran,Chaicharn Deerochanawong,Ambrish Mithal,Juliana Chan,Ketut Suastika,Chin Meng Khoo,Huu Man Nguyen,Ji Linong,Andrea Luk,윤건호 대한당뇨병학회 2020 Diabetes and Metabolism Journal Vol.44 No.1

The prevalence of obesity in Asia is of epidemic proportions, with an estimated 1 billion overweight/obese individuals in the region. The majority of patients with type 2 diabetes mellitus (T2DM) are overweight/obese, which increases the risk of cardiorenal outcomes in these patients; hence, sustained reductions in body weight and visceral adiposity are important management goals. However, most of the glucose-lowering therapies such as insulin, sulfonylureas, glinides, and thiazolidinediones induce weight gain, which makes the management of overweight/obese T2DM patients challenging. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are the only oral glucose-lowering agents that have been shown to reduce body weight and visceral adiposity. In addition, SGLT-2 inhibitors therapy reduces ectopic fat deposition and improves adipose tissue function and weight-related quality of life. In this article, we aim to consolidate the existing literature on the effects of SGLT-2 inhibitors in Asian patients with T2DM and to produce clinical recommendations on their use in overweight or obese patients with T2DM. Recommendations from international and regional guidelines, as well as published data from clinical trials in Asian populations and cardiovascular outcomes trials are reviewed. Based on the available data, SGLT-2 inhibitors represent an evidence-based therapeutic option for the management of overweight/obese patients with T2DM.

Sarcopenia and vertebral fracture

Fen Lee Hew,Siew Pheng Chan,Swan Sim Yeap 대한골다공증학회 2018 Osteoporosis and Sarcopenia Vol.4 No.4

We read with interest the article by Iida and colleagues looking at sarcopenia in patients with vertebral fractures [1]. Both these conditions are important issues, especially in Asia. Osteoporotic vertebral fractures are not uncommon in the elderly and are under recognised [2]. A recent review article on vertebral fracture found that the age-standardised incidence was highest in South Korea, followed by USA and Hong Kong, e.g., for women, the rates were 1377, 939, and 662 per 100,000 respectively, i.e., 2 of the top 3 countries with a high incidence of vertebral fractures are in Asia [3]. For sarcopenia, the Asian Working Group for Sarcopenia estimated that between 4.1% and 11.5% of the over 65 year old age group would have sarcopenia [4]. Thus, rehabilitation after an osteoporotic fracture should obviously be seen as a musculoskeletal problem rather than just a skeletal problem. This study has highlighted several important issues that would have clinical implications. Sarcopenia assessment premorbid/ prior to, and at presentation, of a fracture is not universally comprehensive with a few exceptions. The fact that this study demonstrated the prognostic role of such assessment is important given the much poorer outcome in terms of ability to return home 1 year after the fracture. Healthcare resources could be directed to those at higher risk to improve outcomes. However, we have several queries and comments: The authors have defined sarcopenia based only on densitometric criteria i.e., muscle mass, rather than the suggested combination of muscle function and muscle mass. Although the authors stated that they could not evaluate walking speed in the patients following a fracture, could the patients have had their grip strength assessed? We are not clear as to why the subjects were divided into “Osteoporosis” and “Without osteoporosis” groups. Since if they have had “osteoporotic vertebral fractures,” shouldn’t they all be osteoporotic? There were 396 study subjects, but only “about” 336 subjects had a 1-year follow-up. Could the authors be more specific as to exactly how many patients had a 1-year follow-up? In addition, can they provide information on those who were not followed up? If the patients who dropped out were significantly different in any of the characteristics, then the conclusion of the study would be less robust. This study only looked at patients hospitalised for their vertebral fracture, presumably consecutive admissions without selection. Were there patients who did not require hospitalization? And were they studied in a similar manner? Almost all the male elderly subjects in this cohort have sarcopenia e 102 out of 111. Do the authors have any comments as to why this is so? Many studies, though not all, have shown higher rates of sarcopenia in men compared to women [4], but never by this much especially when there is no difference in the age between the genders. Or does this reflect the social background of men being less likely to be involved socially and thus less active which may have contributed to the higher rate of sarcopenia? We know that earlier and adequate pain control improves mobility and reduces bone loss. The inclusion criteria include subjects within a month of onset of symptoms. We do know that a month of inactivity can cause quite substantial skeletal muscle loss. Do the authors have data to look at the time of presentation fromonset of symptoms to see if this has any bearing on sarcopenia? As indicated by the authors, vitamin D (in particular) and bisphosphonate treatment may improve outcome, was there data to indicate the rate of treatment in this cohort? Table 3 is titled “Comparison between patients with and without osteoporosis,” but yet the table headings are “sarcopenia” and “without sarcopenia.” Is there a typographical error?

A summary of the Malaysian Clinical Practice Guidelines on the management of postmenopausal osteoporosis, 2022

Terence Ing Wei Ong,Lee Ling Lim,Siew Pheng Chan,Winnie Siew Swee Chee,Alan Swee Hock Ch’ng,Elizabeth Gar Mit Chong,Premitha Damodaran,Fen Lee Hew,Luqman bin Ibrahim,Hui Min Khor,Pauline Siew Mei Lai 대한골다공증학회 2023 Osteoporosis and Sarcopenia Vol.9 No.2

Objectives: The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP). Methods: A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results: This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients’ fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate.

Reply on “Combined orthogeriatric and fracture liaison service for improved postfracture patient care”

Swan Sim Yeap,Fen Lee Hew,Siew Pheng Chan 대한골다공증학회 2017 Osteoporosis and Sarcopenia Vol.3 No.3

To the editor, We would like to thank Dr. Schweser and colleagues for their interest in our paper [1] and on their agreement that we are missing opportunities to prevent future fractures that can potentially be reduced by the introduction of a fracture liaison service (FLS). From our perspective, we are hoping to use this data locally to push for the introduction of FLS in Malaysian hospitals. Thank you for bringing to our attention the benefits of an orthogeriatric service which can complement the FLS. In countries where there are geriatric services available, this would seem to be a mutually beneficial solution to the problem of long term follow-up of post-hip fracture patients. However, in many parts of Asia which are developing countries, geriatrics as a specialty is poorly developed and geriatricians are a very scarce commodity. Thus, we would suggest that the FLS can be started with the input of any specialty that is interested in osteoporosis and osteoporotic fractures. This would also have the advantage of having the FLS reach out to identify and initiate investigations for patients with other osteoporotic fractures such as vertebral or wrist fractures. Regardless of the method, we are all in full agreement that treatment after osteoporotic fractures is suboptimal and measures to improve this situation are urgently needed.

An update of the Malaysian Clinical Guidance on the management of glucocorticoid-induced osteoporosis, 2015

Swan Sim Yeap,Fen Lee Hew,Premitha Damodaran,Winnie Chee,Joon Kiong Lee,Emily Man Lee Goh,Siew Pheng Chan 대한골다공증학회 2017 Osteoporosis and Sarcopenia Vol.3 No.1

Objectives: This Clinical Guidance is aimed to help practitioners assess, diagnose and manage their patients with glucocorticoid-induced osteoporosis (GIO), using the best available evidence. Methods: A literature search using PubMed (MEDLINE) and The Cochrane Library identified all relevant articles on GIO and its assessment, diagnosis and treatment, from 2011, to update from the 2012 edition. The studies were assessed and the level of evidence assigned. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results: Consider treatment early in all patients on glucocorticoids (GC) as fracture risk increases within 3e6 months of starting GC. The decision to start treatment for GIO depends on the presence of prior fracture, category of risk (as calculated using Fracture Risk Assessment Tool), daily dose and duration of GC treatment, age, and menopausal status. General measures include adequate calcium and vitamin D intake and reducing the dose of GC to the minimum required to achieve disease control. In patients on GC with osteoporotic fractures or confirmed osteoporosis on dual-energy X-ray absorptiometry, bisphosphonates are the first-line treatment. Treatment should be continued as long as patients remain on GC. Algorithms for the management of GIO in both pre- and post-menopausal women and men have been updated. Conclusions: In post-menopausal women and men above 50 years, bisphosphonates remain the mainstay of treatment in GIO. In pre-menopausal women and men below 50 years, bisphosphonates are recommended for those with a prevalent fracture or at very high risk only.

Trends in post osteoporotic hip fracture care from 2010 to 2014 in a private hospital in Malaysia

Swan Sim Yeap,M.F.R. Nur Fazirah,C. Nur Aisyah,Siti Yazmin Zahari Sham,Intan Nureslyna Samsudin,Subashini C. Thambiah,Fen Lee Hew,Boon Ping Lim,Yew Siong Siow,Siew Pheng Chan 대한골다공증학회 2017 Osteoporosis and Sarcopenia Vol.3 No.2

Objective: Following an osteoporotic fracture, pharmacological treatment is recommended to increase bone mineral density and prevent future fractures. However, the rate of starting treatment after an osteoporotic hip fracture remains low. The objective of this study was to survey the treatment rate following a low-trauma hip fracture at a tertiary private hospital in Malaysia over a period of 5 years. Methods: The computerised hospital discharge records were searched using the terms “hip,” “femur,” “femoral,” “trochanteric,” “fracture,” or “total hip replacement” for all patients over the age of 50, admitted between 2010 and 2014. The medical charts were obtained and manually searched for demographic data and treatment information. Hip operations done for nonelow-trauma-related fracture and arthritis were excluded. Results: Three hundred seventy patients over the age of 50 years were admitted with a hip fracture, of which 258 (69.7%) were low trauma, presumed osteoporotic, hip fractures. The median age was 79.0 years (interquartile range [IQR], 12.0). Following a hip fracture, 36.8% (95 of 258) of the patients received treatment, but out of these, 24.2% (23 of 95) were on calcium/vitamin D only. The median duration of treatment was 1 month (IQR, 2.5). In 2010, 56.7% of the patients received treatment, significantly more than subsequent years 2011e2014, where approximately only 30% received treatment. Conclusions: Following a low-trauma hip fracture, approximately 72% of patients were not started on active antiosteoporosis therapy. Of those who were, the median duration of treatment was 1 month. This represents a missed opportunity for the prevention of future fractures.

A summary of the Malaysian Clinical Guidance on the management of postmenopausal and male osteoporosis, 2015

Swan Sim Yeap,Fen Lee Hew,Premitha Damodaran,Winnie Chee,Joon Kiong Lee,Emily Man Lee Goh,Malik Mumtaz,Heng Hing Lim,Siew Pheng Chan 대한골다공증학회 2016 Osteoporosis and Sarcopenia Vol.2 No.1

Aim: This Clinical Guidance is aimed to help practitioners assess, diagnose and manage their patients with osteoporosis (OP), using the best available evidence. Methods: A literature search using PubMed (MEDLINE) and The Cochrane Library identified all relevant articles on OP and its assessment, diagnosis and treatment, from 2011, to update from the 2012 edition. The studies were assessed and the level of evidence assigned. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results: This article summarizes the diagnostic and treatment pathways for postmenopausal and male OP, while addressing the risk-benefit ratio for OP treatment. Recognising the limitation of only depending on bone mineral density in assessing fracture risk, a move to assess 10 year fracture risk using tools such as FRAX, is recommended as a guide to decision-making on when to start treatment. A re-evaluation was done of the position of calcium supplementation and on the importance of vitamin D. There has been concern about the potential adverse effects of the long-term usage of bisphosphonates, which have been discussed fully. Algorithms for the management of postmenopausal and male OP have been updated. Conclusions: Adequate intake of calcium (1000 mg from both diet and supplements) and vitamin D (800 IU) daily remain important adjuncts in the treatment of OP. However, in confirmed OP, pharmacological therapy with anti-resorptives is the mainstay of treatment in both men and postmenopausal women. Patients need to be regularly assessed while on medication and treatment adjusted as appropriate. © 2016 The Korean Society of Osteoporosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).