Background Good-quality evidence has shown that early glycaemic, blood pressure and LDL-cholesterol control in people with type 2 diabetes (T2D) leads to better outcomes. In spite of that, diseases control have been inadequate globally, and therapeutic inertia could be one of the main cause. Evidence on therapeutic inertia has been lacking at primary care setting. This retrospective cohort study aimed to determine the proportions of therapeutic inertia when treatment targets of HbA1c, blood pressure and LDL-cholesterol were not achieved in adults with T2D at three public health clinics in Malaysia. Methods The index prescriptions were those that when the annual blood tests were reviewed. Prescriptions of medication were verified, compared to the preceding prescriptions and classified as 1) no change, 2) stepping up and 3) stepping down. The treatment targets were HbA1c < 7.0% (53 mmol/mol), blood pressure (BP) < 140/90 mmHg and LDL-cholesterol < 2.6 mmol/L. Therapeutic inertia was defined as no change in the medication use in the present of not reaching the treatment targets. Descriptive, univariable, multivariable logistic regression and sensitive analyses were conducted. Results A total of 552 cohorts were available for the assessment of therapeutic inertia (78.9% completion rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61–72%), anti-hypertensive (34–65%) and lipid-lowering therapies (56–77%), and lesser in insulin (34–52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64). Conclusions Although therapeutic intensifications were more likely in the presence of non-achieved treatment targets but the proportions of therapeutic inertia were high. Possible causes of therapeutic inertia were less of the physician behaviours but might be more of patient-related non-adherence or non-availability of the oral medications. These observations require urgent identification and rectification to improve disease control, avoiding detrimental health implications and costly consequences. Trial registration Number NCT02730754, April 6, 2016.

Glycemic control among patients with prediabetes and type 2 diabetes mellitus (T2D) in Malaysia is suboptimal, especially after the continuous worsening over the past decade. Improved glycemic control may be achieved through a comprehensive management strategy that includes medical nutrition therapy (MNT). Evidence-based recommendations for diabetes-specific therapeutic diets are available internationally. However, Asian patients with T2D, including Malaysians, have unique disease characteristics and risk factors, as well as cultural and lifestyle dissimilarities, which may render international guidelines and recommendations less applicable and/or difficult to implement. With these thoughts in mind, a transcultural Diabetes Nutrition Algorithm (tDNA) was developed by an international task force of diabetes and nutrition experts through the restructuring of international guidelines for the nutritional management of prediabetes and T2D to account for cultural differences in lifestyle, diet, and genetic factors. The initial evidence-based global tDNA template was designed for simplicity, flexibility, and cultural modification. This paper reports the Malaysian adaptation of the tDNA, which takes into account the epidemiologic, physiologic, cultural, and lifestyle factors unique to Malaysia, as well as the local guidelines recommendations.

Background: Good-quality evidence has shown that early glycaemic, blood pressure and LDL-cholesterol control in people with type 2 diabetes (T2D) leads to better outcomes. In spite of that, diseases control have been inadequate globally, and therapeutic inertia could be one of the main cause. Evidence on therapeutic inertia has been lacking at primary care setting. This retrospective cohort study aimed to determine the proportions of therapeutic inertia when treatment targets of HbA1c, blood pressure and LDL-cholesterol were not achieved in adults with T2D at three public health clinics in Malaysia.Methods: The index prescriptions were those that when the annual blood tests were reviewed. Prescriptions of medication were verified, compared to the preceding prescriptions and classified as 1) no change, 2) stepping up and 3) stepping down. The treatment targets were HbA1c < 7.0% (53 mmol/mol), blood pressure (BP) < 140/90 mmHg and LDL-cholesterol < 2.6 mmol/L. Therapeutic inertia was defined as no change in the medication use in the present of not reaching the treatment targets. Descriptive, univariable, multivariable logistic regression and sensitive analyses were conducted. Results: A total of 552 cohorts were available for the assessment of therapeutic inertia (78.9% completion rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61-72%), anti-hypertensive (34-65%) and lipid-lowering therapies (56-77%), and lesser in insulin (34-52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64). Conclusions: Although therapeutic intensifications were more likely in the present of non-achieved treatment targets but the proportions of therapeutic inertia were high. Possible causes of therapeutic inertia were less of the physician behaviours but may be more of patient-related non-adherence or non-availability of the oral medications and these require urgent identification and rectification to improve disease control, avoiding detrimental health implications and costly consequences.

BackgroundNSAIDs are frequently used in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). NSAID-induced UGI adverse events are well described in the Western population but data is lacking in Asian patients.ObjectivesTo describe the prevalence and direct healthcare costs of NSAID-induced UGI adverse events in a large cohort of RA and OA patients in Malaysia.MethodsA retrospective cohort study of RA and/or OA patients who received long-term NSAIDs (minimum 4 weeks prescription of any NSAID) between 2010 and 2013 was conducted in 4 large tertiary care centres with rheumatology units in Malaysia. Electronic clinical records and pharmacy prescriptions were reviewed. Resource use data was collected in patients who developed UGI adverse events within the 24 months follow up period. Unit costs were estimated by combining top down (general overheads for hospital services) and bottom up (activity-based costing for clinic visits, hospitalisation, diagnostic investigations, medications) approaches.Results634 patients were included in the final analysis with mean age 53.4±12.5 years, 90% female, diagnosis of RA in 60%, OA in 10% and both RA and OA in 30%. 45% and 8% of patients were on concomitant prednisone and aspirin respectively. 89% of patients had no previous upper GI disease. 59% and 41% of patients were grouped under non-selective and COX-2 inhibitor respectively. 84 (13.2%) patients developed UGI adverse events (Figure 1), consisting of 78 (12.3%) patients with dyspepsia, 5 (0.79%) with peptic ulcer disease (PUD) and 1 (0.16%) with upper GI bleeding (UGIB). The total direct cost was RM37,352 (USD 11,419) with a mean cost of RM447±535 (USD 137±163) per patient (Table 1). The largest cost components were pharmacotherapy (34%), oesophagoduodenoscopies (OGD) (23%) and outpatient visits (18%). The mean cost of dyspepsia was RM409±513 (USD 125±157) per patient. The mean cost of PUD and UGIB was approximately double (RM806±579) (USD 246±177) and quadruple (RM1,602) (USD 490) of dyspepsia respectively.Healthcare resourceMean cost per patient in RM (USD) DyspepsiaPUDUGIBAll patients with UGI adverse events (n=78)(n=5)(n=1)(n=84) Outpatient visits77 (23)146 (45)146 (45)82 (25)Emergency Dept visits28 (9)0146 (45)28 (9)Inpatient stay46 (14)136 (41)679 (207)59 (18)OGD85 (26)253 (77)211 (65)103 (32)Blood tests4 (1)32 (10)57 (17)6 (2)Radiology8 (3)008 (3)Blood transfusion4 (1)56 (17)280 (86)10 (3)Pharmacotherapy150 (46)183 (56)84 (26)151 (46)Mean cost per patient in RM ±SD409 ±513806±5791602 (490)447±535 (USD)(125±157)(246±177)(137±163)ConclusionsThe low prevalence of UGI adverse events in Malaysian rheumatology patients suggests judicious use of NSAIDs in tertiary care setting resulting in a low cost implication for the management of these events.Disclosure of InterestNone declared

Aims: This prospective study aimed to determine the proportions of therapeutic inertia when treatment targets not achieved in adults T2D at three public health clinics in Malaysia. Methods: The index prescriptions were those when the annual blood tests were reviewed. Prescriptions were verified and classified as 1) no change, 2) stepping up and 3) stepping down. Multivariable logistic regression and sensitive analyses were conducted. Results: At follow-up, 552 participants were available for the assessment of therapeutic inertia (78.9% response rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61-72%), anti-hypertensive (34-65%) and lipid-lowering therapies (56-77%), and lesser in insulin (34-52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64). Conclusions: Although therapeutic intensifications were more likely in the present of non-achieved treatment targets but the proportions of therapeutic inertia were high.