(or How I Learned To Stop Worrying and Love the Pharmaceutical Industry)

I’d like to try to change the way you think about preventative medications.

The goal of prescribing blood pressure-lowering medications is not to lower blood pressure.  The goal of prescribing cholesterol-lowering medications is not to lower cholesterol.  The goal of prescribing medications for osteoporosis (low bone density) is not to raise bone density.  Let me explain.  The goal of medications that lower blood pressure and cholesterol is to prevent heart attacks and strokes.  The goal of medicines that treat osteoporosis is to prevent fractures.

The distinction may seem silly but is actually critical.  Strokes, heart attacks and fractures are what doctors and researches call clinical outcomes.  Clinical outcomes are things that directly affect patients, things that patients can notice for themselves.  Blood pressure, cholesterol and bone density, on the other hand, are intermediate (or non-clinical) outcomes, things that doctors can measure but that patients can’t feel directly.

The important lesson is that medicines that improve intermediate outcomes don’t always improve clinical outcomes.  There are medications that lower blood pressure without decreasing stroke or heart attack risk.  There are medications that lower cholesterol without decreasing stokes or heart attacks (like estrogen).  So the important question to ask is not “will this medicine improve my bone density?”  The important question is “will this medicine decrease my risk of fracture?”

Statins, a family of cholesterol-lowering medications which include Lipitor, Zocor, Crestor, and others, have been a boon for patients because of their proven benefit in preventing strokes and heart attacks.  Zetia, a cholesterol-lowering medicine that works differently than statins, has been proven to lower cholesterol but has never been studied to see if it improves clinical endpoints.

Last week’s NY Times had a disturbing article about Merck’s handling of data from a study about Zetia.  After completing a trial testing the effectiveness of Zetia, Merck has decided that they will only release data about some of the outcomes that were measured.  That’s definitely a reason for the rest of us to worry and for patients on Zetia to talk to their doctor.

Many of my colleagues and patients are very hostile to the pharmaceutical industry.  I’m not.  Without the pharmaceutical industry, after all, we’d never have statins.  I assume that, like all industries, they will try to sell us more than we need and will try to put the best spin on their products.  So the burden is on us, the consumers, to be educated and discriminating shoppers.

(Thanks to my colleague, Dr. Yaron Elad, for bringing the article to my attention.)

Tangential Miscellany:

A bright and happy Chanukah to all my Jewish readers!

Last week’s post generated many comments from you, and I appreciated them very much.

With Thanksgiving approaching and New Year’s resolutions around the corner many of us are reviewing our commitment to our exercise program (or realizing that for the last few months we’ve had no commitment and therefore no exercise program).  With this perfect timing, this issue of the Journal of the American Medical Association published a study looking at the benefit of using pedometers for increasing physical activity.  The study was also reported in this LA Times article.

The study was a review of the existing medical literature on pedometers, pooling together the data from 26 existing studies on the topic.  The review showed that pedometer users increased their physical activity, significantly decreased their body mass index, and decreased their blood pressure.  In addition to just using a pedometer, having a specific step goal, like 10,000 steps per day, was a strong predictor of increased activity.  That’s an important reminder about something that shouldn’t surprise us and is a useful trick in many aspects of life: making a specific goal is a critical step to achieving it.

So despite the fact that I’ve been giving out pedometers to my patients for about a year, I’m embarrassed to say that I stopped using mine (well, I actually lost it) months ago.  Time to break out a new one.

Let me know if you’d like a pedometer.  Now is always the right time for rededication to healthy goals.

Tangential Miscellany:

My wife and I wish you and yours a joyous Thanksgiving.  I hereby grant all of you a one day reprieve from the dietary limitations I scold you about during the rest of the year.  You may eat what you like provided that you are surrounded by loved ones and that happy expressions of affection and gratitude fill your home.

A patient of mine told me yesterday that she thought too many of my posts were negative:  this supplement doesn’t help, that medication doesn’t work, this intervention doesn’t make a difference.  She’s right.  A lot of my posts are negative.  There are two reasons for that.  One is that we’re constantly bombarded by advertisement and bogus information in the mass media about the latest and greatest medical wonder, usually long before any evidence exists about its effectiveness.  So I partially see my job as deflating those claims and reminding you that a lot of this stuff doesn’t do anything.  The other reason is that effective therapies are just so darned rare.  For every proven claim, there are so many others that are purely speculative, so I’d like to spread a little healthy skepticism to my readers.

But I guess everyone wants a positive story once in a while.

Of course the big picture is overwhelmingly positive.  Americans are living longer than ever, with an average life expectancy at birth of 77.8 years.  Treatments for high blood pressure, high cholesterol, diabetes, and heart disease are dramatically better than they were even ten years ago.  New surgical techniques make recovery from surgery easier.  (A very sweet 76 year-old lady who has been under my care for years was just admitted two days ago with acute appendicitis.  Her appendix was removed and she went home in wonderful condition this morning.)  New advances in understanding have revolutionized treatment for diseases like stomach ulcers.  (They’re caused by a bacterium!  Who knew?)  And the future promises further advances on all fronts.

So there’s great reason for optimism.

Next week, I’ll probably be back to something negative, like reminding you that your vitamin C supplement is worthless.

Tangential Miscellany:

Do you have a health-related topic you’d like me to write more about?  Less?  Let me know!

Acute low back pain is a very common problem, so one would think that we would already know how to treat it optimally.  Sadly, we don’t.

A study in this week’s Lancet raised serious doubts about two of the most common therapies sought out by patients with low back pain: non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulation.  The study received much coverage in the general media including this US News article.

The study enrolled 240 patients with acute low back pain.  All the patients received advice from a physician to take acetaminophen (the ingredient in Tylenol) four times a day and to remain active.  They were then randomized into four groups.  One group received diclofenac (an NSAID, similar to ibuprofen and naproxen) and spinal manipulation.  A second group received spinal manipulation and placebo pill.  A third group received diclofenac and sham spinal manipulation.  The last group received the placebo pill and sham spinal manipulation.  All four groups recovered from their back pain at the same rate.

So the best advice for acute low back pain is to take acetaminophen four times a day and to stay active.  The manipulation and stronger pain medicine may make you feel like you’re getting more care, but you won’t get better any sooner.

It’s humbling to find out that what physicians do is frequently useless, but it’s better than not knowing.

Tangential Miscellany:

Since we’re in flu season, several patients have asked me about the safety of thimerosal, a mercury containing preservative in some formulation of the flu vaccine.  The CDC has a very helpful Q&A page about it.

Methicillin resistant Staphylococcus aureus (MRSA) is a drug-resistant strain of Staph which has been getting a lot of media attention recently, having caused several serious infections in schools, especially in student athletes.  This search for MRSA in Google News reveals the many stories and heightened concern that this bacterium has been generating.

A few years ago MRSA infections occurred only in hospitals or nursing homes.  It became prevalent in these settings because the wide use of broad spectrum antibiotics selected for resistant strains by killing all other bacteria.  In the last few years, however, MRSA has become very common in the community.  Patients who have never been in healthcare facilities are getting serious MRSA infections.  This became so common that doctors had to change the antibiotics that we were using to treat community-acquired skin infections.  The previous first line antibiotic, cephalexin (Keflex), isn’t effective against MRSA and is now rarely used for skin infections.

This Times article and this fact list by the Centers for Disease Control have very useful summaries of what MRSA infections look like, and how to prevent them.  I encourage you to take a look.

We’re stuck in an escalating arms race with microorganisms in which our ever-improving antimicrobial medicines are being met with ever-increasing bacterial drug resistance.  Prevention seems to be the best strategy: frequent and meticulous hand washing, laundering items like towels that are used by more than one person, and frequently cleaning surfaces that touch bare skin, like shower floors.  Twenty-first century pharmaceuticals have made old-fashioned hygiene more essential than ever.

(Thanks to Rachel G. for sending me a link to the Times article.)