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    Tuesday, May 11, 2004

    The Oldest Profession: I didn't blog much about last month's recommendations by the American College of Physicians that all diabetics should be taking those miracle drugs, statins, regardless of their cholesterol levels because I was too busy. But, those guidelines, and the organization that published them, deserve some scrutiny. Here's the media report:

    Most diabetics, regardless of their cholesterol levels, should be taking cholesterol-lowering drugs to reduce their risk of a heart attack, the American College of Physicians says.

    .....Simply having diabetes makes a man two to four times more likely to have a heart attack or stroke than someone without the disease. Diabetes makes a woman's risk of a heart attack two to six times greater. Researchers say that's because a diabetic's blood is thicker and more prone to clot.

    The new guidelines say diabetics should take cholesterol-lowering statins — even if their cholesterol levels are good — if they have any one of the following health problems: high blood pressure, obesity, smoking, or a family history of heart disease.

    Dr. Richard Nesto, chairman of cardiovascular medicine at the Lahey Clinic in Burlington, Mass., told ABCNEWS that a diabetic's arteries are unusually inflamed.

    "A cholesterol level in a diabetic patient exists in a person who has chronic inflammation," he said. "That makes this cholesterol much more dangerous to the blood vessel. Furthermore, statins are very good not only at lowering cholesterol but lowering the inflammation."

    Basically, I feel the same way this guy does about these recommendations. First of all, the background paper was a meta-analysis, which means it culled through all of the papers ever written about diabetics and statins, pooled all the data, and put them through a statistical mill to come up with a meta-outcome. The trouble is, published papers tend to lean toward favorable outcomes for an intervention. Unfavorable outcomes tend to not get published, making meta-analyses a horrible way to measure the effectiveness of a therapy.

    The other problem is that there's no direct comparison of other, cheaper, means of preventing heart disease in diabetics - such as the use of daily aspirin, also a potent anti-inflammatory and clot-preventer.

    Why would an organization such as the American College of physicians publish treatment guidelines based on such flimsy evidence? The background paper says that its two authors have no conflict of interest and that they work at the Veterans Administration. The guidelines themselves state that "financial support for ACP guideline development comes exclusively from the ACP operating budget."

    But, what they don't tell you is that the authors of the background paper, Doctors Sandeep Vijan and Rodney Hayward, are also faculty members of the University of Michigan, which has a cozy relationship with Pfizer, makers of the popular (and expensive) statin Pravachol. Coincidence? Don't bet on it. The influence may be subtle, but you can bet its there.

    And although the American College of Physicians says they don't get specific outside funding for their guidelines, the College is not shy about using industry to fund itself. A few years ago they got together with some of their bedfellows, noting:

    Industry plays a large part in the operation of the College, providing approximately 20% of College revenues; the Foundation and College are looking to this meeting for new win-win possibilities with industry.

    Looks like they found an excellent win-win possibility with their most recent guideline.


    posted by Sydney on 5/11/2004 08:07:00 AM 0 comments


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