Monday, December 31, 2018

Practice Changing: Start early oral feeding within 24 hours as tolerated rather than delaying oral nutrition in initial management of acute pancreatitis

The American Gastroenterological Association (AGA) Clinical Practice Guideline Committee developed guidelines on the initial management of acute pancreatitis within the first 48-72 hours of admission.  This period is significant as appropriate and timely management can influence the course of disease and duration of hospitalization.

The guideline has challenged many traditional practices that have continued over the years in the management of acute pancreatitis and includes many new recommendations such as goal-directed fluid replacement, early (within 24 hours) enteral feeding including for those who are unable to tolerate oral feeding, and cholecystectomy prior to discharge for patients with biliary pancreatitis.

Some key recommendations are:

  • Goal-directed therapy for fluid management is recommended; the guideline advices against use of hydroxyethyl starch fluids.
  • Prophylactic antibiotics are not recommended in patients with severe and necrotizing acute pancreatitis.
  • Enteral rather than parenteral nutrition for patients who are unable to feed orally.
  • Early oral feeding (within 24 hours) as tolerated is recommended, rather than keeping the patient nil by mouth as has been done traditionally.
  • Either nasogastric or nasojejunal route can be used in patients with predicted severe or necrotizing pancreatitis who require enteral tube feeding.
  • Compared with conservative management, urgent ERCP had no impact on outcomes, including mortality
  • In patients with acute biliary pancreatitis, cholecystectomy is advised during the initial admission rather than post-discharge to prevent recurrent biliary events.
  • A brief alcohol intervention is recommended during admission in patients with acute alcoholic pancreatitis.

(Source: Crockett SD, Wani S, Gardner TB, et al; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018;154:1096-101).

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Revisiting 2018: A roundup of Top health stories in India

2018 has been an eventful year for the country, especially in the medical arena. A lot has happened and it has left all of us in anticipation of the coming year 2019.

MBBS curriculum revised after more than two decades … an ambitious target for complete elimination of TB from the country by 2025… legislations have been passed …. some only by the Lower House….some have been tabled in the Parliament and are yet to be discussed before they can be enacted … outbreaks….natural calamities….These were but few of the stories that made headlines this year.

India took a step closer to universal health coverage with the launch of Ayushman Bharat.

But, perhaps the most momentous of all events this year was the dissolution of autonomy of medical profession and replacement of the Medical Council of India (MCI) with a Board of Governors.

Let’s take a look at some of the top health stories in India in 2018. These have been listed in no specific order.

Medical Council of India dissolved and so was the autonomy of the medical profession

The Medical Council of India (MCI) was dissolved with immediate effect on Sept. 26, 2018 and superseded by a Board of Governors after the Govt. brought an Ordinance called the Indian Medical Council (Amendment) Ordinance, 2018 to set up a committee to run the MCI until Parliament passes the National Medical Commission (NMC).  A 7-member Board of Governors was announced with   Dr. VK Paul as its chairman.

New MBBS curriculum

The MBBS curriculum was revised. In November, the new undergraduate curriculum was finalized by the MCI BoG. It will be implemented in the 2019-20 academic session. The “Competency-based UG Curriculum for the Indian Medical Graduate” focuses on medical ethics, better doctor-patient relationship and outcome-based learning. Another new feature is the introduction of elective subjects. Now students can pick up subjects of choice and dedicated time has been allotted for self-directed learning and co-curricular activities. The new MBBS curriculum has a course called Attitude, Ethics and Communication (AETCOM) which will run across years. Students will be assessed for how they communicate with patients; how they counsel people for organ donations or other challenging procedures; how sensitively do they offer care and obtain consent. All these things will count along with competencies and skills.

National Medical Commission Bill 2017

The government is hoping to pass the National Medical Commission (NMC) Bill. The bill is currently pending in Parliament and will be first taken up in the Lok Sabha. The Bill seeks to replace the MCI with a National Medical Commission as a regulatory body for medical education and practice in the country. Among other provisions, the Bill establishes four autonomous Boards under the supervision of the NMC:  Under-Graduate Medical Education Board, Post-Graduate Medical Education Board, Medical Assessment and Rating Board and Ethics and Medical Registration Board.

The Bill was introduced in the Lok Sabha on Dec. 29, 2017; it was referred to a Standing Committee on January 4, 2018 on account of opposition from the Indian Medical Association (IMA) to certain provisions of the Bill. The Standing Committee submitted its report on March 20, 2018 following which the Union Cabinet approved certain official amendments to the NMC Bill. It is unlikely to get passed seeing the tough stand taken by the IMA.

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana launched

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana, the world’s largest government funded healthcare program was launched by the Prime Minister Shri Narendra Modi at Ranchi, Jharkhand on Sept. 23, 2018. It provides a cover of up to Rs. 5 lakhs per family per year, at any government or empanelled private hospital, for secondary and tertiary care hospitalization. More than 10 crore vulnerable entitled families - approximately 50 crore beneficiaries - will benefit from the scheme. The amount of 5 lakh would cover all investigations, medicine, pre-hospitalization expenses etc. All pre-existing conditions are covered. There is no restriction on family size, age or gender.

India sets a target for complete elimination of TB by 2025 at the Delhi End TB Summit

“India is determined to address the challenge of TB in mission mode. I am confident that India can be free of TB by 2025. The global target for eliminating TB is 2030, but today I announce that the target for India to eliminate TB is 2025, five years before the global target,” said the Prime Minister Narendra Modi as he inaugurated the Delhi End TB Summit and launched the TB Free India Campaign on March 13, 2018.

The Delhi End TB Summit was jointly organized by the Government of India, Stop TB Partnership and WHO South East Asia Regional Office (SEARO).

Supreme Court’s allowed “Living Will” in a landmark decision

In a landmark judgement, the Supreme Court of India allowed an individual to draft a living will specifying that they not be put on life support if they slip into an incurable coma.

The order was passed by a five judge Constitutional bench comprising Chief Justice of India, which said “Human beings have the right to die with dignity.” Though the judges gave four separate opinions, all of them were unanimous that a Living Will should be allowed, because an individual should not be allowed to continue suffering in a vegetative state when they don’t wish to continue living, and know full well that they will not revive. However, the Apex Court has set forth strict guidelines on how to execute the mandate of the living will.

Surrogacy (Regulation) Bill 2018 passed by the Lok Sabha

The Surrogacy (Regulation) Bill 2018, which had been introduced in the Lok Sabha in 2016, was passed by the Lower House on Dec. 19, 2018. The Bill is to be debated in the Rajya Sabha and passed by the Upper House before it can be enacted.

The Bill prohibits commercial surrogacy, and allows altruistic surrogacy. Altruistic surrogacy does not involve any monetary compensation to the surrogate mother other than the medical expenses and insurance coverage during the pregnancy. The intending couple must be Indian citizens and married for at least five years with at least one of them being infertile.  The surrogate mother has to be a close relative who has been married and has had a child of her own. Only Indian citizens can avail surrogacy.

Undertaking or advertising commercial surrogacy, exploiting the surrogate mother and selling or importing human embryo or gametes for surrogacy have been considered offences under the Bill with a penalty of 10 years and a fine of up to 10 lakh rupees.

Consumer Protection Bill 2018 passed by the Lok Sabha

The Consumer Protection Bill 2018 was passed by the Lok Sabha on Dec. 20, 2018. The bill, among other things, proposes setting up of the Consumer Disputes Redressal Commission and forums at the District, State and National levels to examine and decide on consumer complaints. Appeals from the District Commissions will be heard by the State Commission and from the State Commission by the National Commission. Appeals from the National Commission will be heard by the Supreme Court.

The Bill has also defined the pecuniary jurisdiction of the three disputes redressal agencies, which have been substantially increased from those provided in the present Consumer Protection Act 1986.

·                For District Forum, the jurisdiction has been increased to Rs one crore (from up to Rs 20 lakh at present).
·                For State commission, the jurisdiction has been increased to between Rs one crore and up to Rs 10 crore (from more than 20 lakh but not exceeding Rs one crore at present).
·                For National commission, the jurisdiction has been increased to above Rs 10 crore (from more than one crore at present).

Other amendments proposed are as follows:

·                District, state and national fora do not require judicial members.
·                Not only persons but associations and other bodies can complain to consumer fora
·                Consumer Mediation cells at district, state and national level.
·                District, state and national councils, which are advisory in nature
·                A Central consumer authority which has judicial powers, can conduct investigations, search and make judgements 

Cabinet approves Allied and Healthcare Professions Bill, 2018

In November, the Union Cabinet chaired by Prime Minister Shri Narendra Modi approved the Allied and Healthcare Professions Bill, 2018 for regulation and standardization of education and services by allied and healthcare professionals. The Bill provides for setting up of an Allied and Healthcare Council of India and corresponding State Allied and Healthcare Councils which will play the role of a standard-setter and facilitator for professions of Allied and Healthcare.

The Bill will also have an overriding effect on any other existing law for any of the covered professions.

Nipah virus outbreak in Kerala

In May, an outbreak of the Nipah virus was reported from Kerala. It was localized in Kozhikode and Malappuram districts of Kerala and claimed 17 lives. The outbreak was officially declared over on June 10, 2018. This was the third outbreak reported in India.

An advisory released by the Health Ministry said that “the Nipah virus disease is not a major outbreak and is only a local occurrence”. The outbreak was traced to fruit bats. In July, the Indian Council of Medical Research (ICMR) confirmed fruit bats were the primary source of the virus.

Zika virus outbreak in Rajasthan

The third outbreak of Zika virus in less than two years was reported in India from Jaipur in Rajasthan. The first case was reported in the end of September. More than 130 cases were detected. For the first time, during this epidemic, scientists found mosquitoes that were infected with the virus, indicating that it was being transmitted locally. Sequencing of five  Zika virus strains collected during the Jaipur outbreak suggest that the known mutations linked to fetal microcephaly are not present in the current strain.

In January-February 2017, the first three cases of laboratory-confirmed Zika virus infection in India were detected in Ahmedabad, Gujarat. In the same year in July, transmission of Zika virus was also confirmed from Krishnagiri District in Tamil Nadu. The World Health Organization (WHO) puts India in category 2 in the classification of Zika’s prevalence, which indicates an ongoing transmission of the virus.

HIV and AIDS (Prevention and Control) Act, 2017

The HIV and AIDS (Prevention and Control) Act, 2017 was notified by the Government and came into force from Sept. 10, 2018. The Act aims to end the epidemic by 2030 and safeguard the rights of people living with or affected by HIV by addressing HIV-related discrimination through legal accountability and establishing mechanisms for complaint enquiry and grievance redressal.

The Act lists various grounds on which discrimination against HIV positive persons and those living with them is prohibited. These include the denial, termination, discontinuation or unfair treatment with regard to: (i) employment (ii) educational establishments (iii) health care services (iv) residing or renting property (v) standing for public or private office and (vi) provision of insurance (unless based on actuarial studies). The Act also prohibits the requirement for HIV testing as a pre-requisite for obtaining employment or accessing health care or education. 

ICMR has a new Director General

Professor Balram Bhargava, Professor of Cardiology at All India Institute of Medical Sciences (AIIMS), New Delhi took charge as the new Director General of Indian Council of Medical Research (ICMR) and Secretary of the Department of Health Research, Ministry of Health & Family Welfare.

A new Director General of Health Services appointed

Dr S Venkatesh is the new Director General of Health Services (DGHS).

A new Drugs Controller General of India

Joint Drugs Controller Dr S Eswara Reddy was appointed as the new Drugs Controller General of India (DCGI).

New IMA National President

Dr Santanu Sen, also a Member of Parliament, took over as the National President; Dr RV Asokan was elected as the Secretary General.

India assumes office of CMAAO President-Elect

Dr KK Aggarwal took over as the President-elect of Confederation of Medical Associations in Asia and Oceania (CMAAO).

Supreme Court bans sale of Bharat Stage IV vehicles from April 1, 2020

A three judge bench of the Supreme Court headed by Justice Madan B Lokur has said that no Bharat Stage IV vehicle shall be sold across the country with effect from April 1, 2020. The Bharat Stage VI (or BS-VI) emission norm would come into force from April 1, 2020 across the country. 

The BS IV norms have been enforced across the country since April 2017. In 2016, the Centre had announced that the country would skip the BS-V norms altogether and adopt BS-VI norms by 2020.The apex court was deciding whether grace period should be given to automobile manufacturers for the sale of BS-VI non-compliant vehicles after April 1, 2020.

MTNL Perfect Health Mela celebrated its silver jubilee

The MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India, celebrated its silver jubilee with the theme “Affordable Healthcare”. A National Campaign on Hands-only CPR 10 in collaboration with Ministry of Youth Affairs, Govt. of India was launched on the inaugural day. “Evening Conclaves” thematic panel discussions with celebrity guests were the highlight of the Mela this year. Topics discussed at these Conclaves included antimicrobial resistance, indoor pollution, harm reduction, safe water and air, CSR, infertility and non-communicable diseases.

A one-of-its-kind Spiritual Inter-Faith Conference on air, sanitation and antimicrobial resistance was also organized by HCFI along with the World Fellowship of Religions, in which eminent dharma Gurus of all religions participated as speakers.

Kerala Floods

In August, Kerala suffered its worst flood in 100 years. All 14 districts of the state were placed on red alert. According to the Kerala government, one-sixth of the total population of Kerala had been directly affected by the floods and related incidents. The Government of India declared it a Level 3 Calamity, or “calamity of a severe nature”.

Viral load test for people living with HIV/AIDS 

The Viral Load testing for all People Living with HIV/AIDS (PLHIV) was launched by the Health Minister in February as “a big step forward in treating and monitoring people living with HIV”. The initiative will provide free of cost viral load testing for 12 lakh PLHIV on treatment in the country at least once a year. It will optimize the utilization of 1st line regimens, thus preventing drug resistance. It will also help in strengthening ‘Mission Sampark’ in tracking LFU (Loss to Follow Up) PLHIV.

Govt. ban on manufacture of oxytocin formulations set aside by Delhi High Court

In May, the Ministry of Health and Family Welfare restricted the manufacture of Oxytocin formulations for domestic use to public sector only. It also banned the import of Oxytocin and its formulations. This order was to come into effect from July 1, 2018.

As per the order, no private manufacturer would be allowed to manufacture the drug for domestic use. Only Karnataka Antibiotics & Pharmaceuticals Ltd (KAPL), a public sector company, would be manufacturing this drug for domestic use and will supply the drug to registered hospitals and clinics in public and private sector directly. Oxytocin in any form or name would not be allowed to be sold through retail Chemist.

But, on Dec. 14, the Hon’ble Delhi High Court set aside the Govt.’s decision to ban private firms from producing and selling oxytocin. The bench of Hon’ble Justice S Ravindra Bhat and Hon’ble Justice AK Chawla said that the government’s decision was arbitrary and unreasonable and that there was no scientific basis behind the Center’s decision restricting private companies from making or supplying the drug to prevent its alleged misuse in the dairy sector for increasing milk production.

Cabinet approves the Protection of Human Rights (Amendments) Bill, 2018

The Union Cabinet chaired by Prime Minister Shri Narendra Modi approved the Protection of Human Rights (Amendments) Bill, 2018 for better protection and promotion of human rights in the country.

National Viral Hepatitis Control Program launched

The National Viral Hepatitis Control Program was launched by the Health Minister on World Hepatitis Day (July 28) with the goal of ending viral hepatitis as a public health threat by 2030 in the country.

India retains the WHO South-East Asia Regional Director position

India retained the top WHO position in South-East Asia Region Office (SEARO) with Dr Poonam Khetrapal Singh unanimously re-elected as Regional Director WHO South-East Asia for another five-year term beginning February 2019. She is the first woman to have been elected to the position of Regional Director for WHO South-East Asia Region after an illustrious career in the Indian civil service, World Bank and WHO.

Last year Soumya Swaminathan an Indian Paediatrician and Clinical Scientist known for her work in Tuberculosis on 3 October 2017 was appointed as the Deputy Director General of Programmes at the World Health Organization.

ENDS Controversy

In August, the Ministry of Health released an advisory on Electronic Nicotine Delivery Systems (ENDS) including e-cigarettes, Heat-Not-Burn devices, Vape, e-Sheesha, e-Nicotine Flavored Hookah, and the like products asking states not to allow its sale or distribution. 

But on 28th December Public Health England (PHE) released a new film showing the devastating harms that come from smoking, and how this can be avoided by switching to an e-cigarette or using another type of quit aid.

The film has been released as part of PHE’s Health Harms campaign, which encourages smokers to attempt to quit this January, by demonstrating the personal harm to health from every single cigarette. The film features smoking expert Dr Lion Shahab and Dr Rosemary Leonard, visually demonstrating the high levels of cancer-causing chemicals and tar inhaled by an average smoker over a month, compared to not smoking or using an e-cigarette.Research estimates that while not risk-free, vaping is at least 95% less harmful than smoking.

Dr Lion Shahab, leading smoking cessation academic from University College London, said: “The false belief that vaping is as harmful as smoking could be preventing thousands of smokers from switching to e-cigarettes to help them quit. Research we and others have conducted shows that vaping is much less harmful than smoking and that using e-cigarettes on a long-term basis is relatively safe, similar to using licensed nicotine products, like nicotine patches or gum. Using e-cigarettes or nicotine replacement such as patches or gum will boost your chances of quitting successfully.”

Govt. bans use of antibody test kits to diagnose malaria

The Health Ministry prohibited the manufacture for sale, sale and distribution of the test kits used in Antibody Detecting Rapid Diagnostic Tests for routine diagnosis of malaria after it was found that the test was triggering false alarms. As per the notification, although the test is economical, the false positive rates in endemic areas were high. People with fever who tested positive in the rapid antibody test, were later tested negative in antigen test.

Plastic Waste Management (amendment) rules notified

The Ministry of Environment, Forest and Climate Change has notified the Plastic Waste Management (Amendment) Rules 2018. The amended Rules lay down that the phasing out of Multilayered Plastic (MLP) is now applicable to MLP, which are “non-recyclable, or non-energy recoverable, or with no alternate use.” 

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Sunday, December 30, 2018

The Top Cardiology Trials of 2018: ODYSSEY

Treatment with alirocumab, a PCSK9 inhibitor, reduced cardiovascular outcomes and all-cause deaths by 15% in patients with acute coronary syndrome (ACS) and higher-than-ideal atherogenic lipoprotein levels despite intensive or maximally tolerated statin therapy in the ODYSSEY trial.

The ODYSSEY trial was a 3-year multicenter, randomized, double-blind, placebo-controlled trial involving almost 19,000 patients who had had a previous ACS within 1 month to 1 year before enrollment. Their LDL-cholesterol level was at least 70 mg/dL, non−HDL cholesterol level was at least 100 mg/dL or an apolipoprotein B level was at least 80 mg/dL; they were on statin therapy at a high-intensity dose or at the maximum tolerated dose.

Patients were randomized to biweekly injections of alirocumab or placebo. The dose could be uptitrated if LDL-cholesterol <50mg/dL was not achieved.

After 2.8 years, alirocumab significantly reduced cardiovascular (CV) death, myocardial infarction (MI), stroke, or hospitalization (primary end point) from 11.1% in the placebo group to 9.5% in the alirocumab group. Mortality was also reduced with alirocumab from 4.1% in placebo group down to 3.5% in the alirocumab group.

The benefits were greater among patients who had a baseline LDL-cholesterol of ≥100 mg/dL, where there was a 3.4% absolute risk reduction vs patients who had a lower baseline level. In that subgroup, you would only have to treat about 30 people to prevent a MACE event and there was a 1.7% reduction in mortality.

ODYSSEY Outcomes is the second outcomes trial with a PCSK9 inhibitor to show a reduction in LDL-C and cardiovascular endpoints. The earlier FOURIER trial, which used a fixed dose of the PCSK9 inhibitor evolocumab, showed no mortality advantages. Compared with FOURIER, the ODYSSEY Outcomes trial enrolled a higher-risk group of patients, had a longer duration of follow-up (ranging from two to five years), involved a different dosing strategy and had a slightly different primary endpoint

(Source: N Engl J Med. 2018;379:2097-210; Medscape, ACC News)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Using the Smartphone to monitor heart rate: This is the future

Smartphones have become an integral part of our daily life now, so much so that a world without smartphones now seems inconceivable.

As technology has evolved, the use of phones has undergone a revolution. Each new version of the smartphone is equipped with better and often some mind-boggling features. Physical keypads have made way for touch screen. You can video chat with someone anywhere in the world. All you need is an internet connection on your smartphone. Apps like Google Assistant make it possible to interact with the phone through natural voice. Phones today, therefore, can perform many more functions beyond just making calls.

Apple has now taken a step ahead leaving a trail for the future with two new features in Apple Watch Series 4.

An ECG app on Apple Watch Series 4 is now available. As the first direct-to-consumer product, it helps people to take an ECG right from their wrist, whenever they experience symptoms such as rapid or missed heart beat and also share the data with their doctors.

The irregular rhythm notification feature on Apple Watch can now also monitor heart rhythms in the background and send a notification if an irregular heart rhythm is detected on five rhythm checks over a minimum of 65 minutes

According to a news release from Apple, “New electrodes built into the back crystal and Digital Crown on Apple Watch Series 4 work together with the ECG app to enable customers to take an ECG similar to a single-lead reading. To take an ECG recording at any time or following an irregular rhythm notification, users launch the new ECG app on Apple Watch Series 4 and hold their finger on the Digital Crown. As the user touches the Digital Crown, the circuit is completed and electrical signals across their heart are measured. After 30 seconds, the heart rhythm is classified as either AFib, sinus rhythm or inconclusive. All recordings, their associated classifications and any noted symptoms are stored securely in the Health app on iPhone. Users can share a PDF of the results with physicians”.

Rhythm classification from a 12-lead ECG by a cardiologist was compared to the rhythm classification of a simultaneously collected ECG from the ECG app in around 600 participants. The ECG app on Apple Watch showed 98.3% sensitivity in classifying AFib and 99.6% specificity in classifying sinus rhythm in classifiable recordings; 87.8% of recordings could be classified by the ECG app.

In a sub-study of the Apple Heart Study, which included participants that received an irregular rhythm notification on their Apple Watch while simultaneously wearing an ECG patch, 80% showed AF on the ECG patch and 98% showed AF or other clinically relevant arrhythmias. With over 400,000 participants, the Apple Heart Study was the largest screening study on atrial fibrillation ever conducted, also making it one of the largest cardiovascular trials to date.

The ECG App and the irregular heart rhythm notification have been provided De Novo classification by the US FDA. They are available as part of a free update to watch OS 5.1.2.

Health care today has shifted from being ‘paternalistic’ to ‘patient-centric’. The patient now wants to be a part of decision making. He has literally all information related to his illness at his fingertips because he has a smartphone.  

Technology has again empowered patients, who can use the App to monitor themselves for signs of AF and be alerted about the event right at the time it is occurring.

It’s a promising tool indeed, yet it needs to be used cautiously.

(Source: Medscape, Apple News)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Saturday, December 29, 2018

Use PPIs with caution in patients at high risk of hip fractures

As per a meta-analysis of observational studies reported online Dec. 12, 2018 in the journal Osteoporosis International, proton pump inhibitors (PPIs) are significantly associated with an increased risk of hip fracture. This effect is not seen with histamine 2 receptor antagonists (H2RAs).

The meta-analysis included 24 observational studies with 2,103,800 participants. Of these, 319,568 were hip fracture patients. Analysis showed that patients on PPIs had a greater risk of hip fracture than those who were not on PPI (risk ratio 1.20; p<0.0001).

The risk increased with the dose of PPIs. The observed risk was high for both low and medium doses of PPIs and it was even greater for patients taking high dose PPIs; low dose RR 1.17 (p = 0.002); medium dose RR 1.28 (p <0.0001) and higher dose RR 1.30 (p <0.0001).

But no association was found between the use of H2RAs and increased risk of hip fracture.

The study recommends cautious prescription of PPIs, especially long-term and higher dose PPIs, in patients who are at high risk of hip fracture. The authors further say that “patients should be concerned about the inappropriate use of PPIs; if necessary, then, they should continue to receive it with a clear indication”.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA