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medpundit |
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Friday, September 29, 2006I've been concentrating my efforts so far on the evidence based medicine lectures. Each of the lecturers in this series has made an effort to weigh the research evidence in an unbiased way. For instance, what is the best treatment of chronic kidney disease, congestive heart failure, or diabetes? So far, none of the speakers at the lectures I've attended have admitted to any drug industry ties, though the series is supported by grants from the pharmaceutical companies. And, to the Academy's credit, they've doubled the continuing medical education credits attendees can claim to encourage attendance at these sorts of lectures. However, even given all of that, the take home message of all of them so far has been to load up patients with drugs at the earliest possible stages of disease. I'm oversimplifying, but only a bit. The chronic kidney disease message was don't be afraid of polypharmacy. Ditto the congestive heart failure message. Ditto the diabetes control. Putting someone on four drugs to control their hypertension is fine as long as it lowers their blood pressure. Oh, and while you're at it, put them on a statin because it might delay the progression of kidney disease, too. If they have diabetes, don't be afraid to put them on three more drugs to control their diabetes. If they have heart failure, be sure to add a beta-blocker. And you know what? If that beta-blocker makes their heart rate go down too low, put a pace maker in. It's worth it if you can get them to stay on the beta-blocker. Whew. The problem here is that the composite patient with all of those diseases is not a rare bird. He's the American robin of American medicine. Most diabetics at some point will also have hypertension and chronic kidney disease and eventually heart failure. Follow the recommendations of the evidence and they could end up on nine or ten different medications. This is not necessarily a good thing. The studies which support each of these recommendations were done on pristine populations - people who had either hypertension or diabetes but not both. And the real kicker is, that there are no studies comparing the fates of patients taking all of the medication recommended by the evidence with those taking none, or only the minimal required to improve their functional capacity. This is an important distinction, because much of the evidence based therapy is aimed at preventing death or hospitalization, not at making the patient feel better. More drugs means more potential for side effects, interactions, and medication errors (Both on the part of patients in taking them correctly and on the providers in refilling them correctly. It's hard to keep track of long lists.) There may be a very real downside in taking all of those we recommend for each separate condition, but no one has done the studies to find out. And why would they? Medical research funding is dominated by pharmaceutical companies. They aren't going to pay for a study to find out if people shouldn't be taking their drugs. My profession has been co-opted by the pharmaceutical industry. posted by Sydney on 9/29/2006 11:43:00 AM 4 comments 4 Comments:
Further complicating the problem is the way the medications are developed. Generally, there is a range of doses, sometimes three or four, that are tested for safety & efficacy. Each dose obviously needs a test subject pool along with at least one set of controls. That's a lot of people. Statistically speaking, one needs to find a significant impact to justify efficacy, and to do that you either need large numbers of test subjects, or high doses of drugs. And, of course, there's practically no adjustment for body size. Putting these things all together means that doses are probably more than necessary, for most people. Sometimes one can easily detect that (e.g. too low of a blood pressure or glucose) but sometimes one cannot.
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Are you sure that these talks really were from an evidence-based medicine perspective, and that the speakers really weighed the evidence in an "unbiased" way?
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Roy,
At least, it's a kind of relief for me to see this kind of debate in your country. Now, add to the equation in underdeveloped world: the suspicion with big pharmaceutical corporations needing to test its effects with more "innocent" patients, the dire situation of the medical class as a whole (I'm talking about continued education here), the abandonment of public health, etc. |
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