Wednesday, December 31, 2008

Happy New Year / Anniversay and Best and Worst in Medicine 2008

I started this blog one year ago, and has been a phenomenal experience. I have enjoyed posting and reading your responses. I had no idea how much work a medical blog would be and have a great amount of respect for physicians like Kevin Pho of KevinMd and Robert Centor of DB's Medical Rants who also manage a heavy clinical load and are for more prolific then I have been. Though physician blogs range from sharing experiences to deliberating they health care system, my main purpose of this blog was to clarify medical issues that are discussed in the media. In today's New England Journal of Medicine, Susan Dentzer discusses some of the pitfalls of health care journalism. I am hopeful that this blog has helped filled some of these gaps. Here are some of the Best and Worst of 2008.

Vytorin is Out
The EHANCE trial which I discussed in Vytorin and Zetia: What to do now? failed to show any major benefit over generic simvastatin alone. The company tried their best (as I shared the letter the sent me in Dear Doctor: Vytorin ) the make excuses, but the reality is that they never proved the benefit of having two drugs to lower cholesterol when a higher dose of a statin could do the trick. Whether or not it is the LDL cholesterol or the drug used to lower it is still debateable, but for now, statins should be used to achieve cholesterol goals. However, if goals can not be acheived with a statin alone or statins can not be tolerated adding Zetia is not a bad option as showe in the SANDS trial (Zetia In, Vytorin Out)

Too Low Could Be Bad for Diabetics
The media got it wrong when the reported that the ACCORD study was stopped (ACCORD Study: Don't stop your diabetes medicines, Please! ) Both groups did much better than would have been expected, and some argue that the trial should not have been stopped. The message got out that lowering A1c might not be important, but it clearly is. However, their may be problems if you push the A1c too low.

Side Effects, Side Effects, Side Effects
Many of my posts (and the ones that got the most responses) regarding over-hyping side effects of drugs. The Wall Street Journal reported that Lipitor made women "stupid" (Lipitor and Memory Loss), Spiriva could cause stroke ( Spriva and Stroke: FDA warnings create buzz and confusion ), kids on Singulair might commit suicide ( Vytorin and Singulair: Problems for the Company, Confusion for the Public ) and of course concerns about the only new drug for the single leading preventable cause of death in the US in a decade ( Where's the Good News about Chantix? ) Some of this may be due to the fact that the FDA, under much public scrutiny, decided that it would report to the public drugs they were investigating, even if there was no clear evidence that these drugs were harmful ( More FDA warnings should not be cause for worry ). The bottom line is that there is no perfectly safe drug. Doctors and patients must balance the risk of medication side effects with the benefit it provides. If you are at high risk for a heart attack, it is probably worth risking a rare (though serious) side effect or Lipitor.

Cipro Causes Tendon Ruptures
That said.... there are some side effects, that even if uncommon deserve attention. In my post Tendon rupture with Cipro? FDA caves to Public Citizen, I question the FDA's decision to make a label change to Cipro, suggesting that they were merely responding to public pressure. I still contend that the announcement was not helpful to physicians because no real numbers were released, helping to determine a risk benefit ration. However, the many responses I got to this post suggest that there may be much more to this story. The difference between the Cipro example and Lipitor is that there are lots of other classes of antibiotics that can be used in most cases, whereas the best drugs to treat cholesterol are statins. In addition, the numbers for even the rare side effects of statins are well documented. Not so much for tendon ruptures with quinolones.

Prevention Magazine Creates a Scare
In probably the worst example of health care journalism, Men's Health Magazine published an article about 8 drugs doctors would never take (The truth on the 8 drugs doctors wouldn't take). I learned about this from a patient whose horrible asthma was finally well controlled on Advair, but stopped becuase her fiancee read that Advair could kill you. There were many problems with this article, but the worst was that they never actually asked physicians about the drugs they wouldn't take. I did (via Sermo) and most disagreed with the list (If you want to find out the 8 drugs doctors would never take....ask them!). PLEASE be careful of what you read, and talk to your doctor before stopping any medication.

Asthma Inhalers go Green
Asthma inhalers are no longer made with ozone depleting CFC's. This is good news, but some patients (and even physicians) were not aware of this and some of the implications, including direct costs to the patient. Hopefully, this post clarified some of the issues.

Salmeterol Issue Clarified
With so much negative (and often incorrect) information about asthma medications, specifically products containing long acting beta agonists (LABA's) such as Advair and Symbicort, it was great to post Good News for Asthma Patients which indicated that if LABA's were taking with an inhaled corticosteroid, they were safe. The FDA recently met on this (The Lowdown on LABA's) and seemed to agree. Now if only they will take away that boxed warning on Advair and Symbicort (Dear FDA, Remove the Boxed Warning from Advair and Symbicort )

Generics Just Fine
There is a lot of confusion about generics, but a study this year reported in JAMA showed that generics are generally just as good. With the high price of medications and our economy in the tank, most patients are switching to generics when they can. Hopefully they feel more comfortable doing this. (Generics Just As Good As Brand Name )

Students Not Going Into Primary Care
OK, this is obviously not good news, but I listed it under "best" for two reasons. First, I was one of the authors on the study showing that only 2% of US students are choosing to go into primary care internal medicine (Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them!), and was proud to see the article published and discussed. More importantly, the article came at a critical time. The presidential debates had focused on covering the ininsured and decreasing the cost of health care. No one (except for thousands of bloggers) were really discussing the primary care crisis. I am hopeful that this study (and others that coincidentally came out at the same time) changed the discussion. We are now seeing the first time that the Obama administration has recognized the problems in primary care.

JUPITER: CRP Likely a Factor
OK, I am probably a little biased on this one too since we were one of the Jupiter sites ( Jupiter is Out, and the News is Good!). However, this study was important becaused it showed that there is more to the story than just LDL, since the patients in this study would not have normally qualified for statins. The anti-pharma and drug safety people will be critical of this study for a while (Remember when Sidney Wolfe wanted Crestor pulled from the market? Seems like Crestor has no more side effects then placebo, at least in this study). However, the data hear is pretty strong and I am checking CRP's on most adults.

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