NAM NS2 12/20.1.1/0058. S4 A48/20.1.1/0583. DYNA TEICOPLANIN 200, 400 mg. Each vial contains 200, 400 mg teicoplanin respectively. S4 A43/20.1.1/0573, 0575. DYNA TEICOPLANIN SOLVENT. Each ampoule contains 3,2 ml water for injection. S4 A43/34/0574. FORURI. Each sachet contains 3 g fosfomycin,
12 16 20 19
Wrapping up the year: Wishing you rest, renewal, and a bright start to 2025! 6 EVENTS
Diabetes: Breaking barriers and bridging gaps 8 PRODUCT NEWS
Do smart insulin pens and new generation insulins address unmet needs in T1DM?
GASTROENTEROLOGY
Online CPD: MMX mesalamine: A breakthrough in mild-tomoderate UC treatment
House of Stroke: Navigating intracranial haemorrhage and ethical dilemmas
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Hypertension and diabetes: A deadly duo 23 WEBINAR REPORTS
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Ketamine - New frontiers in the treatment of depression
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As the year draws to a close, we wish all our readers a restful and rejuvenating December break. After the dedication and hard work of the past months, may this holiday season bring you the opportunity to recharge, so that 2025 is met with renewed energy and focus. We thank you for your ongoing commitment to advancing medical care and improving the health of your patients - your contributions are invaluable.
In this combined November/December issue, we spotlight the remarkable advancements shaping today’s medical landscape. With technology playing a more transformative role than ever, this edition features the latest in type 1 diabetes care. The introduction of smart insulin pens promises a new level of precision, convenience, and control, helping patients manage their condition more seamlessly and effectively. Alongside this, we explore pioneering treatments in stroke care that continue to evolve, offering improved outcomes for patients in critical situations.
Our focus on mental health and endocrine disorders includes an in-depth look at testosterone replacement therapy (TRT) and its potential to treat depression in men living with hypogonadism. With hypogonadism’s impact on mental wellbeing often under-acknowledged, this article delves into TRT’s role in addressing depressive symptoms and enhancing quality of life, bringing needed attention to an important and sometimes overlooked area of men’s health.
For those managing patients with both type 2 diabetes and hypertension, our summary of the latest treatment guidelines provides valuable insights. These recommendations aim to equip clinicians with evidence-based strategies that can make a meaningful difference in managing these co-occurring conditions effectively.
In addition, we shed light on a critical issue for South Africans:
Malaria. Our infographic highlights seven essential facts about malaria, a disease with unique challenges in our country. From prevention strategies to understanding malaria’s spread in South Africa, these insights can support clinicians in recognising and responding to this serious health threat.
And finally, we are pleased to offer opportunities for continued learning. Complete our online quiz to earn four CPD points, and for those who missed our recent CPD-accredited webinars, replays are available to earn an additional eight points.
We hope this issue enriches your knowledge and supports you in delivering the highest standard of care.
Wishing you a peaceful, welldeserved break, and may the new year bring you inspiration, success, and fulfillment. Happy holidays, and here’s to a bright start in 2025!
Hope you enjoy the read!
Regards
René Bosman
Once known primarily for battling infectious diseases, Africa is now grappling with a surge in non-communicable diseases (NCDs), with diabetes emerging as a leading concern. Over the past decade, the continent has witnessed a 60% increase in NCDs, signalling the need for urgent action. This year’s World Diabetes Day theme, Breaking Barriers and Bridging Gaps, underscores the importance of equitable access to diabetes care, a message articulated by Dr Stavros Nicolaou, senior executive: Strategic Trade at Aspen Group. He made these remarks during a media briefing held on November 14, marking the global observance of World Diabetes Day.
Unlike HIV, which is closely monitored and diagnosed early, diabetes often progresses unnoticed. Its symptoms - such as dry mouth and frequent urinationare easily overlooked, leading to late diagnoses. As a result, patients often face severe complications, including chronic kidney disease (CKD), cardiovascular (CV) issues, and hypertension.
The rising prevalence of diabetes is particularly alarming among younger generations, heavily influenced by sedentary lifestyles - a phenomenon referred to as couch child syndrome. This shift has resulted in the early onset of type 2 diabetes (T2DM), affecting even children and adolescents.
The economic toll of diabetes is also staggering. For instance, 15% of a major South African medical scheme’s expenditure is directed towards managing diabetes, costing billions annually. Without urgent intervention, the strain on healthcare systems and economies will only intensify. The launch of a year-long campaign launched by Aspen aims to raise awareness, improve screening, and enhance access to life-saving treatments for individuals living with diabetes.
Diabetes in South Africa:
An overview
Diabetes is a chronic condition that results in elevated blood glucose levels (hyperglycaemia), leading to long-term complications that affect multiple organs, explained Dr Renya Daya, president of the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA).
In South Africa, diabetes is an increasingly prevalent concern, shaped by various socio-economic and healthcare-related challenges. There are three primary types of diabetes: Type 1 diabetes (T1DM), T2DM, and gestational diabetes (T4DM). Although type 3 diabetes is sometimes mentioned in medical discussions, it is not yet officially recognised as a distinct category.
1 T1DM: An autoimmune disorder where the pancreas fails to produce insulin, requiring lifelong insulin therapy. This type is typically diagnosed in childhood or early adulthood.
2 T2DM: Often linked to lifestyle factors, including poor diet, obesity, and lack of physical activity, T2DM represents most diabetes cases in South Africa. It is more prevalent in adults but
3
is increasingly being diagnosed in children and adolescents.
T4DM: Occurs during pregnancy, putting both the mother and the child at risk. Women who experience gestational diabetes have an increased risk of developing T2DM later in life.
The prevalence of T1DM in sub-Saharan Africa is not well-documented due to the lack of a national patient registry, but estimates suggest that ~100 000 individuals live with T1DM in South Africa.
The situation with T2DM is even more concerning, with an estimated 24 million people affected across Africa. By 2045, the number of individuals living with T2DM is expected to more than double, placing immense pressure on healthcare systems, particularly in countries like South Africa, where 80% of the population relies on public healthcare services, noted Dr Daya.
Diabetes significantly increases the risk of both macrovascular (large vessel) and microvascular (small vessel) complications, which have longterm, life-threatening consequences.
_ Macrovascular complications: These include CV diseases such as heart attacks and strokes, the leading causes of death among diabetic patients.
_ Microvascular complications: Diabetic retinopathy (which can lead to blindness), nephropathy (kidney disease requiring dialysis), and neuropathy (nerve damage). Diabetic foot disease, which may result in amputations, is another severe complication that drastically reduces a patient’s quality of life. The cumulative effects of these complications significantly shorten life expectancy. Diabetic individuals typically lose an average of six years of life, which can rise to 11 years if compounded by heart or kidney disease.
Access to diabetes care in South Africa is inequitable, with stark contrasts between the private and public healthcare sectors. The public healthcare system is plagued by a shortage of specialists, leaving many patients underserved. The country currently has only 101 endocrinologists (87 for adults and 14 for paediatrics), compared to the ideal requirement of over 800. Similarly, there are only 200 cardiologists and 120 nephrologists in South Africa - far fewer than the numbers needed to provide adequate care, stressed Dr Daya. This shortage of specialists is exacerbated by factors such as emigration, retirement, and limited training opportunities for new professionals. Alarmingly, ~50% of individuals living with diabetes remain undiagnosed, often presenting with severe complications like heart attacks or infections, underscoring the need for improved awareness and early detection.
Several key factors contribute to the increase in diabetes prevalence, including age (>45), family history, ethnic background, obesity, and sedentary lifestyles. A significant driver of diabetes is obesity, which is becoming increasingly prevalent in South Africa. Close to 50% of the population is either overweight or obese, with women facing two to three times the risk of developing diabetes compared to men with the same BMI. The increase in childhood obesity is a particularly concerning development, with children as young as four years old showing signs of obesity, which is often followed by the early onset of T2DM. This troubling trend is contributing to the early mortality of individuals, particularly those between the ages of 30 and 60. The resulting loss of
income and productivity places a significant burden on both the healthcare system and the economy.
Dr Zaheer Bayat, immediate past-president of SEMDSA, reflected on his experience during the early 2000s HIV crisis, where he witnessed the death of children from the disease.
This experience serves as a stark reminder of the potential healthcare and economic disaster posed by the growing diabetes epidemic. Dr Bayat identifies three major challenges in diabetes management:
Obesity, glucose control, and access to care.
_ Obesity: Obesity is a significant global issue, particularly in South Africa, where ~50% of the population is overweight or obese. Socio-cultural factors, including a preference for fast food and a sedentary lifestyle, have compounded the problem. In underprivileged areas with limited resources and busy schedules make it nearly impossible for many individuals to prioritise health and fitness.
_ Glucose control: Managing blood sugar levels is a challenge, with only ~50% of diabetes patients worldwide achieving adequate glucose control. Dr Bayat emphasised that just as the global HIV response has focused on improving diagnosis, access to care, and treatment adherence, the same focus should be applied to diabetes management.
_ Access to care: The shortage of
healthcare professionals - particularly endocrinologists - further complicates diabetes management in South Africa. Dr Bayat called for a coordinated approach, citing successful models like the Tshwane Insulin Project, which trains nurses to administer insulin and monitor patients.
The shift in diabetes types
Dr Bayat also observes a shift in diabetes types. While T1DM is typically diagnosed in childhood or early adulthood, more adults are now being diagnosed with it. Similarly, T2DM is increasingly affecting younger individuals, including children as young as 10- or 12-years.
He highlighted the lack of transitional care facilities in South Africa, where paediatric patients struggle to transition to adult care as they age. Only a few clinics in the country provide transitional care. This gap in the healthcare system needs urgent attention to ensure a smooth transition for these patients.
To effectively fight the diabetes pandemic, South Africa - and the wider African continent - must invest in healthcare education, improve access to care, and foster early detection and prevention. With growing challenges such as obesity and limited healthcare resources, a unified and strategic approach is critical. The ongoing campaign for World Diabetes Day serves as a pivotal moment to spark national and continental conversations on tackling this urgent health crisis. SF
it comes to insulin dosing and achieving precise blood glucose control. Maintaining consistent glycaemic control can be especially challenging for individuals relying on insulin therapy. However, recent advancements in digital technologies, such as continuous glucose monitoring (CGM) and smart insulin pens, are playing an increasingly important role in optimising insulin delivery, reducing dosing errors, and improving overall diabetes management.1-7
For people on insulin therapy, poor outcomes often arise from difficulties with accurate dose adjustments, insulin omission, or non-adherence - whether intentional or unintentional. A patient-centred approach that actively engages the individual in managing their condition has become crucial for successful treatment outcomes.1
Novo Nordisk at the forefront of diabetes care innovation
Novo Nordisk has long been a leader in diabetes care innovation. For over a century, the company has played a pivotal role in developing advanced insulins and, more recently, in creating a connected diabetes management ecosystem. This ecosystem integrates smart insulin pens and digital technology to enhance accessibility and patient outcomes. 6,7,8
In October 2024, Novo Nordisk South Africa introduced its latest smart insulin pens, the NovoPen® 6 and NovoPen Echo® Plus.
How smart devices are transforming the diabetes landscape
The latest American Diabetes Association (ADA) standard of care guidelines recommend the use of CGM for all individuals living with diabetes who are on multiple daily injections or continuous subcutaneous insulin infusion and capable of safely using the devices. In addition, the ADA recommends smart insulin pens for those using injectable therapy. 5 According to experts, smart insulin pens have revolutionised patient outcomes. These technologies have simplified insulin
delivery and made self-management easier for those on insulin therapy. 3,4,5
Smart insulin pens streamline therapy tracking and enhance communication between patients and healthcare providers. By securely sharing data with healthcare teams, these devices facilitate retrospective reviews of insulin usage, including dose timing and, in some cases, glucose data. 3,4
Additionally, they address common challenges faced by people on multiple daily injections, such as dosing errors, missed or delayed doses, and the risk of hypoglycaemia due to stacked doses. Research shows that missing just two mealtime insulin bolus doses per week can increase HbA1c levels by 0.4%, highlighting the importance of timely insulin administration. 3,5
NovoPen® 6 and NovoPen Echo® Plus: Enhancing diabetes management
The NovoPen ® 6 and NovoPen Echo® Plus are equipped with advanced features to improve diabetes management. For instance, the digital dose memory function automatically records the last insulin dose, reducing the risk of missed or double dosing and ensuring precise delivery. 6
Both pens are compatible with any Novo Nordisk Penfill ® 3ml cartridges such as insulin degludec 100 units/ml. The NovoPen ® 6 administers insulin in 1-unit increments, with a maximum dose of up to 60 units, while the NovoPen Echo® Plus delivers insulin in 0.5-unit increments, with a maximum dose of 30 units.9
These pens also log insulin doses and sync with diabetes apps (compatible with selected self-monitoring blood glucosemeters and CGM sensors, allowing for comprehensive data analysis and management. The data can be used to analyse glucose and insulin trends, enabling healthcare providers to create personalised treatment plans that optimise blood glucose control and reduce risk factors. 6 The convenience of real-time feedback and the ability to easily track doses alleviates stress for individuals managing their condition. Furthermore, accurate and timely dosing helps mitigate the risk of both hypoglycaemia and hyperglycaemia, ultimately improving overall safety and control.6
Identifying patients who could benefit from smart insulin pens
Healthcare providers can identify patients who may benefit from smart insulin pens by asking the following questions:10
_ Do you sometimes miss your bolus injections?
_ Do you often forget whether you have taken your insulin dose?
_ Have you ever accidentally taken a double dose of insulin?
_ Do you track your insulin dosages?
_ Would reminders for taking your insulin doses be helpful for you?
_ Do you often feel overwhelmed by the complexity of managing your insulin regimen?
Patients answering ‘yes’ to these questions may benefit from the added accuracy and real-time data integration provided by smart insulin pens.10
NovoPen Echo® Plus NovoPen® 6
60-unit maximum dose 1-unit dose increments
30-unit maximum dose 0.5-unit dose increments
NovoPen® 6 / Echo® Plus records and stores the last 800 doses*1
Wireless transfer of insulin dosing data via Near Field Communication (NFC) technology1
Dose memory display of the amount and time since last injection1
No battery replacement or recharge needed1
NovoPen® 6 / Echo® Plus has an in-use battery lifetime of at least 4 years†1
* Corresponding to at least 3 months of use.
† No need to be recharged.
Sponsored by
power of
Insulin degludec 100 units/ml, launched in South Africa in 2019, has a duration of action beyond 42 hours which results in a flat and stable profile. Faster insulin aspart, launched in South Africa in 2022, is formulated by adding niacinamide for faster absorption. The onset of action occurs five minutes earlier than regular insulin aspart, which more closely mimics the endogenous insulin profile.11
Studies show that insulin degludec and faster insulin aspart reduce hyperglycaemia as well as severe and nocturnal hypoglycaemia. This has led to increased glycaemic stability and improved TIR, which ultimately enhances overall HbA1c control.2,13,14,15
Adolfsson et al studied the impact of the connected NovoPen ® 6 on insulin regimen management and glycaemic control in participants living with type 1 diabetes who were using a basal-bolus insulin regimen and CGM. The participants tracked their insulin data over multiple visits, with key outcomes including time in range (TIR), hyperglycaemia, hypoglycaemia, and missed bolus doses. 2
According to the ADA, TIR is an important measure of glycaemic status, particularly when assessed through a 10- to 14-day CGM period with at least 70% wear. TIR, along with other CGM metrics, provides valuable insights for clinical management and correlates with HbA1c levels. Key CGM parameters, such as time below range (<3.9mmol/L) and time above range (>10mmol/L), are essential for insulin dose adjustments and evaluating treatment plans.12
In Adolfsson and colleagues’ study, participants experienced less glucose variability, increased TIR, and reduced time in hyperglycaemia and severe hypoglycaemia (<3.0mmol/l). These improvements were evident early on, occurring after just five visits to healthcare professionals.2
An increase in TIR is associated with significant clinical benefits. For example, a 5% increase in TIR corresponds with notable improvements in glycaemic control. In this study, the 8.5% increase in TIR suggested an HbA1c improvement of around 0.4%-0.7%. 2
Importantly, while time in hypoglycaemia did not increase, the occurrence of hypoglycaemia decreased, and glucose variability was significantly reduced. This indicates that the improved TIR was driven by more stable glucose levels, rather than simply lower overall glucose readings. The significant 28% increase in bolus doses from baseline likely contributed to these improvements.2
The study also revealed that missed bolus doses are common among individuals living with T1DM, with about 25% of meals missing a dose on average. Reducing missed doses is a critical challenge, as missed boluses correlate with higher HbA1c levels. The use of smart insulin pens helped reduce missed doses by 43%, suggesting that these devices can aid in dose timing and adherence, leading to better glycaemic control. 2
Danne et al investigated the relationship between insulin injection adherence, smart insulin pen use, and glycaemic control in a real-world setting across 16 countries. The study demonstrated that treatment adherence and engagement with a smart insulin pen (NovoPen 6® or NovoPen Echo Plus®) significantly improved glycaemic outcomes for adults self-administering basal insulin degludec and bolus insulin.13
Over a 14-day period, each missed basal, or bolus insulin dose was associated with a decrease in TIR by 2.8% and 1.7%, respectively. Missing two basal or four bolus doses during this time resulted in a clinically significant reduction in TIR, underlining the importance of consistent insulin administration.13
Participants missed an average of six bolus doses during the study period, enough to cause a noticeable reduction in TIR. Moreover, engagement with the smart insulin pen, measured by the frequency of data uploads to the mobile app, was strongly associated with improved glycaemic control. Participants who consistently uploaded data from their smart insulin pens achieved better TIR outcomes compared to those with lower engagement.13
This study confirmed previous findings that higher adherence to insulin dosing, facilitated by smart insulin pens, leads to better glycaemic control. Fewer missed injections correlate with improved HbA1c levels, and real-time insights into injection timing and adherence provided by smart insulin pens offer significant benefits in helping patients manage their treatment more effectively.13
Conclusion
The use of smart insulin pens, coupled with innovations in insulin therapy, marks a significant step forward in diabetes management. These tools improve insulin adherence, reduce dosing errors, and empower individuals with diabetes to achieve more stable glycaemic control. The integration of new-generation insulins with technology presents a promising approach to diabetes care, offering the potential for better outcomes and improved quality of life for individuals living with T1DM.
1. Cranston I, Jamdade V, Liao B, Newson RS. Clinical, Economic, and Patient-Reported Benefits of Connected Insulin Pen Systems: A Systematic Literature Review. Adv Ther, 2023.
2. Adolfsson P, Hartvig NV, Kaas A, Møller JB, Hellman J. Increased Time in Range and Fewer Missed Bolus Injections After Introduction of a Smart Connected Insulin Pen. Diabetes Technol Ther, 2020.
3. Lingen K, Pikounis T, Bellini N, Isaacs D. Advantages and disadvantages of connected insulin pens in diabetes management. Endocr Connect, 2023.
4. Heinemann L, Schnell O, Gehr B, Schloot NC, Görgens SW, Görgen C. Digital Diabetes Management: A Literature Review of Smart Insulin Pens. J Diabetes Sci Technol, 2022.
5. El Sayed NA, Aleppo G, Aroda VR, et al Diabetes Technology: Standards of Care in Diabetes—2023. Diabetes Care, 2023.
6. Novo Nordisk. Smart Pens. [Internet]. Available at: https://www.novonordisk.com/our-products/ smart-pens/novopen-6.html
7. Kerr D, Klonoff DC, Bergenstal RM, et al A Roadmap to an Equitable Digital Diabetes Ecosystem. Endocrine Practice, 2023.
8. Novo Nordisk. Insulin 100. [Internet]. Available at: https://www.novonordisk.za.com/about/insulin100-years.html
9. Novo Nordisk. NovoPen Echo® Plus user guide. [Internet]. Available at: www.novonordisk.com/ content/dam/nncorp/global/en/our-products/ pdf/instructions-for-use/novopen-echo-plus/ Novopen-echo-plus-UK.pdf
10. Adolfsson P, Hartvig NV, Kaas A, Møller JB, Hellman J. Increased Time in Range and Fewer Missed Bolus Injections After Introduction of a Smart Connected Insulin Pen. Diabetes Technol Ther, 2020.
11. Broeng-Mikkelgaard S, Brøsen BJM, Kristensen PL, et al. The effect of insulin analogs in people with type 1 diabetes at increased risk of severe hypoglycemia. Front Pharmacol, 2023.
12. American Diabetes Association. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes - 2024. Diabetes Care, 2024.
13. Danne TPA, JOubert M, Hartvig NV. Association Between Treatment Adherence and Continuous Glucose Monitoring Outcomes in People with Diabetes Using Smart Insulin Pens in a RealWorld Setting. Diabetes Care, 2024.
14. Lane W, Bailey TS, Gerety G, et al Effect of Insulin Degludec vs Insulin GlargineU100 on Hypoglycemia in Patients With Type1 Diabetes - The SWITCH1 Randomized Clinical Trial, JAMA, 2017.
15. Brøsen JMB, Agesen RM, Alibegovic AC, et al The Effect of Insulin Degludec Versus Insulin Glargine U100 on Glucose Metrics Recorded During Continuous Glucose Monitoring in People with Type 1 Diabetes and Recurrent Nocturnal Severe Hypoglycemia. Journal of Diabetes Science and Technology, 2023. SF
Ulcerative colitis (UC) is a prevalent inflammatory bowel disease characterised by inflammation in the colon, typically beginning in the rectum. UC has a bimodal incidence pattern, primarily affecting individuals aged 15-30, with a secondary peak in older adults.
Symptoms include bloody diarrhoea, abdominal pain, and urgency, with 10%-30% of patients experiencing extraintestinal manifestations like joint pain and skin conditions.
First-line treatment for mild-tomoderate UC involves 5-aminosalicylates, administered orally or topically to reduce inflammation and maintain remission. Recent advances have led to the development of multi-matrix system
(MMX) mesalamine, a multi-matrix release formulation that delivers the drug gradually throughout the entire colon, potentially increasing its effectiveness for inflammation control. Studies highlight MMX mesalamine’s efficacy in both inducing and maintaining remission: clinical trials show significant symptom relief and remission rates at doses of 2.4g and 4.8g daily, with some patients achieving remission even after previous treatment failures.
Real-world evidence supports MMX
mesalamine’s sustained effectiveness, with up to 64.4% of patients in remission after 12 months. Adherence plays a crucial role in outcomes, as lower adherence correlates with higher recurrence. MMX mesalamine is generally safe, with adverse events comparable to placebo in clinical trials, making it a promising therapeutic option for long-term UC management.
To access the article and quiz, go to https://www.medicalacademic.co.za/ courses/ SF
In the final installment of our three-part series on Boehringer Ingelheim House of Stroke Symposium, featuring some of the country’s foremost stroke specialists, we delve into the intricate challenges of managing intracranial haemorrhage and explore the ethical dilemmas faced in stroke care.
Navigating intracranial haemorrhage
Dr Eitzaz Sadiq, consultant neurologist and lecturer at the University of the Witwatersrand and head of the Neurology Unit at Helen Joseph Academic hospital
Intracranial haemorrhage (ICH) is a severe complication of stroke, particularly following thrombolysis treatment. Thrombolysis, a
critical intervention for ischaemic stroke, dissolves clots and restores blood flow to the brain but increases the risk of haemorrhagic transformation, leading to significant neurological decline.
The definition of symptomatic ICH (sICH) varies across studies, causing discrepancies in case reporting. The National Institute of Neurological Disorders and Stroke defines
sICH as any hemorrhagic transformation resulting in neurological deterioration, risking over-diagnosing minor petechial bleeds.
The Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria offers a stricter definition, considering only haemorrhages associated with significant neurological worsening (more than four points on the NIHSS score) as symptomatic.
Depending on the criteria, the incidence of sICH post-thrombolysis ranges from under 2% to 7.4%.
Radiologically, intracranial haemorrhages are classified into haemorrhagic infarctions and parenchymal haematomas. Haemorrhagic infarctions, subdivided into HI1 and HI2, typically involve small petechial bleeds that are often asymptomatic.
In contrast, parenchymal hematomas (PH1 and PH2) are more severe, with PH2 representing large haemorrhages that can cause significant mass effect and worsen outcomes.
Predicting the risk of haemorrhagic transformation after thrombolysis is challenging. Several scoring systems incorporate factors such as age and stroke severity to estimate the risk, but these are not commonly used in clinical practice to determine thrombolysis eligibility.
Patients with the highest risk of haemorrhage often benefit most from thrombolysis. These scores guide post-thrombolysis monitoring and help manage patient and family expectations.
Clinical signs of haemorrhagic transformation include sudden neurological deterioration, decreased consciousness, new headaches, nausea, vomiting, and a sudden rise in BP within 36-hours post-thrombolysis. Most haemorrhages occur within 12-hours of treatment, but monitoring should continue for up to 36-hours as late haemorrhages can occur.
Managing intracerebral haemorrhage following thrombolysis is critical in stroke care. The American Heart Association and American Stroke Association’s 2017 guidelines recommend immediately stopping the thrombolysis infusion upon detecting a bleed.
Standard management principles for intracerebral haemorrhage, including maintaining adequate breathing and circulation, controlling
BP, and managing intracranial pressure, should be followed.
Reversing the coagulopathy induced by thrombolysis is essential to prevent further hemorrhage expansion. This process involves administering agents that can reverse the effects of alteplase, the thrombolytic drug commonly used. The aim is to stop the bleeding and minimise neurological damage.
Dr Sadiq emphasised the critical role of blood products, specifically cryoprecipitate, fresh frozen plasma (FFP), and prothrombin complex concentrates (PCC), in managing this severe condition. Understanding the coagulation pathway and the timely administration of these agents are crucial for effective treatment.
Cryoprecipitate, containing Factors VIII, XIII, von Willebrand factor, and fibrinogen, is essential in treating ICH. Dr Sadiq stressed that cryoprecipitate can benefit all patients with ICH, but its administration should be guided by fibrinogen level checks.
Without waiting for results, 10 units of cryoprecipitate should be administered, followed by a repeat fibrinogen level test after 30 minutes. This process may need to be repeated until fibrinogen levels reach 150mg/dl.
The key challenge with cryoprecipitate is its availability and the need to thaw it from a frozen state, which can be time-consuming in emergencies. Despite its widespread use, the evidence supporting its effectiveness is limited, relying mostly on expert opinion and small observational studies.
PCC, containing Factors II, VII, IX, and X, along with proteins C and S, is another essential product in managing ICH. However, PCC requires fibrinogen as a substrate, meaning it is less effective if fibrinogen levels are low.
PCC is particularly beneficial for patients on warfarin with depleted factors, but its use increases the risk of thrombotic events. Unlike cryoprecipitate, PCC may need to be used with cryoprecipitate to provide more comprehensive treatment.
However, which also contains multiple clotting factors, can be used as an alternative to PCC. However, FFP poses challenges due to its larger volume and slower administration, which can be problematic in emergency settings. Additionally, the risk of transfusion reactions and the need for thawing make FFP less ideal compared to other options.
Despite its limitations, FFP is still considered for patients on warfarin with ICH, like the use of vitamin K, which also lacks strong evidence for benefit in this context.
Antifibrinolytic agents like aminocaproic acid and tranexamic acid, which inhibit plasmin, were briefly discussed by Dr Sadiq. Although the data supporting their use is limited, ongoing trials show promise. These agents are appealing because they are readily available, work quickly, and do not require thawing, making them practical in emergencies, especially for patients who decline blood products for religious reasons.
The role of platelets in managing ICH was also mentioned, with the suggestion that they might be beneficial in patients with thrombocytopenia, although this is not well-established.
Dr Sadiq emphasised that surgical intervention should only be considered once coagulopathy is reversed. He highlighted the Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial, which explored minimally invasive surgery combined with alteplase catheter irrigation, showing some survival benefits but not meeting primary outcomes.
The ethical dilemma – choosing treatment or not Dr Johann Smuts, neurologist in private practice, and lawyer
Dr Smuts delivered a compelling presentation on the ethical dilemmas surrounding the treatment of stroke patients, particularly when the
treatment options themselves carry significant risks, such as thrombolysis or thrombectomy. Dr Smuts began by addressing the core question: Should we treat a patient knowing the potential for harmful outcomes exists?
He argued that the ethical concern is not whether to treat but rather how to treat. Once a patient enters the care of a physician, there is an ethical obligation to provide treatment. The dilemma arises when the treatment itself may lead to adverse outcomes, such as bleeding risks associated with thrombolytic therapy. This highlights the importance of balancing the potential benefits of treatment with the risks, a decision that must be made with careful consideration of the patient’s condition and the available medical evidence. He emphasised the growing importance of understanding legal principles in stroke medicine, especially as advancements in treatment raise patient expectations and increase the likelihood of malpractice litigation.
To navigate these legal waters, Dr Smuts structured his discussion around four primary sections:
1 Competency: This refers to a patient’s mental capacity to make informed decisions about their treatment. Competency is task-specific, meaning the level of understanding required varies depending on the complexity of the decision. For example, a patient must comprehend the nature of the treatment, the risks involved and be able to communicate their decision effectively. In stroke cases, where cognitive impairments are common, assessing competency becomes particularly challenging.
2
Doctor-patient relationship: The establishment of a doctor-patient relationship is crucial as it forms the legal duty of care. This relationship can be formed through physical, telephonic, or even digital interactions and implies a contractual obligation to provide care. Once treatment is initiated, the relationship persists until formally terminated, and failing to properly conclude this relationship can lead to accusations of patient abandonment, which is a common ground for malpractice suits.
3 Informed consent: Informed consent is not just a formality but a process that ensures the patient makes knowledgeable decisions about their treatment. Dr Smuts highlighted the need for thorough documentation of informed consent, ideally through written forms. The consent process should include explaining the
diagnosis, the proposed treatment, its risks, and any reasonable alternatives. In situations where the patient is not competent to give consent, substitute consent from a legal guardian or next of kin may be necessary.
4
Malpractice: Malpractice occurs when there is a duty to treat, a breach of that duty, an injury, and a causal link between the breach and the injury. Dr Smuts explained that the standard of care is a key element in malpractice cases, where the behaviour of the physician, rather than their knowledge, is scrutinised. Deviation from clinical guidelines, especially without proper documentation or patient discussion, can be grounds for malpractice if it leads to patient harm. Informed consent is particularly critical in stroke treatment due to the high stakes involved. He stressed that informed consent must be more than a simple offer to answer questions. It should be a comprehensive discussion that provides the patient with all necessary information to make an informed choice.
The discussion should cover the nature and seriousness of the condition, the reasons for recommending a specific treatment, the risks involved, and the potential outcomes if the treatment is not administered.
The concept of implied consent was also discussed, particularly in emergency situations where the patient is unable to provide consent. In such cases, treatment is justified based on what a reasonable person would likely choose under similar circumstances. However, even in emergencies, it is crucial to document the decision-making process as thoroughly as possible.
Dr Smuts outlined the four essential elements of malpractice:
1 Duty of care: This is established through the doctor-patient
relationship and implies a legal obligation to treat the patient with the expected standard of care.
2 Breach of duty: A breach occurs when the care provided falls below the accepted standard. This could involve doing something wrong (an error) or failing to do something right (an omission).
3 Injury: There must be a significant injury or harm resulting from the breach of duty. Minor injuries or those that do not result in lasting damage are unlikely to support a successful malpractice claim.
4 Causal link: There must be a direct link between the breach of duty and the injury. This link must be more than speculative; it must be shown that the injury was a foreseeable consequence of the breach.
An emerging legal concept in stroke medicine is the doctrine of loss of chance. This doctrine suggests that even if the probability of a better outcome with treatment is <50%, the patient may still have a case if it can be shown that the treatment would have provided a significant chance of improvement that was lost due to the physician’s actions or inaction. This concept is gaining traction and could have significant implications for malpractice cases in stroke medicine.
1 Managing ICH post-thrombolysis requires immediate cessation of treatment and careful administration of blood products, with cryoprecipitate being vital for stabilising fibrinogen levels.
2 Ethical stroke treatment involves balancing treatment risks with patient competency and informed consent, emphasising the legal obligation to provide care while navigating potential malpractice risks. SF
This article was independently sourced by Specialist Forum.
Testosterone is a key hormone that plays an essential role in maintaining men’s energy, strength, stamina, and mental clarity. However, when testosterone levels decline - a condition referred to as hypogonadism - it can lead to a variety of physical and psychological issues.1,2
These may include reduced libido, diminished energy, decreased life satisfaction, and the onset of symptoms such as weakness, irritability, and, notably, depression, one of the leading causes of disability worldwide.1,2
Although depression is more prevalent in women than in men (8.3% vs 4.6%), there is no significant gender difference in the prevalence of clinically significant depression in older adults (8.6% of men vs 7.9% of women). As men age, both the prevalence of depression and the incidence of hypogonadism increase. 2
Research has demonstrated that men living with depression tend to have lower testosterone levels, particularly in cases that are severe or resistant to treatment. In such cases, >40% of men are found to have hypogonadism.1
This pattern is observed not only
in elderly men but also in those with co-existing conditions such as HIV or chronic sleep deprivation. Interestingly, testosterone levels in depressed men are often low regardless of changes in body weight or physical activity.1
In healthy young men, total testosterone levels typically range from 10.4nmol/L to 34.7nmol/L, with only 0.5% to 3.0% being free testosterone (unbound to sex hormonebinding globulin [SHBG] or albumin). 3
As men age, levels fall into the hypogonadal range (< 9.72nmol/L10.41nmol/L) as early as age 40. Early studies suggested a steady decline of 0.4% per year after age 40, and free testosterone levels drop even faster due to an agerelated increase in SHBG. 3
Recent research shows that testosterone levels decline even in healthy, young men. For instance, a study of men aged 34 found
no baseline age effect on testosterone trajectories over a 12-year period, but it did highlight declining Leydig cell function.
3
Factors such as obesity, alcohol consumption, and certain chronic conditions like type 2 diabetes have been shown to accelerate testosterone decline, often more significantly than age itself.
3 The decline in testosterone is driven by a variety of mechanisms, including impaired luteinizing hormone receptor signaling, oxidative stress-induced dysfunction in mitochondrial cholesterol transport, and the loss of Leydig cells. Genetic factors also play a role in how testosterone levels change over time. 3
There is compelling evidence that links testosterone deficiency (TD) to increased depressive symptoms. A 2004 study using
Veterans Affairs data found that men with testosterone levels <6.93nmol/l had a 21.7% incidence of major depressive disorder over two years, compared to eugonadal men. 3
Similarly, a 2005 study found that men with testosterone levels <8.67nmol/l were at greater risk of depression, with an adjusted hazard ratio of 2.1. Other studies have also supported this link. 3
A 2006 Canadian study found significantly lower testosterone levels in middle-aged men with depression, while the Health in Men Study showed that men with free testosterone levels <60pg/ml were three times more likely to experience depression. Long-term studies have further confirmed that low testosterone levels predict a higher risk of developing depression over time. 3
Can TRT improve depression in hypogonadal men?
Several studies have investigated the potential of testosterone replacement therapy (TRT) to alleviate depressive symptoms in men with hypogonadism. The evidence suggests that TRT can improve depression by enhancing brain function, particularly in older men and those experiencing age-related testosterone decline (often referred to as andropause).1
One of the earliest studies demonstrating the potential benefits of TRT in treating depression was conducted by Pope et al (2003), who carried out an eight-week randomised, placebo-controlled study to assess the effects of testosterone transdermal gel in men with refractory depression and low or borderline testosterone levels. 4
Participants with hypogonadism were randomly assigned to receive either 1% testosterone gel (10g/day) or a placebo while continuing their existing antidepressant treatment. At the end of the trial, those receiving testosterone gel showed significantly greater improvement in Hamilton Depression Rating Scale (HAM-D) scores compared to the placebo group.4
In their meta-analysis, Zarrouf et al (2009) assessed TRT for depression and found that individuals treated with TRT showed a 50% reduction in HAM-D scores compared to those on placebo. Subgroup analyses revealed that TRT was particularly effective in men with hypogonadism, showing a significant reduction in depression, while the effects were less pronounced in eugonadal participants. TRT was effective in individuals living with HIV as well as their HIV-negative counterparts.1
Vartolomei et al (2018) analysed 15 randomised controlled trials (RCTs)
involving 1586 men with late-onset testosterone deficiency (TD) to assess the impact of TRT on depression. 5
Their findings indicated that TRT reduced depressive symptoms in men with mild pre-treatment depression, but the effect was not significant in men with major depressive disorder. Among men without pre-treatment depression, TRT led to a reduction in depressive symptoms, though the clinical significance of this reduction remains uncertain. 5
There is compelling evidence that links testosterone deficiency to increased depressive symptoms
Khera et al (2012) conducted a 12-month observational study to evaluate the long-term effects of TRT on depression symptoms in hypogonadal men. This study involved 849 men prescribed 1% testosterone gel, with depressive symptoms assessed using the Patient Health Questionnaire-9 (PHQ-9). 6
At baseline, 92.4% of participants reported depressive symptoms, with 17.3% having moderately severe to severe symptoms. Significant improvements in both total testosterone levels and PHQ-9 scores were observed by the third month of TRT.6
At 12 months, PHQ-9 scores showed a clinically meaningful average improvement of 5.62 points, and the percentage of men with moderately severe to severe symptoms dropped from 17.3% to 2.1%. 6
As part of the Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men (TRAVERSE) trial, Bhasin et al (2024) conducted a depression substudy to assess the effects of TRT on depressive symptoms in hypogonadal men, both with and without a history of depression.7
This substudy aimed to evaluate the potential of TRT to induce remission and improve depressive symptoms, energy,
sleep, and cognition in middle-aged and older men with hypogonadism.7
Participants were divided into three groups: Men meeting rigorous criteria for low-grade persistent depressive disorder (LG-PDD), those with significant depressive symptoms (PHQ-9 > 4), and all participants enrolled in the parent trial. The study used a randomisation process where participants received either TRT (1.62% transdermal testosterone gel) or placebo gel.7
The primary outcome for the LG-PDD subgroup was the proportion of men achieving remission, defined by a PHQ-9 score of <4 and a Geriatric Depression Scale (GDS-15) score <5 at six-, 12-, and 24-months. Secondary outcomes assessed changes in depressive symptoms using the PHQ-9, GDS-15, and the Hypogonadism Impact of Symptoms Questionnaire (HIS-Q), which measured mood, energy, sleep, and cognition.7
Among the men who met the criteria for LG-PDD, the primary outcome revealed no significant difference in remission rates between the TRT and placebo groups. However, TRT showed numerically greater improvements in depressive symptoms, although these differences were not statistically significant.7
For the larger group of men with significant depressive symptoms (PHQ-9 > 4), TRT demonstrated more favourable outcomes. Testosterone-treated men showed greater reductions in depressive symptoms compared to those on placebo.7
The improvements in mood, as measured by the HIS-Q mood domain, were significant at six-, 12-, and 24-months (P=.008), and TRT was also associated with improved energy scores (P=.010). However, there were no significant differences in sleep or cognitive function scores between the TRT and placebo groups.7
In a post-hoc analysis of men with severe depressive symptoms (PHQ-9 ≥ 15), no significant changes were noted between the testosterone and placebo groups. In contrast, men with mild to moderate depressive symptoms (PHQ-9 scores between 5-14) showed substantial improvements in depressive symptoms on TRT (P = .012).7
TRT shows promise as an effective treatment for mild-to-moderate depression in men with low testosterone levels. Studies suggest that TRT can significantly reduce depressive symptoms, boosting mood and enhancing quality of life by restoring testosterone levels and supporting brain function.
References are available on request. SF
Maternal iron deficiency (ID)/ID anaemia (IDA) can have profound long-term effects on both mothers and their infants. During pregnancy, maternal ID/IDA increases the risk of complications such as preterm birth, low birth weight, and developmental delays in infants.
These conditions can impair brain development, particularly during the critical period of six- to 24-months, leading to lasting cognitive, neurodevelopmental, and attention deficits.
Early ID can result in slower myelination, disrupted neurogenesis, and poor
executive function, which may hinder the child’s academic achievement and social development.
Intravenous iron therapy plays a crucial role in managing maternal ID/IDA, especially when oral iron treatments are ineffective or poorly tolerated. Addressing maternal ID/IDA early is vital, as timely intervention
can prevent adverse outcomes, improve maternal health, and support healthier longterm development in children. Improving screening and early treatment strategies are essential to mitigate these risks.
To access the article and quiz, go to https://www.medicalacademic.co.za/ courses/ SF
Individuals living with type 2 diabetes mellitus (T2DM) frequently experience a range of metabolic disorders known as cardiometabolic syndrome (CMS). Apart from diabetes, CMS includes a cluster of cardiovascular disease (CVD) risk factors such as hypertension, dyslipidaemia, central obesity, and chronic kidney disease (CKD). Managing these risk factors is crucial to improving patient outcomes and preventing long-term complications.1
Iof developing hypertension in individuals living with diabetes include older age, obesity, urban living, male gender, and longer diabetes duration. 2
Understanding the interconnectedness between diabetes and hypertension is essential for effective management.
Hypertension in diabetes is driven by factors such as maladaptive autonomic nervous system changes, immune dysfunction, and increased activation of the reninangiotensin-aldosterone system (RAAS).1
Additionally, obesity, exacerbated by sedentary lifestyles and excessive caloric intake, worsens insulin resistance, leading to oxidative stress, inflammation, and endothelial dysfunction, all of which contribute to persistent high blood pressure (BP).1
Increased sodium intake also plays a significant role in the pathogenesis of hypertension. Sodium retention leads to increased blood volume and arterial pressure, and in individuals with CKD, the kidney’s compensatory mechanisms often fail, worsening hypertension.1
Furthermore, premature vascular ageing and dysregulation of the autonomic nervous system, characterised by increased sympathetic activity, further exacerbate hypertension in individuals living with diabetes.1
BP targets in T2DM patients
Managing hypertension is a critical aspect of diabetes care, as rigorous BP control can significantly reduce the risk of diabetes-related complications. The 2024 American Diabetes Association (ADA) guidelines emphasise individualising BP targets for patients with diabetes and hypertension through a shared decision-making process. 3
This approach should consider the patient’s CV risk, potential adverse effects of antihypertensive medications, and personal preferences. For most patients, a BP target of <130/80mmHg is recommended, provided it can be safely achieved. 3
For pregnant women with diabetes and chronic hypertension, initiating or adjusting therapy at a BP threshold of 140/90mmHg has been associated with better pregnancy outcomes without increasing the risk of small-for-gestational-age births. 3
Conversely, for those with BP readings <90/60mmHg, treatment should be deintensified. A target range of 110135/85mmHg is suggested to reduce the risk of accelerated maternal hypertension. 3
For individuals with BP >120/80mmHg, the
ADA recommends lifestyle interventions, including weight loss when necessary, adopting a Dietary Approaches to Stop Hypertension or DASH eating pattern, reducing sodium, increasing potassium intake, moderating alcohol consumption, quitting smoking, and increasing physical activity. 3
Pharmacologic therapy is recommended for patients with confirmed BP readings of ≥130/80mmHg, with the goal of achieving BP <130/80mmHg. For individuals with BP ≥150/90mmHg, combination therapy or single-pill combinations should be initiated promptly, along with lifestyle modifications. 3
Managing hypertension is a critical aspect of diabetes care, as rigorous BP control can significantly reduce complications
The first-line treatment is typically an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB). Patients with a urinary albuminto-creatinine ratio ≥300mg/g, or between 30mg/g-299mg/g, should be treated with an ACEi or ARB at the maximum tolerated dose. 3
If one class of medication is not well tolerated, substitution with the other is recommended. Patients on these treatments should have their serum creatinine, estimated glomerular filtration rate, and potassium levels monitored within seven- to 14-days of initiation and at least annually thereafter. 3
Keep in mind that the pathophysiology of hypertension in individuals of African descent differs from other ethnic groups, often requiring tailored antihypertensive strategies. The initial recommended treatment includes a thiazide-like diuretic or a calcium channel blocker (CCB), such as amlodipine. 4,5
Antihypertensive therapy choices Telmisartan, an ARB, is widely preferred for managing hypertension in individuals with diabetes due to its unique ability to prevent CVD progression. Studies have shown that
telmisartan monotherapy effectively lowers BP and improves metabolic parameters in individuals living with T2DM, including those with or without complications. 6,7,8
However, combination therapy such as telmisartan and amlodipine, a dihydropyridine CCB, is often needed to meet BP targets, as timely control is crucial for reducing CV risk. Telmisartan/amlodipine, lower BP through complementary mechanisms. Telmisartan blocks the angiotensin II type 1 receptor (AT1), reducing vasoconstriction and associated adverse effects such as aldosterone secretion and catecholamine release. 8
Additionally, telmisartan acts as a partial agonist of peroxisome proliferatoractivated receptor γ, improving glucose tolerance and lipid metabolism.
Amlodipine, on the other hand, inhibits calcium influx in smooth muscle cells, promoting vasodilation and reducing peripheral resistance. 8
The Telmisartan and Amlodipine Single-pill Combinations vs Amlodipine Monotherapy for Superior Blood Pressure Lowering and Improved Tolerability in Patients with Uncontrolled Hypertension (TEAMSTA-5) study, which included participants with T2DM showed significantly greater BP reductions with the combination therapy, along with higher goal rates for SBP and DBP compared to amlodipine alone. Importantly, peripheral oedema, a common side effect of amlodipine, was less frequent in the combination therapy group.9
The TEAMSTA-10 study, and also included participants living with T2DM, evaluated patients who failed to achieve DBP control with amlodipine alone. The results confirmed that telmisartan/ amlodipine combinations significantly outperformed amlodipine monotherapy. These studies underscore the efficacy of combining telmisartan and amlodipine in achieving BP control and reducing CV risk in patients with T2DM.10
The management of hypertension in individuals living with T2DM is complex but essential for reducing the risk of CVD, CKD, and other complications. Evidence supports the use of combination therapies such as telmisartan and amlodipine for achieving optimal BP control in this population. Individualised treatment plans, incorporating lifestyle changes and pharmacologic interventions, are key to improving outcomes for patients with T2DM and hypertension.
References are available on request. SF
Generic medicines are a cornerstone of modern healthcare, offering affordable alternatives to branded drugs without compromising on quality or efficacy. These drugs are chemically similar to their branded counterparts, produced once the original product’s patent expires, and are rigorously regulated to ensure safety and effectiveness.
This makes them a viable option for reducing healthcare costs and improving access to essential medicines, particularly in countries like South Africa, where medication expenses constitute a significant part of the healthcare budget.
One of the most compelling benefits of generic drugs is their ability to improve access to treatment. Because they are sold at a fraction of the price of branded drugs, patients can afford medications that were previously out of reach, and healthcare systems can allocate their resources more efficiently.
The lower cost of generics is primarily due to their reduced research, development, and marketing expenses. Once the patent for a branded drug expires, generic manufacturers can replicate the drug, leading to competition that drives down prices.
In some cases, the entry of generic versions into the market has resulted in price drops of up to 60% for branded drugs. This makes generics an indispensable tool for managing healthcare costs, especially in low- and middle-income countries.
In South Africa, legislation like Act 90 promotes the use of generics by mandating substitution at pharmacies, ensuring patients have access to more cost-effective treatments. These savings can be reinvested in new technologies or treatments, enhancing the sustainability of healthcare systems.
Regulatory authorities such as the South African Health Products Regulatory Authority, the American Food and Drug Administration, and the European Medicines Agency play a crucial role in
ensuring that both branded and generic medicines meet international standards for quality, safety, and efficacy.
These bodies enforce compliance with good manufacturing practices by conducting audits and inspections of manufacturing facilities to ensure that they meet required standards. Additionally, post-marketing activities, such as random product testing and monitoring for adverse drug reactions, help maintain the safety of generic drugs in the market.
The approval process for generic drugs differs from that of branded medicines. While branded drugs undergo extensive clinical trials to demonstrate safety and efficacy, generic drugs must only prove bioequivalence. Bioequivalence means that the generic product has the same active ingredients, strength, dosage form, and route of administration as the branded drug, and it works in the same way within the body. This is determined by assessing bioavailability – the rate and extent to which the active ingredient reaches systemic circulation.
In cases where excipients (inactive ingredients) differ between branded and generic drugs, adverse reactions may occur, particularly among patients with sensitivities to certain substances, such as lactose. It is essential to examine the professional information leaflet and report any adverse events to ensure patient safety.
Special attention is required for elderly patients and those with cognitive impairments or those on multiple medications (polypharmacy), as generic substitutions can lead to confusion, dose duplication, and other risks. Educating patients about their medications and
ensuring clear communication between healthcare providers and pharmacists are critical steps in preventing such issues.
Bioequivalence studies are typically conducted using a single-dose, two-period crossover design in healthy volunteers. The goal is to compare the pharmacokinetic profiles of the generic and branded drugs, focusing on parameters like the area under the curve and peak concentration. A 90% confidence interval within a logarithmic range of 80%-125% is required for approval, ensuring that any differences in drug exposure are minimal and do not affect the drug’s effectiveness.
For narrow therapeutic index drugs (NTI), such as warfarin or immunosuppressants, small variations in drug levels can have significant safety implications. However, studies have shown that with proper monitoring, generic NTI drugs can be safely substituted for their branded counterparts.
To watch a replay of the webinar, click here or scan the QR code.
This webinar was sponsored by Cipla and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail. SF
This article was independently sourced by Specialist Forum.
Ketamine is gaining considerable attention in psychiatric practice, particularly for its role in managing treatment-resistant depression (TRD). Traditional antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), fail to achieve full remission in ~40% of individuals.
Consequently, TRD, affecting up to 20% of the population, has become a significant concern, especially in countries like South Africa, where poverty and violence exacerbate depression rates. Conventional treatments, such as combining antidepressants or augmenting them with atypical antipsychotics and lithium, are not always effective, necessitating alternative approaches.
Ketamine offers a groundbreaking treatment option as the first nonmonoaminergic antidepressant. Unlike traditional antidepressants, it targets the glutamate system, particularly the NMDA receptors, promoting rapid neural growth and synaptic plasticity, resulting in fast-acting antidepressant effects.
Additionally, it influences GABAergic interneurons, which contributes to sustained benefits. Despite these promising effects, concerns about ketamine’s long-term safety, efficacy, and potential for abuse remain.
Ketamine has demonstrated clear effectiveness in treating TRD and acute suicidal ideation. Its ability to rapidly reduce suicidal thoughts is particularly notable, with relief often occurring within hours.
This rapid response makes ketamine a valuable alternative to more invasive interventions like electroconvulsive therapy, giving hope to patients in acute crisis. However, research is still ongoing regarding ketamine’s potential in treating other conditions such as post-traumatic stress disorder, obsessive-compulsive disorder, eating disorders, and substance use disorders. Determining its exact role in the treatment algorithm and appropriate patient selection are critical areas of investigation.
The term difficult-to-treat depression is becoming increasingly preferred over TRD. This shift in terminology maintains hope for patients by suggesting that treatment options are still available. TRD is defined as the failure of two antidepressants administered at the maximum tolerated dose
for an adequate time (usually two weeks). Given the complexity of TRD, treatment needs to be aggressive and prompt, as prolonged untreated depression becomes more difficult to manage.
Clinicians are advised to adjust treatment strategies if no response is observed within two weeks or if only partial improvement is noted. Tools such as the PHQ-9 help clinicians monitor the severity of depression and track patient progress. In clinical practice, more than two antidepressants may be tried, and strategies such as medication augmentation and psychotherapy (particularly cognitivebehavioural therapy) play crucial roles in treatment plans. The PHQ-9 is also useful for medical aid submissions and treatment approvals, streamlining the administrative process for patients requiring advanced therapies.
Ketamine’s tolerability and safety are generally positive, though some adverse effects exist. Dissociation, a hallmark effect of ketamine, is a point of debate among clinicians. While European psychiatrists like Dr Rochefri Kasper consider it an undesirable side effect, some American psychiatrists view it as potentially therapeutic.
However, dissociation is not necessary for ketamine’s antidepressant effects. High doses to induce dissociation can increase the risk of addiction, as patients may seek progressively higher doses. Other neurological effects, such as drowsiness and unsteadiness, are common, and ketamine can raise blood pressure due to its cardiac stimulation effects. There are also concerns about ketamine-induced bladder issues, particularly with long-term abuse.
Despite these risks, studies indicate no significant increase in abuse potential when ketamine is properly administered for psychiatric conditions. However, caution is warranted for patients with psychotic disorders, active substance abuse, or uncontrolled hypertension.
Ketamine treatment requires a psychiatrist’s oversight Ketamine treatment typically requires
a psychiatrist’s oversight, though administration is often handled by sedation specialists. A safe, private environment is essential during administration due to the dissociative effects of ketamine, and patient monitoring by trained sedationists is critical.
The South African Society of Anaesthesiologists provides detailed guidelines regarding sedation expertise and necessary equipment, including blood pressure and pulse monitors and resuscitation devices.
In addition to medical equipment, comfort measures such as blankets, eye masks, and calming music contribute to a positive patient experience. Music has been shown to reduce dissociation, anxiety, and even hypertensive changes during ketamine administration. Although postsession integration is debated, adequate preparation, including mental and physical readiness, remains key to a successful treatment process.
As the field evolves, ketamine’s role in acute suicidality and potential for maintenance treatments is gaining traction, though further research is needed, especially regarding long-term use and the integration of ketamine-assisted psychotherapy into mainstream clinical practice.
To watch a replay of the webinar, click here or scan the QR code.
This webinar was sponsored by Netcare Akeso and Ukukhyane Wellness and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail. SF
This article was independently sourced by Specialist Forum.
THypertension poses a significant global health challenge, particularly in South Africa, where its diagnosis and treatment remain suboptimal. The prevalence of hypertension is alarming, with studies showing that only 10% of individuals are hypertensive at age 55, but this figure increases to >90% by age 80.
hese statistics underscore the necessity of proactive management strategies to avert long-term health consequences, as poorly controlled hypertension contributes substantially to cardiovascular disease (CVD) and overall mortality.
Only 26% of South African men are aware of their blood pressure (BP) status, and treatment and control rates for both genders falling <30%. Around 40% of adults are hypertensive, but only 9% achieve adequate control. The problem is particularly pronounced among South African patients of African descent, who face a more than threefold increase in mortality rates due to hypertensionrelated complications compared to their counterparts of European descent. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) are integral components of hypertension management, offering avenues to lower BP and reduce CV risk.
The British Hypertension Society has outlined a treatment algorithm that is particularly beneficial in diverse patient populations. For patients <55-years, initial treatment involves either an ACEi or a lowcost ARB, while those >55-years or of African or Caribbean descent are advised to start with a calcium channel blocker (CCB). This structured approach enhances the likelihood of effective BP control, reducing long-term risks associated with hypertension.
Both ACEi and ARBs are effective in managing hypertension, however, they exhibit different side effect profiles. ACEi are associated with a higher incidence of complications, including cough and angioedema, which can lead to nonadherence to treatment.
In contrast, ARBs typically offer a more
favourable safety profile with fewer adverse effects. Notably, reports of increased myocardial infarction risks are less common with ARBs, making them a preferred choice in many cases.
In patients with impaired renal function, ACEi can cause a transient increase in creatinine levels but may offer longterm renal protection. In individuals with conditions like aortic stenosis or hypertrophic obstructive cardiomyopathy, caution is warranted due to the risk of exacerbating outflow obstruction. Clinicians must be vigilant about drug interactions when prescribing these medications:
_ Combination with other RAAS Blockers: Concurrent use of ACEi and ARBs is generally not recommended.
_ Diuretics: The combination may increase the risk of hyperkalemia, particularly with potassium-sparing diuretics.
_ Non-steroidal anti-inflammatory drugs: These can reduce the efficacy of ACEi and increase the risk of renal complications. Patients living with diabetes may experience interactions between ACEi or ARBs and dipeptidyl peptidase 4 (DPP-4) inhibitors. While ACEi can be combined with DPP-4 inhibitors, careful monitoring is necessary due to potential BP increases.
Given that only 10% of hypertensive patients currently achieve target BP control, the inclusion of both ACEi and ARBs is crucial. ACEi are often more costeffective and accessible in resource-limited settings, while ARBs are recommended as first-line treatment for patients of African descent living with hypertension due to their efficacy and lower risk of adverse effects. Moreover, when considering chronic obstructive pulmonary disease, ARBs are preferred since ACE inhibitors
may exacerbate cough, complicating clinical assessments.
Patient-centric approaches
Tailoring treatment strategies based on individual patient characteristics, drug availability, and tolerability is vital. Combining long-acting medications and utilising single-pill combinations can enhance adherence and simplify treatment regimens. Regular monitoring and patient education are essential to achieving effective hypertension management.
Hypertension management in South Africa demands a nuanced understanding of the roles of ACEi and ARBs. Individualised treatment approaches that consider patient demographics, comorbidities, and potential side effects are crucial for optimising outcomes. By prioritising effective strategies and addressing the unique challenges faced by diverse populations, healthcare providers can significantly improve hypertension control, ultimately reducing the burden of this critical health issue.
To watch a replay of the webinar, click here or scan the QR code.
This webinar was sponsored by McLeods and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail.
This article was independently sourced by Specialist Forum.
Mast cells, originating in the bone marrow and maturing in tissues exposed to the external environment, are crucial components of the innate immune system. Upon activation, they release various mediators, including histamine, proteases, and cytokines, contributing to the allergic response and chronic inflammation.
Particularly significant is the release of platelet-activating factor (PAF), which plays a critical role in the severity of allergic reactions, including anaphylaxis. PAF acts as a potent chemoattractant for eosinophils and neutrophils, exacerbating inflammation and leading to symptoms such as bronchospasm and angioedema.
Pathophysiology and management of AR
AR is one of the most prevalent chronic diseases affecting both adults and children. It can significantly impair quality of life and lead to various complications. Dr Corli Lodder discussed the rising prevalence of AR, attributing it to factors like urbanisation, climate change, and extended pollen seasons. Research indicates that the symptoms of AR contribute to emotional distress and fatigue, necessitating a comprehensive management approach.
The pathophysiology of AR is characterised as a type I hypersensitivity reaction, involving both early and latephase responses. She discussed the concept of priming, explaining how the nasal mucosa becomes increasingly sensitive to allergens due to underlying Th2 inflammation. This process leads to more frequent and severe symptoms over time.
Intranasal steroids are a cornerstone in managing AR. These medications help suppress the priming effect and reduce mast cell degranulation frequency, thereby alleviating symptoms. Understanding the interactions among various inflammatory mediators, particularly PAF, is crucial for effective management.
Dr Lodder called for a reevaluation of common assumptions regarding allergic conditions. She advocated for a nuanced understanding of underlying mechanisms and the implementation of appropriate treatment strategies. Addressing misconceptions and emphasising the importance of proper management can significantly improve patient outcomes and enhance the quality of life for those suffering from allergic conditions.
Effective management of AR begins with a thorough clinical diagnosis based on patient history. Healthcare providers must actively listen to patients, distinguishing between AR, viral infections, and sinusitis. Key indicators, including the chronicity and progression of symptoms, can help differentiate allergic conditions from other issues.
Physical examinations play a vital role, as signs such as pale, swollen nasal turbinates and allergic shiners can indicate AR. Anterior rhinoscopy allows for visualisation of nasal passages and assessment for inflammation, and it is also essential to inquire about associated conditions like asthma and atopic dermatitis.
Allergen testing is crucial for identifying specific triggers, informing avoidance strategies and potential allergen immunotherapy. However, not all patients will have identifiable allergens through standard testing, especially in cases of local allergic rhinitis.
Management strategies encompass
education, allergen avoidance, nasal irrigation, and pharmacotherapy. Education is vital in helping patients understand their chronic condition and the necessity of adhering to treatment plans. Allergen avoidance, nasal irrigation, and appropriate pharmacotherapy – primarily intranasal corticosteroids and non-sedating antihistamines – are key components of effective management.
In summary, AR and related conditions require a multifaceted approach to diagnosis and management. A comprehensive understanding of immunological mechanisms, patient history, and effective treatment strategies is essential to improving outcomes and enhancing the quality of life for affected individuals. Collaboration and shared decision-making between healthcare providers and patients are crucial in managing these chronic conditions effectively.
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This webinar was sponsored by Inova and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail.
PAF* AWAY THEIR ALLERGIES3,4
ACTION RUPANASE® BLOCKS HISTAMINE FOR RELIEF OF DAYTIME SNEEZING, RUNNY, ITCHY & BLOCKED SYMPTOMS, AND PAF* FOR RELIEF OF NASAL CONGESTION AT NIGHT 2-6
†based on once a day dosing
*platelet activating factor
**To treat Total Nasal Symptom Score
§Allergic Rhinitis
Available in pack sizes of 10’s, 20’s & 30’s
References: 1. South African Medicine Price Registry. Database of Medicine Prices, 01 November 22 [online]. [cited 2022 Nov 17]; Available from URL: http://www.mpr.gov.za/. 2. Marmouz F, Giralt J, Izquierdo I, et al. Morning and evening efficacy evaluation of rupatadine (10 and 20 mg), compared with cetirizine 10 mg in perennial allergic rhinitis: a randomized, double-blind, placebo-controlled trial. J Asthma Allergy 2011;4:27–35. 3. Picado C. Rupatadine: pharmacological profile and its use in the treatment of allergic disorders. Exp Opin Pharmacother. 2006;7(14):1989-2001. 4. Ridolo E, et al. Rupatadine for the treatment of allergic rhinitis and urticaria: a look at the clinical data. Clin Invest 2014;4(5):453-461. 5. Smolensky MH, Lemmer B, Reinberg AE. Chronobiology and chronotherapy of allergic rhinitis and bronchial asthma. Adv Drug Deliv Rev 2007;59:852–882. 6. Alfaro V. Role of histamine and platelet-activating factor in allergic rhinitis. J Physiol Biochem 2004;60(2):101-112. 7. RUPANASE® professional information, 02 October 2014. 8. Steubner P, et al. Effects of rupatadine vs placebo on allergen-induced symptoms in patients exposed to aeroallergens in the Vienna Challenge Chamber. Ann Allergy Asthma Immunol 2006;96:37-44.
Scheduling status: S2 Proprietary name (and dosage form): RUPANASE
This article was independently sourced by
Osteoporosis is not a normal part of ageing, stressed Teréza Hough, CEO of the National Osteoporosis Foundation of South Africa (NOFSA). It is a systemic skeletal disease that deteriorates bone mass and quality, leading to increased porosity, bone fragility, and susceptibility to fractures.
She emphasised the widespread, global nature of osteoporosis, highlighting that 80% of individuals living with an osteoporotic fracture are never diagnosed or treated for osteoporosis.
Projected statistics indicate a significant increase in hip fractures, especially in ageing populations, with fractures in men expected to rise by 310% and in women by 240% from 1990 to 2050.
In South Africa, there is limited epidemiological data on osteoporosis. However, current estimates suggest that around 2.5 million individuals >50-years are affected.
Studies show that vertebral bone density and fracture rates in South Africans from African and European descent are comparable, emphasising the need for country-specific diagnostic tools like the FRAX tool, designed to enhance fracture risk assessment in South Africa.
Risk factors for osteoporosis include both modifiable (eg smoking, excessive alcohol, low BMI, poor nutrition, lack of exercise) and non-modifiable factors (eg genetics, family history, certain medications, and medical conditions like rheumatoid arthritis and diabetes). For women, bone mass loss can accelerate post-menopause, increasing fracture risk.
Osteoporotic fractures, particularly vertebral and hip fractures, lead to substantial morbidity. Only one in three vertebral fractures are diagnosed, with many cases going untreated.
These fractures not only result in physical limitations but also decrease quality of life, with conditions like kyphosis and chronic pain leading to complications such as breathing and digestive issues, and increased dependency and depression.
DXA scans, though often used to assess osteoporosis risk, are not diagnostic tools but rather risk indicators for osteoporotic fractures. These painless scans take about 20–30 minutes, providing a T-score based on bone density compared to peak bone mass, typically achieved between ages 25 and 30.
The diagnosis of osteoporosis, especially in older adults, has significant emotional and physical repercussions. Patients often feel frail, which can lead to anxiety, fear of movement, and even depression, impacting their quality of life and increasing their dependency on family or caregivers. This change also affects family members, who may face financial and emotional burdens as they support the patient’s daily needs and safety.
Lifestyle modifications are crucial for osteoporosis prevention and management. A calcium- and vitamin D-rich diet, limited alcohol, and no smoking are fundamental.
Weight-bearing exercises like walking or low-impact activities such as yoga and Tai Chi help maintain bone and muscle health, reducing the risk of fractures. However, high-impact activities and certain exercises should be avoided in severe osteoporosis cases, and individual exercise plans should be developed with healthcare providers.
Vitamin D, mostly obtained from sunlight, is vital for calcium absorption. Given common deficiencies due to limited sun exposure, fortified foods and, if necessary, supplements are recommended.
Managing medication, especially polypharmacy in older adults, reduces fall risk, as certain drugs can increase dizziness or coordination loss. Routine vision checks and home modifications also support fall prevention. Pharmacologically, options include antiresorptive and bone-forming agents, though some newer treatments are yet to be widely available.
In summary, early screening, comprehensive lifestyle guidance, and a proactive approach to fall prevention are key to managing osteoporosis and improving patients’ quality of life.
To watch a replay of this webinar, click here or scan the QR code.
This webinar was sponsored by Cipla and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail.
At least 1 in 3 women and 1 in 5 men will suffer from an osteoporotic fracture during their lifetime1
1 in 3 hip fracture patients re-fracture at 1 year1
20 % risk of suffering a second spine fracture within the year following the first one1
28 % of Women and 37 % of Men who suffer a hip fracture, will DIE within the following year1
Reduced fracture rates are observed only in patients with proper persistence and compliance (adherence > 80 %) on long-term BP therapy2
Alendronate sodium equivalent to alendronic acid 70 mg tablets.
This article was independently sourced by
His detailed exploration into the physiology and classification of pain, alongside the practical application of guidelines, provides an essential framework for healthcare providers aiming to improve patient outcomes.
Prof Chetty stressed the importance of recognising pain as a complex, multidimensional experience. It is not merely a physical sensation but is influenced by emotional, social, and even spiritual factors. Pain can be exacerbated by psychological conditions like anxiety and depression, which affect patients’ perception and tolerance. Additionally, social issues such as financial strain and isolation often amplify the pain experience, complicating its management.
Pain classification: Acute vs chronic
Prof Chetty outlined the distinction between acute and chronic pain, a critical factor in guiding treatment approaches.
_ Acute pain : Typically arises suddenly due to injury or illness and serves as a protective mechanism to signal harm and encourage healing. It is usually selflimiting and improves as the underlying cause resolves.
_ Chronic pain : Persists beyond three months and often has no identifiable cause, requiring a more extensive treatment plan that integrates physical, psychological, and social interventions. Chronic pain can lead to a detrimental cycle of stress, depression, and increased pain perception, making early and effective intervention essential.
Prof Chetty referred to the 2020 update by the International Association for the Study of Pain, which redefines pain as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’.
This modern definition recognises pain as a subjective experience influenced by
In his recent presentation, Prof Sean Chetty provided a comprehensive overview of pain management guidelines, emphasising a holistic understanding of pain beyond its physical dimensions.
biological, psychological, and social factors. It highlights the importance of respecting patients’ reports of pain even when there is no clear physical evidence, underscoring the subjective nature of pain.
The ‘inflammatory soup’ phenomenon was discussed as a process where injury releases various chemicals, such as bradykinin and prostaglandins, which sensitise the peripheral nerves and lower the threshold for pain signals. This sensitisation results in increased nociceptive input, enhancing pain perception. By understanding these mechanisms, healthcare providers can better target treatments to disrupt the pain signal pathway.
Prof Chetty introduced the concept of descending inhibitory pathways, which act like shock absorbers for the body’s pain signals. These pathways help dampen the ascending pain signals from the periphery to the brain, reducing the intensity of pain perception. Effective pain management strategies often involve enhancing these inhibitory pathways to mitigate the patient’s pain experience.
He highlighted the importance of applying established pain management guidelines to ensure comprehensive and consistent care. These guidelines often follow a structured approach:
_ Assessment (A): Always start by asking the patient about their pain, assessing its intensity, duration, and impact on their daily life.
_ Belief (B): Believe the patient’s report of pain, acknowledging their experience as valid and significant.
_ Choice (C): Choose appropriate pain control measures based on the type
and severity of pain. This may involve pharmacological treatments, such as NSAIDs or opioids for nociceptive pain, and specific neuropathic agents like gabapentinoids for neuropathic pain.
_ Delivery (D): Administer pain relief promptly to prevent escalation of symptoms and minimise the risk of chronic pain development.
_ Empowerment and education (E): Educate patients about their pain condition and treatment options, empowering them to participate actively in their pain management. This not only improves adherence but also helps reduce anxiety and enhance overall outcomes.
The role of communication
Effective communication is pivotal in pain management. Prof Chetty emphasised the need for healthcare providers to interpret patients’ verbal and non-verbal cues, addressing underlying emotional distress that may influence their pain perception. Demonstrating empathy and understanding can significantly impact the patient’s experience, often alleviating pain even before pharmacological interventions are initiated.
To watch a replay of this webinar, click here or scan the QR code.
This webinar was sponsored by Zydus and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail.
S5
Tramadol hydrochloride 100 mg I 150mg I 200mg tablets
S5
Tramadol hydrochloride 50mg capsules
S5
Tramadol hydrochloride 37,5mg + Paracetamol 325mg tablets
S5
Tramadol hydrochloride 100mg/2ml ampoules
S5 TRAMAZAC CO 37,5 (film coated tablets). Each film coated tablet contains 37,5 mg tramadol hydrochloride and 325 mg paracetamol. Reg. No.: A45/2.9/0303. S5 TRAMAZAC 50 (capsules). Each capsule contains 50 mg tramadol hydrochloride equivalent to 50 mg tramadol. Reg. No.: A39/2.9/0415. S5 TRAMAZAC SR 100 (sustained release tablets). Each tablet contains 100 mg tramadol hydrochloride equivalent to 100 mg tramadol. Reg. No.: A44/2.9/0496. S5 TRAMAZAC SR 150 (sustained release tablets). Each tablet contains 150 mg tramadol hydrochloride equivalent to 150 mg tramadol. Reg. No.: A44/2.9/0497. S5 TRAMAZAC SR 200 (sustained release tablets). Each tablet contains 200 mg tramadol hydrochloride equivalent to 200 mg tramadol. Reg. No.: A44/2.9/0498. S5 TRAMAZAC INJECTION 100 mg/2 ml. Each 2 ml ampoule contains tramadol hydrochloride 100 mg. Reg. No.: A39/2.9/0318. For full prescribing information refer to the approved package insert. Zydus Healthcare SA (Pty) Ltd. Block a, Southdowns Office Park, 22 Karee Street, Centurion, 0157. Tel: +27 (0)12 748 6400. ZYD AD/11/24.
Benign prostatic hyperplasia (BPH) is a prevalent condition in ageing men, leading to symptoms like difficulty in starting urination, weak urine flow, urgency, and frequent urination. The condition arises from an enlarged prostate, which obstructs the urethra and impairs urinary function. With the evolution of medical therapies, alpha-1a blockers have become a cornerstone in the management of BPH, significantly alleviating symptoms and improving quality of life.
Alpha-1a blockers are a class of medications designed to target the alpha-1a adrenergic receptors primarily located in the prostate and bladder neck. By blocking these receptors, the drugs relax smooth muscle tissues in these areas, reducing urinary obstruction and facilitating better urine flow.
Early alpha blockers, like doxazosin, were effective but had limitations due to their non-selective action on both alpha-1a and alpha-1b receptors. This lack of specificity often led to systemic side effects such as postural hypotension (sudden drops in blood pressure upon standing), especially in elderly patients.
To address these concerns, newer and more selective alpha-1a blockers, such as tamsulosin and silodosin, were developed. These medications provide targeted action, focusing primarily on the alpha-1a receptors in the prostate while minimising effects on the blood vessels. As a result, they are associated with a lower risk of cardiovascular side effects, making them a safer choice for elderly and frail patients who are at a higher risk of falls and fractures due to blood pressure changes.
Tamsulosin vs silodosin
Tamsulosin is one of the most widely used alpha-1a blockers due to its wellestablished efficacy and tolerable side effect profile. It is often the preferred first-line therapy for BPH, particularly in patients with mild to moderate symptoms. Its balanced approach provides symptom relief with fewer severe side effects, making it suitable for long-term use.
On the other hand, silodosin is a newer,
highly selective alpha-1a blocker that offers enhanced efficacy in specific clinical scenarios. Its greater selectivity means it targets the prostate more precisely, leading to more pronounced relaxation of the prostate and bladder neck muscles.
This can be especially beneficial for patients with acute urinary retention or those undergoing prostate radiotherapy, as it helps quickly alleviate obstructive symptoms and supports bladder function recovery. However, silodosin’s strong localised action comes with a trade-off: A higher incidence of ejaculatory dysfunction, a side effect that impacts nearly all users. This condition, characterised by reduced or absent ejaculation, can be distressing for sexually active men and often leads to discontinuation of the medication.
Cost considerations and safety profile
Historically, the cost of newer selective alpha-1a blockers like silodosin was a barrier to widespread use. However, as prices have become comparable to tamsulosin, the choice of medication is increasingly driven by patient-specific factors rather than cost alone.
The decision between using tamsulosin or silodosin as a first-line treatment is influenced by the patient’s overall health, potential side effects, and personal preferences. For instance, while tamsulosin remains a practical starting option for most patients, silodosin may be preferred in cases where rapid symptom relief is necessary, despite its higher risk of sexual side effects.
Combination therapies and advanced options
For patients who do not achieve sufficient
symptom relief from alpha-1a blockers alone, combination therapy is often considered. This typically involves adding a 5-alpha reductase inhibitor like finasteride or dutasteride, which works by reducing prostate size over time.
These drugs inhibit the conversion of testosterone to dihydrotestosterone (DHT), a hormone that contributes to prostate growth. Although this combination can be effective, it requires patient education about the gradual onset of benefits, which may take several months to manifest.
For persistent irritative symptoms, such as urgency and frequency, additional treatments like anti-muscarinic agents or beta-3 agonists (eg mirabegron) may be employed. These medications help relax the bladder, reducing overactive symptoms. However, their use must be carefully managed to avoid exacerbating urinary retention, particularly in patients with significant residual urine volume.
To watch a replay of this webinar, click here or scan the QR code.
This webinar was sponsored by Cipla and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail. SF
Antimicrobial resistance (AMR) is one of the most pressing global health challenges, with projections suggesting that, if left unchecked, AMR could lead to 10 million deaths annually by 2050. Prof Adrian Brink, a leading expert in the field, emphasised the urgent need for antibiotic stewardship, particularly in primary care, to combat this growing threat.
Antibiotic stewardship involves promoting the responsible and appropriate use of antibiotics to preserve their efficacy, ensuring that these life-saving medications remain effective for future generations.
A critical concept in the stewardship framework is minimising ‘collateral damage’, a term that, in the context of antibiotics, refers to the unintended harm caused by the misuse of antibiotics. This includes using antibiotics for viral infections, administering incorrect doses, or prescribing them for unnecessarily long durations.
Such practices create an environment where resistant bacteria can thrive, leading to infections caused by multidrug-resistant organisms and severe complications like superinfections or antibiotic-resistant Clostridioides difficile diarrhoea.
Prof Brink drew attention to the growing threat of AMR in South Africa and other regions, where pathogens like Klebsiella pneumoniae and Staphylococcus aureus exhibit alarmingly high resistance rates.
He advocated for a ‘One Health’ approach, integrating human, animal, and environmental health efforts to curb AMR. This approach includes reducing antibiotic use in agriculture, improving sanitation, and preventing environmental transmission of resistant bacteria.
The responsibility for tackling AMR largely falls on GPs, who prescribe the majority of antibiotics in primary care settings. One of the key drivers of resistance is the overprescription of antibiotics for viral infections, such as colds and respiratory tract infections, which are not treatable with antibiotics.
Studies show that a significant proportion of patients in South Africa mistakenly believe that antibiotics can cure viral infections, highlighting the urgent need for public education campaigns. However, limited funding has hindered large-scale awareness initiatives.
To address this, Prof Brink proposed several strategies for optimising antibiotic stewardship in primary care. One key approach is reducing diagnostic uncertainty, which can lead to unnecessary antibiotic prescriptions.
Tools like point-of-care CRP testing can help distinguish between bacterial and viral infections, allowing clinicians to make more informed decisions about whether antibiotics are necessary. Although implementing these tools in busy primary care settings can be challenging, advances in rapid diagnostic technology offer promising solutions.
Vaccination is another critical tool in the fight against AMR. Vaccines can prevent infections, thereby reducing the need for antibiotics. For example, South Africa’s rotavirus vaccine has significantly reduced antibiotic-treated diarrhoea in children, and maternal RSV vaccination has decreased antibiotic prescriptions for infants by 13%. Similarly, large-scale influenza vaccination campaigns have demonstrated a reduction in antibiotic use by up to 65%.
Education also plays a pivotal role in optimising stewardship. Prof Brink highlighted the importance of training healthcare providers, particularly GPs, in appropriate prescribing practices. Younger GPs tend to have better
knowledge of antibiotic stewardship principles, underscoring the need for ongoing education and integration of stewardship training into medical curricula. Furthermore, collaboration with pharmacists, who play an underutilised but crucial role in stewardship, can enhance patient education and ensure proper antibiotic prescribing.
Finally, innovative approaches, such as bacteriophage therapy and an increased focus on the human microbiome, offer exciting potential for reducing AMR. Bacteriophages, which are viruses that target specific bacteria, present a promising alternative to traditional antibiotics in treating resistant infections. Understanding the microbiome’s role in resistance could lead to novel therapies that promote the growth of beneficial bacteria, further helping to combat resistance.
To watch a replay of this webinar, click here or scan the QR code.
This webinar was sponsored by Pharma Dynamics and is accredited for one (1) CPD point. Once you have watched the replays, send an e-mail to john.woodford@newmedia.co.za and request to have your CPD point allocated to your profile on the HPCSA database. Include the webinar names and your HPCSA number in your e-mail. SF
According to Kimmig et al., Staphylococcus aureus is one of the leading causes of community-acquired and hospitalacquired bloodstream infections ranking second after Escherichia coli. Hospital mortality is high, and reports have indicated that this may range between 15 and 40 %
By adhering to treatment guidelines and infection disease-bedside consultation, it is possible to reduce mortality by up to 50 %.1
According to WHO, 2019, tigecycline is a
