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Vol.6 | Issue 1 | January 2017
Published by:
Diabetes as CHD risk
equivalent: Need a re-
look at the concept?
First Feature
Second Feature
Use of Nonsteroidal Anti-
Inflammatory Drugs and
Cardiovascular safety:
where do we stand?
Guideline Updates
Rome IV criteria for functional
Gastrointestinal Disorders
Clinical Queries
Approach to patients with
Obesity
Third Feature
Management of HIV/AIDS is
cheaper than heart attack?
Contents
First Feature
Advisors
National
Dr. Adrija Rahman Chattopadya, Bangaluru
Dr. Bahulesh Metha Mumbai
Dr. Satish Chug, Hariyana
Dr. Abbas Ali, UP.
Dr. Akilesh Varma, Bilalpur
Dr. Hari Dass, Kerala
Dr. Panigrahi, Mumbai
Dr. Bahulesh Metha, Mumbai
Dr. Ravi Wankehedkar, Mumbai
Dr. Anilkumar Singh, Bihar
International
Prof. Dr. Riaz Qureshi – Saudi Arabia
Prof. Dr. Pratap Prasad – Kathmandu
Dr. Preethi Wijayaguna Wardane – Srilanka
Dr. Antonetto Perera – Srilanka
Dr. ALP Seneverethne – Srilanka
Dr. Azizkhan Tank – Pakistan
Dr. Noor Akthar – Pakistan
Dr. Kanu Bala – Bangladesh
Dr. Falahuzzaman Khan – Bangladesh
Dr. Katherine Currow – Australia
Dr. Sivashunmuganathan – Malaysia
Dr. J.P. Tabon – Malta
Dr. Ohneba Owusu Danso – Ghana
Dr. Garth Manning – CEO, WONCA
Editorial
Rajesh Enjamoori,
Ostium Medicomm Pvt. Ltd.
Design & Layout
Pharmasquire Media & Publishing Pvt. Ltd.
`100 Per Copy
Vol.6 | Issue 1 | January 2017
Diabetes as CHD risk
equivalent: Need a re-look at
the concept?
Second Feature
Use of Nonsteroidal Anti-
Inflammatory Drugs and
Cardiovascular safety:
where do we stand?
Guideline Updates
Rome IV criteria for functional
Gastrointestinal Disorders
Clinical Queries
Approach to patients with
Obesity
04
08
16
20
National President, IMA
Dr. K K Aggarwal, Delhi
Secretary General, IMA
Dr. TN.Tandon, Delhi
Dean, IMACGP
Dr. V.C.Shanmugananthan, Bangalore
Secretary, IMACGP
Dr. K.Gunasekaran, Trichy
Joint Secretaries
Dr. MuthuRanjan, Chennai
Dr. Sridhar, Chennai
Emeritus Editor
Prof. Dr. S.Arulrhaj,India
Executive Editor
Dr. T. Ravisankar
Editorial Board
Dr. J. A. Jayalal, Chennai
Dr. Raman Kumar, Delhi
Dr. Punitha Rebacca, Chennai
Dr. K. Surya Rao, AP
Dr. K. M. Abul Hasan,TN
Dr.V.K.Monga, NewDelhi
Third Feature
Management of HIV/AIDS is
cheaper than heart attack?
13
Message
Ÿ General Practitioners are the backbone of Medical practice.
Ÿ General Practitioners are mini multi-specialists.
Ÿ Family Physicians are first contact and all-purpose doctors.
Ÿ General practitioners are the most complete and comprehensive doctors.
Ÿ GPs are the foundation stone of Medical practice.
Ÿ GPs, wake up now and hoist the flag of affordable medical practice.
Ÿ GPs are most relevant in today's India.
Ÿ Family Physicians only can lead India's India's health delivery system.
Ÿ GPs are primary health deliverers.
Ÿ GPs are the most economical Practitioners yet the most neglected ones.
Ÿ GPs are the most complete and abundant subset of doctors.
Ÿ IMA is committed to strengthen Family Medicine in India.
Ÿ IMA through its college of GPs is keen to create qualified Family Doctors in India
Dr. K. K. Agarwal
Recipient of Padma Shri, Vishwa Hindi Samman, National Science Communication Award and Dr B C Roy
National Award.
Hony. Prof. of Bioethics SRM Medical College Hospital & Research Centre.
Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand.
President Heart Care Foundation of India.
Editor in Chief IJCP Group of Publications, eMedinewS
Dr. K. K. Agarwal,
National president, 15.01.17
Indian Medical Association,
New Delhi.
Deans message for the
Family Doctor Journal
Dear Friends,
Enormous strides have been made in the field of Medical Sciences, many of which have been translated into
astounding applications relieving the pain and suffering of those mortals afflicted with various illnesses.
As members of the Medical Profession, each one of us is a Family Doctor in the core of our heart, irrespective of
our specialization and level of accomplishment. This is so as the training that all of us undergo as
undergraduates is structured in a manner befitting the requirements of a Family Doctor.
Today the concept of Family Doctor is one that encompasses basic knowledge in almost all specializations,
which is an absolute necessity to guide the patient in the right direction at times of need.
In fact it is the Family Doctor who along with the treating specialist will be able to tailor make the treatment
programme, that is best suited to the patient taking into consideration the family as a whole of which the
patient is a constituent component.
Thus the practicing Family Doctor is a Specialist unto himself and Continuing Professional Development is the
only means by which he can keep himself abreast of the advancements in all spheres of medicine and
surgery in the best interest of the patient.
The Family Doctor journal is one such means of updating ones knowledge and I wish the readers a happy
prosperous and meaningful year ahead.
Dr V. C. Shanmuganandan
Long live IMA
Dr V. C. Shanmuganandan
1
Editorial
IMACGP is the largest organization dedicated to strengthen Family Doctor in India. Having a legacy of over 50
years , IMACGP is upscaling the Knowledge & skills of Primary Care Physicians of India through continued
Professional Development Programs in the form of International , National, Regional Conferences & IMA
evarsity online university accredidated Post Graduate Program in Primary care & related specialties.
Another milestone in their yomen service is the representation of the Family Doctor Journal , online & Print to
the members of College & other Primary Care Physicians pf all over the world.
The Family Doctor will definitely help the Family Doctor to be abreast with current developments in Medical
Field so that the care they offer to the needy citizen will match their expectations offering appropriate &
affordable Healthcare .
Members suggestions to improve the Journal are welcome.Your contribution to the Family Doctor is most
needed.
Wishing you all a Happy Independence Day.
Best Wishes,
Prof .Dr.S.Arulrhaj
Chief Patron , IMACGP
Dear Family Doctors,
Warm greeting from IMA College of General Practitioners, India.
Prof. Dr. S. Arulrhaj,
MD., FRCP (G)
Acute Medicine Physician
Chairman
2
FAMILY DOCTOR the age old concept of the health provider. A Doctor with the basic qualification, to provide
the initial care, diagnosis or the differential diagnosis and most significantly relief from the initial symptoms.
Family doctor was the first face of health care in the country for centuries. He is the one practically following
the social and preventive medicine faithfully in the community.
It’s not the patient alone who matters for the Family doctor. He is the one who knows the family in total and
provides the necessary preventive medicine to the family. The atmosphere the patient lives in and the socio
economic statuses of the family contributes to the line of management for the Family Doctor.
The concept of Family Doctor is not the procession or the character of only the basic undergraduate in
Medicine. Even a specialist or super specialist who performs the above character when he treats a patient
also renovates themselves as a Family Doctor.
Amicable, affordable and someone within your place of living and most important in the families heart and
mind is the Family Doctor.
In the days of extensive investigation with less communication the amenable down to earth
communication stands as the hallmark of a Family Doctor.
He not only provides health care services but also take part in the decision making of the family in so many
social aspect.
In the days of corporate and litigation, FAMILY DOCTOR concept is the need of the hour – say need of the
decade and century for the developed INDIA.
LET’S TAKE PRIDE TO BE A FAMILY DOCTOR.
THE FAMILY DOCTOR
Dr. T. N. Ravisankar
Executive Editor
3
Diabetes is a CHD risk equivalent or risk factor?
Diabetes mellitus (DM) is considered as one of
the well-established risk factors for cardiovascular
1
disease. The risk for future coronary heart
disease (CHD) events that is attributable to
diabetes alone in the absence of coexisting CHD
was not well established until the publication by
Haffner et al. on this subject in 1998. Haffner et
al. concluded that the elevation in risk of CHD
events was essentially similar to nondiabetic
individuals with a prior myocardial infarction
episode. This concept was concluded based on
a non-significant adjusted hazard ratio of 1.2 for
CHD mortality over a period of 7 years of follow-
up in a Finnish cohort. After this study, the
concept that “Type 2 DM is a CHD risk
2
equivalent” was widely accepted. It is seen in
many instances that cardiovascular disease is
increased in type 2 DM subjects due to various
risk factors that play an important role from
initiation of atherosclerosis over its long natural
history from endothelial dysfunction to clinical
events. Some of these risk factors could be a
common history for both DM and CHD,
reinforcing the hypothesis that both disorders
3
share a “common root”. However, studies after
Haffner et al, 1998 raise equivocal findings to the
original concept that diabetes is a CHD risk
equivalent, although they do not dispute the fact
that diabetes is CHD risk factor.
Adult Treatment Panel III (ATP III) guidelines,
3
2001: Diabetes as a CHD risk equivalent
The Adult Treatment Panel III (ATP III) guidelines
in 2001 recommended diabetes as a
coronary heart disease (CHD) risk equivalent. A
goal LDL cholesterol of <100 mg/dl was
recommended for patients with CHD and
CHD risk equivalents.
Consider drug (Statins, Fibrates, bile
sequestrants, nicotinic acid) simultaneously
with therapeutic lifestyle changes like diet,
weight management and physical exercise if
LDL is above goal for CHD and CHD
equivalents like diabetes.
First Feature
Dr. D. Selvaraj, MD, FIAMS
Physician & Diabetologist, SRRA HOSPITAL,
Tuticorin, Tamilnadu
Diabetes as CHD risk equivalent:
Need a re-look at the concept?
4
Evolving evidence- Diabetes as a CHD risk equivalent
Table 1: Evidences pertaining to the concept that diabetes is a CHD risk equivalent.
Year Study Results
1998
Elevation in risk was essentially similar to nondiabetic
individuals with a prior myocardial infarction.
2000
Most individuals had 10-year risk >20%, but only those with
multiple risk factors had rates of CHD events equivalent to
patients with established CHD.
The study suggested that therapeutic goals for risk factors
should be based on the entire risk factor profile, rather
than just the presence of diabetes.
2008
In an analysis adjusting for some CV risk factors, socioeconomic
status, and CV drugs:
Patients with diabetes had a lower risk of MI or CV death
(hazard ratio 0.63 in men and 0.54 in women) than
patients with previous MI.
No adjustment was made for most traditional risk factors
(blood pressure, smoking status, etc), which would have
likely attenuated the association in patients with diabetes.
2015
Presence of prior CHD alone was associated with
approximately twice the age-adjusted rate of CHD
compared to prevalent diabetes alone (Figure1)
Prior CHD was not CHD risk- equivalent to having diabetes
alone, except among individuals with a long duration of
diabetes (≥10 years) (Figure 2)
Table 1.Evolving evidences around “Diabetes as a CHD risk equivalent”
5
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0 1 2 3 4 5 6 7 8 9 10
None
DM alone
CHD alone
DM + CHD
Context from above evidences
2
The observational study of Haffner et al
that originally generated the concept of
diabetes-CHD equivalence had multiple
l i m i t a t i o n s , i n c l u d i n g b e i n g v e r y
underpowered.
Diabetes approximately doubles the risk of
C V e v e n t s. T h e a s s o c i a t e d r i s k i s
further increased by longer duration of
diabetes, increasing hemoglobin A ,
1 c
[8-11]
and traditional CV risk factors.
M o s t s t u d i e s w e r e c o n d u c t e d i n
caucasians; so the applicability of this
evidence to high risk ethnic populations is
unclear.
Figure1. KaplanMei er estimates of
coronary heart disease defined by baseline
history of diabetes or CHD among four
7
cohorts.
3
2.6
2.2
1.8
1.4
1
DM<5yrs
DM 5-9 yrs Dm³10 yrs Prior CHD, No
DM
Hazard Ratio
7
Figure 2. Risk of CHD by duration of diabetes versus prior CHD
6
Recent changes in perspectives
In the 2013 ACC/AHA assessment of risk guidelines,
diabetes was considered as only one of the many
variables in its risk assessment equation rather than
a CHD risk equivalent .
The assertion that all patients with diabetes are
7
CHD equivalent has been controversial.
Implementation
It is observed that acetylsalicylic acid do not
reduce CV events among patients with diabetes,
however it decrease events for those with
12-13
previous CV disease. Risk calculators can be
used to estimate overall CV risk for patients with
diabetes. The UKPDS risk engine is designed for
patients with diabetes and the Best Science
Medicine calculator predicts benefits with
14-15
varying interventions.
Conclusion
The above discussion gives a varied perspective
to diabetes as a CHD equivalent. Although
diabetes does confer an increased risk of CV
events, it is not automatically equivalent to
having a previous CHD, and thus does not always
warrant aggressive pharmacotherapy. It is
important to take into account individual CV risk
before deciding on treatment for each patient.
References
1. Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV,
Mitch W, Smith SC, Sowers JR. Diabetes and cardiovascular
disease: a statement for health professionals from the American
Heart Association. Circulation. 1999; 100:1134–1146.
2. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality
from coronary heart disease in subjects with type 2 diabetes and
in nondiabetic subjects with and without prior myocardial
infarction. N EnglJMed 1998; 339:229-34 .
3. ATP III At-A-Glance: Quick Desk Reference. Available at:
http://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-
guidelines/quick-desk-reference-html. Accessed 25th August
2016.
4. Howard BV, Robbins DC, Sievers ML et al. LDL Cholesterol as a
Strong Predictor of Coronary Heart Disease in Diabetic Individuals
With Insulin Resistance and Low LDL (The Strong Heart Study) .
ArteriosclerThrombVasc Biol. 2000;20: 830-835.
5. Bulugahapitiya U, Siyambalapitiya S, Sithole J, Idris I. Is diabetes a
coronary risk equivalent? Systematic review and meta-analysis.
Diabet Med 2009;26(2):142-8
6. Schramm TK, Gislason GH, Køber L, Rasmussen S, Rasmussen
JN,Abildstrøm SZ, et al. Diabetes patients requiring glucose-
lowering therapy and nondiabetics with a prior myocardial
infarction carry the same cardiovascular risk: a population study
of 3.3 million people. Circulation 2008;117(15):1945-54.
7. Rana JS,Liu JY, Moffet HH et al. Diabetes and prior coronary heart
disease are not necessarily risk equivalent for future coronary
heart disease events. J Gen Intern Med. 2015. 31(4):387-93.
8. Emerging Risk Factors Collaboration. Diabetes mellitus, fasting
blood glucose concentration, and risk of vascular disease: a
collaborative meta-analysis of 102 prospective studies. Lancet
2010;375(9733):2215-22.
9. Wannamethee SG, Shaper AG, Whincup PH, Lennon L, Sattar N.
Impact of diabetes on cardiovascular disease risk and all-cause
mortality in older men: influence of age at onset, diabetes
duration, and established and novel risk factors. Arch Intern Med
2011;171(5):404-10.
10. Zhang Y, Hu G, Yuan Z, Chen L. Glycosylated hemoglobin in
relationship to cardiovascular outcomes and death in patients
with type 2 diabetes: a systematic review and meta-analysis.
PLoS One 2012;7(8):e42551.
11. Howard BV, Best LG, Galloway JM, Howard WJ, Jones K, Lee ET, et
al. Coronary heart disease risk equivalence in diabetes depends
on concomitant risk factors. Diabetes Care 2006;29(2):391-7.
12. Berger JS, Brown DL, Becker RC. Low-dose aspirin in patients with
stable cardiovascular disease: a meta-analysis. Am J Med
2008;121(1):43-9.
13. De Berardis G, Sacco M, Strippoli GF, Pellegrini F, Graziano G,
TognoniG,et al. Aspirin for primary prevention of cardiovascular
events in people with diabetes: meta-analysis of randomised
controlled trials. BMJ 2009;339:b4531.
14. UKPDS Risk Engine. Available at: www.dtu.ox.ac.uk/riskengine.
Accessed 25th August 2016.
15. The Absolute CVD Risk/Benefit Calculator. Available at:
http://bestsciencemedicine.com/chd/calc2.html). Accessed
25th August 2016.
7
Second Feature
Dr. G. Mathiprakasam BSC, MBBS, MNAMS,
Jothi nursing home, Thoothukudi,
Tamilnadu - 628002
Use of Nonsteroidal Anti Inflammatory
Drugs and Cardiovascular safety: where
do we stand?
NSAID use in primary care: Overview
Musculoskeletal disorders are one of the frequent
reasons for visits to a family physician.
Symptomatic pain relief through nonsteroidal anti-
inflammatory drugs [NSADs] is usually the first
treatment objective in a range of conditions from
back pain to arthritis. NSAID prescription for pain
relief is challenging in view of the clinical variables
of patients presenting with pain, e.g. age-related
physiological changes, co-morbidities, and co-
t h e r a p i e s. S e v e r a l s t u d i e s h i n t e d t h a t
indiscriminate NSAID use could lead to
1,2,3
complications including cardiovascular events.
Here, we focus on evidences related to the CV risk
associated with different classes of NSAIDs and
guidelines about logical prescribing of NSAIDs in
primary care.
What does evidence say?
Several clinical studies and meta-analyses were
conducted to evaluate the adverse effects of
NSAIDs, especially the cardiovascular [CV] risk, in
the last two decades. The summary of the
4-
important evidences are presented in the Table 1.
8
What do guidelines say?
American Heart Association guidelines
(2007–2008) stated that coxibs carry the highest
CV risk and recommended the use of naproxen
9,10
as the drug of choice for patients with CV risk.
Further, American College of Rheumatology
guidelines stated that selective NSAIDs do not
appear to have relevant drug–drug interactions
11
with the anticoagulant effect of aspirin.
Therefore, the choice of NSAID should be
dependent on patient’s cardiovascular risk status
as well as the concurrent pharmacological
therapy.
In February 2014, the FDA convened a joint
meeting of the same 2 advisory committees to
review the CNT meta-analysis and other
information since the 2005 meeting. Based on
this meeting and its own analysis, the FDA
reached several conclusions regarding the CV
12
risks of NSAIDs (Box 1). Despite differences in
how the analyses were conducted, the results
suggest that differences in CV risk may exist
among all the types of NSAIDs. Therefore, USFDA
8
Study Result
VIGOR (Vioxx gastrointestinal outcomes
4
research) study, 2000
Ther apeut ic Arthritis Res earch and
5
Gastrointestinal Event Trial (TARGET), 2004
COX-2 selective NSAIDs and conventional
NSAIDs carry the same degree of in CV risk
irrespective of aspirin use
APPROVe(adenomatous polyp prevention
6
on Vioxx) 2005
1.92 times greater risk of confirmed
thrombotic events and 4.6 times greater
risk of cardiac failure with rofecoxib
compared with placebo
Naproxen and low-dose ibuprofen are
least likely to increase cardiovascular risk
Diclofenac in doses available without
prescription elevates CV risk
COX-2 selective NSAIDs had a significantly
higher relative risk than naproxen or
ibuprofen
Coxib and Traditional NSAID Trialists (CNT)
8
Collaboration (Meta-analysis, 2013)
The risk of major vascular events (MVE) was
increased by approximately one-third in
patients taking coxibs or diclofenac
compared with placebo
Risk of hospitalization secondary to heart
failure was doubled by all NSAIDs studied
Overall, evidence suggests that vascular risks of high-dose diclofenac and ibuprofen are comparable to
coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs. Although
8
NSAIDs increase vascular and gastrointestinal risks, the size of these risks can be predicted [Figure 1].
Table 1. Clinical evidences of CV risk and NSAIDs
9
is strengthening labelling requirements of all
prescription NSAIDs to indicate that their use is
associated with an increased risk of a heart
attack or stroke.
Box 1: Highlights of the US FDA February 2014
advisory committee meeting on cardiovascular
12
safety of NSAIDs
The risk of heart attack or stroke can occur as
early as the first weeks of using an NSAID. The
risk may increase with longer use of the NSAID.
The CV risk appears greater at higher doses.
It was previously thought that all NSAIDs may
have a similar risk. Newer information makes it
less clear that the risk for heart attack or stroke
is similar for all NSAIDs; however, this newer
information is not sufficient for us to determine
that the risk of any particular NSAID is definitely
higher or lower than that of any other
particular NSAID.
NSAIDs can increase the risk of heart attack or
stroke in patients with or without heart disease
or risk factors for heart disease. A large
number of studies support this finding, with
varying estimates of how much the risk is
increased, depending on the drugs and the
doses studied.
In general, patients with heart disease or risk
factors for it have a greater likelihood of heart
attack or stroke after NSAID use than patients
without these risk factors because they have a
higher risk at baseline.
Patients treated with NSAIDs after a first heart
attack were more likely to have mortality risk
during the first year after the heart attack
compared with patients who were not treated
with NSAIDs after their first heart attack.
There is an increased risk of heart failure with
NSAID use.
20
15
10
5
0
7
2
2
A
Coxib
Baseline major vascular
event risk
Fatal
Fatal + Non fatal
4
2
Baseline upper gastrointestinal
complication risk
20
15
10
5
0
8
2
2
B
Diclofenak (75mg twice a day)
4
2
20
15
10
5
0
7
2
2
Ibuprofen (800 mg three times a day)
C
15
6
20
15
10
5
0
-5
-1
0
D
Naproxen (500 mg twice a day)
2% pa 0.5% pa
16
6
0.5% pa 0.2% pa
Major vascular events Upper gastrointestinal complications
Major vascular events Upper gastrointestinal complications
Absolute annual excess risk
per 1000 (SE)
+
Absolute annual excess risk
per 1000 (SE)
For each category of drug (coxib,diclofenac,ibuprofen, and naproxen), the predicted annual absolute risks of major
vascular events (± 1 SE) are shown (left) for patients with predicted risk of 2.0% or 0.5% per annum of a major vascular
event. For comparison, predicted annual absolute risks of upper gastrointestinal complications (± 1 SE) are shown for
patients with predicted risks of 0.5% or 0.2 % per annum (right)
Figure 1. Annual absolute effects per 1000 of coxibs and tNSAIDs at different baseline
CV and GI risks
10
Implications for Primary Care Physicians
According to evidence obtained from meta-
analyses and expert consensus statements
following implications can be made regarding
prescription NSAIDs in primary care.
1. NSAIDs need not be totally avoided in cases
of low absolute risk of a CV event. NSAIDs
should be used at the lowest effective dose
and for the shortest time possible with
appropriate monitoring.
2. Patient selection is important, especially for
patients with established heart disease or risk
factors, as well as risk factors for a
gastrointestinal [GI] bleed.
3. NSAIDs having low CV risk may have higher
potential to cause upper GI bleed e.g.
naproxen. Therefore, patient selection is
important, especially for patients with
established heart disease and risk factors for
a GI bleed.
Patient requires NSAID
therapy
High GI Risk
High CV Risk
[on aspirin]
High CV Risk
Low CV Risk
High CV Risk
[on aspirin]
High CV Risk
Low CV Risk
Avoid NSAID
if possible or
low-dose
celecoxib
+
PPI
Celecoxib
+
PPI
Low-dose
Celecoxib*
Naproxen or
low-dose
celecoxib
Any
nonselective
NSAID
Avoid NSAID
if possible or
low-dose
celecoxib
+
PPI
Low GI Risk
4. It is prudent to evaluate the benefits and risks
of alternative therapy before initiating NSAID
treatment.
Figure 2 gives simplified algorithm to guide NSAID
3
prescribing in primary care
Conclusion
The risk of adverse effects of NSAIDs varies
depending upon the clinical condition, type and
dose of medication. Both nonselective NSAIDs
and cyclooxygenase (COX)-2 selective NSAIDs
(coxibs) are found to increase such risk. The risk
largely depends on the duration and frequency
of therapy. CV events such as acute myocardial
infarction, stroke, or CV-related death is extremely
less over a short-course therapy of NSAIDs in
conditions like acute and limited musculoskeletal
injury. Long-term NSAID use should invariably be
guided by careful assessment of overall risk and
benefit associated with specific NSAID treatment.
References
Low-dose celecoxib=200mg once daily; *H pylori should be tested and treated ,if present, in patients with peptic ulcer
history
3
Figure 2: Decision making algorithm for long-term NSAID therapy
11
References:
1. Fosbol EL, Folke F, Jacobsen S et al. Cause-specific
cardiovascular risk associated with nonsteroidal antiinflammatory
drugs among healthy individuals. Circ Cardiovasc Qual
Outcomes. 2010;3(4):395-405.
2. Bavry AA, Thomas F, Allison M et al. Nonsteroidal anti-
inflammatory drugs and cardiovascular outcomes in women:
results from the women's health initiative. Circ Cardiovasc Qual
Outcomes. 2014;7(4):603-10.
3. Scarpignato C, Lanas A, Blandizzi C et al. Safe prescribing of non-
steroidal anti-inflammatory drugs in patients with osteoarthritis--an
expert consensus addressing benefits as well as gastrointestinal
and cardiovascular risks. BMC Med. 2015;13:55.
4. Bombardier C, Laine L, Reicin A, et al. Comparison of upper
gastrointestinal toxicity of rofecoxib and naproxen in patients with
rheumatoid arthritis. VIGOR StudyGroup. N Engl J Med.
2000;343(21):1520–1528.
5. SchnitzerTJ, Burmester GR, Mysler E et al. Comparison of
lumiracoxib with naproxen and ibuprofen in the Therapeutic
Arthritis Research and Gastrointestinal Event Trial (TARGET),
reduction in ulcer complications: randomised controlled trial.
2004;364(9435): p665-74
6. Bresalier RS, Sandler RS, Quan H, et al. Cardiovascular events
associated with rofecoxib in a colorectal adenoma
chemoprevention trial. N Engl J Med.2005;352(11):1092–1102.
7. McGettigan P, Henry D. Cardiovascular risk with non-steroidal anti-
inflammatory drugs: systematic review of population-based
controlled observational studies. PLoS Med. 2011;8(9):e1001098
8. Bhala N, Emberson J, et al. Coxib and traditional NSAID Trialists’
(CNT) Collaboration. Vascular and upper gastrointestinal effects
of non-steroidal anti-inflammatorydrugs: meta-analyses of
individual participant data from randomisedtrials. Lancet. 2013;
382(9894):769–779.
9. Antman EM, Bennett JS, Daugherty A etal. Use of nonsteroidal
antiinflammatory drugs: an update for clinicians: a scientific
statement from the American Heart Association. Circulation.
2007;115:1634–42. [PubMed]
10. American College of Rheumatology Ad Hoc Group on Use of
Selective and Nonselective Nonsteroidal Antiinflammatory Drugs.
Recommendations for use of selective and nonselective
nonsteroidal antiinflammatory drugs: an American College of
Rheumatology white paper. Arthritis Rheum. 2008;59:1058–73.
11. Hochberg MC, Altman RD, April KT et al. American College of
Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in
osteoarthritis of the hand, hip, and knee. Arthritis Care Res
(Hoboken) 2012;64:465–74.
12. US Food and Drug Administration. FDA Drug Safety
Communication: FDA strengthens warning that non-aspirin
nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart
attacks or strokes. Available at: http://www.fda.gov/Drugs/Drug-
Safety/ucm451800.htm. Published July 9, 2015. Accessed on
August 21 2016.
12
Third Feature
Padmasri Prof. (Dr) Kutikuppala Surya Rao
MD ( Fam Med PGIM) Ph.D (Andhra University)
FCGP, DFM, FHM (CMC Vellore) MNAMS (Med) FRCP (London)
Family Medicine Specialist and HIV/AIDS Expert
Email:kutikuppalasuryarao@gmail.com
Management of HIV/AIDS is cheaper
than heart attack ..?
(Special article to commemorate World AIDS Day 2016)
The World AIDS Day is observed on December 1
each year globally. The day is observed to raise
awareness among people towards the problem
of AIDS and HIV, a disease that affects the
immune system of the body. The Theme of this
year is HANDS UP FOR HIV PREVENTION LEADERSHIP
COMMITMENT IMPACT.
Among the current problems facing the world,
perhaps the biggest of them all are AIDS and HIV
infections. According to official data, more than
35 million people have died of these infections
between 1981 and 2016. Despite improved
preventive measures such as condoms, Harm
reduction, VMMC (Voluntary Medical Male
Circumcision) as well as improved antiretroviral
treatments, the problem still remains a worry
across the globe.
W H O R E C O M M E N D A T I O N S F O R T H E
IMPLEMENTATION OF VMMC
This massive public health intervention called for
80% coverage of male circumcision by 2016 in
the 14 priority countries (aiming to reach 20.8
million people).
It was estimated that performing this number of
circumcisions would cost US$1.5 billion but would
lead to savings of US$16.5 billion by 2025 due to
averted HIV treatment and care costs. VMMC
80% coverage would also prevent up to 3.4
million new HIV infections. Unfortunately VMMC is
not a priority in India. According to latest statics
there are 1.85 Lakhs of HIV positive cases
combindly in Andhra and Telengana. In India this
is the highest incidence of HIV in Telugu States
after Maharashtra which as around 1.45 Lakhs.
Even today 35 years after first few cases detected
in Los Angles in USA, South Africa is dubbed with
highest number of HIV positive cases next Nigeria
then India in third position
The was the year 1986. The news of the first
discovery of deadly HIV/AIDS virus had made its
way to India. But the government refused to
believe the tests. Nobody could dream that a
13
country like India deemed to be culturally
superior to the West could have the virus.
It was only after the samples were sent to
Washington John Hopkins University, where they
confirmed as positive which the government
accepted subsequently. Facing enormous
opposition, I initiated a war against HIV/AIDS in
1987 having trained in Manchester infirmary
United Kingdom and continuing all possible
efforts to eradicate this HIV/AIDS. It has been
exactly 30 years since the first HIV patient was
diagnosed in India. During this period, the country
has made significant strides in medical
management that what was a death sentence
30 years ago is now a manageable problem like
any other chronic desease such as Dibetes,
Melitus, Bronchial asthma or Hyper Tension. The
next big frontier that HIV/AIDS research needs to
conquer is finding a cure. But of equal
importance is the struggle against the stigma that
is attached to AIDS patients.
Two weeks back it came to light that an HIV
positive woman in West Bengal was allegedly
assaulted and driven out of her village by locals.
The woman, 27 years old was treated at the
Barasat District Hospital with severe injuries to her
head. She was ostracised for about eight months,
ever since the villagers came to know that she was
suffering from AIDS in November last year. This
episode is an eye opening that a vigorous war
should be launched on AIDS STIGMA till it is
eliminated totally from gross routes.
The Durban international AIDS Conference which
took place from 18th to 22 July 2016 in South
Africa warned that another AIDS epidemic is at
sight if we do not augment our HIV/AIDS
prevention activities till a potent vaccine is
discovered. This global conference was
organized at a time when each year, hundreds of
thousands of Asians, Indians and Africans are
dying for lack of HIV drugs that were available in
rich countries but beyond the financial reach of
poor ones.
Even after three decades of its existence,
treatment of HIV is still elusive for many positive
patients in India and elsewhere. In Asia, more than
5 million people are living with HIV across South /
South East Asia and East Asia. While most
national epidemics appear to have stabilized,
HIV prevalence is increasing in Bangladesh,
Pakistan, and the Philippines. The region is also
home to the two most populous nations in the
world China and India – and even relatively low
prevalence rates translate into large numbers of
people.
As a result of advanced researches in AIDS
treatment, now the patients can be given a
substantial life and death can be postponed
dramatically. The average life expectancy of AIDS
patients on a quality treatment is around 71.5
years. It is also proved that impact of starting
Antiretroviral Therapy (ART) late would end up to 15
years reduced life expectancy. Therefore it is
recommended by WHO to start ART irrespective of
CD4 counts once a person is confirmed HIV
positive. However there is, a great risk of excess
mortality due to delay in HIV diagnosis. Recently,
the efficacy of ART on reducing the risk of sexual
transmission of HIV has been estimated at greater
than 95%. This component is going to play vital
role among discordant couples who are
in t e res t e d t o have a chil d wit h o ut H I V
transmission. To prevent mother to child
transmission, appropriately administering ART is
universally accepted.
14
Though treatment of AIDS is extremely cost
effective when we compare with cost of
management of several other diseases such as
heart, kidney, and liver, this is not yet well
understood by people in India. In a moderate
hospital an open heart surgery would cost around
Rs 2 lakhs; kidney transplantation around 5 lakhs
and the average cost of liver transplantation is 18
lakhs. Whereas the best treatment for HIV/AIDS
including the latest tests of diagnosis HIV genome,
monitoring of CD4 counts, viral load, kidney
functioning, liver functioning, etc. would cost
around Rs 25 to 30 thousand only. Even this cost is
a heavy burden for many patients due to which
they avoid coming for treatment. In certain
instances, where both couples are positive the
husband often takes treatment while wives stay
away from treatment due to fear of expenditure.
N O V I G I L A N T N AT I ONAL P O L I C Y ON ART
PRESCRIPTION
In countries like India, as there is no strictly
implemented vigilant national policy on ART
prescription, a variety of doses are being
administered by different physicians. Adding fuel
to the fire, some quacks have gone to an extent of
prescribing ART drugs as per their whims and
fancies. Some patients having read a brand
name of ART in newspaper go for self prescription;
some other patients imitate prescription of other
HIV affected persons and go to the point of
purchasing drugs over the counter (OTC). This
problem has been accentuated due to the poor
vigilance of the government on drug sales. This
sort of practice in the country has already been
grooming and there is no wonder this problem
may soon assume monstrous proportions and
lead to the emergence of poly drug resistant
AIDS. And if corrective measures are not soon
initiated, this lurking problem may threaten the
very efficacy ART therapy.
15
Guideline Updates
Rome IV criteria for functional
Gastrointestinal Disorders
Key Changes in Rome IV
Functional gastrointestinal disorders (FGIDs)
are spectrum of chronic disorders of
gastrointestinal tract. They are characterized
by abdominal pain, bloating, distention,
and/or bowel habit abnormalities like
1
constipation, diarrhea, or mix of both. Rome
IV is a comprehensive knowledge resource
improvised from Rome III, which was
published 10 years ago. Key changes made
1,2
in Rome IV are:
Added new diagnoses with known
etiologies e. g. opioid-induced
constipation
Removed “functional” terminology when
possible to avoid vagueness and stigma-
tization
Added new articles e.g. Intestinal Micro-
environment and the Functional Gastro-
intestinal Disorders and modified others
Included threshold changes for diagnostic
criteria based on Rome Foundation
Questionnaire Committee conducted a
survey of physical symptoms including FGID
symptoms
Functional bowel disorders are now
described on a spectrum of symptom
presentations [Figure 1]. Therefore,
removed redundant terminology e.g. The
term discomfort is avoided in IBS criteria as
it is just a less severe form of abdominal
pain.
Figure 1. Conceptual framewzork to explain
FBDs.
FC
Bloating
IBS
M
Distention
Fdr
D
C
FC: Functional Constipation
F Dr: Functional diarrhea
IBS-C: Irritable bowel
syndrome with predominant
constipation
IBS-D: Irritable bowel syndrome with
predominant diarrhea
IBS-M: Irritable bowel syndrome with
predominant irregular bowel habits
(mixed D/C)
Dr. R Ramasubramanian MD. DM(Gastro)
Professor of medical gastroenterology,
Thoothukudi medical college, Thoothukudi,
Tamilnadu.
16
Footnote: The Functional Bowel Disorders are classified
into 5 distinct categories: IBS, FC, FDr, FAB/FAB, and
unspecified FBD (U-FBD). Although often thought of as
existing as completely separate and discrete disorders,
it is important to acknowledge that significant overlap
exists between these disorders. These disorders should
be thought of as existing on a continuum, rather than as
in isolation. This figure illustrates that a patient with IBS
(right) will have symptoms of abdominal pain, in
contrast to a patient with FC or FDr, who does not have
abdominal pain. Bloating and distention are common
symptoms frequently reported by patients with any FBD.
Classification of Functional Gastrointestinal
disorders based on Rome IV criteria
The Rome Foundation classification of FGIDs
is based primarily on symptoms and not on
1, 2
physiological criteria. Functional GI
disorders are classified as:
C1. Irritable bowel syndrome
C2. Functional constipation
C3. Functional diarrhea
C4. Functional abdominal bloating/distension
C5. Unspecified functional bowel disorders
C6. Opioid-induced constipation
1,2
Snapshot of FGIDs according to Rome IV
C1. Irritable Bowel Syndrome
IBS is an FGID with recurrent abdominal pain
associated with defecation or a change in
bowel habits
Diagnostic Criteria for Irritable Bowel
Syndrome
Recurrent pain in abdomen at least once a
week in the last 3 months, associated with
two or more of the following :
1. Related to defecation (Changed from
previous Rome criteria ”improvement with
defecation”)
2. Change in frequency of stool in patients.
3. Change in form of stool in patients.
Note: All these should fulfill in the last three
months and onset of symptom at least six
months before diagnosis..
The term discomfort has been eliminated
from the current definition and diagnostic
criteria of Rome IV.
IBS Subtypes: IBS has 3 main subtypes. They
are predominant constipation (IBS-C),
predominant diarrhea (IBS-D) and mixed (IBS-
M).
Treatment: Counseling, dietary fiber
supplementation and life style modification
by including exercise, stress reduction and
attention to impaired sleep are important
part of IBS management. Drugs used for IBS
1
are explained in Table 2.
17
1
Table 2.Therapeutic Options for Irritable Bowel Syndrome Based on Predominant Symptoms
Symptoms
Class of Drugs
Name of the Drug
Diarrhea
Opioid agonists
Loperamide
Diet
Low/no gluten;low FODMAP
Bile sequestrants
Cholestyramine,Colestipol
Probiotics
Multiple products available
5-HT3 antagonists
Ondansetron
Mixed opioid
agonists/antagonist
Eluxadoline
Antibiotics
Rifaximin
Constipation
Psyllium
PEG
Chloride Channel
activators
Lubiprostone
Guanylate cyclase C
agonists
Linaclotide
Abdominal pain
Smooth muscle
antispasmodics
Dicyclomine, Mebeverine
Peppermint oil
Enteric coated capsules
Tricyclic antidepressants
Desipramine
SSRIs
Paroxetine,Sertraline,Citalopram
C2. Functional Constipation (FC)
FC is a FGID in which symptoms of difficult,
infrequent, or incomplete defecation
predominate.
C2. Diagnostic Criteria for Functional
Constipation
1. Must include 2 or more of the following:
a. Straining during more than 25% of
defecations
b. Hard or lumpy stools more than 25% of
defecations.
c. Sensation of incomplete evacuation
more than 25% of defecations.
d. Sensation of obstruction/blockage in
ano-rectum more than 25% of
defecations.
e. Manual maneuvers to facilitate more
than 25% of defecations (e.g. digital
evacuation, support of the pelvic floor)
f. Fewer than 3 spontaneous bowel
movements per week
2. Loose stools are rare without the use of
laxatives.
3. Insufficient criteria for IBS
Note: All these should fulfill in the last three
months and onset of symptom at least six
months before diagnosis.
18
Rome IV highlights the concept that FC and
IBS-C are disorders that are on a continuous
spectrum.
Treatment: Treatment of FC consists any of
Psyllium, PEG, Lubiprostone and Linaclotide
1
addressing the symptoms.
C3. Functional Diarrhea (FDr)
FDr patients does not meet criteria for IBS
although abdominal pain/bloating may be
present.
C3. Diagnostic Criteria for Functional Diarrhea
Loose or watery stools, without predominant
abdominal pain or bothersome bloating,
occurring in >25% of stools. (The term mushy is
removed from the previous criteria and 75%
of the stool being loose has been changed.)
Note: All these should fulfill in the last three
months and onset of symptom at least six
months before diagnosis.
Treatment: Loperamide and Cholestyramine
(4 g twice daily) are used for the treatment of
Fdr
C4. Functional Abdominal Bloating/Distension
Functional abdominal bloating (FAB) /
distention (FAD)is characterized by symptoms
(subjective) of recurrent abdominal fullness,
pressure, or a sensation of trapped gas(FAB),
and/or measurable (objective) increase in
abdominal girth (FAD).
Treatment: Simethicone, a-Galactosidase,
peppermint oil, Lubiprostone, linaclotide can
be used as treatment. Desipraminein
conjunction with cognitive behavioral
therapy has also shown positive results.
C5. Unspecified Bowel Disorders
When a patient do not fulfill diagnostic
criteria for any of the 4 specific FBDs
categories, then it is unspecified FBD.
C5. Diagnostic Criterion for Unspecified Functional
Bowel Disorder
GI symptoms which cannot be attributed to
an organic etiology and do not meet criteria
for IBS or functional constipation, diarrhea, or
abdominal bloating/distention disorders.
Note: All these fulfill in the last three months
and onset of symptom at least six months
before diagnosis.
C6. Opioid-Induced Constipation (OIC)
OIC has symptoms of reduced bowel
frequency, development or worsening of
straining, a sense of incomplete evacuation
while initiating opioid therapy.
Treatment: Laxatives are recommended for
both the prophylaxis and management of
OIC in patients with cancer. Lubiprostone is
used for treatment of OIC in adults with non-
cancer pain.
Conclusion
Rome IV is the result of a 6-year effort of 117
internationally recognized investigators and
clinicians representing 23 countries along with
10 administrative staff and consultants. Rome
IV criteria are an excellent guide for
clinicians, which cover all bio-psychosocial
aspects of patient-centered care and can
easily applied in routine practice.
References:
1. Lacy BE, Mearin F, Chang L, et al. Bowel
disorders. Gastroenterology.2016; 150:
1393-1407.
2. Drossman DA. Functional Gastrointestinal
disorders: History, Pathophysiology, Clinical
features, and Rome IV. Gastroenterology.
2016;150: 1262-79.
19
Clinical Queries
Approach to patients with Obesity
Dr. Aarathy Kannan MD, Diploma in
Diabetology,
MBA (HM) Physician & Diabetologist,
Sundaram Arulrhaj Hospitals,
Tuticorin, Tamilnadu
Obesity: A public health challenge
Obesity is increasing in an epidemic proportion
in both developed and developing countries.
Obesity in children and adolescents is
especially a cause of concern. Over the last 20
years, obesity has become the most prevalent
nutritional and metabolic health problem
globally leading to substantial morbidity and
mortality. Various factors like behaviour,
genetics, and environment are known to
affect people with obesity, which is difficult to
control with dieting. It is the key risk factor for
many chronic and non-communicable
diseases. Approximately, 62% of primary care
patients are overweight or obese, and obesity
1
is now a National Health Priority Area. This
article focuses on patient-centric approach of
screening and management of obesity in
primary care practice.
Screening and Diagnosis: Key Clinical
Questions
A significant portion of patients reported to be
obese received no screening in primary care
settings.
Who should be screened for obesity and
overweight?
Everyone should be screened including
children and adults during primary care visit.
Are Asian Indians different in terms of obese
phenotype?
The typical obesity phenotype observed in
Asian Indians (Table 1) consists of higher
percentage of body fat at a lower value of
body mass index (BMI), high waist–hip ratio
(W–HR) at a relatively low waist circumference
and less lean body mass as compared to
Caucasians and other Asian ethnic groups
2
(Figure 1). Therefore, BMI or W-HR or other
screening results should be interpreted in
Indian context.
Table 1: The Asian Indian obesity phenotype
Higher body fat with relatively less body BMI
a
Less lean body mass
b
High BF/BMI ratio
20
c
High waist–hip ratio
Variable subscapular/triceps ratio
d
High intramyocellular lipids
a b
Particularly in lower limbs; Higher body fat per
c
u n i t B M I ; A b s o l u t e v a l u e o f w a i s t
d
circumference may not be excessive;
Insufficient evidence
a, Body mass index; b, Waist-to-hip ratio. AIs,
Asian Indians; U. Slum, urban slum; MAs, Mexican
Americans;
Is Assessing BMI adequate for screening?
BMI is a useful parameter for screening in obesity.
However, it is not sufficient to assess risk in an
individual, because it measures only body size
and cannot give direct measure of body fat
distribution, or overall health in an individual.
Also, BMI is not always accurate with certain
body types such as in muscular men.
Furthermore, the amount and distribution of
body fat may vary based on ethnicity, sex, and
3, 4
age .
When and how waist circumference should be
measured?
Waist circumference should be measured at
the same time when BMI is calculated,
especially in people with a BMI of 25 to 35
2
kg/m , as it can provide additional information
in risk assessment. Waist circumference is
measured from the top of the iliac crest and
around the navel. While measuring, the tape
should be parallel to the floor and snug without
compressing the skin. The measurement should
5
be made at the end of a normal expiration.
Excess body fat, specifically abdominal fat, is
associated with more health risks, including
cardiovascular disease, type 2 diabetes,
hypertension, dyslipidaemia, and all-cause
mortality, as a continuous variable. It is seen
that waist circumference is the most practical
measure of abdominal visceral fat. A waist
circumference of more than 40 inches (102
cm) for men and more than 35 inches (88 cm)
for women is the generally recommended as
cut-point to diagnose elevated risk.
Approach to Patient management and
Treatment
In January 2015, the Endocrine Society of US
released new guidelines on the treatment of
obesity to include the following: Diet, exercise
a n d b e h a v i o u r a l m o d i f i c a t i o n ,
pharmacotherapy and surgery.
Counselling and Behavioural Modification
Behaviour plays an important role in obesity.
Modification of factors related to obesity is one
30
25
20
15
10
5
0
AIs (UK) Ais (US) Ais (URBAN)
Ais (U.SLUM) CAU CASIANS H.AS
a
1
0.95
0.9
0.85
0.8
0.75
AIs (UK) Ais (US) Ais (URBAN)
Ais (U.SLUM) CAU CASIANS M.AS
b
Figure 1: Comparisons of anthropometric
profiles of Asian Indians in different
geographical locations vs. ethnic groups
21
way to treat the disease either alone or in
conjunction with other treatments. Some of the
behaviour modifiers include: changing eating
habits, increasing physical activity, education
about an individuals own body, how to
nourish it appropriately with balanced diet,
e n g a g i n g i n a s u p p o r t g r o u p o r i n
extracurricular activity, and setting realistic
weight management goals. Comprehensive
approach to obesity management for primary
7
care physician is shown in Box 1.
Box 1.The 5 A’ s of Obesity Management
ASK for permission to discuss weight and
explore readiness.
ASSESS obesity-related risks and other “root
causes” of obesity.
ADVISE on health risks and treatment
options.
AGREE on health outcomes and behavioral
goals.
ASSIST in accessing appropriate resources
and providers.
Pharmacotherapy
According to Endocrine society clinical
practice guideline publish ed in 2014,
pharmacotherapies approved by FDA for
8
obesity are given in Table 2.
Is the treatment planning same if the patient is
pregnant?
Weight loss is not recommended in women
who are pregnant because of the possible risk
6
to the fetus.
When an obese person may be referred for
bariatric surgery?
Bariatric surgery is the surgical approach to the
management of obesity. The various types of
bariatric surgery are Roux-reEn-Y Gastric
By pa ss, Gastr ic Sle eve re secti on and
Adjustable Gastric Banding.Primary health
care providers (PCPs) play an important role
both before and after surgery in the care of
their patients who choose bariatric surgery.
Patients with the following criteria may be
9
considered as candidates for bariatric surgery:
Patients with a body mass index (BMI)> 40
2
kg/m or more without coexisting medical
problems or excessive surgical risk.
2
Patients with a BMI of 35 kg/m or more and
one or mo re sever e o besity- related
comorbidities, such as type 2 diabetes
mellitus, hypertension, hyperlipidemia,
obstructive sleep apnea, or severe urinary
i n c o n t i n e n c e , o r p a t i e n t s w i t h a
considerably impaired quality of life.
Implications in clinical practice and the future
The potentially preventable illness and
premature death caused by obesity is a socio-
economic burden. In view of the high
prevalence of obesity, there is a need to
investigate the effectiveness of simple, cheap
and pragmatic interventions that have the
ability to reach the high number of people
requiring weight management. Much of the
m a n a g e m e n t p r o t o c o l s o f o b e s i t y
management could be initiated by general
practitioners and primary care settings are the
ideal place to intervene since most of the
population can potentially be exposed here.
Guidelines recommend that primary care
physicians should identify people with obesity
and offer clinical management.
22
Table 2: FDA approved drugs for management of Obesity
Agent
Mechanism of Action
Notes
Diethylpropion
Norepinephrine-releasing agent
Approved for short-term use
(3 months)
Liraglutide
Lorcaserin
GLP-1 receptor agonist
5 HT2c receptor agonist
Recommended for patients with
cardiovascular disease.
Natrexone/Bupropion
Opiod antagonist/dopamine
and norepinephrine reuptake
inhibitor
Orlistat
Pancreatic and gastric lipase
inhibitor
Recommended for patients with
cardiovascular disease
Phentermine/topiram
ate
N o r e p i n e p h r i n e - r e l e a s i n g
a g e n t / G A B A r e c e p t o r
modulation agent
References
1. S Jansen, B Desbrow, L Ball. Obesity management by
general practitioners: the unavoidable necessity.
Aust J Prim Health. 2015; 366-8.
2. Anoop Misra, Naval K Vikram. Insulin resistance
syndrome (metabolic syndrome) and Asian Indians.
Current science 2003; 83( 12): 1483.
3. Flegal KM, Shepherd JA, Looker AC, et al.
Comparisons of percentage body fat, body mass
index, waist circumference, and waist-stature ratio in
adults. Am J Clin Nutr.2009;89:500-508
4. Flegal KM, Ogden CL, Yanovski JA, et al. High
adiposity and high body mass indexfor-age in US
children and adolescents overall and by race-ethnic
group. Am J Clin Nutr. 2010; 91:1020-1026.
5. Pi-Sunyer FX, Becker DM, Bouchard C, et al; National
I n s t it ut e s o f H e a l t h . T h e p r a c t i c a l g u i d e .
Identification, evalua tion, and treatment of
overweight and obesity in adults. NIH publication 00-
4084.
http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.p
df. Published October 2000. Accessed Aug 22, 2016.
6. A m e r i c a n C o l l e g e o f O b s t e t r i c i a n s a n d
Gynecologists. ACOG Committee opinion no. 548:
weight gain during pregnancy. Obstet Gynecol.
2013; 121:210-212.
7. Vallis M, Piccinini-Vallis H, Sharma AM, et al. Clinical
review: modified 5 As: minimal intervention for
obesity counseling in primary care. Can Fam
Physician. 2013; 59: 27-31.
8. J. Mich ael Gonzalez- Camp oy. Agents an d
Mechanisms of Action: Summary of the Endocrine
Society's Guideline on the Pharmacological
Management of Obesity.
9. Mechanick JI, Youdim A, Jones DB, et al. Clinical
practice guidelines for the perioperative nutritional,
metabolic, and nonsurgical support of the bariatric
surgery patient-2013 update: cosponsored by
american association of clinical endocrinologists,the
obesity society, and american society for metabolic
& bariatric surgery. Endocr Pract. 2013; 19:337-372.
23
IMACGP
IMA is the largest Professional organization with wide mix of membership ranging from General Practitioners
to Super specialist and Primary care physicians to corporate giants. The rapid progress that engulf the
medical profession mandate it for every practitioners to be updated and upkeep their professional skills
and knowledge.
With the objective of empowering the General practitioners serving in the nuke and corners of our country
with evidenced based skills, aptitude, life skills and therapeutic knowledge IMA College of General
Practitioners was started in 1963 by Dr.P.C.Batla.
True to its objective, the college had initiated various structured training courses and continuous
professional developments programmes and to reach out them at their door steps. FCGP is a prestigious
Fellowship of our college offered to young doctors with aptitude for General practice through examinations
and also to the Veteran general practitioners for their meritorious services for more than 20 years with the
Honorary fellowship.
Subspecialty skill empowers the General practitioners as the primary Care consultant to provide point of
care treatment and also they pick up the early warning signs and enable the patients to get adequate and
appropriate treatments. To provide these skills on the Sub speciality, IMA CGP Started the fellowship
certificate courses like cardiology, diabetology, toxicology, and Reproductive gynecology.
To enhance the scope and penetrability of Family MEDICINE, IMACGP had tied up with the Royal college of
GP UK to open the MRCGP (International) training and examination facility in India and also with the George
WASHINDTON University in USA to provide point of care emergency skills.
India is becoming a Digital country .Based on this perception it is envisioned to initiate Digital learning
process or work based learning prinples.IMA CGP Had identified the MedRC group as technical partner and
launched out lot of subspecialty courses. The formation of IMA EVarsity after due deliberation and approval
of CWC had enabled the college to promote and be reached to the needy doctors and fulfill their
expectations. Through this blended learning process coursers like Diploma in Family Medicine, Diabetes
and Emergency medicine courses are initiated varsity is picking up and IMA CGP will accredit these courses
and hope and wish Medical council of India will also adopt this digital learning through E Varsity. The courses
of E Varsity are accredited by Tamilnadu Medical council.
IMACGP IS THE FOUNDER MEMBER OF WONCA and the chief patron of IMACGP is the active chairman of
Commonwealth Medical Association Trust, IMACGP envisions to conduct CPD courses across the
commonwealth countries through E varsity.
The college has released two standard text books of Family medicines and this is our third edition coming out
as International Publication and privileged to be the Editor for the same.
The college strives and strain to make our college in to a full pledged university and functioning E-varsity
shall remain the beginning of this journey
Hope this book will empower Family Doctors and this will percolate in to our society and heal our community.
Long live IMA Long Serve IMACGP
24
Notes
25