over diagnosis/over treatment in today`s medical firmament

1
OVER DIAGNOSIS/OVER
TREATMENT IN TODAY’S
MEDICAL FIRMAMENT
-Dr. C.V. Krishnaswami
BMJ/02nd March 2013
2
Fiona Godlee – Cite this as: BMJ 2012; 344: e3783
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4
5
Over Diagnosis Over Treatment
S.No
Pt.
UID
1 1140
2 1145
3 1146
4 1227
Pt.
Name
SS
RKV
DK
K. R
AGE
52
33
37
72
Diagnosis
T2DM
T2DM
Duration
Treatment
Presently on
5 years
C/o. Frequent hypos
Body pain
Tab. Glucored forte
1 bd,
Tab. Triglucored
forte 1 bd,
Tab. Amoxycillin
250 mg
1 bd sos,
Tab. Diclofenac
10 mg 1 hs,
Tab. Avil sos.
3 years
Patient has come for
further management
and evaluation of his
diabetic status.
Tab. Zoryl M 1 od, Tab. Diapride
Tab. Supradyn 1 sos. 1 mg 1 od.
Peripheral
neuropathy
(metformin
1 year
induced)
Fatigue syndrome
(? Statin induced)
T2DM
IGT
ASCVD/HTN - on
polypharmacy
Complaints
C/o. Fatigue and
paraesthesia
of feet continues.
Presently paresthesiae
of feet.
fatigue towards evenig
past few month.
IP/
OP
Clinical response
Tab. Trigabantin
300 mg 1 hs,
No H/o. Hypos.
Tab. Glynase XL
IP Body pain
10 mg 1 bd,
reduced.
Inj. H.Mixtard
15 U pre breakfast
OP
Presently
asymptomatic
Metformin, Statin, Tab. Glynase XL
Inj. Novomix 30
10 mg 1 bd,
12U pre breakfast, Cap. Renerve G
8U pre dinner,
100 mg 1 hs,
OP
Tab. Renerve G 1
Tab. Neurobion
at night 100 mg,
Forte,
Tab. Neurbion Forte Inj. Novomix 30
1 od.
10 U pre breakfast.
Tab. Ecosprin
75 mg 1 od,
Tab. Rosuvas
10 mg 1 hs,
Tab. Toresa
Present asymptomatic. 10 mg 1 od,
Came for expert opinion. Cap. Angizem DP
5-6years
Known diabetic, only on 90 mg 1 od,
diet.
Tab. Olmezest
40 mg 1 od,
Tab. Matzok
50 mg 1 hs,
Tab. Stamina OD
1 od.
Cap. Angizem DP
90 mg 1 od on
A/D,
Tab. Metzok
50 mg 1 at 7 PM,
Tab. Ecosprin
75 mg 1 after
lunch
on A/D,
Tab. Toresa
10 mg 1 od,
Presently asymptomatic.
Now he is being managing
OP with 50% of his previous
medication.
No rebound sequelae.
6
Over Diagnosis Over Treatment
S.No
Pt.
UID
5 1256
6 1257
7 1299
Pt.
Name
DDD
J. P
S.P.R
Age
62
58
33
Diagnosis
HTN
CAD
T2DM
T2DM
HTN
Mild T2DM
HTN - under
control
Duration
20 years
15 years
1 year
Complaints
Treatment
Inj. Lantus 16 units
at bed time,
Tab. Jalra
Came for expert opinion.
50 mg 1 bd,
Started as Chest
Tab. Amaryl M2
discomfort or
Forte
uneasiness revealed
1 bd,
block in LAD.
Tab. Nitrocontin
Done coronary
2.6 mg 1 bd,
angiogram
Tab. Betaloc
with PTCA stenting 12.5 mg 1 bd,
1 year back
Tab. Ecosprin
(2011 in MMM).
150 mg 1 od,
C/o. Burning micturition.
Tab. Clopilet
Irritation while
75 mg 1 od,
passing urine.
Tab. Dytor
10 mg 1 hs
(nearly 2 years).
Tab. Semireclimet
1-0-1/2,
Tab. Clopilet
75 mg 1 hs,
Tab. Dilzem SR
C/o. Right leg &
90 mg 1 hs,
knee pain
Tab. Telista
severe past 1 month.
40 mg 1 od,
Occasional giddiness.
Tab. Atocor
20 mg 1 hs,
Cap. Ebiza L 1 od
(all above medicines
nearly 2 years).
He has come
for opinion
& advice
Presently on
IP/
OP
Clinical response
Tab. Nitrocontin
2.6 mg 1 bd,
Tab. Ecosprin
75 mg 1 od,
Tab. Clopilet
He is comfortable with out
75 mg 1 od,
treatment regime for
Tab. Diamicron
OP T2DM.
80 mg 1 tds,
Burning micturition is
Syp. K-Mac 1 bd,
much better.
Tab. Seloken XL
12.5 mg 1 od,
Inj. H.Mixtard
30 U pre breakfast.
Tab. Telista
Leg pain & knee pain
40 mg 1/2 at 8 AM,
reduced
Tab. Dilzem SR
significantly.
90 mg 1 hs,
OP She is feeling good.
Tab. Coversyl
Her blood sugars are
2 mg 1 od,
well under control with
Tab. Natrilix SR
our treatment regime.
1.5 mg 1 od
Telma, Tab. Ecosprin Tab. Seloken XL
& Statin.
25 mg 1 od.
He is doing well with our
advice regarding diet &
life style modification.
He is doing extremely fine
OP
and he lost nearly 10 kgs
in over 3 months.
No panic attacks.
He is doing very fine.
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Over Diagnosis Over Treatment
S.N Pt.
Pt. Name AGE
o UID
8 1499
9 1704
RK
R. R
Diagnosis
52 T2DM
83 HTN and Asthma
Duration
Complaints
Treatment
Presently on
Tab. Glycomet SR
500 mg 1 bd,
Tab. Ecosprin
75 mg 1 od,
Tab. Ramistar 1 od.
1 1/2
years
At present
asymptomatic.
Came for a
general checkup
3 years
Tab. Atenolol
25 mg 1 od,
C/o. Sinus tachycardia Tab. Ecosprin
(fast heart rate).
75 mg 1 od
H/o. Mild asthma
(since 2 months),
for 2-3 years.
Seroflo
No DM/HTN
200 mcg 1 puff
daily or alternate
days.
Tab. Atenolol
25 mg 1 od
for 1 week
then
12.5 mg 1 od
for 1 week
then
6.25 mg 1 od
for 1 week
and then stop.
IP/
OP
Clinical response
Presently asymptomatic.
T2DM - he was not
OP required any
OHA. Sugars were
under controlled.
Prof. B.M. Hegde
opinion:
He is a healthy individual.
O/E: There is no trace of
wheeze and BP is
120/80 mmHg with
normal HR: 70 / min.
Advised:
1. Stop the Seroflo
OP inhaler, as there is
no Asthma.
2. Stop the Clopidegrel
and to gradually
taper Atenolol
every week.
3. After 2 weeks
check BP and PR.
If needed to use
BM Pulser.
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Over Diagnosis Over Treatment
S.No
Pt.
UID
10 1938
Pt.
Name
K. R
AGE
53
Diagnosis
T2DM
CAD
Hypothyroidism
Duration
Since
1995
Complaints
C/o. Breathlessness
gradually
even with little activity.
C/o. Weight gain nearly 20 kgs in
6 months
(previously she used
to be 90 to 95 kgs 6 months back).
Since 2005, able
to move
around with 90-95 kgs
of weight.
Now with increased
weight & oedema
both upper and
lower limb,
feeling breathlessness
and difficult to move
around even little.
Treatment
Presently on
IP/
OP
Clinical response
After admission,
her prescription
was modified with
Inj. H. Mixtard 30/70
the omission
30 U pre breakfast
of statin and metformin.
Tab. Cardace
and 30 U pre dinner
The dose of Tab. Eltroxin
5 mg 1 od,
(taken for 3 years),
was increased to
Tab. Ecosprin
Tab. Eltroxin 100
125 mcg from 100 mcg
75 mg 1 od,
mcg
as her TSH value while on
Tab. Isosorbide 5
2 od (since 1995),
100 mcg of Thyroxin was
mg
Tab. Glicalizide
71.4 µU/ml.
1 bd,
80 mg 1 bd,
She had 4 sessions
Tab. Calaptin
Tab. Metformin 500
of Dynamic Acupuncture
40 mg 1 bd,
mg
Mediated Metaphysical
Tab. Diamicron
1 bd (since 1995),
(DAMM) Therapy
80 mg 1 tds,
IP
Tab. Atocor 20 mg 1
by Mr. Rajan Iyer.
Tab. Eltroxin
od,
At the time of
150 mcg 1 od,
Tab. Cardace 5 mg 1
discharge, her
Inj. H.Actrapid
od,
vital signs were stable,
25 U pre breakfast,
Tab. Ecosprin 75 mg
she has lost
Inj. Insulatard
1 od,
0.6 kgs in weight.
15 U pre breakfast,
Tab. Neurobion
She is advised to increase
Inj. H.Actrapid
forte 1od,
the dose of Tab. Eltroxin to
15 U pre dinner,
Tab. Isosorbide 5 mg
150 mcg
Inj. Insulatard
1 bd,
after 1 month and maintain
25 U pre dinner.
Tab. Calaptin 40 mg
that for 3 more months.
1 bd.
It is advised that no change
be made in her
Anti-diabetic prescription.
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Over Diagnosis Over Treatment
S.No
Pt.
UID
Pt.
Name
11 1964 V. S.V
Age
82
Diagnosis
Duration
Complaints
Treatment
Presently on
Tab. Vertin
8 mg 1 tds
for 1 week,
Tab. Nootrophil
800 mg 1 bd,
Tab. Syndopa
110 mg 1/2 bd
Revamping of his
(until review),
hypertensive
Tab. Cardivas
medications.
3.125 mg 1 bd,
Tab. Cardivas
C/o. Edema feet.
Tab. Repace
3.125 mg 1/2 bd,
Not a known diabetic.
HTN
50 mg 1 bd,
Tab. Centrum
Patient was given
Prostate
Tab. Prazopress XL Silver
HTN
Tab. Thiazide (Aquazide)
carcinoma with
5 mg 1 bd
1 after lunch,
(40 years) which caused intense
extensive bone
(until review),
Tab. Honvan 1 hs,
hyponatremia
metastasis
Tab. Shelcal
Tab. Arachitol O 1
and had extra
(Stage4) - treated
50 mg 1 od,
hs,
pyramidal
Tab. Ranitin
Tab. Amifru
reaction to
150 mg 1 od,
1/2 od (3/7)
Tab. stemetil Cap. Dexorange
leading to difficulty in
1 od,
expressing, dizziness etc.
Tab. Centrum silver
1 od,
Tab. Neurobion forte
1 od,
Tab. Honwan 1 od
+ Zometa
infusion monthly.
IP/
OP
Clinical response
He required very
minimal dose
IP
of anti-hypertensives.
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Over Diagnosis Over Treatment
S.No
Pt.
UID
Pt.
Name
12 1996 M. T.R
AGE
74
Diagnosis
Duration
Mild T2DM with
renal
decompensation (?
10 years
Iatrogenic)
ASCVD/HTN
BPH
Complaints
C/o. Weakness
past 10 days.
Swelling of feet
for the past 6 months,
now with change
of medications
under control.
He gets heaviness
of head when
the BP is high.
Treatment
Tab. Nebimac
5 mg 1 od,
Tab. Veltam
0.4 mg 1 hs,
Tab. Ecosprin
75 mg 1 od,
Tab. Reclide
40 mg 1 od,
Tab. Doxocard
1 mg 1 od,
Tab. Dytor Plus
20 mg 1 od,
Tab. Moxovas
3 mg 1 od.
Presently on
Tab. Veltam
0.4 mg 1 hs,
Tab. Dytor
20 mg 1 od,
Tab. Bronac
600 mg 1 after
lunch,
Tab. Ferium XT
1 hs,
IP/
OP
Clinical response
His blood sugars were never
more than 140 mg/dl
throughout and his blood
pressure was within
normal range.
After stopping his OHA for
blood sugar and drugs for
high blood pressure,
his weakness subsided,
he feels energetic,
his heart rate has improved
IP
nicely (56-58/mt).
At the time of discharge,
he feels much comfortable,
has no odema feet,
improved pulse rate,
reduced weight to 66.6kgs
(1.5 kgs less).
He was advised not to
take any OHA or
anti hypertensives
till further advice.
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Over Diagnosis Over Treatment
S.No
Pt. Pt.
UID Name
13 2010
14 1101
GR
RL
Age
Diagnosis
Duration Complaints
No specific complaints.
His come for opinion
and advice
regarding diabetes.
Treatment
Tab. Diabetrol 2-0-1,
Tab. Zomalis 50 mg
1 hs ( 3 years),
Tab. Betacard
Tab. Glynase XL
100 mg 1 od,
5 mg 1 bd.
Tab. Polytorva
5 mg 1 hs (15 years)
and Ayurvedhic
treatment.
60
T2DM
HTN
57
Tab. Glyciphage
500 mg 1/2-0-1/2,
Tab. Depsonil
Known T2DM for 1
1.2 mg 1 bd,
year.
Tab. Tryptomer
HTN / CAD.
10 mg 1 hs,
Hypothyroid.
C/o. Cough of 1 year
Tab. Clopitab A 1 od,
Migraine - 20
duration on
Tab. Nitrocontin
years.
T2DM
anti TB therapy.
2.6 mg 1 bd,
Bronchostenosis - (1year)
Admitted for
Tab. Losar H
?.
HTN, CAD
rationalisation
50 mg 1 od,
Acute
(2 years)
of her current BP
Cap. Rcinex
exacerbation of
and diabetic medication. 600 mg 1 od,
bronchitis on
Tab. Combunex
treatment for
1000 mg 1 od,
endobronchial
Tab. Liv 52 D 1 hs,
tuberculosis.
Tab. Banadon
40 mg 1 od,
Tab. Zincovite 1 hs.
8 years
Presently on
Tab. Romilast
10 mg 1 at 6 PM,
Tab. Thyronorm
50 mcg 1 od,
Tab. Deriphyllin
Retard
150 mg 1 bd
(if necessary).
IP/
Clinical response
OP
He is very fine.
He is over diagnosed
and over treated
for diabetes.
After starting ayurvedic
treatment in the
first week of
february 2013, his
blood sugars
has dropped from
OP
200 mg/dl
to 110 to 120 mg/dl.
Sometimes experiences
hypo in the early
mornings.
So advised
to stop Diabetic
drugs and statin
(Diabetrol, Zomalis and
Polyatorva).
Anti diabetic and anti
hypertensive medications
were stopped.
Observation in the hospital
IP revealed only normal blood
sugars and normal BP.
The cough was brought
under control with
bronchodilators.
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Over Diagnosis Over Treatment
S.No
Pt.
UID
15 1106
16 1270
Pt.
Name
PKM
P. A.S
AGE
46
64
Diagnosis
Hypothyroidism
T2DM on diet
control
HTN
T2DM
Duration
HTN
(7year)
13 years
Complaints
Known HTN
since 2006 / T2DM
and Hypothyrodism
for last 1 month
presented with ulcer
over the
right lower leg
(above ankle).
Patient got admitted
for rescheduling
treatment and
Pulsed Electro
Magnetic Field
Energy therapy
using by BM
pulser
over precardium.
Treatment
Tab. Tribet
2 mg 1 od,
Tab. ASP-Atrova
10 mg 1 hs,
Tab. Win-BP
20 mg 1 od,
Tab. Nebula AM
5 mg 1 od,
Tab. Thyrup
100 mcg 1 od
(for last 1 month).
Patient was on
Tab. Aldomet
250 mg 1 bd,
Tab. Ecosprin
150 mg 0-1-0,
Tab. Atocor
20 mg 1 hs
(2006 - 2010).
Tab. Sorbitrate
5 mg SL SOS,
Tab. Seloken XL
25 mg 1/2-0-0,
Tab. Repace
25 mg 1 od,
Cap. Modlip Ash
2-0-0,
Tab. Aciloc RD
1-0-1 (2010 - 2012)
Tab. Triexer
3 mg 1 bd,
Tab. Vozukam,
Tab. Olmezet,
Tab. Ecosprin,
Tab. Nebicard,
Tab. Clopigred.
Presently on
IP/
OP
Clinical response
Tab. Nebula AM
5 mg 1/2 od,
Tab. Thyrup
50 mcg 1 at 6 AM.
Ulcer over the right
meleolus is completely
healed.
OP
He is doing well with
1/3rd of his previous
prescription.
Tab. Diamicron
80 mg 1 tds,
Tab. Vigocil
0.3 mg 1 bd.
Instructed to follow
Diet advice
and life style modifications
daily.
BM Pulser was applied
over the
IP
precordium during
his stay here
for about 20 hrs a day.
With the above said
treatment,
he settled well.
Published Online: April 13, 2009 (DOI: 10.1001/archneurol.2009.42)
13
By John Gever, Senior Editor, MedPage Today
Published: April 14, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine,
University of California , San Francisco
14
Journal Watch General Medicine Alert for July 13, 2010
15
Lancet Article
16
17
Journal Watch General Medicine Alert for August 9,2012
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Statins and Risk of incident diabetes: a collaborative meta-analysis of
randomised statin trails
-www.thelancet.com vol375 February 27, 2010
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20
BMJ 2003; 326:4-5 (4 January)
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Metformin induced Vitamin B12 deficiency and polyneuropathy
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THE RCPE UK CONSENSUS STATEMENT ON DIABETES OPENS UP MORE QUESTIONS.
What after metformin?
For an old-time Fellow of the RCPE like me who is still in active clinical practice after
four and a half decades, it is rather puzzling to note that the British members of the
RCPE consensus group fail to trace or mention the history of biguanides – their
clinical and biochemical aspects propounded in a classic monograph by Robert D
Cohen and H Frank Woods with a foreward by the redoubtable Sir Hans Krebs.
There is no mention of the University Group Diabetes Program study’s implications
on the elder sibling-drug phenformin and the later reports on metformin-induced
renal impairment and increased mortality. Also to be taken into account are vitamin
B12 malabsorption-anaemia and irreversible peripheral neuropathy in about 30%
of the cases of those treated with this drug and invariably misdiagnosed as diabetic
neuropathy! Why is there a total lack of interest in doing credible clinical research
on the above points? Is the glossing-over of this important money-spinning drug, as
noted by Marcia Angell (former Editor-in-chief, the New England Journal of
Medicine) in her book, due to any nexus between the pharma companies and the
medical profession?.
Author’s Response
By John Gever, Senior Editor, Medpage Today (September 26, 2009)
24
BMJ/02nd March 2013
25
BMJ/02nd March 2013
26
Journal Watch General Medicine Alert for May 22, 2008
27
BMJ / 19 March 2011
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Where the prescription looks like the laundry list!
PROF. B. M. HEGDE
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http://www.hindu.com/
Online edition of India's National Newspaper
Sunday, Dec 05, 2010
DRUGS GALORE: One beta blocker, one ACE inhibitor, one blood thinner, one sugar
lowering drug, of course, one cholesterol lowering drug and many others for every
patient.
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THANK YOU