OVER DIAGNOSIS/OVER TREATMENT IN TODAY’S MEDICAL FIRMAMENT

-Dr. C.V. Krishnaswami

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BMJ/02nd March 2013

Fiona Godlee – Cite this as: BMJ 2012; 344: e3783

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

AGE Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

1 1140 SS 52T2DM

5 yearsC/o. Frequent hyposBody 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.

Tab. Trigabantin300 mg 1 hs, Tab. Glynase XL 10 mg 1 bd, Inj. H.Mixtard15 U pre breakfast

IPNo H/o. Hypos. Body painreduced.

2 1145 RKV 33T2DM

3 years

Patient has come for further management and evaluation of his diabetic status.

Tab. Zoryl M 1 od, Tab. Supradyn 1 sos.

Tab. Diapride1 mg 1 od.

OPPresently asymptomatic

3 1146 DK 37

Peripheral neuropathy (metformininduced) Fatigue syndrome(? Statin induced) T2DM

1 year

C/o. Fatigue and paraesthesiaof feet continues. Presently paresthesiaeof feet.fatigue towards evenigpast few month.

Metformin, Statin, Inj. Novomix 30 12U pre breakfast, 8U pre dinner, Tab. Renerve G 1 at night 100 mg,Tab. Neurbion Forte 1 od.

Tab. Glynase XL 10 mg 1 bd, Cap. Renerve G 100 mg 1 hs,Tab. NeurobionForte, Inj. Novomix 30 10 U pre breakfast.

OP

4 1227 K. R 72

IGTASCVD/HTN - on polypharmacy

5-6years

Present asymptomatic. Came for expert opinion. Known diabetic, only on diet.

Tab. Ecosprin75 mg 1 od, Tab. Rosuvas10 mg 1 hs, Tab. Toresa10 mg 1 od, Cap. Angizem DP90 mg 1 od, Tab. Olmezest40 mg 1 od, Tab. Matzok50 mg 1 hs, Tab. Stamina OD 1 od.

Cap. Angizem DP 90 mg 1 od on A/D, Tab. Metzok50 mg 1 at 7 PM, Tab. Ecosprin75 mg 1 after lunch on A/D, Tab. Toresa10 mg 1 od,

OP

Presently asymptomatic. Now he is being managing with 50% of his previous medication.No rebound sequelae.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

Age Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

5 1256 DDD 62

HTNCADT2DM

20 years

Came for expert opinion. Started as Chest discomfort or uneasiness revealed block in LAD. Done coronary angiogram with PTCA stenting -1 year back (2011 in MMM). C/o. Burning micturition. Irritation whilepassing urine.

Inj. Lantus 16 units at bed time, Tab. Jalra50 mg 1 bd, Tab. Amaryl M2 Forte 1 bd, Tab. Nitrocontin2.6 mg 1 bd, Tab. Betaloc12.5 mg 1 bd, Tab. Ecosprin150 mg 1 od, Tab. Clopilet75 mg 1 od, Tab. Dytor10 mg 1 hs(nearly 2 years).

Tab. Nitrocontin2.6 mg 1 bd, Tab. Ecosprin75 mg 1 od, Tab. Clopilet75 mg 1 od, Tab. Diamicron80 mg 1 tds, Syp. K-Mac 1 bd, Tab. Seloken XL 12.5 mg 1 od, Inj. H.Mixtard30 U pre breakfast.

OP

He is comfortable with out treatment regime for T2DM.Burning micturition is much better.

6 1257 J. P 58T2DMHTN

15 years

C/o. Right leg & knee pain severe past 1 month. Occasional giddiness.

Tab. Semireclimet1-0-1/2, Tab. Clopilet75 mg 1 hs, Tab. Dilzem SR 90 mg 1 hs, Tab. Telista40 mg 1 od, Tab. Atocor20 mg 1 hs, Cap. Ebiza L 1 od(all above medicines nearly 2 years).

Tab. Telista40 mg 1/2 at 8 AM, Tab. Dilzem SR 90 mg 1 hs,Tab. Coversyl2 mg 1 od, Tab. Natrilix SR 1.5 mg 1 od

OP

Leg pain & knee pain reduced significantly. She is feeling good. Her blood sugars are well under control with our treatment regime.

7 1299 S.P.R 33Mild T2DMHTN - under control

1 yearHe has come for opinion& advice

Telma, Tab. Ecosprin & Statin.

Tab. Seloken XL 25 mg 1 od.

OP

He is doing well with our advice regarding diet & life style modification. He is doing extremely fine and he lost nearly 10 kgsin over 3 months. No panic attacks. He is doing very fine.

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Over Diagnosis Over Treatment

S.No

Pt. UID

Pt. Name AGE Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

8 1499 RK 52 T2DM1 1/2 years

At present asymptomatic. Came for a general checkup

Tab. Glycomet SR 500 mg 1 bd, Tab. Ecosprin75 mg 1 od,Tab. Ramistar 1 od.

OP

Presently asymptomatic. T2DM - he was not required any OHA. Sugars were under controlled.

9 1704 R. R 83 HTN and Asthma 3 years

C/o. Sinus tachycardia (fast heart rate). H/o. Mild asthma for 2-3 years. No DM/HTN

Tab. Atenolol25 mg 1 od,Tab. Ecosprin75 mg 1 od(since 2 months), Seroflo200 mcg 1 puffdaily or alternate days.

Tab. Atenolol25 mg 1 odfor 1 week then 12.5 mg 1 odfor 1 weekthen 6.25 mg 1 odfor 1 week and then stop.

OP

Prof. B.M. Hegdeopinion: 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 Serofloinhaler, as there is no Asthma.2. Stop the Clopidegreland to graduallytaper Atenololevery week.3. After 2 weeks check BP and PR.If needed to useBM Pulser.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

AGE Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

10 1938 K. R 53T2DMCADHypothyroidism

Since 1995

C/o. Breathlessness gradually even with little activity. C/o. Weight gain -nearly 20 kgs in6 months (previously she used to be 90 to 95 kgs -6 months back). Since 2005, able to move around with 90-95 kgsof weight.Now with increased weight & oedemaboth upper and lower limb, feeling breathlessness and difficult to move around even little.

Inj. H. Mixtard 30/70 30 U pre breakfast and 30 U pre dinner(taken for 3 years), Tab. Eltroxin 100 mcg 2 od (since 1995), Tab. Glicalizide80 mg 1 bd, Tab. Metformin 500 mg 1 bd (since 1995), Tab. Atocor 20 mg 1 od, Tab. Cardace 5 mg 1 od, Tab. Ecosprin 75 mg 1 od, Tab. Neurobionforte 1od, Tab. Isosorbide 5 mg 1 bd, Tab. Calaptin 40 mg 1 bd.

Tab. Cardace5 mg 1 od, Tab. Ecosprin75 mg 1 od, Tab. Isosorbide 5 mg 1 bd, Tab. Calaptin40 mg 1 bd, Tab. Diamicron80 mg 1 tds, Tab. Eltroxin150 mcg 1 od,Inj. H.Actrapid25 U pre breakfast, Inj. Insulatard15 U pre breakfast, Inj. H.Actrapid15 U pre dinner, Inj. Insulatard25 U pre dinner.

IP

After admission, her prescription was modified with the omission of statin and metformin. The dose of Tab. Eltroxinwas increased to125 mcg from 100 mcg as her TSH value while on 100 mcg of Thyroxin was71.4 µU/ml.She had 4 sessionsof Dynamic Acupuncture Mediated Metaphysical(DAMM) Therapyby Mr. Rajan Iyer.At the time of discharge, her vital signs were stable, she has lost 0.6 kgs in weight. She is advised to increase the dose of Tab. Eltroxin to 150 mcg after 1 month and maintainthat for 3 more months. It is advised that no changebe made in her Anti-diabetic prescription.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

Age Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

11 1964 V. S.V 82

HTNProstate carcinoma with extensive bone metastasis (Stage4) - treated

HTN(40 years)

Revamping of hishypertensive medications. C/o. Edema feet. Not a known diabetic. Patient was given Tab. Thiazide (Aquazide) which caused intense hyponatremiaand had extra pyramidal reaction to Tab. stemetil -leading to difficulty inexpressing, dizziness etc.

Tab. Vertin8 mg 1 tdsfor 1 week, Tab. Nootrophil800 mg 1 bd, Tab. Syndopa110 mg 1/2 bd(until review), Tab. Cardivas3.125 mg 1 bd, Tab. Repace50 mg 1 bd, Tab. Prazopress XL5 mg 1 bd(until review), Tab. Shelcal50 mg 1 od, Tab. Ranitin150 mg 1 od, Cap. Dexorange1 od, Tab. Centrum silver1 od, Tab. Neurobion forte 1 od, Tab. Honwan 1 od+ Zometainfusion monthly.

Tab. Cardivas3.125 mg 1/2 bd, Tab. Centrum Silver 1 after lunch, Tab. Honvan 1 hs, Tab. Arachitol O 1 hs, Tab. Amifru1/2 od (3/7)

IP

He required very minimal dose of anti-hypertensives.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

AGE Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

12 1996 M. T.R 74

Mild T2DM with renal decompensation (? Iatrogenic)ASCVD/HTNBPH

10 years

C/o. Weakness past 10 days. Swelling of feet for the past 6 months,now with change of medicationsunder control. He gets heaviness of head when the BP is high.

Tab. Nebimac5 mg 1 od, Tab. Veltam0.4 mg 1 hs, Tab. Ecosprin75 mg 1 od, Tab. Reclide40 mg 1 od, Tab. Doxocard1 mg 1 od, Tab. Dytor Plus20 mg 1 od, Tab. Moxovas3 mg 1 od.

Tab. Veltam0.4 mg 1 hs, Tab. Dytor20 mg 1 od, Tab. Bronac600 mg 1 after lunch, Tab. Ferium XT 1 hs,

IP

His blood sugars were never more than 140 mg/dl throughout and his blood pressure was withinnormal 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 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 hypertensivestill further advice.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

Age Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

13 2010 GR 60T2DMHTN

8 years

No specific complaints. His come for opinion and advice regarding diabetes.

Tab. Diabetrol 2-0-1, Tab. Zomalis 50 mg 1 hs ( 3 years), Tab. Betacard100 mg 1 od, Tab. Polytorva5 mg 1 hs (15 years) and Ayurvedhictreatment.

Tab. Glynase XL 5 mg 1 bd.

OP

He is very fine. He is over diagnosed and over treated for diabetes. After starting ayurvedictreatment in the first week of february 2013, his blood sugarshas dropped from 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).

14 1101 RL 57

Known T2DM for 1 year.HTN / CAD.Hypothyroid.Migraine - 20 years.Bronchostenosis -?.Acute exacerbation of bronchitis on treatment for endobronchialtuberculosis.

T2DM (1year)HTN, CAD (2 years)

C/o. Cough of 1 year duration onanti TB therapy. Admitted for rationalisationof her current BP and diabetic medication.

Tab. Glyciphage500 mg 1/2-0-1/2, Tab. Depsonil1.2 mg 1 bd, Tab. Tryptomer10 mg 1 hs, Tab. Clopitab A 1 od, Tab. Nitrocontin2.6 mg 1 bd,Tab. Losar H 50 mg 1 od, Cap. Rcinex600 mg 1 od, Tab. Combunex1000 mg 1 od, Tab. Liv 52 D 1 hs, Tab. Banadon40 mg 1 od, Tab. Zincovite 1 hs.

Tab. Romilast10 mg 1 at 6 PM, Tab. Thyronorm50 mcg 1 od, Tab. DeriphyllinRetard 150 mg 1 bd(if necessary).

IP

Anti diabetic and antihypertensive medications were stopped. Observation in the hospital revealed only normal blood sugars and normal BP. The cough was broughtunder control withbronchodilators.

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Over Diagnosis Over Treatment

S.NoPt. UID

Pt. Name

AGE Diagnosis Duration Complaints Treatment Presently onIP/OP

Clinical response

15 1106 PKM 46

HypothyroidismT2DM on diet controlHTN

HTN(7year)

Known HTN since 2006 / T2DM and Hypothyrodismfor last 1 month presented with ulcer over the right lower leg (above ankle).

Tab. Tribet2 mg 1 od, Tab. ASP-Atrova10 mg 1 hs, Tab. Win-BP20 mg 1 od, Tab. Nebula AM5 mg 1 od, Tab. Thyrup100 mcg 1 od(for last 1 month).Patient was on Tab. Aldomet250 mg 1 bd, Tab. Ecosprin150 mg 0-1-0, Tab. Atocor20 mg 1 hs(2006 - 2010).Tab. Sorbitrate5 mg SL SOS, Tab. Seloken XL 25 mg 1/2-0-0, Tab. Repace25 mg 1 od, Cap. Modlip Ash2-0-0, Tab. Aciloc RD 1-0-1 (2010 - 2012)

Tab. Nebula AM5 mg 1/2 od, Tab. Thyrup50 mcg 1 at 6 AM.

OP

Ulcer over the right meleolus is completelyhealed.He is doing well with 1/3rd of his previous prescription.

16 1270 P. A.S 64 T2DM 13 years

Patient got admittedfor rescheduling treatment and Pulsed Electro Magnetic Field Energy therapy using by BM pulserover precardium.

Tab. Triexer3 mg 1 bd, Tab. Vozukam, Tab. Olmezet, Tab. Ecosprin,Tab. Nebicard, Tab. Clopigred.

Tab. Diamicron80 mg 1 tds, Tab. Vigocil0.3 mg 1 bd.

IP

Instructed to followDiet advice and life style modifications daily. BM Pulser was applied over the precordium during his stay herefor about 20 hrs a day. With the above said treatment, he settled well.

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Published Online: April 13, 2009 (DOI: 10.1001/archneurol.2009.42)

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By John Gever, Senior Editor, MedPage TodayPublished: April 14, 2009Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California , San Francisco

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Journal Watch General Medicine Alert for July 13, 2010

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Lancet Article

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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, 201019

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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 afterfour and a half decades, it is rather puzzling to note that the British members of theRCPE consensus group fail to trace or mention the history of biguanides – theirclinical and biochemical aspects propounded in a classic monograph by Robert DCohen 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 implicationson the elder sibling-drug phenformin and the later reports on metformin-inducedrenal impairment and increased mortality. Also to be taken into account are vitaminB12 malabsorption-anaemia and irreversible peripheral neuropathy in about 30%of the cases of those treated with this drug and invariably misdiagnosed as diabeticneuropathy! Why is there a total lack of interest in doing credible clinical researchon the above points? Is the glossing-over of this important money-spinning drug, asnoted by Marcia Angell (former Editor-in-chief, the New England Journal ofMedicine) in her book, due to any nexus between the pharma companies and themedical profession?.

Author’s Response

By John Gever, Senior Editor, Medpage Today (September 26, 2009)

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BMJ/02nd March 2013

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BMJ/02nd March 2013

Journal Watch General Medicine Alert for May 22, 2008

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BMJ / 19 March 2011

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Where the prescription looks like the laundry list!

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.

http://www.hindu.com/

Online edition of India's National Newspaper

Sunday, Dec 05, 2010

PROF. B. M. HEGDE

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THANK YOU

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