A poster posited a link between Parkinson's Disease (PD) and Statin use, which led me to an article in Movement Disorders, 2006 (PubMed ID 17177184) that points out, in a retrospective study, a strong link between low LDL and Parkinson's incidence. The lower the LDL, the more people had PD: up to 3 times as often with an LDL below 93.
However, that same article seemed to find a 'neuroprotective' effect for statins. The poster obviously knew more biochemistry than me, so I'm not incredulous, that's just what I found in an admittedly quick search. Updated articles are welcome. It certainly did confirm a link between low LDL and Parkinson's, from which I can infer that LDL is perhaps not entirely deserving of the pejorative 'bad' cholesterol label.
A Google search on statins, however, on the broader issue of Number Needed to Treat analysis, showed very high NNTs, like 33 here, based on a 2003 Lancet article. I'm not sure how reliable that is. However, with an NNT of 33 in people with diabetes, I suppose there is good reason to question statin use given the lack of mortality benefit, and given the serious side-effects; I'm not sure about PD, but pancreatitis and rhabdomyolysis are no picnic.
Just don't ask what the NNT is for epinephrine in out-of-hospital resuscitation. The evidence for a lot of our critical situation algorithms seems a bit thin from podcasts I listen to. Just a tad bit hard to study.
Showing posts with label medications. Show all posts
Showing posts with label medications. Show all posts
2.22.2008
2.20.2008
The Cholesterol Controversy, or Are We Getting Fleeced by Statins?
5 billion a year, according to this wellness site that I found with a Google search, is how much the big drug companies are fleecing the public for. A lot of this flap came from the 'failed' Vytorin study, which is unpublished but findable in the Medical Letter here, and in a statement from the American College of Cardiology here.
The study was a randomized trial of people with Familial Hypercholesterolemia and showed no difference--actually, Vytorin was less effective than simvastatin--in slowing the growth of plaque. Forbes said their stock tanked. The wellness site above points to it as evidence that lowering cholesterol is a farce (and, of course, we should buy his book).
The Health Beat blog, which I like but which appears to have a bias against pharma, takes on the topic here. For a bit, I felt betrayed. Here I had been talking to people about lowering their LDL and treating cholesterol for weeks, and the dogma is that statins as a class are being used more and more, not less.
We've been looking at pictures like those at right for years of medical school, learn
ing how to treat it with drugs. Don't they work? Well, actually, yes. Let's talk about endpoints. There is a big study in the Lancet in 2008 (PubMed ID 18191683 at pubmed.gov) that was a meta-analysis of 18,686 diabetics which supported a reduction of 1/3 in major vascular events.
A 2006 study in the Archives of Internal Medicine (PubMed ID 17130382) showed a reduction in major vascular events with NO reduction in all-cause mortality. There was, of note, a 14% reduction in the incidence of stroke.
Critics,
including Health Beat, argue that lowering LDL numbers do not affect all-cause mortality and therefore are not useful as there is no quantifiable evidence that quality of life goes up, and there are side effects to statins. True. Also, the Lancet article in particular is a meta-analysis of industry-funded studies, which it admits.
Still, large meta-analyses are about as trustworthy as evidence-based medicine gets, and many drug studies are industry funded.
Are statins a fraud? Just money? A plot by Big Pharma to fleece us of billions?
Of course Big Pharma wants to make money, and tons of it. It is the fundamental mission of private companies to make lots of money and they should. No one should have any illusions about that. This perhaps goes towards why we should have a public health care system. But I digress. The question is if people were fleeced, should ask for their money back, were betrayed, and so on. The wellness sites and others point out that lowering cholesterol naturally with diet and exercise is a better way to do it and statins are a rip-off.
Guess what? We tell our patients that. We say, you should lose weight, eat right, and exercise. A lot. Now. And how many do? In six weeks of primary care, I saw TWO people who had done that. They were healthy, happy, had great numbers and a very high quality of life. We encouraged them, held them up as examples. TWO of them.
So should we avoid treating with statins? If I have a person who, for whatever reason (perhaps because they're a tad lazy) can't lose weight, watch their saturated fat intake, or exercise, should I tell them to just go away? Umm...no. Should I avoid giving an elderly, male, smoking, diabetic a drug that might reduce his chances of having a stroke because he SHOULD quit, eat greens, and run a marathon? No. I'll tell him that every visit. But guess what? He just might not listen.
We should accurately represent what statins do: they make a noticeable difference in the risk of a cardiovascular event, but it is mild. It's not a miracle cure. You should stop if you get muscle aches and so on.
But call them a con and a fleece? Western medicine has said all along that patients should eat right, exercise a lot, not smoke, lower their stress level, and so on. It's easy to jump on the statin 'push' and say doctors and the medical establishment are just in it for the cash, because it absolves all those sedentary junk-food eating patients of any responsibility for their terrible disease burden. As an added side bonus, it often helps sell diet books and alternative medicine, which as far as I know, doesn't come with a money-back guarantee, either. Far from it.
OF COURSE Big Pharma wants to make money. Most doctors (I admit, not all) want to help patients. And we figure that even those people who choose not to modify their lifestyle deserve some recourse to try and prevent badness. Crazy us.
To close the circle, let's go back to the Vytorin study. The drug failed to beat simvastatin with regards to thickness of plaque in people with FH, a rare genetic disorder. So, the endpoint doesn't matter (mortality, heart attacks, and strokes matter) and the population is not applicable to every patient. Is it disappointing? Sure. Does it mean statins don't do anything? No. Patients and doctors shouldn't rely on them to get them out of the work of modifying behavior.
There is no quick fix.
The study was a randomized trial of people with Familial Hypercholesterolemia and showed no difference--actually, Vytorin was less effective than simvastatin--in slowing the growth of plaque. Forbes said their stock tanked. The wellness site above points to it as evidence that lowering cholesterol is a farce (and, of course, we should buy his book).
The Health Beat blog, which I like but which appears to have a bias against pharma, takes on the topic here. For a bit, I felt betrayed. Here I had been talking to people about lowering their LDL and treating cholesterol for weeks, and the dogma is that statins as a class are being used more and more, not less.
We've been looking at pictures like those at right for years of medical school, learn
ing how to treat it with drugs. Don't they work? Well, actually, yes. Let's talk about endpoints. There is a big study in the Lancet in 2008 (PubMed ID 18191683 at pubmed.gov) that was a meta-analysis of 18,686 diabetics which supported a reduction of 1/3 in major vascular events.A 2006 study in the Archives of Internal Medicine (PubMed ID 17130382) showed a reduction in major vascular events with NO reduction in all-cause mortality. There was, of note, a 14% reduction in the incidence of stroke.
Critics,
including Health Beat, argue that lowering LDL numbers do not affect all-cause mortality and therefore are not useful as there is no quantifiable evidence that quality of life goes up, and there are side effects to statins. True. Also, the Lancet article in particular is a meta-analysis of industry-funded studies, which it admits.Still, large meta-analyses are about as trustworthy as evidence-based medicine gets, and many drug studies are industry funded.
Are statins a fraud? Just money? A plot by Big Pharma to fleece us of billions?
Of course Big Pharma wants to make money, and tons of it. It is the fundamental mission of private companies to make lots of money and they should. No one should have any illusions about that. This perhaps goes towards why we should have a public health care system. But I digress. The question is if people were fleeced, should ask for their money back, were betrayed, and so on. The wellness sites and others point out that lowering cholesterol naturally with diet and exercise is a better way to do it and statins are a rip-off.
Guess what? We tell our patients that. We say, you should lose weight, eat right, and exercise. A lot. Now. And how many do? In six weeks of primary care, I saw TWO people who had done that. They were healthy, happy, had great numbers and a very high quality of life. We encouraged them, held them up as examples. TWO of them.
So should we avoid treating with statins? If I have a person who, for whatever reason (perhaps because they're a tad lazy) can't lose weight, watch their saturated fat intake, or exercise, should I tell them to just go away? Umm...no. Should I avoid giving an elderly, male, smoking, diabetic a drug that might reduce his chances of having a stroke because he SHOULD quit, eat greens, and run a marathon? No. I'll tell him that every visit. But guess what? He just might not listen.
We should accurately represent what statins do: they make a noticeable difference in the risk of a cardiovascular event, but it is mild. It's not a miracle cure. You should stop if you get muscle aches and so on.
But call them a con and a fleece? Western medicine has said all along that patients should eat right, exercise a lot, not smoke, lower their stress level, and so on. It's easy to jump on the statin 'push' and say doctors and the medical establishment are just in it for the cash, because it absolves all those sedentary junk-food eating patients of any responsibility for their terrible disease burden. As an added side bonus, it often helps sell diet books and alternative medicine, which as far as I know, doesn't come with a money-back guarantee, either. Far from it.
OF COURSE Big Pharma wants to make money. Most doctors (I admit, not all) want to help patients. And we figure that even those people who choose not to modify their lifestyle deserve some recourse to try and prevent badness. Crazy us.
To close the circle, let's go back to the Vytorin study. The drug failed to beat simvastatin with regards to thickness of plaque in people with FH, a rare genetic disorder. So, the endpoint doesn't matter (mortality, heart attacks, and strokes matter) and the population is not applicable to every patient. Is it disappointing? Sure. Does it mean statins don't do anything? No. Patients and doctors shouldn't rely on them to get them out of the work of modifying behavior.
There is no quick fix.
5.10.2007
NY Times Takes on Pharma
The New York Times has recently had two fascinating and, I think, accurate articles highlighting the relationship between doctors, health care, and pharmaceutical companies, in anemia treatment, and in antipsychotic use in children.
I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.
Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.
Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.
There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.
Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.
I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.
Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.
Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.
There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.
Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.
1.28.2007
Who's Really Gorked Out? Part 2
The best part of psychiatry is the meds. They do some cool stuff. According to our patients, they make your life better, fix your mood, take away your pain.
'I've been feeling this way all my life, I just want you to fix me'.
'That's what meds do, they glue you back together'.
'Why won't you give me my pills that take the voices away?'
On the other hand, according to this article in the NYT, psych drugs kill people. By making them fat.
So who to believe? The drug-pushing, soul-less ad folks at the drug companies, or the liberal hippies who want to treat colon cancer with Lemon Grass herbal tea?
Well, neither. I first read the article, which is about olanzapine (Zyprexa), a new anti-psychotic. My reaction was typical for a medical student, new as I am to my profession, in that I dismissed the worries. 'Oh', I thought to myself, 'of course, worry about the weight gain in the context of a crushing psychiatric illness'. But then I talked to my resident. His response was actually measured. Yes, in general, treatment is necessary, as it was in the case of this patient, who had severe bipolar illness with psychotic features, or perhaps a misdiagnosed thought disorder such as schizophrenia. But, he pointed out, olanzapine was probably a bad choice for long-term therapy, as it does lead to the weight gain mentioned. Which is why we don't use it at the UW.
So, in the end, the article has merit. A better choice would have been a different antipsychotic, leaving the Zyprexa for short-term use in people predisposed to side-effects like drug-induced Parkinsonian symptoms (like young, African-American patients who need help for a week or so). The key is to avoid over-reacting and shooting off one's mouth. Patients will come in with all sorts of concerns about medications. We can't listen only to the drug companies OR the 'I cured my liver cancer with aromatherapy' people. The best path is the middle one.
'I've been feeling this way all my life, I just want you to fix me'.
'That's what meds do, they glue you back together'.
'Why won't you give me my pills that take the voices away?'
On the other hand, according to this article in the NYT, psych drugs kill people. By making them fat.
So who to believe? The drug-pushing, soul-less ad folks at the drug companies, or the liberal hippies who want to treat colon cancer with Lemon Grass herbal tea?
Well, neither. I first read the article, which is about olanzapine (Zyprexa), a new anti-psychotic. My reaction was typical for a medical student, new as I am to my profession, in that I dismissed the worries. 'Oh', I thought to myself, 'of course, worry about the weight gain in the context of a crushing psychiatric illness'. But then I talked to my resident. His response was actually measured. Yes, in general, treatment is necessary, as it was in the case of this patient, who had severe bipolar illness with psychotic features, or perhaps a misdiagnosed thought disorder such as schizophrenia. But, he pointed out, olanzapine was probably a bad choice for long-term therapy, as it does lead to the weight gain mentioned. Which is why we don't use it at the UW.
So, in the end, the article has merit. A better choice would have been a different antipsychotic, leaving the Zyprexa for short-term use in people predisposed to side-effects like drug-induced Parkinsonian symptoms (like young, African-American patients who need help for a week or so). The key is to avoid over-reacting and shooting off one's mouth. Patients will come in with all sorts of concerns about medications. We can't listen only to the drug companies OR the 'I cured my liver cancer with aromatherapy' people. The best path is the middle one.
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