The Professional: Health Magazine for Physicians
When an add-on asthma medicine
The Professional
Health Magazine for Physicians
Volume-2, February-2022
Editors
Dr. Shihan Mahmud Redwanul Huq
Dr. Mahiuddin Ahmed Dr. Tawfiq Aziz
Dr. Safiqul Islam Dr. Md Al-Sadi
Why this magazine?
The articles in this magazine are practical,
short, unique (plagiarism checked), science-
based and peer-reviewed. They are written
by expert practitioners of their respective
fields using clinical practice guidelines and
practical experiences. Here, we will NOT
publish scientific research on medicine but
will publish a summary of practice
guidelines, case scenarios, expert opinion,
day-to-day problems & pitfalls in clinical
practice.
We dedicate our entire project to young
practitioners who will replace us for the
better and serve humanity with more
dedication and precision. We expect and
welcome your participation in this project.
Contact: drmahiuddinahmed@gmail.com
www.facebook.com/groups/theprofessional/
2022
replaces the backbone of asthma
management in Bangladesh:
Montelukast
Author
Dr. Mahiuddin Ahmed (consultant &
associate professor, internal medicine)
The backbone of bronchial asthma
management has always been inhaled
corticosteroid (ICS), whether the delivery
system is a metered-dose inhaler (MDI)
with a spacer or a dry powder inhaler. That
is because asthma is a chronic inflammatory
disease of the airways where the
inflammation is persistent even when
patients are asymptomatic.
Currently, GINA recommends Formoterol
plus ICS combination in all cases of asthma.
This combo is known as ‘MART’ therapy
(maintenance and reliever therapy).
Formoterol is a fast-acting LABA and has
dual advantages (1) it acts as maintenance
LABA and also (2) acts as a reliever during
worsening asthma.
Thus Formoterol plus ICS combination
makes asthma management quite simple
and cost-effective. Prescribe twice daily
MART in optimum dosage for regular
preventive therapy and ask patients to take
additional doses during an exacerbation
(Asthma Action Plan). Traditional
prescriptions of two types of inhalers (blue
inhaler and pink inhaler) are quickly getting
outdated.
The big question is, why do I need to
continue regular inhalers when I don’t
have any symptoms? The answer is, regular
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 The Professional: Health Magazine for Physicians
ICS+LABA significantly reduces the risk of a
severe life-threatening asthma attack.
Titrate ICS+LABA dose from low to medium
or medium to high to maximize efficacy.
We can prescribe Montelukast in two
circumstances (1) as an add-on when
ICS+LABA alone is NOT effective or (2) when
patients refuse to use MDI or DPI (inhaler).
Unnecessary prescription of Montelukast
leads to (1) inadequate asthma control and
(2) poor compliance to ICS+LABA.
If Montelukast is that good to control
asthma, a qualified medical practitioner will
never need to manage asthma patients in
our country. Pardon for being sarcastic.
We will not write anything about
‘Doxofylline’ in this article which is
surprisingly popular in Bangladesh but ‘NOT
yet established’ elsewhere. Besides, adding
Montelukast and Doxofylline will triple the
cost of asthma management needlessly.
Instead, why not practice ‘STOP smoking’
and ‘annual Influvax Tetra’ in addition to
MART?
Practice Tip: Written Asthma Action Plan
(simplified)
Everyone with asthma should have an
Asthma Action Plan in writing. It includes (1)
medicine, (2) recognizing when symptoms
get worse, and (3) what to do in an
emergency. Here is an example.
When asthma is under control-
Formoterol+ICS MDI (+spacer) or DPI twice
daily continue regularly. Rinse mouth &
throat after use.
Annual Influenza vaccine (September or
October)
DO NOT smoke (for smokers)
2022
Follow asthma action plan during
worsening asthma (increasing cough,
wheeze, breathlessness, or peak flow
reading<80% of personal best).
Formoterol+ICS regular twice-daily dose
continue (maintenance)
Formoterol+ICS extra-dose when symptoms
(reliever) or short-acting bronchodilator
(SABA) like salbutamol as per need
Still symptomatic? Add
Prednisolone 40 mg once daily morning for
5-7 days
Still NOT better?
Call the emergency: contact number
(clinic/hospital)
Say 'NO' to Ciprofloxacin plus
Metronidazole combo in treating
acute gastroenteritis (AGE)
Author
Dr. Safiqul Islam (consultant, internal
medicine)
Prescribing antibiotics in AGE creates a false
perception of its benefit among physicians.
Numerous research concludes almost NO or
little benefits of antibiotics in AGE. Adverse
effects, cost, and resistance risk outweigh
any benefits of its use in diarrhea. For the
past ten years, we hardly prescribed any
antibiotics in AGE in our practice. AGE is
self-limiting and will improve regardless of
taking any medicines. Oral rehydration, soft
diet, zinc, reassurance, and patience for one
to three days are enough to manage AGE. In
selected cases, azithromycin (or
doxycycline) is recommended (see
below). Lack of awareness among the
doctors may partly explain the widespread
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 The Professional: Health Magazine for Physicians
and needless practice of ciprofloxacin plus
metronidazole combo in our country.
Let's check the causes of AGE at a glance-
ONE AGE caused by viruses (most common)
1. Rotavirus 2. Calicivirus 3. Adenovirus 4.
Astrovirus 5. Norovirus
Self-limiting, NO role of antibiotics.
Increased risk of antibiotic resistance and
adverse effects (weakness, headache,
antibiotic-associated diarrhea).
TWO Food poisoning (common) by pre-
formed bacterial enterotoxin 1.
Staphylococcus aureus 2. Bacillus cereus 3.
Clostridium spp 4. Campylobacter spp 5.
Salmonella spp 6. Shigella spp
Self-limiting, NO role of antibiotics.
THREE AGE by non-invasive bacteria
(uncommon) 1. Vibrio cholera 2.
Enterotoxigenic E. coli 3. Enteropathogenic
E. coli
Self-limiting. NO role of antibiotics in most
cases. Azithromycin and doxycycline are
indicated in cholera (rice watery diarrhea),
severe cases, very young, and in frail
elderly.
FOUR AGE by invasive bacteria (rare) 1.
Shigella spp. 2. Salmonella spp. 3.
Enterohemorrhagic E. coli 4. Enteroinvasive
E. coli 5. Campylobacter spp.
Azithromycin is recommended.
Ciprofloxacin may paradoxically increase
toxin production and may precipitate
hemolytic-uremic syndrome in children.
2022
Protozoal diarrhea is very rare when the
duration is less than two weeks. Prescribing
Metronidazole in AGE is unnecessary. It
causes mild constipation and creates a
false perception that it is beneficial in
AGE, but it is NOT. Let's stick to the basics
of AGE management (ORS & fluid-
electrolytes management).
We should manage all admitted patients
with AGE as severe cases until proven
otherwise. That may partly explain more
antibiotic prescriptions in IPD.
The secret of prescribing medicine in
heart failure: Dose Titration
Author
Dr. Shihan Mahmud Redwanul Huq
(associate consultant, internal medicine &
critical care medicine)
Heart failure (HF) is one of the most
devastating chronic conditions that a
physician has to manage in practice. We are
all familiar with the medicines for chronic
HF like diuretics, ACEI or ARB, beta-
blockers, and digoxin. Among them, only
three have long-term mortality benefits (1)
ACEI or ARB (2) beta-blockers, and (3)
spironolactone.
Loop diuretics are very effective to treat
symptoms of HF like pulmonary edema and
dependent edema. It also reduces heart size
and hospital admission frequency, and is
considered an essential part of the
treatment protocol when congestive
symptoms are present. However, loop
diuretics and digoxin do not have any
mortality benefits in heart failure. Digoxin
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 The Professional: Health Magazine for Physicians
has very limited use in HF (except in HF
with atrial fibrillation) because of its safety
issue, cardiac toxicity, and needs for
expensive follow-up (frequent follow-up,
electrolytes, drug level) and then, NO
mortality benefit.
Frusemide is short-acting, so consider
twice-daily dosing (8 am, 4 pm). An
additional bedtime dose may require
occasionally if nocturnal dyspnea occurs
despite regular dosing. Dosage ranges from
20 mg daily to 600 mg daily. Switch to
bumetanide when oral absorption of
frusemide is not satisfactory. ACC/AHA
recommends low-dose spironolactone (25
mg to 50 mg daily) in HF. DO NOT prescribe
it if baseline K level>5. Switch to Eplerenone
when painful gynecomastia or loss of libido
is a problem.
Prescribe an ACE inhibitor to every patient
with HF if baseline K<5. Starts with a low
dose, like Ramipril 2.5 mg once daily, then
titrate and aim for maximum tolerable dose
(10 mg daily) unless hyperkalemia or
hypotension occurs. Switch to an ARB if
persistent dry cough is reported.
Prescribe a beta-blocker like carvedilol or
bisoprolol to every patient with HF. Starts
with a low dose say 1.25 mg bisoprolol
daily, then titrate and aim for maximum
tolerable dose (10 mg daily) unless
bradycardia or hypotension occurs. It is
essential to check pulse rate before
prescribing a beta-blocker to any patient.
DO NOT start in acute HF or acute-on-
chronic HF where hypotension is present or
HR<55 bpm. Beta-blocker is recommended
in chronic HF patients with co-morbidities
like COPD and asthma (but optimize
asthma/COPD management). Metoprolol
2022
XR, bisoprolol and nebivolol have
convenient once-daily dosing in contrast to
carvedilol, which explains their more
frequent use in practice. Besides,
polypharmacy is an important issue in HF
prescription and we all want to prescribe
once-daily medicine to keep the drug list
simple and attractive to our patients.
Check urea, creatinine, and electrolytes at
every visit. Don't forget to limit salt intake.
Ivabradine, a sinus-node inhibitor, was
shown in the SHIFT trial to improve
outcomes in chronic HF with reduced
ejection fraction and a heart rate>70 bpm
despite guideline-based therapy. One
should take into account the additional
treatment cost and affordability of the
patient when prescribing Ivabradine.
The PARADIGM-HF (LVEF<40%) and
PARAGON-HF (LVEF 45% or more) studies
have shown that Sacubitril/Valsartan
combination improves clinical outcomes
more than the ACEI or ARB alone in HF with
reduced EF. However, this medicine is
costly, has shown more benefits in women
than men, and is more effective in the
lower end of EF. It is NOT cost-effective in
HF with the higher end of EF (AHA/ACC).
Practice Tip: think again before you stop
diuretics in a patient with chronic heart
failure
Frusemide plus spironolactone combination
is effective and commonly prescribed to
improve congestive symptoms in chronic
heart failure. We have seen many cases
where a first doctor diagnosed HF and
started diuretic therapy with other
medicines. Then after improvement, the
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 The Professional: Health Magazine for Physicians
patient went to a second doctor, a
specialist, who stopped diuretic therapy as
the congestive symptoms are now gone,
chest congestion & cardiomegaly improved.
After the discontinuation of the diuretic,
the patient then again developed
breathlessness, edema, lung crackles and
was required to consult the primary care
physician again. Reluctance to check past
reports and prescriptions (especially at the
time of diagnosis) may partly explain the
situation.
Unless adverse effects, when a patient with
chronic HF remains better with regular
diuretics, think again before you stop it.
Compare these two chest images of a
patient with heart failure taken two weeks
apart. Bilateral pleural effusion, lung
congestion, and prominent lung vascular
markings visualized in the first image before
the start of the diuretic, all of which have
improved after two weeks of treatment
(second image).
Economy class treatment option for
hypertension: Enalapril, nifedipine
SR & Hydrochlorothiazide
Author
Dr. Mahiuddin Ahmed (consultant &
associate professor, internal medicine)
2022
It is essential to calculate the cost of
treating hypertension, as we will be able to
choose cost-effective medicine for our
patients which in turn will improve
compliance.
ACE inhibitors and angiotensin-receptor
blockers (ARB) are the most effective
medicine on the market to control high
diastolic blood pressure. Here is a price
comparison (per tablet) of available ACE
inhibitors and ARB on the market
(Bangladesh).
Ramipril 5 mg, Lisinopril 10 mg, and
Losartan 50 mg daily will cost between BDT
210 and 240 per month (BDT 7 and 8 per
unit).
Olmesartan 20 mg, Telmisartan or
Azilsartan 40 mg daily will cost between
BDT 240 and 360 per month (BDT 8, 10 and
12 per unit). Irbesartan 150 my daily will
cost BDT 975 per month (BDT 32.5 per
unit).
In comparison, Enalapril 5 mg twice daily
will cost BDT 60 per month only (BDT 1 per
unit only). There are no significant
differences in efficacy among the ACEI or
ARB. Dry cough, angioedema, and drug
fever are less likely with ARB than ACEI.
Enalapril is very effective in controlling
diastolic hypertension (the dosage range is
10 mg to 80 mg daily).
Nifedipine SR 20 mg and
Hydrochlorothiazide 25 mg are two other
low cost treatment options for high systolic
BP that costs BDT 21 per month (BDT 0.70
per unit only).
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 The Professional: Health Magazine for Physicians
Practice Tip: communicate with patients
about possible side-effects from anti-
hypertensive medicine
Amlodipine-induced ankle edema is
common. Ask patients not to worry if
edema is mild. Ask for consultation if
edema and ankle pain is troublesome. In a
few cases, tachycardia and palpitation may
occur.
Beta-blockers can cause weight gain and
sexual dysfunction in males. It also can
worsen undiagnosed bronchial asthma &
Raynaud’s disease. Ask for consultation if
any of these happen.
ACE inhibitors can cause dry cough in 1 in
10 cases. Ask for consultation if persistent
dry cough develops or any serious side-
effects like angioedema.
ACEI, ARB, and diuretics all may cause
postural hypotension and dizziness. Advise
patients to stand up from the sitting
position slowly.
Thiazides are the commonest cause of
hyperuricemia and gout. Consider this if
patients develop joint pain.
Footnote: allergy (any medicine especially
thiazides) & drug fever (ACEI and ARB)
The secret of diarrhea-predominant
IBS management: loperamide
Author
Dr. Tawfiq Aziz (consultant & assistant
professor, internal medicine)
IBS can be diarrhea-predominant (IBS-D),
constipation-predominant (IBS-C), or mixed.
Patients with IBS-D frequently seek medical
consultation due to troublesome loose
motion, mucus in stool, abdominal cramps,
and bloating precipitated by anxiety or
stress. An anxious patient with
2022
unremarkable repeated investigations
despite a long history of diarrhea and bowel
problems is classic.
In IBS-D, prescribe a tricyclic antidepressant
at bedtime to control anxiety and stress.
The usual dosage range is 25 mg to 125 mg
per day. Nortriptyline is more tolerable and
acceptable to the patient than
amitriptyline. In IBS-C, prescribe an SSRI and
titrate the dose upward to reach an
effective dosage.
Our patients need to know which
medications work on what, like (1) TCA or
SSRI for anxiety-stress (2) Mebeverine for
abdominal cramp or pain (3) Loperamide (a
weak opioid) for frequent soft stool and
mucus.
During an episode, the usual dose of
loperamide is 2 mg twice daily with an
additional dose after each loose motion
(maximum 16 mg per day). However, twice
daily dosing during maintenance can lead to
severe constipation. Patients may need a
twice-weekly dose or NO dose in between
episodes. So, what should be the ideal
maintenance dose of loperamide in IBS-D?
Ask the patient to tailor the dose of
loperamide to control bowel opening.
Eventually, they will find out the most
appropriate maintenance dose. A
prescribed dose without patient education
invariably leads to constipation or
uncontrolled diarrhea.
A two-week course of Rifaximin is an option
if poor response to loperamide alone.
However, a repeated course of antibiotics
for a frequent diarrhoeal episode is
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 The Professional: Health Magazine for Physicians
unnecessary. Eluxadoline 100 mg twice
daily, which also acts on opioid receptors,
can be prescribed for IBS-D if the response
to loperamide is not adequate. This
medicine is expensive with a small risk of
acute pancreatitis. Most patients with IBS-D
in Bangladesh misuse metronidazole as it
causes slight constipation and lessens
diarrhea. Remember, the 'key' is
loperamide, NOT metronidazole. The
effects of probiotics on IBS are NOT
satisfactory.
Practice Tip: How to investigate a patient
with IBS-D?
First, investigate common causes like stool
R/E with ova and parasites for infections
and TSH for thyrotoxicosis. Consider testing
for Hb, serum ferritin, serum albumin for
malabsorption, and anti-TTG for celiac
disease. Fecal elastase is helpful to exclude
pancreatic insufficiency in suspected cases.
Fecal calprotectin is a non-invasive and
cost-effective test to screen inflammatory
bowel disease (IBD). History of recent
antibiotic ingestion may suggest
Clostridium difficile associated colitis.
Lactose intolerance is usually evident from
the patient’s medical history. In practice,
only a few investigations might require for a
patient who did repeated lab tests in the
past.
2022
A silent pandemic where the art of
prescription writing is at test:
Metabolic syndrome
Author
Dr. Md. Al-Sadi (consultant & assistant
professor, endocrine medicine)
Metabolic syndrome is a diagnosis where
multiple cardiovascular risk factors clusters
in a single patient. It comprises obesity,
insulin resistance (prediabetes & diabetes),
hypertension, and dyslipidemia. This
condition has become increasingly common
in adults and even in adolescents. For IDF
and AHA criteria of metabolic syndrome,
see below.
A diagnosis of metabolic syndrome
requires three or more of the following:
BMI>30
Waist circumference 90 cm or more in men,
80 cm or more in women (South Asians)
FBS 5.6 mmol or more
TG 150 mg or more
HDL-C<40 mg in men or <50 mg in women
Hypertension (SBP 130 or more, DBP 85 or
more)
The name 'metabolic syndrome' is like
ringing an 'alarm bell' to the ear of a
treating physician. Here, we need to pay
meticulous attention to weight loss, diet,
and exercises aside from medicines.
Smoking cessation is also of paramount
importance for smokers.
Prescribing medicines for multiple inter-
related conditions is also tricky as medicine
for one problem can worsen the other or
can improve the other. The secret is to
choose wisely. Below are some highlights
Volume-2 | February-2022
 The Professional: Health Magazine for Physicians
which will help us to correctly choose drugs
for prescription in metabolic syndrome.
Prediabetes & diabetes: insulin and
sulfonylurea may cause weight gain.
Metformin and Gliptins are weight neutral.
Empagliflozin, and semaglutide causes
weight loss. Empagliflozin reduces CVS risk
significantly.
Hypertension: beta-blockers cause weight
gain and may worsen dyslipidemia.
Telmisartan reduces blood glucose and
improves dyslipidemia.
Dyslipidemia: statins reduce CVS risk more
than other anti-lipidemic drugs and are also
recommended in NASH.
Obesity: dietary fibers supplement
(Isubgula husk) and Orlistat may also
improve dyslipidemia. Semaglutide also
improves diabetes.
Books and practice are entirely
different: a myth
Author
Dr. Mahiuddin Ahmed (consultant &
associate professor, internal medicine)
In early study and practice life, we heard
this comment several times that what is in
the book differs entirely from what practice
is. We couldn't disagree more. We need to
find the missing link between study and
practice that is the application of
knowledge.
Textbooks and practice guidelines form the
'backbone' of a doctor. They are written by
expert physicians and recommend 'what to
do' or 'what NOT to do' based on scientific
research. There is a reason why medical
science is science but NOT arts.
2022
How often do we prescribe 'vinpocetine' for
stroke'? Or 'glucosamine+chondroitin' for
osteoarthritis? Or
'ciprofloxacin+metronidazole combo' for
acute gastroenteritis? Or an 'antibiotic' for
upper respiratory tract infections? Or
'multivitamin+multimineral' for
weaknesses? Or 'Widal test' for fever?
These are just a few examples from the
NOT recommended list.
We understand that text and guidelines are
not something that one can follow strictly.
Exceptional circumstances and lack of
resources often make it difficult to follow
specific guidelines. And it is alright NOT to
follow the guidelines on a few occasions
and think or do something out of the box to
save lives.
We will do more good and less harm to our
patient if we follow the science. We can't
say the same if we follow our 'mind' instead
of science.
We need 'scientific knowledge' to master
the 'art' of clinical practice.
Practice Tip: professional behavior
We don't have to behave perfectly. What
we need is professional behavior. You don't
smile at your patient? No problem but don't
show anger even when angry. We don't
need to give more time to our patients. Just
enough time to make sure we don't miss
anything.
Want to publish an article in this magazine?
Contact: drmahiuddinahmed@gmail.com
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Volume-2 | February-2022