Tuesday, February 19, 2008

"Medication Under the Microscope," but Big Picture Lost.

I am sure that Rob Stein meant to inform health care consumers in his piece "Medication Under the Microscope" in today's Washington Post, but with subtitles like Studies Raise Questions About Drugs' Efficacy Against Disease and Pushing Prescriptions?, he may have caused more confusion and fear.

Factually, there is nothing wrong about this piece on some recent surprising findings from studies that according to Stein "has renewed debate about how aggressively doctors use drugs to prevent and treat some of the nation's leading health problems." Stein also does a good job at presenting both sides of the story. My only true objections (other than the way the headlines and subtitles seem to imply that patients should question taking their medications) are:

1. In the beginning of the article, when referencing the ACCORD study, Stein specifically highlights Avandia, which has been in the media a lot lately. Though we know very little about what caused people to die in this study, the ONLY thing we know is that (according to the NIH), it was NOT Avandia.

2. Second person quoted is Dr. Steven E. Nissen from the Cleveland Clinic who seems to be making a career of being quoted in the press on how certain drugs can be dangerous.

3. Under the section "Pushing Pills" there is an opinion from some industry critics that "more emphasis should be placed on improving cholesterol, blood pressure, blood sugar and other risk factors through lifestyle changes, such as eating better, maintaining a healthy weight and exercising more." This is absolutely true. However, it implies that we should put more emphasis on this and save drugs for only the very worst cases. Furthermore, there is no mention of the data on diet and exercise (more on that later).

The article discusses the "suprising" findings of two recent studies.

1. ACCORD- I explain this in detail in a previous post. Briefly, this NIH study on aggressive management of diabetes was stopped early because diabetics treated more aggressively had a greater chance of dying. I warned people not to stop taking their diabetes medications, because in this study patients were likely treated too aggressively. Because of these findings, a similar international study decided to make sure that they weren't harming anyone, and found no differences. Why the discrepancy? Because the international study was aiming for a target of less than 6.5% (guideline recommended) and the NIH study was trying to get patient to normal, or less than 6.0% (which no one recommends).

2. ENHANCE- also discussed in a previous post showed that the addition of zetia to simvistain (Vytorin) was no better at preventing aretery clogging then simvistatin alone. Again, findings were surprising, but not shocking, since there were no outcomes data yet on Zetia. Seems clear that there is likely more to heart disease than just lowering the ldl. However, the patients in this trial had extremely high cholesterol, and it is possible that neither drug was powerful enough to make a major difference.

Efficacy of Lifesytle Modifications
There is no question that we need to focus more on diet and exercise. Diet and exercise is generally cheap and benefits multiple factors. However, in many cases, diet and exercise will not be enough. This is why physicians prescribe medications IN ADDITION TO diet and exercise. Though diet and exercise is the first-line therapy for hypertension, high cholesterol and diabetes, the data on their efficacy alone are not all that impressive.

For prevention of diabetes, one study actually showed that diet and exercise did BETTER than metformin, a diabetes medication. However, the regimen that patients got was quite extreme including prepared meals, personal trainers and even Nike sneakers provided at no cost. Though diet and exercise works to prevent diabetes in patients at risk, it may not be reasonable for many, which is why the ADA last month (for the first time) recommended that physicians consider medications to prevent diabetes.

For high blood pressure, there is some evidence that diet and exercise is effective. Below is a table from the NIH's Hypertension Guidelines that includes the effect of various lifestyle interventions. Please note that doing more than one thing can add up, but the results are not additive. Life Style Modifications
You can see that there is definitely evidence that if you do things like exercise, stop smoking and eat a healthy diet you can have a substantial impact. The best studied diet is the DASH diet, which is very similar to a Mediterranean diet. It showed a significant improvement in lowering blood pressure than just a lower calorie diet with an impressive 11 points off the top number (systolic) and 5 points off the bottome number (diastolic). Though these numbers are meaningful and important, if your blood pressure is 160/100, it is likely that no amount of diet and exercise will be able to get your blood pressure under control.

Bottom Line:

Diet and exercise is key and critical for treating chronic diseases like hypertension and diabetes. Furthermore, there is much more to learn about which medications to give to which patients in treating these conditions. There are currently good medications available (many generic) that have not only shown substantial improvement in blood pressure, sugar and cholesterol control above and beyond what lifestyle modication can acheive, but also have prevented outcomes like heart attacks and strokes and have even saved lives. Should we continue to look carefully at medical treatment? Certainly. Do we need to focus more on diet and exercise? Absolutely! Should we (based on some recent studies) call into question the notion of treating these serious illnesses with medications? Certainly not.

1 comment:

Red Sphynx said...

> the NIH study was trying to get patient to normal, or less than 6.0% (which no one recommends).

Actually, Dr Richard Bernstein (M.D., F.A.C.E., F.A.C.N., FCCWS), author of Diabetes Solution recommends many of his patients get to A1c's of 4.2 - 4.6%. But his approach is starkly different than the ACCORD protocol. He recommends a very low carbohydrate diet, with small amounts of insulin to trim blood sugars. (and some other meds, mostly Metformin.) I mostly follow his approach (no insulin, tho) and maintain A1c's of 4.8-5.2%.

Bernstein's advice is outside the large consensus of the field. But given that the forward to his book is written by the past president of the ADA, he's not a fringe writer, either.

Read Bernstein's comments on the Accord study.

Adam Becker Sr