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Fulltext Underprescription of Fibrate Among Patients With Diabetic Retinopathy in Perak, Malaysia

Jamaluddin J, Mohamed Kamel MA

Cureus, 2024 Jan;16(1):e51434.
PMID: 38298309 DOI: 10.7759/cureus.51434

Objectives Diabetic retinopathy (DR) is a major cause of blindness and its prevalence is increasing. Fibrate, specifically fenofibrate, has been shown to be efficacious in reducing the progression of DR. This study aims to determine the five-year trend of and factors associated with the prescription of fibrate among patients with DR in Perak. Methods Data on all patients with DR in 76 government health clinics in Perak who were audited between 2018 and 2022 were extracted from the National Diabetes Registry (NDR), excluding those who were lost to follow-up. Multivariable logistic regression was used to identify factors associated with the prescription of fibrates. Results Data from 4028 patients were analysed. Commonly prescribed medications were statins (n = 3466, 86.0%), metformin (n = 3212, 79.7%), and angiotensin-converting enzyme inhibitors (n = 2318, 57.5%). Only 63 (1.6%) patients were prescribed fibrate. Factors associated with the prescription of fibrates were patients from the clinics in northern (adjusted odds ratio (aOR) = 0.33, 95% CI: 0.12-0.65) and southern clusters (aOR = 0.23, 95% CI: 0.08-0.655), triglycerides > 1.7 mmol/L (aOR = 4.85, 95% CI: 1.85-12.70), and prescription of insulin (aOR = 2.77, 95% CI: 1.07-7.18) and statin (aOR = 0.10, 95% CI: 0.04-0.27). Conclusion The prescription of fibrate among patients with DR was low, highlighting a missed opportunity for early treatment and improved outcomes in primary care. The prescription of fibrates to reduce the progression of DR should be expanded to primary care. Clinicians should consider the factors associated with the non-prescription of fibrate identified when prescribing to these patients. Policies, including those at the ministry level, to enhance the availability of these medicines, including financial resources for procurement, are necessary to guarantee easy access for patients in different areas. It is crucial for healthcare providers to be knowledgeable about and follow guidelines. Moreover, improving the overall management of DR in patients with multiple comorbidities can be achieved by addressing worries about the side effects of combination therapies through educational campaigns and providing clear directives. Nevertheless, the study's findings should be interpreted in light of the limitations discussed.
Fulltext A masquerade in a symptomatic patient with heart failure

Jamaluddin J, Mohamed Kamel MA, Jamil SN

Malays Fam Physician, 2023;18:19.
PMID: 37205147 DOI: 10.51866/tyk.291

We describe the case of a 72-year-old housewife who presented to a primary care specialist clinic for reassessment following multiple hospitalisations for heart failure within the past 9 months. She presented with decreased effort tolerance and tiredness for the past 1 year. Her symptoms had remained the same despite current treatment. During the initial history-taking, she did not report any medical illnesses or surgeries. She had been well and had not undergone any screening for almost 30 years before the first hospitalisation for heart failure. There was neither cough, constipation, dyspepsia, abdominal pain, stool changes, haematuria, per vaginal bleeding nor hoarse voice. The physical examination findings were remarkable for slow movement and speech. Her skin was dry with a markedly increased serum lipid profile. Further investigation and management confirmed the suspected diagnosis.
Fulltext A clinical audit of the diagnosis and management of chronic kidney disease in a primary care clinic

Jamaluddin J, Mohamed Yassin MS, Jamil SN, Mohamed Kamel MA, Yusof MY

Malays Fam Physician, 2021 Nov 30;16(3):68-76.
PMID: 34938394 DOI: 10.51866/oa1171

Introduction: This audit was performed to monitor the diagnosis and management of chronic kidney disease (CKD) according to the clinical practice guidelines (CPGs) of CKD 2018 in a primary care clinic.
Methods: Patients who attended the clinic from April to June 2019 and fulfilled the diagnosis of CKD were included in this study, except for those diagnosed with a urinary tract infection, pregnant women and those on dialysis. These criteria were set based on the CPGs. The standards were set following discussions with the clinic team members with reference to local guidelines, the 2017 United Kingdom National CKD audit and other relevant studies.
Results: A total of 384 medical records were included in this audit. Overall, 5 out of 20 criteria for processes and 3 of 8 clinical outcomes for CKD care did not meet the set standards. These included the following: documentation of CKD classification based on albumin category (43.8%); CKD advice (19.0%); dietitian referral (9.1%); nephrologist referral (45.5%); haemoglobin level monitoring (65.7%); overall blood pressure (BP) control (45.3%); BP readings for diabetic kidney disease (DKD) and non-DKD with > 1 g/day of proteinuria (< 130/80 mmHg, 37.0%); eGFR reduction of < 25% over the past year (77.2%). Identified problems included the absence of a CKD registry, eGFR and albuminuria reports, and a dedicated team, among other factors.
Conclusions: Overall, 8 out of 28 criteria did not meet the standards of CKD care set for this audit. The problems identified in this audit have been addressed. Moreover, strategies have also been formulated to improve the diagnosis and management of CKD in this clinic.
Frequency and predictors of inappropriate medication dosages for cardiovascular disease prevention in chronic kidney disease patients: A retrospective cross-sectional study in a Malaysian primary care clinic

Jamaluddin J, Mohamed-Yassin MS, Jamil SN, Mohamed Kamel MA, Yusof MY

Heliyon, 2023 Apr;9(4):e14998.
PMID: 37025791 DOI: 10.1016/j.heliyon.2023.e14998

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events. This study aimed to assess the frequency of inappropriate medication dosages (IMD) for cardiovascular disease prevention among patients with CKD and its predictors in an urban academic primary care clinic in Selangor, Malaysia. All patients who attended the clinic from April to June 2019 and fulfilled the inclusion criteria were included in this cross-sectional study, except for those with an estimated glomerular filtration rate (eGFR) of more than 90 ml/min, diagnosed with urinary tract infection, pregnant or were on dialysis for end stage renal disease. Their prescriptions on the electronic medical record (EMR) system were evaluated for appropriateness using the dose adjustment recommendations based on the 2018 Malaysian Clinical Practice Guidelines on management of CKD. A total of 362 medical records were included in this study. 16.6% (95% Confidence Interval [CI]: 12.9-20.8) or 60 out of 362 of the patient records analysed contained medications prescribed with inappropriate dosages. Patients with higher stages of CKD were associated with higher odds of IMD, namely CKD stage G3b (adjusted Odds Ratio [aOR] 10.41; 95% CI: 2.31-46.88) and CKD stage 4-5 (aOR 15.76; 95% CI: 3.22-77.28). Other predictors of IMD were diagnosis of diabetes mellitus (aOR 6.40; 95% CI: 2.15-19.01), number of prescribed medications of 5 or more (aOR 4.69; 95% CI: 1.55-14.20), and eGFR reduction of more than 25% over one year (aOR 2.82; 95% CI: 1.41-5.65). Within the limitations of this study, we conclude that the occurrence of IMD for CVD prevention was low in CKD patients in this primary care clinic. Medications with inappropriate dosages identified in this study include simvastatin, fenofibrate, hydrochlorothiazide, spironolactone, metformin, gliclazide, sitagliptin, dapagliflozin and empagliflozin. Clinicians should consider the predictors of inappropriate medication dosages listed above when prescribing to patients with CKD to reduce the risk of medications-related toxicities and adverse effects. Limitations of this study should be considered when interpreting the findings presented.
Fulltext ABC approach for the management of adults with hyperthyroidism: A practical strategy in primary care

Jamaluddin J, Zainal Abidin S, Kathitasapathy G, Mohamad Isa MZ, Mohamed Kamel MA, Kaur P, et al.

Malays Fam Physician, 2023;18:57.
PMID: 37814670 DOI: 10.51866/rv.303

Hyperthyroidism is commonly seen in primary care settings. However, the management of hyperthyroidism might be unclear to primary care doctors. Various guidelines have been published to assist clinicians in the management of thyroid disorders at various levels of care. The extensive coverage of these guidelines may not appeal to busy clinicians, and the guidelines do not focus on often resource-limited primary care settings. In this article, we aim to describe a practical guide for managing hyperthyroidism in primary care settings using an ABC approach.
Fulltext Five-year trend in secondary prevention medication prescription and risk factor control among patients with diabetes mellitus and cardiovascular diseases in Perak health clinics

Jamaluddin J, Mohamed-Kamel MA, Din NSS, Mohamad-Isa MZ

Malays Fam Physician, 2024;19:46.
PMID: 39156231 DOI: 10.51866/oa.572

INTRODUCTION: Prescription of secondary prevention medications (SPMs) and effective control of cardiovascular risk factors (RFs) are crucial to reduce the risk of recurrent cardiovascular events, particularly in high-risk individuals including those with diabetes mellitus (DM). This study aimed to analyse the trends in SPM prescription and identify the factors associated with RF control among patients with DM and cardiovascular diseases in Perak health clinics.
METHODS: Data of patients with ischaemic heart disease (IHD) and cerebrovascular diseases (CeVDs) audited from 2018 to 2022, excluding those lost to follow-up, were extracted from the National Diabetes Registry. Descriptive and trend analyses were conducted. Multivariable logistic regression was utilised to identify the factors associated with RF control.
RESULTS: Most patients (76.7%) were aged ≥60 years and were Malays (62.3%). The majority had IHD (60.8%) and CeVDs (54.7%) for ≥5 years. SPM prescription increased significantly over the past 5 years. However, blood pressure (BP) and lipid control remained static. Good BP control was associated with a DM duration of ≥10 years and poor control with Malay ethnicity and prescription of two or three antihypertensives. Good DM control was associated with an age of ≥60 years and age at DM diagnosis of ≥60 years and poor control with Malay and Indian ethnicities, DM duration of ≥10 years and prescription of two or three and more glucose-lowering drugs. Poor lipid control was associated only with Malay and Indian ethnicities.
CONCLUSION: SPM prescription has increased over time, but the achievement of treatment targets, particularly for lipid control, has remained poor and unchanged. Statin use is not associated with lipid control. The accessibility and availability of alternative lipid-lowering drugs must be improved to enhance overall RF control, especially lipid control, in patients with DM and cardiovascular diseases.