Gimmee a Pill!

When I was a child I had four great-grandparents.  Two were from Russia and two were from Poland.  My grandparents were actually born in the United States.  My last great-grandparent died at the age of 96 when I was 31 and in training after medical school.  She was someone I knew as a full person and not just as a grandparent.  Interestingly enough she actually came to the United States not once but twice.  She returned to Russia because she did not like the conditions in New York City when my maternal grandmother was five years old.  She quickly returned to the United States when she got back to Russia.

My great grandmother suffered from congestive heart failure and loved to eat anything salty.  Pickles, lox you name it she ate it and then she would call me up and complain she was short of breath.  She wanted no part of diet restriction and all she would say was “Gimmee a pill”.  Then she would infer that I wasn’t as smart as I should have been because I didn’t have a pill to solve her problem.

We as a population have become much like my great grandmother.  Maybe she was on to something.  The area of life which comes to mind the fastest is that of weight loss.  No one wants to hear or deal with the knowledge base we have.  Eat less, actually a great deal less, and get some exercise, actually a great deal of exercise, and guess what?  You will lose weight and keep it off.  Whoa that’s just not going to cut it. “Gimmee a pill” screams America and what America wants is big Pharma to continue to serve up.

What is a significant weight loss induced by pills?  Give up?  One would hope it would be 20-30 pounds, or in the case of gastric bypass or the Biggest Loser TV show, at least an entire person worth.  You will find out that’s not the case.

Should drugs even be used in what is generally a self induced problem?  Obesity is epidemic in this country, and childhood obesity has become a national disaster that will dwarf all health care spending deficits.  As you will see in my next blog, approving these drugs is not an easy task, and as most people will remember the diet drug combo known as Phen-Fen was removed from the market only when its serious side effect of heart valve problems became an issue.  This has made it even harder to approve these drugs as the heart problems did not become evident for many years after the drugs were marketed.  What is “reasonably safe” and is this a problem for which there is a “medical solution”?

I will discuss these issues in my next blog.  Until then I’m going for ice cream.

Tags: childhood obesity, congestive heart failure, Obesity, weight loss
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No “right” answers

When it comes to prescribing drugs, doctors must weigh the risk of giving any drug versus the benefits of those drugs.  Common drugs that we use today have significant and at times fatal reactions. 

Guess the drugs that correspond to the following side effects:

Side effects: Anaphylactic shock and death. Drug: Penicillin. 

Side effects: fatal bleeding, anaphylactic shock and asthma with severe respiratory distress.  Drug: Aspirin.

Side effect: respiratory depression with cessation of breathing. Drug: morphine. 

I could go on and on.

This is the practice of medicine.  You have a disease and need a treatment.  Doctors try and find a treatment which is not worse than the disease.  The drugs reported on in this study were being used in the disease of congestive heart failure.  Congestive heart failure, when it is Class 3 or 4, has almost 100% mortality at five years.  This class of drugs when used in this disease state significantly increases your chance of living and improving your quality of life.  Is it worth it to take the drug?

It is true that the same benefit is received when you take angiotensin converting inhibitors but many patients have side effects from those drugs.  The angiotensin converting enzyme blockers are better tolerated.  They are also much more expensive and many patients are given angiotensin converting enzyme inhibitors first and then when they are not tolerated switched over.

What this study really does is to provide a starting point for further evaluation.  There is a wealth of data that the FDA has and these studies are meant to serve as a means of impelling them to review their data or providing it to people who will.

In the next weeks the public will hear about the diabetic drug Avandia which has been in the news over the past year.  It is very possible that this drug which already carries a “black box” warning, which is the highest level of warning the FDA has, maybe removed from the market.  We will have to wait and see.

In the meantime, if you are taking these drugs continue them and discuss this with your doctor.  If you really don’t want to get lung cancer don’t smoke.  In London, the cigarette packages say smoking kills in large print.  Better than our warnings.

Tags: angiotensin converting inhibitors, Avandia, congestive heart failure, Drugs
Posted in Heart Failure, diabetes | 1 Comment »

Correcting Urban Legends in Medicine

Urban legends are situations or things that are thought to exist but don’t.  Their power is such that they can lead to excessive attempts to change behavior that didn’t need to be done in the first place. 

Urban legends in medicine lead to an overuse of resources and an enormous increase in the overall cost of medical care in spite of contrary evidence.  I don’t claim to know how to stamp it out.  Education is one way, but people and physicians are incredibly resistant to it.

One such “Urban Medical Legend” is preoperative cardiac risk evaluation.  The legend holds that it is possible to identify and then rectify the condition of patients who are at risk for cardiovascular incident and death before they have an operation.  This is the so called cardiac clearance for surgery.  It comes in two flavors the “emergency clearance” and the classical “elective clearance.”

Although there are Guidelines published by The American College of Cardiology in conjunction with The American Heart Association, neither are closely followed by most practitioners.  The guidelines suggest that patients who have no evidence of angina or congestive heart failure are at no adverse risk for any surgery.  In the process of screening for “problems” patients are generally subjected to nuclear stress tests and these tests identify those lesions that are “significant.”  However, significant lesions cause angina and not myocardial infarctions and many myocardial infarctions are from lesions that are not considered significant.

 The most important study done on this was a study that identified these patients and then randomized them to medical therapy and “corrective” therapy, either angioplasty or coronary artery bypass surgery.  This study revealed that the “corrected group” had a statistically significant worse outcome than the medically treated group because of the incidents that occurred during the correction.  This included the data for the surgery that they then went for after they were cleared.

The medical therapy most often applied is the use of preoperative beta blockers.  These are drugs like Toprol and atenolol which control heart rate and blood pressure.  This too has been called into question in that the routine use of these drugs can have important consequences for patients.

There is no perfect answer but what we presently do is unjustified by the data.  The use of selective functional testing and the selective correction and treatment is evidence based but not necessarily the current standard of practice.  This arises from legal concerns, compensation from testing and procedures and possibly from surgeons.

We as physicians need to do better.  This is one area that we can make a difference in the quality and cost of health care.  Beware of clearance that requires testing that you would not have gotten without the pending surgery.

Tags: Angina, congestive heart failure, Myocardial Infarction, urban legends in medicine
Posted in Heart Failure, Myocardial Infarction | No Comments »