Geriatrics 22/1/98

5. Fromm E. The Art of Loving. London: George Allen & Unwin Ltd.
oral hypoglycaemic agents. As most of our patients are relatively old, their control is generally loose toprevent hypoglycaemic complications.
Unexpected Life-Threatening Drug Interaction:
Often, the classic side-effects of appetite sup- Hypoglycaemia secondary to Anti-Helicobacter
pression, nausea and vomiting due to the high dos- pylori Therapy
age of antibiotics were neglected, with most physi- cians stressed on compliance for successful eradi-cation to prevent recurrence. Unfortunately, the Ulcer syndrome and diabetes are both common combination of hypoglycaemic agents with mark- in elderly people in Hong Kong. Detection of the edly reduced calorie intake can result in danger- causative agent Helicobacter pylori(Hp)1 is essen- ous hypoglycaemia. As most of upper endoscopy tial for better cure of peptic ulcer. Unfortunately, was done as out patients in Hong Kong, some of we faced a patient suffering from dangerous the hypoglycaemic complications may be missed.
hypoglycaemia secondary to oral hypoglycaemic Elderly people living alone will be particularly vul- agents and Helicobacter Pylori eradication combi- Although glibenclamide should be avoided in A 78-year-old gentleman was admitted to hos- elderly diabetic patients due to its long half life, it pital for diabetic control, he was maintained on is still one of the most commonly prescribed glibenclamide 10mg om, 5mg noon and metformin sulphonylureas, especially in the government gen- 1g tds, as his sugar control improved after admis- eral out patient clinics. We hope that our experi- sion by better dietary restriction, with fasting/2hr ence will alert our colleagues to avoid glibenclamide haemoglucostix 8.1 and 11.5 mmol/l respectively.
in elderly diabetics, particularly the prescription of As he was found to be anaemic with haemoglobin of 9.8g/dl and iron saturation of 9% only, upper To conclude, all diabetic patients offered Hp endoscopy was performed which showed multiple eradication therapy should be warned of the po- duodenal ulcers with positive rapid urease test. So tential side effects, with similar information dis- one week course of amoxycillin 1g bd, omeprazole patched to the relatives. Physicians should be pre- 20 mg bd, and clarithromycin 500mg bd was pared to reduce the dose of hypoglycaemic drugs s t a r t e d . I n s u b s e q u e n t t w o d a y s , h i s at least temporarily when prescribing drugs that haemoglucostix was progressively lower requiring may suppress the appetite of patients.
reduction in dosage of glibenclamide until on day3 post-endoscopy, his haemoglucostix was 0.9-1 mmol/l which persisted for one day despite all dia- Dr. Yu-Tak Hung, MBChB, FHKCP
betic drugs were stopped, with confirmed blood glu- cose value as low as 1.6 mmol/l only. On direct Dr. Kin Wong, LMCHK
questioning, he was found to have omitted meals because of poor appetite, which was attributed to Dr. Edmund Chow, MBBS, FRACP
the triple therapy. His diabetic drugs were slowly re-introduced and the original dosage resumed five Department of Medicine, Our Lady of Maryknoll Hospital. Shatin Pass Road, Wong Tai Sin, Kowloon, Hong Kong.
Address Correspondence to: Dr. Y.T. Hung Ulcer syndrome is common worldwide and has been related to Helicobacter pylori infection1. As a 1. Tytgat GNJ, et al. Campylobacter pylori and its role in peptic ulcer result its detection indicates the need for eradica- disease. Gastroenterol Clin North Am 1990;19:183-196.
tion therapy2. At present, the commonly prescribed 2. Consensus Statement, Medical treatment of peptic ulcer disease.
drugs are triple therapy of omeprazole, amoxycillin JAMA 1996;275:8:622-627.
and clarithromycin for one week, which is gener- 3. Yousfi MM, et al. Metronidazole, omeprazole and clarithromycin: an effective combination therapy for Helicobacter pylori infection.
ally well tolerated except causing some nausea3.
Aliment Pharmacol Ther 1995;9:209-212.
Diabetes mellitus is also common in our ageing and affluent society, most of them being non-insu-lin-dependent diabetes on dietary restriction and Permission granted for electronic reproduction in Hong Kong Medicine Online. Single copy may be made for the purpose of research, training or private study, and NOT for commercial distribution. Journal of the Hong Kong Geriatrics Society • Vol. 8 No.1 Dec. 1997 ter. They were all invited to come to our hospitalfor factor XII screening. One of her daughters re- fused to come, while the blood tests of other familymembers did not show evidence of factor XII defi- This is a reasonably well written paper which makes a valid point. The main thrust of the paper Table 1. Results of family member screening is that anorexia is caused by triple therapy given totreat Hp and that in the presence of diabetes, this anorexia leads on to hypoglycaemia. The main con- clusion is that hypoglycaemic agents should be re- viewed prior to commencing anti-Hp therapy.
The main problem with the paper is that this aetiology of hypoglycaemia is not specific to anti- Hp therapy and in fact could be caused by anymedication given to an elderly sick diabetic patient.
This in fact is well known and is a matter of good (PT control 10 to 12 seconds; APTT control 27 to 37 seconds) Also in the discussion some time should have The APTT and PT measure the plasma intrinsic been given to discussing whether anti-Hp therapy and extrinsic coagulation activity respectively.
should have been given at all. Some authors be- However, prolongation of APTT does not always in- lieve that elderly frail patients should only be given dicate increased bleeding tendency. Factor VIII, IX, H2 antagonists, mainly due to the risk of XI and von Willebrand factor (vWf) deficiencies were pseudomembranous colitis from antibiotics but associated with prolonged APTT and bleeding com-plications. Similar consequences were also reported diabetes mellitus may represent another group in patients with factor VIII, IX and von Willebrand where this approach may be appropriate.
factor inhibitors1,2,3. Subjects with prekallikrein andHMW kininogen deficiency had neither bleeding nor Prolonged Activated Partial Thromboplastin
thrombotic tendency. On the contrary, patients with Time (APTT) in an 86-year-old Patient
lupus anti-coagulant syndrome had higher risksof thromboembolism despite their prolonged APTT4.
The above elderly lady was deficient in factor XIIwhich is a zymogen of a serine protease that ini- An 86-year-old female smoker was admitted to tiates the contact phase of intrinsic pathway of co- a medical ward in December 1996 because of acute agulation in vitro. It was first discovered by Ratnoff exacerbation of chronic obstructive pulmonary dis- and Colopy in 1955 during a routine pre-operativescreening of John Hageman who had this plasma ease. She was afebrile and her shortness of breath defect5. Factor XII deficiency is inherited as an au- improved with bronchodilators and oral antibiot- tosomal recessive trait6. Bennett, et al, reported a ics. Blood tests including blood gases were normal.
kindred probably inherited as an autosomal domi- However, clotting profile was ordered by a new in- nant characteristic7. Since neither homozygous or tern and showed a prothrombin time (PT) of 10 sec- heterozygous is symptomatic, the true prevalence onds (control 10 to 12 seconds) and an activated of the deficiency is not known. Some authors be- partial thromboplastin time (APTT) of 53.6 seconds lieved that factor XII deficiency is the most com- (control 27 to 37 seconds). The clotting profile was mon cause of isolated prolonged APTT in a non- rechecked twice and revealed similar results (PT bleeding subject. Heterozygotes had factor XII lev- 10.1 and 10.2 seconds; APTT 54.6 and 57 seconds).
els between 20-60% were reported with an averageof about 50%8. Homozygous subjects had virtually The patientís APTT was completely correctable by undetected factor XII activity (less than 1% of nor- addition of normal plasma incubated for 2 hours mal pooled plasma)8. It has been shown that Asians at 37 degree Celsius. The plasma concentrations have lower level of factor XII9. Diagnosis of factor of relevant clotting factors were determined and the XII deficiency is usually made by noting a prolonged results were: factor XII 18%, factor XI 89%, factor APTT and normal PT in an asymptomatic patient.
IX 230%, and factor VIII:C 31.8% of normal. Factor Definitive diagnosis needs specific quantitative fac- XII deficiency was established. No circulatory in- hibitors were identified. She had no evidence or The absence of haemorrhagic consequence in history of abnormal bleeding. The patientís family either heterozygous and homozygous factor XII de- consisted of a son, 2 daughters and a granddaugh- ficient subjects suggested this factor is not neces-sary for normal haemostatasis to occur in vivo.
Permission granted for electronic reproduction in Hong Kong Medicine Online. Single copy may be made for the purpose of research, training or private study, and NOT for commercial distribution.

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