Saiful Shahrizal Shudim

INTRODUCTIONGraves’ disease is the most common cause of thyrotoxicosis. Restoration of euthyroidism is vital to prevent further complications including cardiac impairment. Refractory Graves’ disease is uncommon and, thus, poses a challenge in preparing a patient for definitive therapy. We describe a case of refractory Graves’ disease who successfully underwent definitive surgical therapy. CASEA 25-year-old female with a seven-month history of Graves’ disease was referred for recurrent syncope due to multifocal atrial tachycardia. She had multiple previous admissions for severe thyrotoxicosis within the last five months where she was treated with thionamides and multiple five-to-seven-day courses of Lugol’s iodine each time. On admission, thyroid functions tests showed free T4 (fT4) of 92.5 pmol/L (normal range: 11.5 - 22.7) and TSH of <0.01 mIU/L (normal range: 0.55-4.78). The thyroid ultrasound revealed diffuse enlargement of both thyroid lobes with increased vascularity. She was treated with carbimazole up to 80 mg/day, however, fT4 remained at a range of 77.9 – 90.1 pmol/L. Additional therapy with lithium carbonate (1200 mg/day), dexamethasone (8 mg/day) and cholestyramine resin (2 g twice a day) failed to normalize the fT4 level. Switching carbimazole to propylthiouracil (900 mg/day) also did not prove successful. Plasmapheresis was initiated which near-normalized her fT4 after 11 cycles. Tachyarrhythmias were controlled with carvedilol 25 mg twice a day, verapamil 80 mg thrice a day and ivabradine 7.5 mg twice a day. She underwent a successful semi-urgent total thyroidectomy and was eventually discharged after seven days post-operatively with levothyroxine replacement, calcitriol and calcium supplementation. CONCLUSIONThis case highlights the management challenges in a case of Refractory Graves’ disease. Adjunct to maximal medical therapy, plasmapheresis is a potential modality to achieve a euthyroid state prior to thyroidectomy.

INTRODUCTION/BACKGROUND Diabetic kidney disease (DKD) is a global health challenge that has garnered increasing attention due to its significant impact on individuals and healthcare systems worldwide. In Malaysia, DKD accounted for the majority of new dialysis patients, increasing cardiovascular risk and hence, escalating healthcare expenses. METHODOLOGYThis clinical audit aims to assess the screening and treatment of DKD among T2DM patients in Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, Pahang. All T2DM patients attending the diabetes clinic in HOSHAS from June to July 2023 were included in this clinical audit. Electronic medical records were assessed for demographic data, blood pressure and glycaemic targets, screening and treatment of macro- or microalbuminuria. RESULTSWe included 141 patients in this audit. Of those, 63.8% were females, with a mean age of 52.8 ± 15.0 years and an average duration of diabetes of 13.0 ± 8.4 years. The screening rate for albuminuria was high (93.6%) but only 25.5% of the patients had further quantification of albuminuria. Overall, 31.9% achieved a blood pressure target of below 140/80 mmHg but only 19.0% with albuminuria achieved a BP target of below 130/80 mmHg. A total of 19.1% of patients achieved HbA1c of less than 7%. Among the patients with albuminuria, 71.2% were on ACE-i/ARB and 39% were prescribed SGLT2 inhibitors. CONCLUSIONThis audit highlights the importance of early detection and appropriate management of DKD in T2DM patients. Microalbuminuria assessment, optimal blood pressure and renal-modulation therapy are essential in preventing the progression of albuminuria and reducing the risk of ESKD in patients with diabetes.

INTRODUCTIONDyslipidemia is a major risk factor for cardiovascular disease in patients with Type 2 Diabetes (T2D) and requires aggressive management. The aim of this clinical audit is to assess the appropriateness of dyslipidemia treatment in T2D patients attending the diabetes clinic at Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang. METHODOLOGYAll T2D patients attending the diabetes clinic from June to July 2024 were included in this clinical audit. Electronic medical records were reviewed for demographic data, comorbidities, lipid profiles, cardiovascular disease risk assessments, and statin prescription patterns. RESULTA total of 102 patients were included, with a mean age of 53.2 years, 55.9% being female, and 59.8% having a diabetes duration of more than 10 years. The majority of patients had high to very high cardiovascular risk. Among the patients, 37.3% had chronic kidney disease and 32.4% had ischemic heart disease. The LDL-C control at the latest follow-up was suboptimal, with a mean LDL-C of 2.71 mmol/L. Additionally, 33.3% of patients were not initiated on the appropriate statin intensity, and 12% did not receive any lipid-lowering therapy. 20% of patients were on high doses of atorvastatin (60–80 mg), with limited use of combination therapy. Despite recognizing the patients' cardiovascular risk, there was clinical inertia in intensifying treatment. CONCLUSIONThis clinical audit highlights weaknesses in adherence to clinical guidelines and clinical inertia in dyslipidemia treatment. There is a greater need for continuous education and a stronger emphasis on achieving treatment goals in the management of T2D patients. Additionally, a reassessment of the budget for the availability of combination therapy options is necessary.

INTRODUCTIONAldosterone-to-renin ratio (ARR) sampling is the first line investigation for detection of hyperaldosterone-driven hypertension. Clinical practice guidelines (CPG) advocate testing the ARR in specific indications with special consideration in confounding factors, especially types of antihypertensive medicine. We aimed to determine the adherence of ARR sampling as outlined by CPG. METHODOLOGYWe retrospectively evaluated ARR requests taken from January 2020 till December 2024 in Hospital Sultan Haji Ahmad Shah. Demographic data associated with or without hypertension, indication for screening, interfering medications and outcomes were extracted from medical records. RESULTOut of 287 tests retrieved, only 222 were qualified for analysis. The median age was 34 (interquartile range, IQR 11) with 133 (59.9%) males. The medical duration of hypertension was 5 years (IQR 7). The majority of ARR sampling was sent for onset of hypertension less than age 40 (n = 150, 67.6%). Other indications were resistant hypertension (n = 28, 12.6%), hypertension with hypokalemia (n = 28, 12.6%), hypertension with adrenal incidentaloma (n = 4, 1.8%) and family history with hypertension onset of less than 40 or cardiovascular disease (CVD), n = 4, (1.8%). The ARR were found to be positive or indeterminate in 23 samples (10.4%): highest among cohort of hypertension with hypokalemia, n = 12 (42.9%) then adrenal incidentaloma and family history of young onset hypertension/CVD (25% each) and later was resistant hypertension, n = 4 (14.3%). Hypertension onset of less than 40 only yields a 3.3% positivity rate (n = 5). Interfering medicines did not significantly impact ARR results. Of 23 samples, 15 (65.2%) were confirmed primary hyperaldosteronism. CONCLUSIONARR sampling was overly investigated among hypertensive less than 40 years old. Adherence to indications as per guideline recommendations needs to be strengthened to prevent wasteful resources.

INTRODUCTIONSodium-glucose co-transporter-2 (SGLT2) inhibitors have revolutionized the management of type 2 diabetes mellitus (T2DM) by enhancing glycaemic control, promoting modest weight loss, and providing proven cardiovascular and renal benefits. The impact of SGLT2 inhibitors on insulin-treated T2DM patients has also been highlighted in major clinical trials. This study examines the effects of SGLT2 inhibitors in insulin-treated T2DM patients in a dedicated diabetes clinic, focusing on HbA1c, insulin dosage and regimen, and weight changes after six months of treatment. METHODOLOGYThis retrospective study was conducted at the diabetes clinic of Hospital Sultan Haji Ahmad Shah. Insulin-treated T2DM patients who were initiated on SGLT2 inhibitors between June and August 2024 were included in the study. Patients on concomitant GLP-1 receptor agonist therapy were excluded. Electronic medical records were reviewed for patient follow-up records. RESULTFifty patients were included in the study, with a mean age of 52.32 years, and a predominance of female patients (64%). 74% of the patients were initiated on empagliflozin. The initiation of SGLT2 inhibitors resulted in a 12% reduction in basal-bolus therapy, with insulin treatment being de-intensified to premixed insulin therapy. There was a modest reduction in total daily dose (TDD) of insulin use (mean reduction 1.12 units, SD 19.4), HbA1c (mean reduction 0.36%, SD 1.8), and weight (mean reduction 1.02 kg, SD 7.5). 34% of patients experienced a reduction in TDD insulin use of more than 5 units, and 66% showed a reduction in HbA1c levels. In the empagliflozin-treated group, there was a greater reduction in TDD insulin and weight, while the dapagliflozin-treated group showed a greater reduction in HbA1c. CONCLUSIONInitiation of SGLT2 inhibitors in insulin-treated T2DM patients has shown promising effects, supporting the initiative for insulin deintensification. However, further exploration and investigation are needed to assess the long-term metabolic effects and durability of SGLT2 inhibitor treatment.