dagblog - Comments for "Don’t Give More Patients Statins"

I think that by far the best

artappraiser — Sat, 30 Nov 2013 17:51:36 +0000

In reply to The thing about the statin

I think that by far the best thing about the pushback is that it is publicized so that patients know about it. That these kind of disagreements are no longer kept from the public, from those actually affected, that's the important thing. (Especially in a time when the medical-industrial complex is allowed to use marketing and advertising methods on the public and on practitioners. Not that similar problems didn't happen before that--when doctors were gods who walked the earth--but it has made such problems worse.)

The thing about the statin

rmrd0000 — Sat, 30 Nov 2013 16:05:47 +0000

In reply to Statins by Numbers By Jason

The thing about the statin guidelines is that there was immediate questioning from the medical community. The objections noted that some of the authors of the guidelines had industrial ties. The new risk calculator was also questioned since it fell out of line with prior assessments based on following actual populations over time.

The AHA/ACC Guidelines are just that, they are not laws that have to be followed under risk of penalty. I think the pushback against the guidelines from within the medical community is a good sign. Their are European counterparts to the AHA and ACC. It will interesting to see how they react to the US Guidelines. There is scientific cross- pollination between the US and Europe in that scientific papers from European and US sources are quoted in the medical literature in both places.

The Guidelines are far from being a done deal.

Statins by Numbers By Jason

artappraiser — Sat, 30 Nov 2013 14:40:30 +0000

In reply to Don’t Give More Patients Statins

Statins by Numbers
By Jason Karlawish, New York Times guest op-ed, Nov. 29, 2013

PHILADELPHIA — MEDICINE is having its moneyball moment.

In his book “Moneyball,” Michael Lewis chronicled how the Oakland A’s, in order to identify the best predictors of a winning baseball team, used a highly formulaic, statistics-driven approach in place of the traditional assessments of coaches and managers. This month, in a similar spirit, the American Heart Association and the American College of Cardiology issued new, numerically driven guidelines for the treatment of cardiovascular disease [....]

This is a revolutionary shift. Once upon a time, medicine was a discipline based on the nuanced diagnosis and treatment of sick patients. Now, Big Data, networked computers and a culture obsessed with knowing its numbers have moved medicine from the bedside to the desktop (or laptop). The art of medicine is becoming the science of an insurance actuary.
It is also becoming big business [....]
[Jason Karlawish is a professor of medicine, medical ethics and health policy at the University of Pennsylvania.]

"Medicine is a science of

rmrd0000 — Mon, 25 Nov 2013 05:43:55 +0000

In reply to There has been a relatively

"Medicine is a science of uncertainty and the art of probability"

-William Osler

One physician wrote an Art of Medicine article in the Lancet in 2010 about the value of uncertainty in medicine.

There has been a relatively

rmrd0000 — Mon, 25 Nov 2013 00:41:19 +0000

In reply to Last week, the nation?s

There has been a relatively recent explosion in drug development. For example as recently as 1994, the choices for a diabetic was insulin and a class of drugs called sulfonylureas. There are now over ten classes of drugs that can be used to treat diabetes.some are rarely used. Once you have different groups of drugs with different applications, you can make comparisons.

A similar pharmacological explosion occurred with drugs to treat coronary artery disease and heart failure. There are also balloons and stents to treat coronary diseases and devices to treat heart failure. These new techniques allowed physicians to compare their efficacy to the previous"gold standard" therapy. Physicians applied evidence based medicine when there were alternative therapies.

Note, cancer therapy has also expanded the available treatment options as has rheumatology.

One confounding variable in some diseases is a cultural change that effects how and when diseases appears. Young people with diabetes used to present with a disease caused by an autoimmune disease where cells attacked and destroyed the cells that produced insulin. These kids were thin. Now there are young diabetics who are obese and present with a disease where more insulin is need to get glucose into cells. The disease is identical to what used to be called adult onset diabetes. The disease presentation in children has changed. Do children need the same therapy as adults or are they different?

Many people are eating more healthy and this impacts how and when coronary artery disease presents. Because of environmental/cultural changes treatment regimens will constantly change. Evidence based medicine is a moving target because the patient population is changing.

Last week, the nation?s

Peter Schwartz — Sun, 24 Nov 2013 22:40:40 +0000

In reply to They basically upended

Last week, the nation’s leading heart organizations released a sweeping new set of guidelines for lowering cholesterol, along with an online calculator meant to help doctors assess risks and treatment options. But, in a major embarrassment to the health groups, the calculator appears to greatly overestimate risk, so much so that it could mistakenly suggest that millions more people are candidates for statin drugs.

But it sounds like the real problem is with the "sweeping NEW set of guidelines" and not with the old guidelines. So if you were prescribed under the OLD guidelines, which targeted a smaller group, you probably got a more accurate prescription.

IOW, the "embarrassing" problem seems to be in "over-estimating" the risk and making millions "more" people candidates for the drug than were candidates originally. These drugs have been out for a very long time now.

(That said, though I have a history of heart disease in my family, I resisted taking statins for a long time. I remember one doctor telling me YEARS ago, even decades ago now, that all people should take statins just as a prophylactic. I myself have never suffered serious side effects that I know of--though I know some do.)

OTOH, maybe what they're saying is that if they could make such a big mistake with the new guidelines then even the old guidelines are suspect.

I believe statins are one of those drugs whose properties were discovered accidentally. They were working with the compound to treat some other condition and discovered it lowered cholesterol. The other big benefit is protection from stroke or the worst consequences of stroke.

As you said, somewhere, they don't know why statins work. But to be fair that is true of any number of drugs. They know that a drug works, but not why. As I understand it, they don't really know why aspirin works.

I was doing some work a while back with a nursing organization, and they were talking about "evidence-based medicine" as a "new advance." This raised my eyebrows and I asked somewhat hesitatingly: "But I thought medicine was based on scientific evidence."

Apparently not in many cases. Doctors and other medical professionals do many things that haven't been rigorously tested in a scientific way. They find something that works, and they sort of pass it down from guild member to guild member. The results are reasonably good (even if something else might be much better and even if they don't know why it works), so they keep doing it.

They basically upended

artappraiser — Sun, 24 Nov 2013 21:46:01 +0000

In reply to But do they disagree on the

They basically upended original guidelines; that's what the whole story is about! They basically said "everyone, throw out what you've been doing and how you've been thinking, this is what you should do now"! There is no agreement, there is "controversy": and "turmoil"

...The controversy set off turmoil at the annual meeting of the American Heart Association, which started this weekend in Dallas. After an emergency session on Saturday night, the two organizations that published the guidelines — the American Heart Association and the American College of Cardiology....

But do they disagree on the

Peter Schwartz — Sun, 24 Nov 2013 20:32:26 +0000

In reply to Honest Abe of cardiology; my

But do they disagree on the original guidelines as, say, a minimum?

Honest Abe of cardiology; my

artappraiser — Sun, 24 Nov 2013 04:18:28 +0000

In reply to Don’t Give More Patients Statins

Honest Abe of cardiology; my bold:

“The disease of atherosclerosis is changing before our eyes,” said Dr. Peter Libby, the chief of cardiovascular medicine at Brigham and Women’s Hospital in Boston. The reasons for the changes, he said, are only partly understood.

From (recommended) article:

Flawed Gauge for Cholesterol Risk Poses a New Challenge for Cardiologists
By Gina Kolata, New York Times, Nov. 19/20, 2013

Another excerpt of particular note, mho, as it's encouraging evidence of a medical professor that believes in treating patients instead of treating tests:

But there also is another issue, said Dr. H. Gilbert Welch, a medical professor at Dartmouth. The calculator, like many others used in medicine, is based on a mathematical model that assumes that risk rises in a straight line. As levels of blood pressure rise, for example, the chances of a heart attack or stroke rise in concert, the calculator assumes. In reality, Dr. Welch said, that line is far from straight.

-----

Also see

A credibility disaster for cardiology

on rmrd0000's news thread: New Guidelines for statin use,

which includes discussion & a link to NY Times expert debate on "When Medical Experts Disagree".

New Cholesterol Advice

artappraiser — Sun, 17 Nov 2013 00:47:17 +0000

In reply to Don’t Give More Patients Statins

New Cholesterol Advice Startles Even Some Doctors
By Gina Kolata, New York Times, Nov. 13/14, 2013

Steven L. Zweibel has been taking a statin drug to lower his cholesterol for seven years. It has worked, and he has suffered no problems or side effects.

But, like many patients taking these drugs, he is perplexed by new guidelines on preventing heart disease and stroke — despite the fact that he is the director of cardiac electrophysiology at Hartford Hospital.

“I am very happy to be on Zocor,” said Dr. Zweibel, 47, referring to the statin he takes. “But now the real question in my head is whether I need to be on it.”

The new guidelines, released on Tuesday by the American College of Cardiology and the American Heart Association, represent a remarkable and sudden departure from decades of advice on preventing cardiovascular disease.

According to the new advice, doctors should not put most people on cholesterol-lowering medications like statins based on cholesterol levels alone. And, despite decades of being urged to do so, patients need not monitor their cholesterol once they start taking medication. The guidelines do not even set target levels for LDL, the so-called bad cholesterol.

Doctors are also being told to stop adding other cholesterol-lowering drugs to statins [.....]