Journal of Endocrinology, Metabolism and Diabetes in South Africa - Volume 14, Issue 3, January 2009

As 2009 draws to a close, there is time to reflect on the new-look JEMDSA. Through the tireless work of Professor Stephen Hough, a new publisher was found and the endocrine community drew together to ensure the success of JEMDSA as the official journal of six societies (SEMDSA, DESSA, NOFSA, SASOM, LASSA, and PAEDS-SA). It has been gratifying to witness the coordinated and willing effort of many people who have provided review articles, insightful commentary and some original research.

Results from several randomised controlled trials have demonstrated conclusively that microvascular complications can be reduced in patients with both type 1 and type 2 diabetes. These trials have indicated that an HbA1c level ≤ 7% is a reasonable target to aim for if attempts are to be made to reduce or delay the advent of microvascular complications. This target has therefore been incorporated into the American Diabetes Association (ADA), and subsequently the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines. However, cardiovascular disease (CVD) remains the leading cause of both morbidity and mortality in patients with type 2 diabetes and over 65% of deaths in these patients are attributable to heart disease or stroke. Given the known increasing prevalence of type 2 diabetes globally, the CVD burden due to these conditions is expected to continue rising. It is therefore important to understand the relationship between improved glucose control and the occurrence of macrovascular disease.

The increase in incidence of HIV infection continues to be a major public health problem across the world, but more especially in sub-Saharan Africa. Treatment with highly active antiretroviral therapy (HAART) has improved the prognosis of patients with AIDS, but it has also increased the incidence of various metabolic disorders, in particular insulin resistance accompanied by dyslipidaemia, hyperglycaemia and lipodystrophy. This is often accompanied by frank type 2 diabetes and increased mortality from cardiovascular disease. It is important to understand the mechanistic basis for these side-effects as the incidence of these is likely to increase as the rollout of antiretroviral drugs continues.

Bisphosphonates were discovered 40 years ago and remain the market leader in the field of osteoporosis. Bisphosphonates are classified as inhibitors of bone resorption and they act by inhibiting the mevalonate pathway to inhibit protein prenylation with resultant inhibition of osteoclastic activity. There are three ethical bisphosphonates as well as generic alendronate that have been approved for the treatment of osteoporosis in South Africa. These drugs offer a wide range of variations in dose, frequency of administration and method of administration. The wide choice in method of administration may lead to improved individual compliance to treatment protocols. There is strong evidence to support antifracture efficacy at vertebral and hip sites in patients treated for up to three years but long-term data as well as prospective data in osteopenic patients are lacking. Gastrointestinal side-effects are common, but can often be avoided by taking medication in the prescribed fashion. The acute phase response to intravenous administration can be prevented by co-administration of oral paracetamol or ibuprofen. Bisphosphonates can cause bone pain. The Food and Drug Administration (FDA) has accepted evidence that bisphosphonates do not cause atrial fibrillation. Osteonecrosis of the jaw is a rare complication of oral bisphosphonates as used in osteoporosis but may be associated with high dose intravenous treatment in cancer patients. Atypical low energy femur shaft fractures have been associated with long-term usage of the bisphosphonates. A large national observational register-based study reported that these fractures share the same epidemiology and treatment response as classical hip fractures and are best classified as osteoporotic fractures. The cost-effectiveness and treatment options of the bisphosphonates will ensure that they remain significant players in years to come.

Obesity can have an impact on health at each stage of a woman's life cycle. In young women, obesity has an impact on psychosocial health and, as they grow older, on their reproductive health. Obesity also imposes a number of serious risks during pregnancy. In older women, obesity is associated with the emergence of a number of related chronic diseases, such as type 2 diabetes and cardiovascular disease and an increased risk for many cancers. Of concern in the elderly is the increasing evidence that obesity is an independent risk factor for dementia and Alzheimer's disease. Obesity also has a marked impact on life expectancy. The medical risks associated with obesity in women are important for the woman's future generations. There is emerging evidence that nutrition during fetal and early life can influence risk for obesity and chronic diseases.

Osteomalacia is a condition characterised by failure of bone mineralisation. While abnormalities of vitamin D supply, metabolism or action are the most common and well-known causes, chronic phosphate deficiency, due to either insufficient input (intake or absorption) or renal losses are also important causes of rickets or osteomalacia. Hypophosphataemia also commonly co-exists with vitamin D deficiency, pursuant to secondary hyperparathyroidism. Other causes include chronic calcium deficiency, hypophosphatasia, fluoride and aluminium excess.

It is well established that HMG CoA reductase inhibitors or statins are effective for secondary prevention, that is in patients with established cardiovascular disease (CVD), but whether this benefit applies to those without CVD, in other words for primary prevention is uncertain. Previous studies have provided ambiguous answers on statin use in people at relatively low risk for cardiovascular disease. In addition there has been a debate about the safety and efficacy of statins in certain sub-groups such as the elderly (persons over age 65 or even 75 years of age), women, and those with diabetes mellitus.

A pharmacist is one of few medical professionals in the world to whom a patient or anyone else can go for a consultation or advice without an appointment. They are easily accessed and knowledgeable about a myriad of aspects concerning patients and their medication. It is thus of the utmost importance to take these skills into consideration when it comes to diabetic education. Pharmacists have long-term relationships with most of their chronic patients, which sets a good foundation for mutual trust and respect and better patient compliance.