Friday, May 25, 2012

Yet More on Statins' Lack of Benefit

One more post about cholesterol and I promise to lay off for a while.

Sharon Begley has written a great article for the Saturday Evening Post:
--reviewing the data showing the lack of benefit when statins are taken for primary prevention of cardiovascular disease, and especially going into the "number needed to treat" as a helpful statistic. Along the way she reviews the various adverse reactions associated with statins--diabetes, memory loss as well as muscle aches--and adds a recent study suggesting that if you take a statin and then exercise, your body's ability to repair muscle is reduced. (A wonderful way to prevent heart disease--make it harder to exercise.)

The article says so many good things that it seems petty to pick out one problem, but I was disappointed that Begley (apparently to try to make clear that she was not simply bashing statins for bashing's sake) gave the drugs credit for the marked decrease in deaths from heart disease over the last 3 decades in the US. No one I know of says that drop was due to statins and most believe it primarily related to lifestyle changes and maybe a bit related to better outcomes in the acute care of heart attacks.

Now, you might wonder, if all this is so, then how come the drug industry has been able to convince us to get so crazy about measuing everyone's cholesterol (even kids) and then precribing statins at the first hint of a high measurement? (Begley starts off with the very sensible observation, that if what we know about statins and primary prevention is indeed true, then most of the justification for doing screening cholesterol measurements goes out the window.) The possible answer to that question is contained in a recent article that addresses the "cholesterol myth." While the article itself tends to go overboard in recommending somewhat extreme nutritional approaches, the core message is worth making note of.

Dr. Duncan Adams of New Zealand recently wrote about the "Great Cholesterol Myth":

The way Dr. Adams tells the story, Brown and Goldstein won the Nobel Prize for their discovery about the relationship between high cholesterol and heart disease. They were studying a very special population of patients--those with the gene for familial hypercholesterolemia, whose cholesterol levels are sky-high and who often develop premature heart attacks and vessel disease. Brown and Goldstein assumed that what they were seeing was cause and effect-- high cholesterol levels in the bloodstream cause the vessels to have defects. Dr. Adams marshals arguments that they had it backwards. What if the basic defect in the vessel disease seen in this select group of patients is super-brittle vessel walls? What if cholesterol makes vessel walls flexible? (After all, cholesterol is an essential chemical and we'd die if we had none of it in our bodies.) What if the genes these patients inherited make their vessel walls unable to absorb cholesterol, so they become brittle, and the unabsorbed cholesterol then floats around in the bloodstream?

Dr. Adams' theory shows how by studying a very select group, and then generalizing to the entire population, we could have ended up with the wrong idea about cholesterol as a cause for cardiovascular disease. (Begley explains why it turns out that cholesterol levels by themselves are a very weak predictor of heart attack risk.) Going from what's true of a person with a total cholesterol level of 500, and assuming the same thing is true for a person with a cholesterol of 201, is exactly how drug company marketing prospers.

Can we know for sure that Dr. Adams' hypothesis is correct and that the "majority" view of cholesterol is wrong? Hardly. But it's worth knowing that out there is a potential, logical explanation that could show why we're quite confused in our thinking of how to prevent heart disease. (Hat tip to Jerry Hoffman and Rick Bukata for pointing out the Adams paper.)

Wednesday, May 23, 2012

Statins in the Water Supply, Continued--Why the New Meta-Analysis Is Unreliable

In the immediately previous post, I said that I expected more commentary to appear on the CTT meta-analysis of statins for low-risk patients recently published in Lancet. In this post I will 1) report on one of those commentaries and 2) fill in what I failed to say in the previous post, which is why this whole issue is relevant here.

First, commentary, by Dr. David Newman of Mt. Sinai in New York, and author of the excellent book, Hippocrates' Shadow:

Dr. Newman asks why the CTT meta-analysis, which said that low-risk patients benefit from statin therapy, is so much at odds with previous reviews, conducted by reputable groups, whoch all agreed they wouldn't. He decided that it's because the older reviews answer one question and the CTT meta-analysis, another.

The old reviews, in his (and my) opinion, answer the real question: if patients are put on statins, will they benefit in terms of lower rates of heart/vessel disease and/or lower overall mortality? The answer is that right now there's no proof of that for lower-risk individuals without known heart or vessel disease.

The reason that the CTT folks got as different answer is because they asked a different question: if you go on statins, and if the result of going on  statins is that your cholesterol drops by a certain amount, will you have less heart/vessel disease and lower overall mortality? They found that the answer is yes, and apparently Dr. Newman thinks they crunched their numbers reliably and so this is probably a true result.

Now, suppose I'm a family doc and Mr. Jones, a 50-year-old man with apparent low risk for cardiac disease, comes for his annual visit, and I have to decide whether to put him on a statin. The older reviews address my decision, showing that if all I know is what I know now, then I cannot predict reliably that Mr. Jones would benefit.

The CTT analysis is irrelevant. Maybe if I put Mr. Jones on a statin drug, then he'll drop his LDL (bad) cholesterol by a certain number of points, or maybe he won't. There could be many reasons why he won't--maybe his body works differently, or maybe he forgets to take his medications, or who knows what. Since I cannot guess how he'd respond to the statin, the new analysis really provides me with no useful information. The old studies provide useful information, suggesting that I might have a talk with Mr. Jones about his options, but certainly not specifically recommend a statin drug.

Put another way, the CTT analysis shows how one particular subpopulation of people placed on statins respond, and that for whatever reason--because of the statin, or for some other reason--they seem to do well. But the overall population (low-risk patients without existing disease) is not addressed.

Dr. Newman notes that given this highly selective subpopulation that they looked at, the CTT folks have no grounds to recommend what they did, which is that guidelines should be revised massively to increase the number of patients for whom statins are recommended. The CTT folks (I'd add) were also disingenuous to the extent of their not openly addressing how and why their study came to such different conclusions from the earlier meta-analyses, coyly suggesting it was because they are so much smarter and the old analyses were plain wrong.

OK, so now why am I once again ragging about cholesterol and statins, on a blog that's supposed to be about the ethics of the medicine/drug industry interface? I cannot find clear evidence that the CTT group is in the pay of the drug industry; but they are basically acting as if they were. They are illegitimately recommending that a vast number of new patients should be prescribed statins. They are doing so based on an incorrect analysis, in a way that would probably not be obvious to the average reader, but as Dr. Newman shows is quite evident to the expert who understands data analysis. The Lancet is aiding and abetting this distortion of the data, and by appending an enthusiastic commentary, is even tooting the horn louder in favor of prescribing more drugs. All in all, one more sorry illustration of how the medical literature all too often serves drug industry revenues rather than patient health.

Monday, May 21, 2012

Back to Statins in the Water Supply--But On What Basis?

In the beginning was the polypill. This hypothetical product was first proposed by Wald and Law in 2003, based on the idea that with a general population at fairly high risk for heart disease, it made sense simply to put everyone above a certain age on a combination pill containing a statin for cholesterol, aspirin, and one or more drugs for blood pressure. A recent review by Katherine M. Carey, PharmD and colleagues reviewed a number of studies that tried to assess the vaolue and safety of one or another form of polypill and concluded that at best the results would be modest (subscription may be required):

Well, now says The Lancet, forget the polypill. Just put everyone above age 50 on a statin:

This advice is based on a recently-published-on-line meta-analysis by the Cholesterol Clinical Trialists (subscription required). Their study reviewed a total of 27 clinical trials of statins as primary prevention (that is, for people without known heart or blood vessel disease). They concluded that on combining all these trials, there was a clear advantage to using statins for primary prevention, and that the more they lowered your LDL ("bad") cholesterol, the better they were as a preventive.

To regular readers of this blog, such a study would require some explanation, because it contradicts evidence about statins and primary prevention that has by now been fairly well established, even if little understood by many physicians as well as the general public. See for example:
--which discusses the low level of evidence that statins are any good for primary prevention, as well as raising questions about whether they do whatever good they do by means of lowering cholesterol.

I have been privy to some e-mail discussions among statin and evidence-based-medicine experts, and I believe that several are planning to write letters and commentaries disputing the conclusions of the new Lancet meta-analysis. I am not at liberty yet to share the details of their reasoning. However, I can point to one press response to the Lancet statement about putting everyone on a statin:

Melinda Wenner Moyer, writing for Scientific American, interviewed several critics and pointed out a few of the problems with the CTT meta-analysis. The biggest flaw pojinted out by the critics she quotes is that while the CTT study pupports to demonstrate that statins are good for primary prevention, fully 60 percent of the study participants in the 27 pooled clinical trials had existing heart or vessel disease. To extrapolate from that population to the "low risk" patient identified in the title of the CTT study hardly seems kosher. The othet major criticism is that almost surely, the CTT trial vastly underestimates the frequency of averse reactions to statin drugs--in part, perhaps, because at least some of the clinical trials were designed specifically to exclude patients who had those adverse reactions, again a not-very-kosher study design.

I believe that as the weeks pass there will be even more serious criticisms lodged against the CTT study, so stay tuned.

Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 326:1419-24, 2003.

Cholesterol Clinical Trialists' (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet doi:10.1016/S0140-6736(12)60367-5, published on line May 17, 2012.

Grief: You'd Better Suck It Up After Day 13

I have blogged previously about the American Psychiatric Association's controversial revision of its Diagnostic and Statistical Manual, the promised DSM-V--most recently:

Critics have charged with what appears to be good reasons that the APA has launched an effort to reclassify many states that have previously been viewed as normal into mental illnesses, with no base in the scientific evidence, but with vast opportunities for Pharma to get wealthy selling psychoactive drugs for all these newly "discovered" diseases.

To primary care physicians like me, one of the most egregious reclassifications rumored to be included in the new DSM-V is grief. We have long been taught that while depression is a disease, grief is normal. Treating grief with antidepressants at best does not help and at worst simply postpones the normal healing process. Social support and psychotherapy is almost always the right treatment for grief, except in the few cases of abnormally prolonged or intense grief which have to be addressed as a special set of cases. But in any event, after loss of someone very close, something in the range of 9 to 15 months would be seen as a normal grief reaction.

Dr. Richard A. Friedman of Weill Cornell medical college in New York, writing in last week's New England Journal:
--contrasts this standard wisdom about grief, which was how the existing DSM-IV categorizes the condition, with that of the working groups designing the new DSM-V. They intend to reclassify grief as a depressive disorder and suggest that after 2 weeks of mild depressive symoptoms, a bereaved person has crossed the line over into depression and should be treated as such. Dr. Friedman notes that there are zero scientific data to support this reclassification.

I have not been able to track down a source for this rumor, but I have heard murmurings that if the APA proceeds to issue the new DSM-V (apparently scheduled for next year) with this reclassification, some of the primary care physician organizations, including my own American Academy of Family Physicians, might vote formally to dissociate their members from DSM. This would be an unprecedented move as up till now, starting at least with DSM-III, all medical specialties have been willing to accept as gospel the disease classification proposed by the APA-- which by the way makes a ton of money from selling DSM as its proprietary product. But it is precisely due to the APA treating the DSM as its own private property and cash cow--along with the too-friendly association of leaders in psychiatry with the drug industry over many years--that has led to the present mess.

Friday, May 18, 2012

Hiding the Truth about Drugs: How Long Are Outcomes Delayed?

It has been a good while since I reported on drugs like epoetin, used to stimulate the body to make more red blood cells to counteract the anemia associated with end-stage kidney disease and cancer. My early post: commented mostly on the payment system that tempted dialysis and cancer docs to prescribe more of these drugs than was necessary or safe. But new information now suggests that the truth about the harms and lack of benefit of these drugs could have been known much sooner and many patients saved from bad outcomes. Sadly this is not the first such story in the history of the medicine-pharmaceutical industry relationship.

Dr. Daniel W. Coyne, a kidney specialist at Washington University-St. Louis, has both written a detailed paper and a briefer commentary about his research:
I'm going to go into some detail about Dr. Coyne's findings as they illustrate several points, both about how scientific studies can be fudged to create a positive drug marketing message, and also how our bureaucracy works (or doesn't) to protect patient safety.

Before more recent research in the mid-2000s showing quite definitively that higher doses of epoetin-type drugs produced more strokes and other bad outcomes, the main research trial informing kidney guideline writers was the Normal Hematocrit Trial, conducted in 1996 and published in the New England Journal in 1998: This study was stopped early because of concerns that the higher doses of epoetin were causing more adverse reactions (more on that later). The journal article reported that on careful statistical analysis, there were no serious safety issues found, but that by contrast, quality of life of patients improved in the groups receiving the higher doses of epoetin (that is, those whose red blood cells achieved higher levels, which usually requires higher doses of the drug).

What Dr. Coyne did was simple. The drug company, Amgen, had to submit its own report of the study data to the FDA. As usually is the case, the FDA is under no obligation publicly to release these data and is indeed usually prevented from doing so by the proprietary nature of a company-sponsored study. Dr. Coyne requested the FDA data under the Freedom of Information Act, and was able to obtain the data after being kept waiting a mere 3-1/2 years (more on that later too).  He then sat down and compared in detail the study data reported to the FDA to the same study reported in the medical journal in 1998.

First the safety data. According to the New England Journal, the primary study endpoint, death or non-fatal heart attack, showed no difference between the high- and lower-dose groups. But the reason that the authors concluded this was that the data monitoring board, that stopped the study early, insisted on a tighter threshold for statistical significance, reportedly to correct for the fact that the same data had undergone multiple prior statistical analyses. The usual threshold is P = 0.05, but with the demand for the stricter level of P = 0.008, there was no statistically significant difference. When Coyne looked at the data the drug company submitted to the FDA, he saw that with the unadjusted significance test, there were more adverse events in the higher-dose group, with P = 0.0119, which would normally be interpreted as quite a significant result.

Time out for a sidebar on early stoppage of clinical trials. As I previous blogged--for example, in the past, when drug trials are stopped early because a drug seems superior to the control, it is commonly found with later research that this result is spurious and that had the trial been continued to scheduled completion, there would have been no difference between drug and placebo (or other comparator). What we see in the case of the Normal Hematocrit Trial appears to suggest a double standard for industry-sponsored trials. If the trial is stopped early because the company's drug looks good, then that result is trumpeted as the truth, even if more study would cast doubt on that conclusion. If on the other hand a study is stopped early because the drug causes people to die, then the investigators get to move the goalposts and fudge the statistics, so that it turns out that those people did not really die after all. Without going into all the issues about whether data monitoring boards are truly independent of the study sponsors, and how early stopping can lead to misleading results even of the boards are totally kosher, it would seem a valid take-home lesson that we should authomatically be very skeptical whenever a drug trial is stopped early.

Now, back to the main story and the question of benefits. Dr. Coyne found that the study as reported in the New England Journal indicated benefit in quality of life for patients who had achieved higher red blood cell counts. Reportedly these findings were statistically significant at P = 0.03. When he reviewed the same data as reported to the FDA, he could find no evidence of any statistically significant improvement, with a single exception--it was indeed true that patients getting higher epoetin doses ended up requiring fewer blood transfusions.

So the bottom line--in 1998 the kidney dialysis community was told that higher epoetin doses, leading to higher red cell counts, posed no significant risk of harm and improved patients' quality of life. Based mostly on that one study, the kidney gurus issued several practice guidelines calling for higher levels of red cells, which in turn required docs to prescribe higher doses of epoetin. Around 2006-8, new data emerged suggesting that this was unsafe. In hindsight we now realize that the data from 1996-98 actually show the same thing, and indeed demonstrate lack of any benefit to boot; so between 1998 and 2008, however many dialysis patients were exposed to serious risks of harm, including death, with no corresponding benefit. In total, says Dr. Coyne, Amgen profited to the tune of $37B in total sales of epoetin.

Now for the bureaucracy piece. Dr. Coyne filed his FOIA request for the FDA data in January 2008. He finally received the data in July 2011. Two weeks before he received the data, the FDA issued new labeling for epoetin, calling for lower red blood cell levels. In its warning, the FDA accepted the statistical tests of the data on file, meaning that the FDA now belatedly rejected the statistical fixes that had been published in the New England Journal. He allows us to read whatever we want into the timing of these events.

In his opinion article, Dr. Coyne also reports having contacted some of the academic authors of the New England Journal version of the Normal Hematocrit Trial. They claimed to him that they had tried to insert the information that he later discovered into the published paper, but that the editors at the journal rejected those amendments. Dr. Coyne admits to skepticism, since these same authors published several later papers and also served on the kidney guideline committees, but never made any attempt to alter the impression given by the original publication.

In HOOKED, I mention a couple of other instances where patients suffered due to a delay in revealing the truth about the benefits and harms associated with a drug--Vioxx being the poster child, having caused an estimated 144,000 excess heart attacks during the years when its dangers should have been known. We now have to add epoetin to this dishonor roll.

Many thanks to Dr. Barbara Roberts, author of The Truth About Statins, for calling my attention to this work.

Thursday, May 17, 2012

Genetic Test Firms Steal Marketing Ideas from Pharma

Dr. Michael S. Wilkes of UC-Davis (and NPR), who has been eloquent in addressing issues around the ethics and professionalism of drug marketing, widened his gaze in an editorial a while back:

He commented on another article in the journal on the marketing of genetic screening tests. It is generally agreed that while genetic testing can be very valuable for individuals or families known to be at high risk for an inherited disease, genetic screening tests aimed solely at showing a patient's statistical risk of developing multi-gene diseases such as diabetes or heart disease are seldom clinically useful and often quite misleading. Despite this a firm called Navigenics will very happily sell you one of this fishing-expeditiona genetic screening tests for a modest $999. What the research focused on was the fact that a national primary-care practice group, MDVIP, entered into a marketing agreement with Navigenics to promote this test to their patients, and that as part of this relationship, the company offered a free genetic screening test to these primary physicians, 1/3 of whom accepted the offer.

I'll pick up the commentarty from here in Dr. Wilkes's own words:

An offer of an incentive (in this case a free genetic test) from a new “collaborator” should clearly have raised questions for every one of the doctors. Even if any given doctor genuinely believed the test was in the best interest of a patient, it would be difficult to argue that the test ordering wasn’t influenced by a favor provided by Navigenics with an implicit expectation of reciprocity (“we did you a favor, now it is expected you will do us a favor by ordering this test on your patients”)....Is this type of social influence any different than offer of free drugs to doctors by pharmaceutical companies in an attempt to build loyalty?...

I wonder if any MDVIP physicians ever told their patients that they received a free gift by the very company that profited from the test the doctor was about to order—a test that has no proven value to the patient? Similarly, prior to testing, did the physicians include in their conversations with patients a discussion around informed consent? ...

It seems we have been round this issue before with pharmaceuticals and medical devices. As a profession, haven’t we decided that education developed by a company with a vested interest in the physician’s practice outcomes is not ethically or educationally appropriate? ...

Primary care doctors can either be part of the problem or we can be part of the solution by being vigilant and by self policing to avoid any actual or perceived conflicts of interest in order to maintain the trust of our patients and society. We also need to be informed consumers when it comes to our own education and avoid all commercial influence that seeks to promote profit at the expense of patient well being.

The usual hat tip to Rick Bukata and Jerry Hoffman's Primary Care Medical Abstracts for calling my attention to this article.

Tuesday, May 15, 2012

Bipartisanship in Congress, in Support of Pharma and Device Industries

It's often said today that Congress is totally dysfunctional and cannot agree on anything due to the huge partisan culture war. Well, the good news is that there's bipartisan cooperation on at least one issue. The bad news is that it's all in favor of handing the foxes at the pharmaceutical and medical device industries the key to the FDA henhouse.

The estimable Merrill Goozner: blogged about the latest renewal round of the Prescription Drug User Fee Act, where drug firms agree to pay a lot of the freight for running the FDA's drug approval process, and almost always manage to wring out favorable concessions in exchange for their largesse. Among the Christmas list the industry wants this time, and that Congress, well primed by the lobbyists, is apparently ready to hand them, are:
  • More use of surrogate markers to approve new drugs, without demanding proof that the actual diseases that affect people get any better (e.g., a drug that lowers blood sugar but does nothing to prevent heart attacks or strokes or blindness from diabetes)
  • Complete gutting of the reforms called for in the recent Institute of Medicine report to toughen requirements for testing new devices for safety
Gooz reports that consumer advocacy groups are incensed over these concessions but are getting nowhere with Congress.

The solution, as we have known for a good while, is to stop depending on the drug industry to fund the FDA--though replacing drug bucks with taxpayer bucks won't make that army of lobbyists go away (meaning that at some point or other, campaign finance reform is desperately needed as well).

NOTE ADDED 5/18: A kind colleague at Consumers Union just sent me two links that are very useful in relation to this issue-- first, a Public Citizen fact sheet regarding device regulation:
--and next, a Twitter discussion from the Safe Patient Project at Consumers Un ion regarding the pending legislation in Congress and how it fails to protect patients:!/cusafepatient

Monday, May 14, 2012

Abbott Labs, Again--More on Recent $1.6 Depakote Settlement

Okay, I admit that I'm confused. Last November I posted this about a $1.3B legal settlement paid by Abbott Laboratories over off-label marketing of its drug, valproic acid (Depakote):

Now I learn from our friends at the Health Care Renewal blog that Bloomberg News just announced a $1.6B settlement from Abbott over the same drug for the same reason:

So I have to assume that the article last November was a preliminary announcement and that this recent notice is the final announcement--otherwise Abbott would have paid a total of $2.9B over this one drug which would set a new record and would no doubt have been remarked on in the news media. The amount paid is of interest as previous reports of Pharma settlements often showed that the settlement sum, while in the hundreds of millions of dollars, was still only about 10% or 15% of the annual sales of the offending drug. In this case, $1.6B is the total annual sales figure for Depakote before it became generic. (But don't worry about Abbott, as the company proudly announced that they'd already set aside the funds needed to pay the settlement. Presumably, big drug companies find that sort of loose change under their sofa cushions.)

The settlement is also different from most in that Abbott was forced actually to admit wrongdoing, pleading guilty to a misdemeanor charge. As piddly as that may sound, in past settlements the company has usually been allowed to escape any admission of guilt.

Dr. Roy Poses over at Health Care Renewal focuses (as is his wont) on one aspect of this, which is the responsibility of the company and its CEO for this admitted wrongdoing. The settlement lets Abbott off the hook merely with being on probation for the next 5 years and promising not to do it again. Dr. Poses helpfully gives us Abbott's recent track record that presumably earned it this degree of lenience:
  • Obstructing Justice - In 2003, an Abbott subsidiary settled civil allegations and pleaded guilty to obstructing a federal criminal investigation of its marketing practices, resulting in fines of $614 million ...
  • Suppressing Reports of Drug Contamination - In 2009, the FDA charged that an Abbott subsidiary failed to report bacterial contamination of an optic product ....
  • Blocking Generic Competition - In 2010, Abbott settled with the New York state Attorney General allegations that the company conspired to block generic competition for its lipid lowering drug TriCor ...
  • Inflating Charges - In 2010, Abbott also settled with the US Justice Department for $421 million charges that it defrauded Medicare and Medicaid ....
  • Paying Kickbacks to Doctors - In 2010, an Abbott subsidiary also settled with the US government charges it paid kickbacks to physicians to prescribe other cholesterol lowering drugs...
  • Anti-Competitive Pricing Practices - In 2011, Abbott settled lawsuits alleging that its anti-competitive practices inflated prices of anti-viral drugs...
 Somehow I have the impression that if your typical petty criminal went before the judge with a guilty plea, and had this track record, that he'd be unlikely to get only a few years' probation.
 Dr. Poses is also very concerned about whether the CEO of a company that engages in this sort of illegal behavior ever suffers any penalties. I am very pleased to report that the Abbott CEO has indeed taken a hit, unlike most of his predecessors in similar circumstances. In 2010 his salary was $25,564,283. His 2011 salary was trimmed all the way down to $24,010,902.
Sort of gives new meaning to the term "making out like a bandit."

Sunday, May 13, 2012

The Things that You're Liable to Hear from Pharma Marketers, It Ain't Necessarily So

I just finished listening to the latest issue of Primary Care Medical Abstracts from my friends Rick Bukata and Jerry Hoffman, which means that I have some more recent articles from the medical literature to comment on. This time the theme is: stuff practitioners believe to be true based on the way that Pharma marketing has flooded the medical airwaves, that may actually not be true at all.
  • Chapter 1: Even if the Prozac class of antidepressants are not necessarily more effective than the older tricyclic antidepressants, at least they're a lot safer. A team from Nottingham, England looked at a database of about 60,000 patients 65 or older being treated for new-onset depression. They compared the outcomes for patients on the new-generation (SSRI) vs. older (tricyclic) drugs. They found in virtually every category a higher incidence of adverse reactions among those taking the SSRI-type drugs. The risk of dying within 1 years was 8.1% for people taking the tricyclics vs. 10.6% for the SSRI patients. This is an observational study and not a controlled trial, so you can't exclude the possibility that somehow the sicker patients were given the SSRI drugs and that explains why they had worse outcomes. Still, the huge number of patients included in the study certainly suggests that the safety of SSRIs may have been greatly exaggerated. (Coupland C, Dhiman P, Morriss R, et al. "Antidepressant Use and Risks of Adverse Outcomes in Older People: Population Based Cohort Study." BMJ 343:d4551, 2011)
  • Chapter 2: Alprazolam (Xanax) has unique properties as a drug for panic disorder. While alprazolam is a member of the benzodiazepine class (minor tranquilizers like Valium), company marketing has been highly successful in associating it in physicians' minds specifically with panic disorder, so that if you have a patient with that diagnosis, or who even gets excited once in a while, and you try to treat that patient with any other benzo besides alprazolam, you're an idiot. An international team of folks did a systematic review of 8 studies that compared alprazolam to other benzodiazepines in the treatment of panic disorder. They found no evidence that Xanax is superior to any other drug in that class. They did find, however, that Xanax had a worse addiction profile and many additional adverse reactions compared to its benzo cousins. (Moylan S, Staples J, Ward SA, et al. "The Efficacy and Safety of Alprazaolam versus Other Benzodiazepines in the Treatment of Panic Disorder." Journal of Clinical Psychopharmacology 31:647-652, 2011)
  • Chapter 3: If you want to prevent Type 2 diabetes, reach for a bottle of pills. There's been a huge interest, almost entirely driven by Pharma marketing, in diagnosing the condition "prediabetes" and then throwing medications at it.  This group from NIH utilized a database of over 200,000 patients who were surveyed for lifestyle factors in 1994-96 when none of them had diabetes, and then compared follow-up data in 2004-6 to see which ones ended up developing diabetes. They looked at smoking, body weight, diet, exercise, and alcohol consumption. Every single one of the healthy lifestyle factors was a significant predictor of not developing diabetes later on, with lean body mass being the single most powerful one. Basically, for every additional healthy lifestyle factor that you had, you reduced your risk of diabetes by about 1/3 compared to what it was previously. The main point here is the immensity of the effect--drug companies would kill to be able to announce a drug that reduced future risk of diabetes by 5-10%. The take home message seems to be that if it takes time and energy to counsel patients on lifestyle instead of reaching for ther prescription pad, it's well worth the effort. (Reis JP, Loria CM, Sorlie PD, et al."Lifestyle Factors and Risk for New-Onset Diabetes: A Population-Based Cohort Study." Annals of Internal Medicine 155:292-299, 2011.)

Monday, May 7, 2012

Avastin Continues to Impress for Eye Use

A while back I posted on the controversy about the drugs Avastin and Lucentis:

Quick recap: Eye specialists found out almost by accident that a drug intended for cancer, Avastin, was really good for a particular eye condition, wet macular degeneration, and was also quite inexpensive. The maker, Genentech, then marketed a newer cousin of Avastin, called Lucentis, which of course they priced up the wazoo, and tried every trick in the book to get doctors to use it instead of the cheaper Avastin, which remains officially off label for eye use. (To their great credit, the retinal community refused to go along.)

In the earlier post away back in 2007, I noted that a trial was just beginning that would provide the definitive scientific answer to whether Avastin was as good as Lucentis for eye use, contrary to the interested claims of Genentech that Lucentis was superior. Genentech, quite naturally, refused to fund a head-to-head comparison trial of the two drugs to find out the answer, so an NIH-funded study was launched.

The first results of that study showed that the two drugs worked equally well, as did a more definitive follow-up report from the same study, as now helpfully summarized at Merrill Goozner's blog:

So in case you wondered, we now have sound evidence for what the retinal specialists had all along believed based on the older evidence plus their impressive clinical experience--a cheaper version of the drug works just as well as the much more expensive version.

If the world were just, the FDA would now revise the labeling for Avastin to make it clear that it's indicated for wet macular degeneration, removing Genentech's claim that Lucentis is the only drug so approved. But to the best of my understanding, the world is not fair, and only Genentech can initiate such a label change at the FDA, which of course they would only do over their dead bodies. (If others know the FDA rules better please chime in.)

Saturday, May 5, 2012

Barbara Roberts, "The Truth About Statins"

I recently had the privilege of attending the very important conference in Boston called Avoiding Avoidable Care (about how to both improve quality and reduce costs by avoiding the use of nenbeneficial tests and treatments), and there met Dr. Barbara H. Roberts, a cardiologist who heads the Women's Cardiac Center at Miriam Hospital in Providence, RI. I therefore learned about her new book, The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs (New York: Pocket Books, 2012).

I've not yet had time to read the entire book but zeroed in first on Chapter 7, which is titled, "Big Pharma, the FDA, and the Medical Profession: An Unholy, Very Lucrative Alliance" (for reasons readers of this blog can imagine). Dr. Roberts does a nice job of explaining her own personal experiences with the pharmaceutical industry (she did sponsored talks for a while until the managers decided she was actually telling the audience about the science rather than peddling drugs), and especially in revealing the extent to which organizations in her field, especially the American Heart Association, are in bed with industry and rolling in industry cash--and how that influences the supposedly objective guidelines and food approvals they issue.

I also reviewed what Dr. Roberts had to say about the JUPITER trial, about which I blogged extensively (for a summary see Her analysis to my inexpert eye is both detailed and cogent.

In short this appears to be a great book for both physicians and patients about how statins for cholesterol have been way too aggressively marketed, and why old-fashioned lifestyle changes are probably a more potent and certainly safer way to reduce one's risk of heart disease.

Tuesday, May 1, 2012

The Wages of Sin Are Considerable

In an earlier post, I discussed the implications of Kenneth Frazier, CEO of Merck and former company general counsel, serving on the Board of Trustees of Penn State at the time of their recent coaching scandal:

In that post, I sumarized Mr. Frazier's career at Merck as follows: "So Penn State wants to put its investigation into the hands of a guy who first, did his best (in company with all the corporate leadership) to conceal the truth to assure that a favored brand continued to make profits; and second, once the truth came out, fought like heck to make sure that the human beings who were harmed by those corporate actions didn't get a penny. Sounds like a great plan to restore trust in the university."

The results of Frazier's leadership at Merck thus far have been roughly as follows, as nicely summarized by our good friend Roy Poses over at Health Care Renewal:

Frazier, he tells us, saved Merck megabucks by aggressively fighting all the Vioxx lawsuits. But Merck has since had to pay huge criminal fines for the way it marketed Vioxx,  most recently, a $950M settlement. Merck stock has been in the doldrums as a result.

So how has Merck treated their CEO? According to Dr. Poses (quoting the Dow Jones News Service), "Merck & Co.'s ... leader received compensation valued at $13.3 million for 2011, up 41% from the year before, reflecting his ascension to the drug maker's top post and Merck's ability to exceed certain internal performance targets."

As Dr. Poses has gone blue in the face reminding his readers, this is the norm for corporate America nowadays. Companies are not run for the benefit of their customers, or even necessarily for the benefit of their shareholders, but for the benefit of their top executives, with the full complicity of pliant boards of directors. When this sort of thing happens in the less-developed countries, we call it corruption. As both Dr. Poses' and this site have also blogged about in the past, until individual execs start to suffer real consequences (like how about jail time) for serious misdeeds, we can expect this behavior to continue. (See for instance: