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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
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    Tuesday, March 14, 2006

    Treating the Undiseased: When "pre-hypertension" became an entity, many of us fretted that we would soon be urged to treat what is in essence normal blood pressure. Looks like we're one step closer to going down that road:

    Drug Slows Onset of Hypertension

    Temporarily giving anti-hypertensive medicines to people whose blood pressure is just below the threshold for high blood pressure delays the onset of that disease for only a short time, a new study has found.

    Emphasis on temporary, and the influence is minimal at best:

    The researchers randomly assigned about 800 people with prehypertension to take candesartan or a placebo for two years. After that, everyone took a placebo for two years.

    At the end of four years, 240 people who took a placebo the whole time had developed hypertension -- nearly two-thirds of that group. In the candesartan group, 208 people had become hypertensive.

    The average time to development of hypertension in the placebo group was 2.2 years, while it was 3.3 years in the candesartan group. The drug slowed the onset of the disease but not by much.

    Most people taking candesartan would not benefit from it but would go on to develop hypertension, anyway. In fact, out of 10 people taking the drug for two years, only one would avoid becoming hypertensive at the end of four years.

    The Washington Post writer was smart enough to see through the data and present the story without the positive spin, but the authors of the paper think treating normal blood pressure is "feasible". Sure, beginning blood pressure medication before the onset of actual high blood pressure delays the onset of high blood pressure, but does it make any difference? We don't know. For all we know, the outcome in the end may be just as good if we wait until actual high blood pressure develops before we start medication. We've got enough real disease in this world to keep us busy without pushing treatment on the undiseased, thank you.

    posted by Sydney on 3/14/2006 09:34:00 PM 8 comments


    Unlike you, many doctors see this as a real boon. People are catching on to statins or are just tired of hearing about them. This along with diabetes will give them a reason to bring in their relatively healthy, well insured patients, for more test and monitoring. Don't worry the insurance will pay and the patient's time has no value.

    Big pharma loves it because it makes people feel they cannot live without drugs.

    Having been confronted by more than one doctor on this point I am more than a little skeptical. When you have been told you are taking the food away from the mouths of a poor doctor's children by not scheduling regular doctor visits, even though nothing is wrong, you really start to question a doctor's motives.

    By Anonymous Anonymous, at 7:57 AM  

    "A patient is a well person whose diagnostic workup is not yet complete."

    I read that as humor several years ago. Now I'm not so sure.

    John Fembup

    By Anonymous Anonymous, at 8:35 AM  

    In my darker moments, I wonder if the profit motive isn't driving a lot of this, but in truth I think that the people who push this are really working for ways to limit disease as much as possible. They get carried away in their enthusiasm, though, when they embrace pre-disease states.

    It does make us look kind of bad as a profession, doesn't it? There are still so many real diseases out there that we aren't able to treat or aren't treating adequately and here we are spending our energies on chasing down pre-diseases.

    By Blogger sydney, at 8:50 AM  

    Last time I checked every medication can/does have negative effects, so is it really such a good idea to start every healthy person out there on them? Does the perceived improvement in long-term health truly outweigh the known morbidities that would occur if every adult in the US with "prehypertension" started taking these meds?

    By Blogger LibraryGryffon, at 11:39 AM  

    As more and more people owe their livelihood and their careers to publishing more papers and selling more pharmaceuticals, we're going to see more of this. There are more media sources out there looking for more and more stories. In the end, doctors and patients are going to have to do more thinking about what is relevant and what is not.

    By Anonymous Anonymous, at 11:41 AM  


    Good point. The problem is that the people who write the papers and do the research are the same ones who help write treatment guidelines. It's hard to fight in the trenches against guidelines once they've been adopted by professional societies - no matter how ill-advised they are. The guidelines then, in turn, become benchmarks of quality used to measure doctors by third party payers.

    By Blogger sydney, at 5:19 PM  

    And another thing....

    Yes, we should be asking ourselves if it's worth the risk and side effects (and monetary cost) of putting people on these drugs in the absence of disease, but it's a question we often fail to consider in this country. We don't consider cost because doctors and patients are divorced from the cost. And everyone thinks the third party payors have bottomless pockets.
    Why we don't consider the side effects is beyond me - especially since we don't know the safety of many of our newer drugs over a prolonged period of time. Look how long it took to do a study on Premarin. What was that, fifty or forty years after its introduction?

    By Blogger sydney, at 5:23 PM  

    The side effect issue bugs me as well or rather how authors of the guidelines are quick to say "the side effects are rare" or minor. When the person is actually ill, the side effects may well be minor or rare, but when the person is healthy even minor side effects are important. For some reason nobody seems to make this distinction. Fosomax effect of jaw death is indeed extremely rare and other side effects are mild, especially for old women with osteoporosis who don't have much teeth left, but when somebody prescribes it to a 50- year old who only has mild osteopenia, this may well be another story.

    For a man who already has heart desease the potential side effects of statins are minor compared to his risk of dying of heart attack. For a symptomless woman with no deabetes, high HDL and normal ratio even the small side effect of these drugs may be unacceptable. I find it interesting that while no study has proven benefit of statins in women and that many claim that HDL and triglicerides are more important for women then LDL, the guidelines don't make the any distinction.

    At least HRT improves quality of life of a woman with menopausal symptoms. Of course 10 years ago they were often prescribed to 60+ women without symptoms.

    But, healthy people is much bigger market for drug companies. Also, if you need a prescription refill you need to see a doctor at least once a year.

    By Anonymous Anonymous, at 10:28 PM  

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