New guidelines for ‘deprescribing’ PPIs

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Proton pump inhibitors (PPIs) are a very commonly prescribed class of drugs for patients with acid peptic disorders. They have been generally regarded as safe and well tolerated. And, their long-term use is common.

However, recently, there have been concerns about the use of PPIs, especially long-term use. PPIs have been linked to increased risk of osteoporotic fractures, pneumonia, Clostridium difficile infection and rebound acid hypersecretion, especially in the older population. Long-term use may also affect patient compliance to the prescribed treatment.

Evidence-based recommendations published in the May 2017 issue of Canadian Family Physician to help the physician decide when and how to safely stop the PPIs or reduce their dose, called ‘deprescribing’ PPIs. This can be done in three ways:

• Reducing the dose by ‘intermittent’ use for a fixed duration; ‘on-demand’ use or using a lower ‘maintenance’ dose.
• Stopping the drug can be done by abruptly discontinuing the drug or via a tapering regime.
• Stepping down means abrupt discontinuation or PPI tapering followed by an histamine-2 receptor antagonist (H2RA)

These guidelines recommends deprescribing PPIs in adults who have completed a minimum of 4 weeks of PPI treatment for heartburn or mild to moderate gastroesophageal reflux disease (GERD) or esophagitis, and whose symptoms are resolved.

• Decrease the daily dose or stop and change to on-demand use. This has been given a strong recommendation.
• Or, an H2RA can be considered as an alternative to PPIs. This alternative has been given a weak recommendation due to the higher risk of symptoms recurring.

These recommendations are not applicable to patients who have severe esophagitis grade C or D, or a documented history of bleeding gastrointestinal ulcers or have Barrett esophagus.

(Source: Can Fam Physician. 2017 May;63(5):354-364)

Dr KK Aggarwal
National President IMA & HCFI

Skipping physical activity for even 2 weeks may increase health risks

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The importance of remaining physically active cannot be emphasized enough. Physical activity is critical for maintaining a healthy weight, controlling illness, promoting bone strength, reducing stress and improving general well-being.
The adverse effects of a sedentary lifestyle on health have also been well-documented. Adding to the body of evidence, a new study involving young and healthy adults, presented at the European Congress on Obesity in Porto, Portugal has shown that even taking a 2-week break from physical activity can adversely impact health.

Researchers from the University of Liverpool, UK have shown that just 2 weeks without regular physical activity can lead to metabolic and muscular changes in the body predisposing the individual to the risk of developing type 2 diabetes, heart disease and possibly even premature death. All the study participants were physically active and walked 10,000 steps daily on average and had an average body mass index (BMI) of 25 at baseline.
The exercise regime adopted during the study period of 2 weeks reduced their activity by more than 80%. And at the end of the study period, the daily step count was only around 1500. The amount of food consumed did not change.

The moderate-to-vigorous activity time reduced from a daily average of 161 min to 36 minutes. While, sedentary time increased by 2 hours and 9 minutes. Cardiorespiratory fitness declined. A loss of bone mass and increase in body fat, especially around the waist, was also observed. Pot belly obesity, we know, is associated with increased risk for type 2 diabetes, hypertension, high ‘bad’ LDL cholesterol and low ‘good’ HDL cholesterol.
Being physically active does not only mean ‘a certain period of exercise’ for example, spending an hour at the gym. Instead one should try to be more and more physically active throughout the day, along with eating a healthy diet. There are several ways you can do this:

• Avoid using a lift. Walk up the stairs as often as possible.
• Get off the bus one stop early and walk the rest of the way to your office/destination.
• Have “walk-meetings” instead of “sit-in” meetings.
• Walk down to speak to your colleague instead of using the intercom/phone.
• Take a walk around your building during lunch break.
• Walk to the nearby shops instead of driving.
• Stand up and walk while talking on the phone.
The Indian Medical Association (IMA) has taken an initiative to promote physical activity through its campaign “Move, Move and Move”.
Sit less and walk more and more … Make it a daily routine to undertake activities that keep you fit and active. Choose activities that not only promote strength, balance and flexibility, but most importantly, which you also enjoy…
(Source: A 2-Week Lazy Holiday ‘Could Be a Health Risk’ – Medscape – May 17, 2017)

Enough is Enough: Dilli Chalo on 6th June

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Dear Colleague

IMA has declared “Dilli Chalo” movement on the 6th of June to bring to the attention of the nation regarding atrocities faced by the medical profession.

The charter of demands is as follows. Kindly go through these and suggest more and also suggest modifications in the existing ones. We want to cover all segments of the medical profession (specialities, service doctors, residents, junior doctors, students, practitioners, consultants etc.).

How come the government and the celebrities are watching violence against doctors without any empathetic response?
Make violence against health care providers a non-bailable act with minimum 14 years imprisonment
How come, gradually and now consistently, modern medicine doctors are increasingly being tried as criminals? We are not against accountability but not to be tried under criminal provisions.
We want a single window accountability under the council or under a central tribunal.
Why is the health ministry sitting on the minutes of the inter-ministerial committee – regarding violence, amendments in PCPNDT act, Clinical Establishment Act, capping of compensation and cross pathy?
We want time bound implementation in six weeks.
Why should we be the victims of the limitations of the government? If the government cannot provide free primary and emergent care to all, why are they not engaging the service of doctors in the private sector to provide the same at government rates?

Are AYUSH not qualified doctors in their respective field and are they not qualified to treat common illnesses, then why force them to leave AYUSH practice and treat patients with modern medicine drugs? Is this allowed in other professions? Is this not cheating and injustice to the patients?
We respect AYUSH doctors and their pathies. Let AYUSH practitioners develop their own pathy and grow in their respective pathies and not indulge in crosspathy.
Recently, the government banned 344 fixed dose combinations drugs on the plea that two drugs when combined becomes a new drug. Then why are some state governments allowing AYUSH to co-write allopathy modern drugs?
Let the public be given the best of their system of medicine. Any mix has to be as per a clinical trial registry.
Are we not short of doctors? Are our MBBS doctors before starting practice not giving enough exams conducted by recognized universities?
IMA wants to uphold the highest standards in UG and PG medical education. We are against the proliferation and establishment of poor quality medical colleges.
The limitations of the government are already being faced by the doctors, then why introduced another exam in the name of EXIT?
Would anyone like an elected government to be run by a nominated panel of retired Supreme Court judges or similar eminent people? Then why is the government thinking of replacing it with 20-member nominated body instead of amending the Indian Medical Council Act?

Can the same be done to the Bar Council of India and the Institute of Chartered Accountants of India?

Do all the doctors not have the right to be treated equally in all states? Doctors are already facing the wrath of the limitations of the government, then why does the West Bengal Clinical Establishment Regulatory Commission provide extra separate provisions of fine, compensation and jail up to three years, thereby treating WB doctors like criminals ab-initio?

Are we not supposed to provide easily approachable services e.g. tackle cardiac arrest within five minutes?
Then why are we restricted from opening clinics in the vicinity of residences of citizens? This is the most needed facility available to any citizen.

Are we not responsible for the treatment provided to our patients?

IMA is committed to upholding the rights of the people to get good, reliable and competent medical care.
Then how can the government take away our right to choose the drugs and the company? Will the chemist be responsible for any death that occurs?
Will the government pass a legislation and ask the voters to vote and which button to be decided by the clerk helping the polling booth? Then how can the government allow a chemist to decide which drug is best for the patient and a lab technician to authorize a laboratory report?

If the quality and cost of manufacturing of generic- generic, trade-generic and brand-generic is the same, then why is the government allowing them to be sold at three different prices by the same company?
We want one drug, one company, one price policy.
Every citizen in the country has a right to receive quality and safe medical treatment. Then why push the poorer to treatment from unsafe and unqualified people? We want 25000 extra seats for post MBBS ‘Family Medicine’ course to provide comprehensive primary and emergent care to the public. An ideal GP clinic can be a combination of a doctor, a nurse and a pharmacist.

When Arabian countries provide income tax free pay to look after their patients in rural areas along with higher pays, why can’t Indian government do the same?
Doctors posted in challenging and difficult distinct areas should be given income tax-free pay higher than that given in metro cities.
Are doctors not entitled for equal work- equal pay? Then why the difference in working conditions and pay scales of residents, service doctors across the country?
All doctors in the country should be treated at par.
How can you allow doctors to work for years under contract without making them permanent? Doctors working in bad service conditions because of limitations of the government is injustice and should be resolved immediately pan India.

Reporting the name of the victim of sexual assault is a punishable offence in POCSO and IPC.
We want a central law that any allegation against a doctor be not reported by the media until the doctor is convicted.
How come increasingly Judicial powers are been given to administrators in various acts. Are we not going back to a Jury system?
A doctor should have powers to challenge any regulatory decision in lower courts and not directly in high courts.
Why are the government IEC advertisements not that effective? Why can’t they involve Indian Medical Association (IMA) and eminent doctors in their advertisements?

If the government is dependent on private sector and is asking all of us to provide free OPDs in government sector on 9th of every month then why not give IMA a room at Nirman Bhavan (similar to that has been allotted to WHO) and work together.
This is the minimum they can do. This step will lead to result-oriented coordination between Government and Doctors.

Public-Private Partnership is the need of the hour to uphold and develop health sector in India.

Dr KK Aggarwal
National President IMA & HCFI

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