Dr Debashish Danda

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Primary Care Rheumatology in South Asia Take this survey powered by surveymonkey.com. Create your own surveys for free.

EVERY INDIAN THINKS HE / SHE IS MEDICALLY KNOWLEDGABLE PERSON, WHILE QUALIFIED DOCTORS ARE NOT.

Everyone in India thinks he or she is a medical doctor, irrespective of whether he / she is a common man /minister / big or small politician / beaurocrat / swami / baba / quack / clown / actor or a housemaid.

They all think that they are all experts in finding fault in doctors, and always suggest better alternatives to what expert doctors have done; they gossip, post sensational lies & provoke patients with misinformation. They take pleasure in cooking & spreading crap stories and what not.

Their ignorance ultimately harms the patients and none else, often their own near & dear ones.

They lack common sense to realise a simple truth i.e. why should a doctor do harm to a patient knowingly to spoil his reputation?

THEY HAVE NO BRAINS TO REALISE THAT AN AVERAGE OF 15 YEARS OF STUDIES ARE NEEDED TO PRODUCE A SPRCIALIST & 99% OF THEM ARE AMONGST THE TOP CREAM OF THE SOCIETY BY MERIT.

Yes, every humans can do a mistake. A doctor doesnot do mistake more than a minister, judge, beaurocrat or a journalist.

Be mindful dear citizens. Donot commit such suicidal blunders by demoralising a doctor.

IMAGINE ANY OF US DYING DUE TO NON-AVAILABILITY OF A DOCTOR SOME DAY!

And try to recollect, how many times someone or other in your family was saved from death by doctors; If not, none of us or our near & dear ones would have been around here to read this post. Is it not?

SO, FOR GOD'S SAKE, PLEASE DO NOT BE SO UNGRATEFUL TO DOCTORS.

And finally, you must remember a hard fact of life always i.e. NO MEDICINE , NO DOCTOR, NO SAINT NOR ANY MAGICIAN CAN MAKE MANKIND IMMORTAL!

HURRY BURRY IN LIFE IS JUST NOT ACCEPTABLE ..

IT NEEDS PUNISHING OF SUCH SERVICE PROVIDERS FOR POOR QUALITY SERVICE IN EVERY SECTOR IN INDIA.

India's customer service personnel speaks " BLA BLh Blah.....bla, bla, bla, ....bka, bla, bla, .. " in response to sny query / service. It is just verbal diarrhoea & vomiting in 30 seconds, ...u ask anything... another bout of vomiting & diarrhoea ..all on your ear...

HOW DO THEY GET PAID, WHO PAYS THEM FOR SUCH RUBBISH SERVICES?

SIMILARLY, MANY PAGES OF SMALL PRINTS ONLINE OR ON PAPER THAT ARE MADE TO SIGN BY CUSTOMERS BY " I AGREE" SHOULD BE MADE ILLEGAL & INVALID .

It is utter nonsense and not acceptable.

India's customer service personnel speaks " BLA BLh Blah.....bla, bla, bla, ....bka, bla, bla, .. verbal diarrhoea & vomiting in 30 seconds, ...u ask anything... another bout of vomitinv & diarrhoea ..all on your ear...HOW DO THEY GET PAID, WHO PAYS THEM FOR THE RUBBISH SERVICES?

Donot authorise facebook to share anything from my posts / reels / stories / comments / photos / videos anytime, anywhere.

What you need to know about SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

1. What is SLE?

It is a systemic auto immune disease, in which the body's immune system attacks the healthy cells of one owns body.

2. What causes it?

`The cause is 'UNKNOWN'. But circulating immune complexes is a classical feature of SLE. Broadly, autoimmune response in a susceptible genetic make up of an individual causes it.

3. What happens in SLE?

It is one of the auto immune multi system disease in which the immune system is unable to differentiate between non self (e.g. an organism) and self (one's own system). The major systems involved are Central Nervous system, kidneys, Blood vessels, heart, eyes, skin, joints etc.

4. Is it curable?

SLE is an "INCURABLE DISEASE", just like diabetes and hypertension. But with the recent availability of good treatment modality, SLE has very bright outlook as in diabetes and hypertension. With current treatment options, patients may feel ‘as if cured', but only with medications. Cure means normality without any medications & that does not happen in SLE. If you have any such belief, please remove that from mind. This misconcept often make patients stop treatment and get in to life threatening emergency.

5. What are the available treatment options and its duration?

Majority are treated with initial high dose steroids. Patients who are on steroids need not get frightened, as the actions and side-effects are known to the physicians. Hence they can be monitored. The initial dosage of steroids is as high as 1 mg/kg/day which is tapered slowly after about 2 months and later to a very low dose for maintenance of remission.

Caution: Premature tapering of steroids is dangerous. Which may cause flare up of disease and ultimately, the patient will end up getting more cumulative dose of steroids. So, seek a trained Rheumatologist. There are other second line immunosuppressants line Mycophenolate, Cyclophophamide & Azathioprine which help taper steroids. Remember- steroids are also produced in our own normal body also. Inappropriate use is only more harmful.

6. What is the most common expected side effects of steroids?

 Skin changes like stretch marks

 Opacity of lens

 Increased blood pressure

 Increased blood sugar

 Low immunity leading to infections

 Thin bone and fracture risk

7. What are the other drugs given for SLE?

Along with steroids, Chloroquine or hydroxy chloroquine are given, which has a mild steroid sparing effect. These drugs prevent Nervous system and renal disease relapse, prevent thrombosis and infection and has survival advantage.

• There are 6 types renal involvement and treatments for each differ.

• Mycophenolate & Cyclophosphamide are the most effective treatment options for the worst type of kidney involvement (type III & type IV). They are also useful in brain involvement in SLE.

• To prevent fractures due to decreased bone density, Calcium tablets and vitamin D tablets are prescribed.

8. Should the patients take the drugs over the counter (OTC)?

No. Steroids and all immunosuppressants have long term side effects. Tapering and monitoring should be done to minimize these effects under rheumatologists'supervision. Hence care should be taken in not taking these drugs over the counter.

9. How frequently the doctor should be consulted?

After diagnosis, follow up should be made every month. Once stable, the patient should visit the physician/rheumatologist at-least once in 3 months. An eye check up is a must once in 6 months while on medications. Any inter current infection should be treated promptly.

10. Is there a role for diet restriction?

"No diet can cause nor any diet can cure SLE". But fish can be taken frequently, as it contains Omega 3 fatty acids, which has an anti-inflammatory effect and it can also prevent cardiac complications. Restrict saturated fat and high carbohydrate diet including sweets. Most Indian spices are beneficial especially curcumin present in turmeric. Contrary to middle class psyche of food faddism, spicy food is good in all autoimmune diseases.

11. Is it hereditary?
Most systemic autoimmune diseases have multifactorial etiology and there is a likely hood of the offsprings getting SLE or another connective tissue disorders. But it doesn't follow any inheritance pattern and often not predictable. Genes do play role.

12. What are the concerns regarding pregnancy in a SLE patient?
Pregnancy may flare up the disease leading to a higher risk of miscarriages due to the presence of Anti-phospholipids antibodies or fetal heart block Ro/La antibodies. Pregnancy in SLE needs special care as there is risk to the life of both mother and fetus, if not monitored well.

13. Is there any preventive drug for a SLE patient who becomes pregnant?

No clear evidence in that; directing close monitoring with Rheumatologist/ immunologist and obstetrician is the best option. Blood thinners are also used under supervision in specific circustances...dr debashish danda...

HAPPY TO RESPOND TO QUERIES.....

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BAD MEDICINES USED BY FIBROMYALGIA PATIENTS & RATIONAL APPROACH IN CHRONIC PAIN DISORDERS.

Fibromyalgia / chronic pain disorders should never be treated with opioids including tramadol / dextropropoxyphene etc, or with benzodiazepines.

They are not only addicting, but they quickly cause tachyphylaxis compelling dose escalation for achieving same benefit as achieved by the first dose, but with higher toxicity within a short period; they also cause lowered pain threshold & eventually these agents give only transient benefit if at all, with whole lot of cumulative toxicity including changed personality leading to loss of interpersonal relationships within family, workplace & society.

Addiction to these agents become rule rather than exception, and withdrawl features become worse than the primary disease.

Recent interest in cannabinoids are further worrying, and long term damage to mind & body may be worse as suggested in some recent papers.

HOW SHOULD FIBROMYALGIA & OTHER CHRONIC PSIN DISODERS BE TREATED THEN?

1. Firstly, reassure the patients that these diseases do not kil, nor do they deform, or paralyse the patients.

2. Regular physical activity including aerobics & special biofeedbacks thro rehabilitation experts including JACOBSON'S RELAXATION TECHNIQUES (one can find in youtube) are helpful.

3. GOOD SLEEP HYGIENE IS CRUCIAL as POOR SLOW WAVE SLEEP, MORE OF REM SLEEP, Less than 8 hours sleep in 24 hour, or less of night time sleep causes imbalance between serotonin & substance P.

Avoid caffeine or cola beverages and screen time in the evening. Blue screen exposure prevent melatonin formation that is crucial for night sleep.

Avoid longer than 30 minute day time nap, too much of alcohol & smoking.

Avoid vigorous exercise in late evening as it will increase blood flow to brain with stimulating metabolites that will keep ideal conditions for sleep at bay; ideal time for walking & exercise is in the morning hours.

4. Medications of SSRI group like Fluoxetine (better efficacious than duoloxetine in real world) under physician / rheumatologist's monitoring is effective in vast majority; 20 mg daily after breakfast (never in the evening) for at least few months may give good result especially from fatigue symptoms.

For sleep issues, pregabalin seems to ok for many. Dothiepen (Prothiaden) also works; AVOID AMITRYPTYLINE AS IT MAKES MANY PATIENTS TO EXHIBIT STRANGE DRUNKEN / EUPHORIC BEHAVIOUR; IT IS ADDICTING & CARDIOTOXIC TOO IN SUSCEPTIBLE PEOPLE.

5. TREAT PAIN TRIGGERING, POOR LIFESTYLE & OTHER CO- MORBIDITIES.

TREAT / CONTROL / MODIFY / CURB THE FOLLOWING EFFECTIVELY & APPROPRIATELY BY EXPERTS IN MODERN & EVIDENCE BASED MEDICINE: Obesity, diabetes, hypertension, hyperlipidemia, substance abuse, underlying osteoarthritis or inflammatory arthropathies, autoimmune diseases, hypothyroidism, low vitamin D state, sededentary lifestyle, mechanical / discogenic backache, poor posture, repetitive strain in sitting job like typing, unhealthy high carbohydrate & hydrogenated fat rich & low fibre diet, smoking & regular alcohol intake, consumption of toxic & unproven substances in the name of traditional medicine / herbs & commercial food supplements /so called & commercially hyped natural stuff / so called spiritual / faith based therapy, underlying stressors in life, depression & anxiety states.

TREATING THESE UNDERLYING MALADIES OPTIMALLY BY EVIDENCE BASED MEDICINE IN A CASE OF FIBROMYALGIA GO A LONG WAY IN GIVING RELIEF TO THE PATIENT.

6. Strictly avoid non evidence based tall claims , as they are nothing but traps into vicious cycles of pain begetting more pain.

7. Short term benefits from physical therapy measures like Transcutaneous electrical nerve stimulation (TENS), EMG Biofeedback & several other options provided by physiatrists help cutting the pain cycle.

Pathophysiologically, Fibromyalgia & other chronic pain diseases come under a broad category of diseases knoen as CENTRAL SENSITISATION DISORDERS which include several other disorders within the same spectrum, namely IBS (Irritable bowel syndrome), premenstrual tension, certain migraine headaches, chronic fatigue syndrome & so on. BASICALLY, THESE DISORDERS ARE DISORDERS OF NEURO TRANSMITTERS & as mentioned earlier, sleep disturbances leading to imbalance between substance P (pain inducing chemical) & serotonin (sleep inducing chemical) play crucial role in all the disorders in this spectrum. As gastrointestinal system is the source of many neurotransmitters, this gut- brain axis may also have crucial role in chronic pain / central sensitisation disorders. In real life too, there is strong association between IBS & Fibromyalgia / other chronic pain disoders that exemplify this link.

SCIENCE, LOGIC , RATIONALISM & EVIDENCE BASED APPTOACH IS THE ONLY WAY OF TREATING FIBROMYALGIA & OTHER CHRONIC PAIN DISORDERS.dr debashish danda....

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SAFE FLYING

It is sad that some pilots are not conducting in best possible ways.

Some of the observations about them that are worrisome include:

1. EATING & DRINKING IN COCKPIT IN DANGEROUS WAYS.
Do Pilots have to eat a meal during short flights? Its very important that pilots for short flight come fresh after their meals.

2. GOING TO WASHROOM FREQUENTLY.
Cant the pilot clear their bowel & bladder before boarding flights? It is noticable in every flight (even in 1 hour flights) that both pilots go to washroom one after the other. Agreed, it is nature's call. If not a truly urgent nature's call that disturbs concentration in flying & if it is avoidable, can it be minimised?

3. INDIAN PILOTS ARE GETTING OBESE.
Most Indian domestic pilots these days are noticably obese reflective of overeating & most likely they indulge in other unhealthy lifestyle too. It is very important that there is strict monitoring of pilots' lifestyle. We dont want them to have a heart attack during their flying duty. They must exercise / walk 8000 steps on 5 days a week at least.

4. ZERO TOLERANCE TO ALCOHOL INTAKE BY PILOTS WHILE FLYING. Even low alcohol content drinks disturb power of judgement. Pilots must undergo breath test before entering cockpit. On & off, we hear of drunk pilots, to our utter disbelief.

6. PILOTS MUST HAVE PROPER SLEEP & THEY SHOULD NOT HAVE TOO LONG FLYING HOURS AT A STRETCH. COMPENSATION BY TIME OFF TO CATCH UP / MAKE UP FOR SLEEP DEPRIVATION SHOULD BE MANDATORY. Sleep studies for sleep apnoea / other sleep disorders by pilots must be mandatory & these should be undertaken on periodic basis.

5. REGULAR GENERAL HEALTH CHECK UP INCLUDING MENTAL HEALTH CHECK UP MUST BE MANDATORY FOR PILOT & OTHER CRUCIAL STAFF MAINTAINING THE AIRCRAFT.
Pilots must undergo periodic physical & mental health check up & make sure that they are not taking any dangerous medications or habituated to any intoxicating substances that may precipitate an error of judgement during a crisis.

It is very important that aviation authorities donot compromise safety of passangers.

6. MONITORING OF ALL OTHER CRUCIAL STAFF IS A MUST TOO.
Even the performance of other crucial staff like engineers, technicians, security staff, luggage handlers / porters, mechanics & all staff who go to close proximity of the aircraft, are also to be scrutinised on daily basis. OCCASIONALLY WE COME ACROSS STAFF AT THE ENTRANCE OF THE AIRCRAFT RESPONDIBLE FOR CRUCIAL DATA ON A MONITOR, IS DEEPLY ENGROSSED IN HIS MOBILE GAMES. Its unacceptable.

Indulgence in mobile games or gossiping amongst themselves by crucial / supportive staff of aircraft during duty hours is one of the most dangerous habits that is often noticable by passangers boarding a aircraft.

FLYING IS A SERIOUS MATTER & REGULATORY BODY MUST NOT COMPROMISE EVEN 1% IN SAFETY MATTERS.

https://m.facebook.com/story.php?story_fbid=10160279349313580&id=111445058579&mibextid=Nif5oz

Two pilots have been de-rostered after they were found celebrating while on duty last Wednesday, a spokesperson for the airline said. Both pilots placed a glass of adn on the center console of the flight deck in the cockpit

Read more https://www.hindustantimes.com/india-news/spicejet-de-rosters-two-pilots-for-celebrating-holi-inside-cockpit-101678942771240.html

FEBRUARY 2ND IS THE INTERNATIONAL RHEUMATOID ARTHRITIS (RA) AWARENESS DAY.

Here are responses to FREQUENTLY ASKED QUESTIONS:

1. What is Rheumatoid Arthritis?

It is an autoimmune disease affecting primarily the joints but it can also involve multiple other organs or systems in the body. It affects approximately 1% of population.



2. What causes RA?

Exact triggering event for the autoimmunity is not known; there may be environmental injury (like smoke inhalation) in a genetically susceptible individual. But the pathological processes are fairly well known, which help us to treat the disease.



3. What happens in Rheumatoid Arthritis?

The immune systems which normally fights external invasion by bacteria, viruses etc behave erratically in Rheumatoid arthritis and tends to fight one's own healthy system including the joints.

In other words, the immune system losses the capacity to differentiate self from non-self in Rheumatoid Arthritis.



4. Is it curable?

Rheumatoid arthritis is an incurable disease; but this should not frighten the patient; because, hypertension and diabetes are also not curable. Just like hypertension and diabetes, regular treatment started early should control the disease to a large extent. In fact, at times, patient may feel as if they are cured; but the treatment has to be continued lifelong with close monitoring by the treating doctor. Only less than 10 % of patients, if lucky can stop treatment for ever.



5. What are the treatment modalities available?

The disease modifying drugs are many; one of the most popular, effective combination is that of Sulphasalazine, Methortrexate and Hydroxychloroquin. They can be easily monitored by blood counts, blood for Liver function tests and eye checkup (HFA, OCT, ERG and not usual tests for refraction or fundus alone). These medications are well tolerated, time tested and being used by large majority of the patients of Rheumatoid Arthritis. There are other alternatives that can be worked out in an individualised manner by the treating Rheumatologists, if necessary from a big list of other medications. Biological agents are expensive but effective.



6. How frequently patients should come for follow up?

Initially every month for at least 3 months & thereafter, once in 3 months as per the guideline, we follow.



7. Is there any role of diet?

No food can cause Rheumatoid Arthritis; similarly no strong evidence is there that any diet can control Rheumatoid Arthritis significantly; however, Omega 3 fatty acid present in fish, has got a mild protective role against inflammation, as well as against Cardiovascular complications. Most spices in Indian diet have positive benefit in inflammation. Restrict saturated fat.



8. Is it hereditary?

It is not truly a hereditary disease as it does not follow Mendelian inheritance; however, there is a likelihood that some of the offsprings of patients with Rheumatoid Arthritis may have some form of autoimmune disease or just harbour some autoantibodies (like rheumatoid factor) in their blood without any overt disease.



9. What is the cost of treatment?

The triple therapy mentioned above may cost less than Rs. 1500/- (≤ USD 20) per month in India; but even Methotrexate alone can give good response and it costs not more than Rs. 100/- (≤ USD 2) per Month.





10. Is there any role of alternative system of Medicine?

As far as evidence based medicine goes, there is no data to support this. Infact, unpredictable harm done by the unknown agents is often that you will see in real life Including heavy metal poisoning, crude steroids related toxicity, bone marrow suppression, renal failure, neurotoxicities. These are often noticed in patients taking so called 'natural therapy' and can pose confusing picture for the treating physician. Don’t be & donot let others victims of unscientific traditional medicines.



11. Do the drugs used in Scientific medicines have the side effects?

Yes. There are no medicines without side effects; but all side effects by the scientifically proven medications used to treat Rheumatoid arthritis are known to us and we can monitor them before any major side effects can happen. Also you should know that all forms of medications including traditional ones have side effects too & can be unpredictable in traditional medicines as they are not studied.



12. What are the other modalities of treatment apart from drug therapy?

Short term benefit with intra articular steroids, short term courses of NSAIDS (Non- Steriodal Anti Inflammatory Drugs) are also needed at times especially during active phase of disease. There is important role of physiotherapy, occupational therapy, Podiatry and in advanced disease with damage, joint replacement has got very good role to play for improving quality of life. Joint replacement surgeries are safe & effective.



13. When is steroid needed for Rheumatoid Arthritis?

Steroids are often misused in Rheumatoid Arthritis. High dose steroids are needed only for Vasculitis, ILD (Interstitial Lung Disease) and such serious systemic complications. Very low dose steroids (< 9mg/day of deflazacort) can be useful in very early Rheumatoid Arthritis or as a bridge therapy for tiding over a crisis, like an examination. Because these drugs are available over the counter in some developing nations including India, often patients are unable to stop steroids and buy them on their own and this practice spoils the patient's chances of recovery by optimal medications, as they tend to become steroid dependent.



14. Is the life span shortened in Rheumatoid Arthritis?

In an average, life span may be ≤ 5 years shorter than expected and this is often in untreated or Poorly treated patients.

Take care. THANKS

Dr Debashish Danda MD, DM, FRCP, FACR, FAMS

Professor & Founder of the Department

Clinical Immunology & Rheumatology

Christian Medical College & Hospital, Vellore, India

Past Editor in Chief, International Journal of Rheumatic Diseases (2012-2018)

Past President, Indian Rheumatology Association (2017-2019)

President, Asia Pacific League of Associations for Rheumatologists (APLAR) [2021-2023]

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