Dr Nilesh Nolkha
@nileshnolkha
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Opinionated Doc | Rheumy | Striving to bust arthritis myths (mostly Indian) & restore faith in Indian docs
Kandivali West, Mumbai
Joined June 2009
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Ok i am a modern medicine doctor & will try to answer. First understand that modern medicine talks of healthy lifestyle for almost every disease - everyone should eat healthy, exercise, meditate etc. Lets also first rs understand the problem with these questions (Qs).1
मैं इंडियन मेडिकल एसोसिएशन व फार्मा कंपनियों से विनम्रता के साथ सीधे 25 सवाल पूछता हूँ-
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So, as per news, two treatments will be launched in near future in India for covid
1 is favipravir, so called 'allopathy' drug. 2nd is 'coronil' a ? herbal drug by patanjali. I have serious problems with both. Plz read thread to understand the major issues
..1
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#Medtwitter
#India
#familymed
#rheum
Stop doing following in your practice
1) Checking uric acid (UA) level for every joint pain
2) Giving meds to lower UA without gout
3) Giving un-scientific advice to stop dairy,curd,dals,non-veg etc to patients with raised UA or gout (1)
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Question to Indian nephrologists : Most Indian patients are predominant vegetarians & do not have 0.6-0.8 mg / kg protein / day, which I understand is upper limit for CKD patients. I often see that intake being further restricted 4 CKD patients. What am I missing here ?
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Even in a busy suburb of Mumbai a MBBS gp can earn much more than any specialist. Youngest MBBS gp is 42 year old in my area. Young MBBS gp is a rarity and with right mindset can start earning like a Super specialist without going through additional (& shitty) grind for 8-10 yrs
MBBS Doctors will struggle for jobs within next 10 years !!
Note It.
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So both companies will make huge profits without any solid evidence of of benefits. No system is perfect, but in India we can bypass all protocols if we have right contacts. This kind of 'jugaad' in healthcare severely harms patients, both financially and medically. .9
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@isw_alt
Hmm are we judging mom here ?
In most such cases mother is handling the kid rest of the day, or multitasking many other things which husband may not be handling. Also as an office goer, especially with travelling, the husband may be able to bond with child only while going to
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Favipravir is supposedly approved for restricted use, in mild to moderate covid patients, based on research which is not published or not in public domain. Any research should be out in open so that doctors and scientists can critically review it..2
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One of the biggest cause of sudden liver abd kidney failures any part of world is herbal or natural therapies which were considered 'to have no side effects'. Atleast in llopathy we admit of posible side effects and try to do research on preventing or minimising those ..8
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It’s funny. Despite being a rheumatologist, I end up stopping drugs to lower uric acid everyday in my practice more than giving new prescriptions to start same.
#uricacid
#arthritis
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New beginnings. Long way to go. But glad to receive blessings of father future in rheumatology : The great ‘Dr VR Joshi’ sir, after approval of DNB Rheumatology in Nair hospital.
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...even if we are desperate, couldn't company of Glenmark size do a good trial and publish it before releasing drug ? The course of favipravir will cost per patient 7000 rupees !! Appears more money put in doing ads of it then publishing research on it ..3
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Herbal & ayurvedic drugs should also be subjected to proper research, both to prevent looting of public & also to know any side effects. Just believing people who are releasing the drug that it is safe is not exactly the right way. It's a big lie that herbal therapies are safe.7
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Even in allopathy ( a wrong word, proper word is medicine based on evidence) we use products derived from plant or which were discovered from plant or biological source. But we do proper research and try to find solid evidence before using it in masses..9
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'Coronil' problem is worse. As I know, no safety approvals required for herbal therapies in India. Being safe and actually working is 2 different things. 'hamne fayda paya hamari research mein' iska matlab nahi ki aap sahi the. Sellers have big conflict of interest in claims.5
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This is the state of rheumatology awareness in India 😂
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Even if 'coronil' is safe, but not effective, it will give a false security to pts & may delay seeking proper care. Rt now most corona patients who come early can be saved without any wonder drug...6
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We are releasing a drug which is only studied in ?150 corona patients (pts) and that too we don't have acess to results of study. What about side effects, manipulation of data ?? There are so many problems if you try to fast launch a drug without proper published data..4
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Are you seeing a lot of patients with Chickungunya or post viral arthritis ?
Here’s a primer on how to treat same (feel free to post queries and please retweet for awareness)
..1
#MedTwitter
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For all docs in India: Plz don't continue routine opd care & elective surgeries. Stop all non essential work. We will be called in dire situtn & that would put us & our family at more risk. Contribute to social distancing right now
@omlakhani
@docbhooshan
@DoctorLFC
@Prav2405
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In india patient’s perception are just fixated on results. Even most educated ones fail to understand the unpredictability of medical science. Irrespective of outcome, in western countries, the ratio of being thankful if you explain them properly, is much higher.
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Be scared of a patient who says ‘aap to Bhagwan hai’ ;).
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Sincere advice to all budding doctors
Not every patient complain needs to be treated.
If you don't find anything major on evaluating patient complain, relieving their anxiety and reassuring might be only thing needed.
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For most issues, it’s far better to have a sincere doctor rather than a brilliant doctor 🙂
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Don't like word allopathy. What we use is evidence based medicine (EBM) which keeps on changing as we get better research. Also do understand that baba is not trained ayurvedic doctor. Now let's answer.3
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Even in severest of heel pain (plantar fasciitis) injection in heel should be considered as absolute last choice of treatment.
Haven’t injected a single heel pain patient in last 3-5 years.
Most focus should be on anti-inflammatories, physio and exercises.
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Can relevant person retweet this. Looking for medical students (mbbs preferably, any one beyond 2nd year), looking to write online health blog articles. They will be paid per article basis. Can dm me.
@stethospeaks
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You r right to criticise that doctors make you wait despite appointments. Read this thread plz. I am a super specialist & our consults take more time (10-20 mins or more ). Even after reserving 5-7 extra slots per day,I will end up seeing 5-6 patient over that for urgencies..1
Doctors in Mumbai.
Secretary: You have an appointment at 12:30pm tomm but you might have to wait 30-45mins
Me: so then give me a time where I won’t have to wait so we respect each other’s time.
Sec: That won’t be possible. 🤣🤣
Me: Cancel my appt. 🤷🏻♂️
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4) Randomly checking ANA’s without context
5) Doing X-ray to detect bone spurs for plantar Fascitis
6) labelling every patient with chronic pain as psychosomatic
7) Treating every joint and body pain with medicines (2)
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Modern medicine does of healthy lifestyle to reverse atleast some of above diseases in early stages. Unfortunately for severe diseases, we have to give some form of medicine. Baba has smartly tried to frame Qs in a way which makes people think that we give meds for everything.2
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Q2. Type 2 diabetes (DM) can be reversed with good lifestyle in almost 30 % cases. Many people don't follow or need drugs. Type 1 DM occurs because body is unable to make insulin There is no cure for type 1 diabetes even in ayurveda & not taking insulin may kill such patients.5
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Dietary protein restriction is not required for any arthritis (even gout) patients.
That’s it. That’s the tweet.
#arthritis
#protein
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Success story of a patient with rheumatoid arthritis, obesity and how we avoided early knee replacement
Ms Mamta (centre in pic) came to us in a bad shape. Her knee was severely arthritic, she was suffering from obesity and was advised knee replacement at 46 years of age.
We
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Q1. EBM doesn't have permanent solution, but has very good meds to control bp & avoid complications like heart attacks & stroke. Healthy lifestyle, low salt is recommended. Many ayurveda docs take bp medications lifelong. Even ayurveda doesn't have permanent solution for bp.4
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There is nothing called allopathy. That’s it. That’s the tweet :).
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Q5..Liver cirrhosis means irreversible state. Cant reverse or cure all diseases Baba's questions are very stupid. None of the diseases he questions IMA about, is simple or has a simple cure in ayurveda. Also liver damage due to ayurveda is a real issue. Follow
@drabbyphilips
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Q3. Thyroid deficiency also doesn't have permanent cure in ayurveda or modern medicine. Please do understand that many people who claim that have hypothyroidism cured by some pathy never had it (got an incorrect diagnosis due to some reason) & so medicine was not needed. 6
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Heart wrenching message from doctor friend 4m interiors of Maharashtra
Relativs search mst serious patient in ward, who might die, wait & book bed for their patient before body is packd
Ask everyone around you to get serious if they haven't
Mask up / sanitise / get vaccine
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We see at least one patient a day
who has positive RA factor and we say that you don’t have Rheumatoid arthritis. You probably just need exercises and we will see if anything new develops.
Positive RA factor alone doesn’t mean you have Rheumatoid arthritis
#rafactor
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Anybody taking this in your family ?
Stop and show a good rheumatologist #
It definitely contains steroids. Confirmed by pharmacology department of a renowned medical college in mumbai.
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25 year old patient who is almost bedridden : ‘I did not want to take allopathy treatment for rheumatoid arthritis as I have heard it has many side effects’’
Irony :(
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1/2 in last 2-3 days mumbai govt has come up with bizzare rule of not testing patients who have either cough, cold or fever (and asymp pts). They want all 3. Techi of pvt labs refuse to collect sample too, because of strict directives.
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I am a rheumatologist, a physician, not a surgeon
But
- if you are above 60
- not overweight
- have really bad knees (mobility wise, daily activity wise, cartilage or knee structure is grossly damaged, knee is getting bent etc)
- no major comorbidities (no major lung ,
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Q4 & Q5 Baba's many questions are stupid. Many types of hepatitis get better on its own. Many types of hepatitis like b and c has advanced so much that virtually every patient is prevented from having any cirrhosis with proper meds..9
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..This used to happen even with best of ayurvedic drugs which hasn't changed since ages. EBM in last 30-50 years given brilliant medicines to completely control RA with amazing results. There is no cure of such diseases in any pathy.
Read this
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1...During monsoons, in mumbai government hospitals like kem / sion hospital etc got flooded with malaria, dengue patients etc with a significant number having severe lung injury like seen in covid. The whole system used to be overburdened....
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Q17
@omlakhani
baba ke liye hormones ki class leni padegi. Babaji body is not that simple, that we switch on a button by eating some 'jadibutti' and voila ! we got good hormones...In mumbaiya langauge 'aapke basics mein raada yaa locha hai'...let's give you example..23
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Commonest myths about arthritis in India
- Raised uric acid is bad and causes joint pains
- All arthritis or rheumatism are of same types
- if I stop sour, fermented and non-veg food, my joint pains will go away
- Exercising will cause more harm to joints
- even if my knees
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Disheartening to see young 20 year old girls dying due to sle / lupus because of widespread misinformation and delayed treatment in today’s era. More disheartening to see patient discontinuing treatment and dying despite heart to heart counselling sessions.
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...Smoking cause side effects, may cause cancer, but all smokers do not develop disease. Somebody is advised stenting or bypass surgery based on risks. Just because they survived without surgery or stenting, doesn't means EBM was wrong. He / she took a risk, their choice.12
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@brahmin_naughty
@DrShauryaGarg
@avirajsingh
Govt benefits from medical students
Every govt college runs on medical students
Who stay in cockroach infested rooms
With pathetic canteens
With double duty hrs and sometimes inability to take bath for 2-3 days
Seeing patients loads 10 times more than what a normal human
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Q3. Many arthritis like OA may just need weight loss & exercises. Many like rheumatoid arthritis (RA) are very severe & till 30-50 years back patients used to develop deformities, get bedridden or die due to complications.. 7 cont..
Pic cred
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How much ever I try, Indian doctors (even super
#specialists
) find unproven explanations to give uric acid lowering tablets (ULT) for high Uric acid, when there is no clear proof of benefit.
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@avinashs11
@suchetadalal
Arre bhai, with all due respect to rakesh sir and without being unaware of circumstances, 80 percent of your health is in your hands. No doctor can save you if you have had years of unhealthy lifestyle.
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Looking at the discussion, most nephrologist are aware of this and don’t restrict plant based protein. I guess onus lies on many of us to tell patients that blanket protein restriction may harm and collectively need to clear misconceptions.
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@autopsy_surgeon
Darao mat yaar baccho ko,
Those who have entered medicine
Don’t worry
It’s a long ride
But you will be still far better than many other professions
Also if you push, there are opportunities all over the world
Countries like uk have a modular way of working and can give
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There is no conclusive evidence that these things aggravate or cause arthritis
Curd, lemon, tamarind etc
Dairy products
Wheat
Protein food (including meat, chana dal, legumes, sprouts etc)
Fermented food (pizza / Dosa / idli)
Cabbage
Let’s break myths
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Q6 & 7 Again stupid questions. Not every blockage we treat, is done by stenting. In many heart blockages we recommend healthy lifestyle and may give drugs to lower bad cholesterol / blood thinners (especially if patient has high risk of heart attacks)..cont.11
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Have you been diagnosed with Rheumatoid arthritis (RA) ?
Relax
Yes
👉 It’s not curable, but it’s very treatable
👉 Most patients develop deformities ONLY IF no proper treatment is received
👉 You may need lifelong treatment, but good treatment can give a very good quality
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Q25. Really baba, really kitna gir jaaoge aap ? Kya hum bimmar bhi nahi ho sakte ? Does baba never get ill ? Does his balkrishna guy never fell ill ? Aims mein kaun admit hua thaa ? It means people practicing perfect baba policies will never fall ill ?.31
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Q.14 Parkinson disease (PD) is very severe neurological disease with no permanent cure in any pathy. Ask any PD patient on how dramatically they respond to even 1 dose of some excellent modern medicine. Before they were discovered ayurveda hardly offered any hope..19
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..Babaji L, who discovered Parkinson's disease lack of dopamine in certain brain cells? Who discovered that increasing dopamin levels to these cells you can make dramatic difference to PD patients? Who discovered that deep brain stimulation can help these patients? It was EBM.20
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....The only way to answer Q8-10 is let baba ramdev show any good , strong research related evidence to show that he can reverse high glass number or severe deafness with ayurveda ? Are indian people that mad to use glasses when ayurveda can reverse it ?..16
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One of the biggest myth regarding arthritis in india and very much propagated by doctors.
‘’Excess protein or meat in diet propagates arthritis or a patient with arthritis should avoid protein’’
This is absolute bullshit. For more read this blogpost
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Q15 & 16..Half of India is being treated by modern medicine with minimal or no side effects for heart burn , acidity etc. Are we perfect ?...no. Is judicious use of these medications safe?..hell yes is answer to your question..21
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When I ask people to lose weight for arthritis / rheumatic pains / overall health
Standard response is ‘hum to kuch khate hi nahi’
Then i start going in depth and explaining them calories (see the last one 🥲)
Inspired by
@sibalsahab
1 roti ~ 100 calories (may vary a bit
Success story of a patient with rheumatoid arthritis, obesity and how we avoided early knee replacement
Ms Mamta (centre in pic) came to us in a bad shape. Her knee was severely arthritic, she was suffering from obesity and was advised knee replacement at 46 years of age.
We
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...Is there one type of migraine ?.. no. Do all migraines need continous medications..? ..no. Is migraine a continous disease ? ...No. Does simple migraine need too .any drugs...no ? Can ayurveda treat complex life debilitating migraine ?....no..15
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..Is there limitation in treating insomnia in modern medicine ?...Yes. Hamne kab bola ki ham perfect hain ?. Does insomnia always require medication?...no. Does ayurveda have perfect insomnia medication..no it doesn't. To phir aapka question kaa uddeshya kya hai ?.22
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Q12, Q13 After framing first 12 questions, baba lost it. He forgot that psoriatic arthritis & ankylosing spondylitis are autoimmune diseases and are types of arthritis (a question he raised earlier and I answered). Psoriasis and vitiligo are also autoimmune diseases..17
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Dr Ankur Jindal Pediatric rheumatologist from Pgi Chandigarh awarded the Ira young orator
@IRACON_2022
. He spoke about his work on juvenile scleroderma, antibody deficiency disease, hereditary Angioedema and most importantly Kawasaki disease.
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Q18 Does ayurveda hv treatment of infertility? You have made an insensitive remark of couples who were not fortunate enough to conceive. You have also made joke of all those born by test tube method. Also do you mean these people never tried ayurveda ?..25
To cont..max 25 thread
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Q21 Why this 'kolaveri di ;) ? Is modern medicine bad because we cannot make a person humble or less angry with medicines ?. Kisne claim kiya ? Humne kab bola ayurveda is all bad or we are perfect? Baat ghumana sikhaaya kisne apko ?.28
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A big headache for doctors now-a -days
Online portals doing a battery of tests not asked for, reported in stupid designer formats with adverts for high margin supplements
- Worsens doctor focus
- Takes more time to go thru
- Creates unnecessary anxieties
- Report quality ??
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Recently in our hospital a person lost life due to covid. Age less than 54. Younger brother died earlier. Mother on ventilator and one more family person on ventilator. Just can't imagine what their world must be. All within 15-20 days. We shouldn't scare. But this is scary.
Family of 3: 90 y/o lady infected with COVID19, admitted & passed away. Next week, her son & his wife admitted.
Today, the lady was discharged & her husband expired. Her world turned upside down in 15 days.
This hits harder when it's at your doorstep. Don't let your guard down.
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Q20. So iron tablets are not good ? Don't we advise iron rich foods for all people with low iron and hemoglobin ? Means all government centres giving free iron to pregnant ladies should stop it ? Did we says low hemoglobin always need tablets ? Why ask this question ?. 27
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Modern medicine is based on best scientific methods. We don't care what is origin of therapy as long as it is backed by solid research (not 'fair & lovely makes you fair' type research). The EBM practicioners don't deserve the constant negative commentary. Thank you. End
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Note to qualified practitioners of modern medicine
Medicine is probably only field where quacks, charlatans, unethical practitioners, unproven therapy practitioners, etc can consistently surpass or match qualified practitioners (even those with multiple degrees and 15-0 year
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Q8, 9, 10 I don't understand how do you answer to a wrongly framed question. How do you explain a complex concept of migraine on which books are written in one tweet ?..14
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Every nephrologist prescription I see contains an uric acid lowering medication for CKD patients with Hyperuricemia (without gout)
Is the jury out on this one ?
Q to Nephrologists ?
@tukaramj
@sultan_amar8
#MedTwitter
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Q19. So aging process can be reversed ? Really. We might be stuck with one head of state forever. Jokes apart, besides healthy lifestyle iss there anything which can slow aging? Does baba thinks that healthy lifestyle comes only under his purview & we don't advise it ?.26
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..one hormone you have in body is cortisol & it is released more during stress. Despite being a stress hormone it may be good ! You know, it is a type of steroid (yes a steroid, our body releases steroids!). Did you understand how complex body is ? Leave it,u didnt read theory
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..as said we keep on evaluating risk factors and advise patient treatment based on risk factors for heart attack. The first advise to each such patient is to stop smoking, eat healthy and exercise. How is EBM wrong in such approach ? What does ayurveda do better ? 13
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Q22 Did somebody in modern medicine claim to cure all addictions ? I don't think so. Last 5 questions baba made up to make it 25. I think baba lost medical dictionary by question 20. Asking philosophical questions thereafter ;).29
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Unless the governments constantly bombard the public about carb restriction, high protein diet and physical activity,make it a mandatory subject in school, we Indians are going to have a really tough time ahead. I assume, in most clinics, almost 50 percent of issues are obesity
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@suchetadalal
@CMOMaharashtra
@PawarSpeaks
@priyankac19
@prithvrj
@AUThackeray
@mybmc
When a doctor gets trained in most indian government hospitals, the system goes all out to strangulate every good vein in that doctor's system. Most do not want to do anything with govt healthcare in the future. Thank you
@CMOMaharashtra
for continuing the same trend.
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Self certified Naturopathy guy gave 20000 meds for an incurable condition , for which 5 international doctors have said no treatment is available. The patient and relatives know it for 10 years. Amazing. I believe we should take tips from these guys on how to earn.
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For q12, Q13 will direct to links I and have written..18
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6. To general public : May be when and if this gets over, we should collectively demand better public health care. No health worker should go through guilt of not being able to save patient due to lack of resources...end
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Sorry, but you are missing the point here on uric acid levels & Rx
1) The risk of developing gout even in patients with raised UA is very low
2) We can always start UA lowering therapy once gout develops…1
Read this 👇
@nileshnolkha
Higher levels of UA are associated not only with gout, so why i shouldn t give medications in order to lower UA levels?🤔
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Q23 God only knows why ima needs to answer and I have no answer. Q24, baba should have been made committed head to generate oxygen, nobody would have died. Otherwise IMA or modern medicine people never discouraged any breathing (even yoga) or other exercises which may help. 30
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@ActorMadhavan
Awesome sir. Just one word of caution. You would have lost muscle too sir when you lose weight without strength training. If unfortunately you gain weight again it may be only fat. These cycles can lead to great amount of muscle loss.
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@DiariesDr
Not sure what’s your background is. All my degrees are from govt institutes. But I don’t agree with your pov. Institute May have a role, but ultimately it’s what’s you make of your knowledge and how you approach and improvise is what makes ultimate difference.
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I have a rheumatology joke, but we need to wait until 6 weeks ;)
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My take
Being a rheumatologist, I see a lot of pain, including back ache. In my diagnosis and prescription I always write relevant exercises needed. Patient also given Physiotherapy references and videos from 1st visit. We also give basics on diet to increase protein intake
If this is happening in teaching hospitals, imagine what kind of training medical students are receiving?
As doctors what can be expected from them but over prescription and over diagnosis if that's what they are taught?
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Are you above 35-40 ?
Started having knee pain ?
Especially after prolonged sitting or climbing stairs ?
This is mostly EARLY OSTEOARTHRITIS
It’s high time you do following 👇
☑️ Get vitamin d checked. If low, get supplement
☑️ Maintain adequate calcium intake. Check your
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It’s actually not good to argue with morons. Many have commented in the quoted post that doctors don’t get all the fees. That’s not the point.
In a free economy, why shouldn’t a person, who has studied for 15 - 20 years, be able to charge a decent or for that matter any fee ?
@sambhavhanu
@angryoldman27
I understand but the Doctor will do this Operation for 1000 of patients not just one.
Of course they can charge a good amount but what is the sense in charging Lacs for just 2-3 hours of man work?
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@epicnephrin_e
Please take some time off social media
Constant news of apathy will burn you out
Delete social media apps for a week
You have done your bit
Many others are carrying on the torch
You need to get off the grid
Take care
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Finally..I don't mean to demean ayurveda. However blind faith (without research) of a particular guy (with huge conflict of interest) can be very harmful. Ayurveda principles may have role in preventing many diseases by promoting healthy living...32
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Still my assistants are trained take it on their chin & be empathetic. A lot needs to improve with regards to patient expectations and behaviour before putting blame squarely on doctors and their assistants for waiting time and behaviour..8
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