Read this book - Overdosed America

It's a very eloquent read re the depressing direction modern medicine is going in - it's written by an ex academic family doctor. In particular if you want a clear picture of the cholesterol saga, it's in this book.

Great site for doctors

For a couple of hundred dollars a year you get Rick and Jerry discussing 40 abstracts each month to do with primary care or emergency medicine, Rick is front line doc and Jerry an academic doc who works in an emergency department as well as being a critical appraiser. As likable as Rick is I get these abstracts to hear Jerry. We need many more docs like Jerry. He does the statistical and methodological stuff. Sounds great but is it?

Here they talk about blood pressure pills

Here they talk about aggressive treatment of CVD in the elderly

Jerry should write a book for us front line docs - please Jerry

If placing these audios from this great site upsets the guys and or gals who own it please let me know and I'll take them down. I have put them here hoping more docs will listen to Rick and Jerry.

What do I want more information on at the moment?

Long acting beta agonists - there is a major push going on with regards these. NMow we are supposed to be using one of them in a similar way to ventolin.

It's getting scary.

Medical research is largely or more and more being funded by drug companies - DCs.
The universities and their professors are becoming largely dependent upon DCs.
So are medical journals.
DCs are not primarily interested in the potential for harm.
They have been known to with hold information.
DCs have no interest in unprofitable treatments.
They have a duty to their shareholders not to patients.
They do what's expected of them.
Their influence is everywhere.
They need new drugs which can be patented.
Lifestyle drugs is the name of the game.
It's in their interest to have as many people as possible taking pills.
They have done great things for us but they should not control research to the extent that they do.


Guidelines are becoming a standard to judge performance and determine pay.
More and more of our top medical scientist are being helped financially by the DCs.
Too many sit on guideline committees while being paid by DCs whose products are under consideration.
Too many of our guideline producers have career conflicts of interest too.
Too many do not see these conflicts of interest as a problem.
Their mistakes and prejudices are becoming enforced on the workforce under the guise of evidence based medicine.
Tops scientists for instance should not be the ones to decide on the validity of research in their field of interest. Do the research have others crunch the numbers.
We need independent critical appraisers arguing the pros and cons of research.
Anyone being paid by a drug company should be excluded from having any a seat on anyy guidelines committee.

Evidence based medicine is a great boon and a potential trap
What is true today may not be tomorrow.
Findings may be plain wrong.
Things can be fudged.
DOEMs become more important than POEMs (disease as opposed to patient orientated evidence)
(what matters is not your cholesterol level for instance but where you have an MI stroke etc or not)
Statistical tricks can be played.
Very few doctors have the ability to sort wheat from chaff.
Critical appraisers with no conflicts of interest are a rare breed.
Once something becomes a truth it's very hard to change

Doctors are losing power to the politicians and managers.
Their livelihoods more and more dependent upon, not patients, but those that pay them and control their right to practice.
Controllers love guidelines - so would I if I was one - they simplify.
It's not their job to determine whether guideline are the truth or not.
Doing so would complicate their lives.
They tell us guidelines are only guidelines yet demand explanation if one steps out of line.
The professional and government bodies are part of this system too. They too use guidelines.
Doctors are controlled beings. If not they will be.
They are becoming less and less able to act out of their own knowledge or even the knowledge of experts that disagree with guidelines.
They are destined to become obedient souls - soldiers - unless things change.

Doctoring is becoming more and more a business rather than a profession. The yard stick - when your doctor is with you are they putting your interest before their own? Are they interested in you or more interested in their computer's requests - thats' where the money is? Ask them what's the evidence? Whats the countering evidence? What's the number needed to treat and harm? Who funded the research? Does he or she know the interaction of all those drugs she or he is offering? If you ask me, you'd get a lot of don't knows! Are you prepared for the discomfort of there being no certainty - only possibilities and probabilities

It's getting scary out there. Not too bad just yet maybe but the future looks grim to me.

Here's some of my stuff on these issues

Tight control of sugar levels in type 2 diabetes. Take a look at this for an example of differences in interpretation of evidence. As good as no benefit over less tight control

Things are not black and white. The more one knows the more Grey they become. Managers and controllers can not handle grey. Individual doctors and patients can but that's too anarchistic for the piper payers. The two people that matter in the moment are being taken bit by bit out of the game. But even for the doctors and their patients the whole business is too time consuming - better just to rely on those guidelines. Mostly they are pretty good but ......

Paranoid - yup.

A pile of guidelines from NZGG

NZGG


Population Screening for Colorectal Cancer


Prostate Cancer Screening in New Zealand


A Guideline for the Management of Heart Failure: health professionals guide


Assessment and Management of Cardiovascular Risk


New Zealand Cardiovascular Guidelines Handbook: Developed for Primary Care Practitioners


The Management of People with Atrial Fibrillation and Flutter


Management of Type 2 Diabetes



Guidelines for the Management of Heavy Menstrual Bleeding


Management of Dyspepsia and Heartburn


Depression: information for health practitioners


Guidelines for Medical Practitioners Using Sections 110 and 110A of the Mental Health (Compulsory Assessment and Treatment) Act 1992


Guidelines for the Use of Acetylcholinesterase Inhibitor Drugs in the Treatment of People with Alzheimer's Disease


Diagnosis and Management of Soft Tissue Knee Injuries: Internal Derangements


Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders


New Zealand Acute Low Back Pain Guide, incorporating the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain

Analysis of Chronic Fatigue Syndrome Guidelines

Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation

Diagnosis and Treatment of Adult Asthma

Management of Asthma in Children aged 1-15 years

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006

Guidelines for the Management of Genital Herpes in New Zealand

Hormone Replacement Therapy

How come these have come out black

A major rave

The takeover of the medical profession by managers and bureaucrats over the last ten year has been quite extraordinary and shows no signs of slowing up. Why?

The takeover was inevitable and it is going to intensify. Why?

The cost of drugs and surgery are skyrocketing - many thousands of dollars per year per patient for some treatments.

Customer demand is intense. They want the latest and best. They believe in magic bullets.

Doctors are also susceptible to the latest and the best. They need to be able to do something!!

When third parties are paying the bills, the customers don't care and neither do the doctors, someone has to reign in the spend fest.

The third party payers know that zillions of customers are not benefiting much or are being harmed by many treatments. They put out information re harms and it is largely ignored. They are of course suspected of penny pinching.

Doctors become attached to their treatments even when they have been shown to be harmful. They all too often can not or won't let go or change.

Individual doctors can not keep up with the total knowledge and skills base - even specialists have difficulty in their own field.

The knowledge base is highly polluted. Vested interests, bias, egos, unwillingness to speak out, fraud and spun research fool both doctors and customers.

The ability to assess information is not easy and is extraordinarily time consuming. Evidence based medicine has its problems. The more one knows the more grey things become. Neither customers nor doctors like grey. Each person and organisation comes to the party with their particular bias.

The drug and medical technology companies have a duty to their share holders. Benefits are exaggerated and harms put aside. They have huge resources to influence. They have billions of dollars at stake. They do not have your interests at heart.

Many of the guideline bodies have medical advisers who benefit from handsome handouts from the drug and technology companies. They claim these payouts do not influence them.

The major medical journals make their living from drug company adverts and reprints. They, well some of them, admit this is a problem.

More and more research is drug and technology company funded. University departments are all too often dependent on these companies for their survival.

Those that do systematic reviews have their biases and blind spots. Even professional critical appraisers of information can not avoid bias.

The profession has to a large extent lost the right to call itself a profession. There is just too much evidence that doctors do not have patient interests before there own. Medicine has become a business a very expensive one at that - exponentially growing in cost.

Those that pay the fiddler must feel driven to do something about the above scenarios.

A growing number of potential customers who cannot participate in the latest and greatest bring political pressure to spread the 'benefits'. Yet another reason for external controls.

The result - doctors have become or are becoming pawns of government departments, insurance companies, those they work for and the suppliers of drugs and medical technology.

As guidelines and protocols become rules to be followed one has to ask do the protocol and guideline manufacturers have the patients best interest at heart. To what extent do the above companies influence and control what goes on? As individuals they probably care but they too are subject to external forces and interests. They too may fear stepping out of line.

In the end it seems to me that the doors are now wide open for the drug and technology companies to have their way. Government bodies may do their best to reduce costs and obtain maximum effectiveness but when one looks at the whole statin thing and how this is promoted and its use endlessly extended, it seems we are on a slippery slope and your doctor isn't going to be able to help.

As bad as things may have been when doctors were free to operate from their own assessment of information I see no light the way things are going. When your doctor is a corporal in the medical machinery there's not much he can do. If he or she is top brass there still isn't much they can do. They are caught up in it all.

The end result of where we are going is disempowered patients and doctors with third party payers thinking they are in control whilst being manipulated by the drug and technology companies. What's the solution? I have no idea. It's all too big for anyone to sort out. So things will bumble on until things fall apart and yet another system is promoted.

America performs huge numbers of heart operations for coronary artery disease - billions and billions of dollars are spent - patients know they have benefitted and the demand grows. Yet the stats show they actually obtain little benefit - there are exceptions of course - their results keep the whole thing going. The evidence for benefit is unimpressive. Some people are harmed. Yet both doctors and patients are keen!

Anyone got any solutions??

Statins June 2006

Statin-Treatment Guidelines: 198 to 1 odds that the drug won’t help

What is most troubling about the results of this new analysis is not just that the U.S. and Canadian guidelines identify a larger pool of people as candidates for statin therapy in order to prevent one cardiac death. But it is also the fact that the crucial topic of drug-related harm was ignored by those who established the guidelines. “Treatment guidelines don’t discuss harms. I don’t know why,” said Douglas G. Manuel, MD, the lead author of the analysis, in a telephone interview.

The “winners” are the Australian and British guidelines because they are the most effective in potentially avoiding the most deaths. However, the New Zealand guidelines were deemed the most efficient because they potentially avoided almost as many deaths while recommending statin drugs to the fewest people. Based on the New Zealand guidelines, the number needed to treat is 108, or for everycardiac death prevented, 108 people must take statins for five years. (By comparison, the number needed to treat is 198 and 154, for the U.S. and Canada, respectively.)

Resuscitation update 2005 guidelines

CPR , ACLS, BCLS and heaps of other stuff

Short movie on 2005 basic life support View Presentation

Other movies on Advanced and paediatric can be accessed here

Here's a wee movie on AEDs. View Presentation

Osteoporosis

Site maintained by Susan Ott, MD Associate ProfessorDepartment of MedicineUniversity of Washington. Osteoporosis and Bone Physiology .

She has a fracture risk calculator.

This site has no advertisements and is not funded by anyone but the lady herself.

Calcium plus vitamin D: Modest effects
Jackson RD. Calcium plus Vitamin D Supplementation and the Risk of Fractures. New Engl J Med 2006:354:669-83.
This study of 36,282 women from the Women's Health Initiative showed no significant reduction in fractures in those assigned to take supplements of calcium and vitamin D, but there was an increased risk of kidney stones. This news is not all that surprising because some previous studies did not show benefits of excess calcium in ordinary women. The findings of kidney stones suggest that calcium intake should not be greater than 1500mg/day.

Seattle Times About Suddenly Sick

Blood pressure
Obesity
Osteoporosis
Deep vein thrombosis
Femal sexual dysfunction

About Suddenly sick

Seattle Times staff reporters Susan Kelleher and Duff Wilson interviewed more than 160 doctors, patients, medical analysts, regulatory officials and other experts for "Suddenly Sick."
They traveled to Europe, Canada and around the country, obtaining records and interviews with patients, officials with the World Health Organization, and doctors attending medical conferences.

The series also relied on thousands of pages of medical-journal articles, financial disclosures by researchers, cost-benefit studies by government and industry groups, Securities and Exchange Commission records, transcripts of Food and Drug Administration hearings, U.S. Patent and Trademark Office filings, and tax returns filed by not-for-profit foundations with the Internal Revenue Service.

Big Pharma

An ophthalmologist, who spoke to The Age on condition of anonymity, said the drug companies were teaching key opinion leaders how to "push poll" other doctors. "The opinion leaders become product champions," he says. "This is what will slowly kill the profession and its standing in the community. It has gone way beyond a couple of endorsed pens and umbrellas."

Blood Pressure

Click on table to enlarge. These figures help to put relative risk, absolute risk and percentage chance in perspective. 20% reduction sounds a lot. 96.8 % chance of surviving as opposed to a 96% chance doesn't sound like very much. 4S was a trial of statins on folk that had already had a CVD event ie secondary prevention. The WOSCOPS was a trial of statins for primary prevention in high risk patients. That BP result is interesting!! Click here to see where this came from.

while hypertension is an established risk factor for coronary heart disease at all ages and in both sexes, most high blood pressure-lowering trials have shown no reduction in coronary or total mortality in women and younger individuals (2) Uffe Ravnskov and in many studies, no effect has been demonstrated on male mortality either (3). This clearly indicates that hypertension is not a causa vera of coronary heart disease and "risk marker" would be a more appropriate description.

Here are three facts that currently co-exist in the world of medical research. Starting in the early nineteen eighties when the Medical Research Council (MRC) UK carried out the first ever long-term study into the effect of blood pressure lowering on mortality and morbidity. The drugs used were a diuretic and a beta-blocker.

Up to this point, you may be surprised to hear, this issue had never been studied. It was sort of assumed that a high blood pressure caused CHD, so if you lowered the blood pressure, you would prevent CHD.

The primary finding of the MRC trial was that blood pressure lowering had no impact on the rate of death from CHD. (There was some reduction in stroke and renal failure.)

Jumping to the present day, the ALLHAT study recently showed that there was no difference in CHD prevention between diuretics, beta-blockers, ACE-inhibitors and Calcium Channel blockers.

However, a recent meta-analysis in the NEJM shows that ACE inhibitors do provide protection against CHD.

From second article

From the European Heart Journal Issue 20, October 2000.

‘No randomized trial has ever demonstrated any reduction of the risk of either overall or cardiovascular death by reducing systolic blood pressure from our thresholds to below 140mmHg.’

‘Most importantly, the current paradigm considerably over-estimates the risk in the mid-range of pressure (roughly 125 — 180mmHg). .......... Consequently, a large proportion of the population considered at increased risk with the current cut-point are in fact at no increased risk.’

Developers of guidelines, ourselves included, have been overburdened by evidence which gives undue emphasis to the relative risks........ We think it is time to consider basing guidelines explicitly on clinically more useful absolute measures of the effects of treatment. Indeed, we suggest that the clinical credibility and success of the guidelines process depends on it.

Yup! Convince me, as a GP, that the benefits out weigh the harms - present it in a black and white manner. Be brutally straight forward about harms. What about harms that might take 20 years to show up!! Talk about these too! Present guidelines in ways that lay people can understand. I like percentage chance with and without intervention.

Find visual ways like this prostate risk roulette wheels

Statins - cholesterol

Concerned Scientists Dispute New Cholesterol-Lowering Guidelines

Statin Drug Treatment Carries Great Risk, Few Benefits

"These drugs have been shown to produce an alarming array of side effects," states Uffe Ravnskov, MD, PhD, THINCS Chairman. "Furthermore, the public and medical profession do not realize that statins only benefit a small and select portion of the population."

It has also been ignored that in the first statin trial EXCEL, mortality was already higher among those taking statins after one year compared with the non-treated control individuals.⁷ This trial is never mentioned in the many reviews published by those who proselytize for statin treatment and the higher mortality in the statin group was not even mentioned in the abstract of the paper.

The above can be found on this website Lots of articles by Phds.


This guy has written heaps of little essays on statin
Malcolm Kendrick MD

Guidelines - Managers love them!!

Tight glycaemic control reduces the risk of and slows the progression of microvascular and macrovascular complications. A stepped approach is recommended to lower and maintain HbA1c to as close to physiological levels as possible, preferably less than 7%, without hypoglycaemia.

The above comes from here. The New Zealand guidelines website. This website is a great source of information. I use it heaps. It has enabled me to get and keep reasonably up to speed. Many of those involved in developing these guidelines see them for what they - works in progress - not the final solution. However for many they are - the gospel. They are sourced in an evidence based way and so they must be as close to the truth as we can be for moment. There are some who say EBM - evidence based medicine - though based on sound principles, has become a religion in some people's hand, potentially dangerous to doctors and patients.

Take the information in the guideline above and compare it to the next two paragraphs which come from what seems like an impeccable source to me.

Tight glucose control did not prevent premature mortality or significantly reduce any clinically important diabetes-related complications.

In overweight patients treated with either insulin or sulfonylureas, there was no effect on diabetes-related complications, regardless of the degree of glucose control. (Click here to get full article)

Now I am not an academic or an expert on diabetes. I don't know how to sift B.S. from the good stuff. But the point is very few of us can. And we have all been burnt by what was the truth and now isn't. We have also been burnt by the opinion of experts.

In a recent analysis of review articles on the treatment of type 2 diabetes, we found that the experts writing them often did not tell us—the readers—the most important research evidence published in the past 25 years in the treatment of patients with type 2 diabetes.2 It's time to explore the value of experts and examine our reliance—or even addiction—to the pronouncements of experts.

Don't get me wrong I use the opinion of experts everyday. I couldn't function without them. And I check up on them too!!

In NZ the health managers and others living in airy fairy abstraction land may wonder why doctors aren't doing what's best for their patients, ie following their rules, ie guidelines to the letter. Well numero uno we aren't being paid as well as they are in the UK to be obedient robots. There they get paid 12 thousand pounds or so to audit their post heart attack patients for mild depression and then offer them counselling services that don't even exist. Don't believe me read NHS Blog Doc. He has some hilarious stories to tell. Click on him.

There are problems with guidelines. They are not necessarily best practice. They get it wrong sometimes. Even if they are on the mark they change. The truth is not static. Also there can be different interpretations of the evidence - see above. If a doctor is forced to prescribe against what he or she knows to be true, this is not good for their health or their future happiness. The sacrifice of integrity is a high price to pay.

Health managers have taken over the medical profession - well nearly. Guidelines are on the way to becoming rules. We can feeeeeel it coming. Payment and punishment based on guidelines. Obedience and a loss of integrity can have soul destroying outcomes. No wonder many doctors are not advising their kids to follow them into what is fast becoming a job - rather than a profession.

Doctors really do not want to be force fed and neither do many of their patients. Why should patients obey these guidelines? Really why should they. What is actually in it for them? 99 folk swallow a pill everyday for a year and get zip out of it. Doctors see and patients experience the side effects. Neither experience the benefits.

How long do you have to take BP pills for before you experience a benefit? You never do experience a benefit. Even if you are one of the lucky ones who would have had a stroke but don't have one, you can not know you would have had a stroke if you hadn't take the pill and so you have no experience of benefit. The doctors don't experience the benefit directly either. Yes your BP may be lower but so what - you maybe one of the unlucky ones that gets a stroke anyway. The benefits are theoretical as far as the individual and his doctor are concerned but the side effects are not.

His blood pressure maybe perfect but he has a cough, feels tired and has swollen legs - all caused by the the three different pills he is on. Having a normal blood pressure doesn't make him feel any better. So why should he persist? He knows doctors can be wrong. He knows folk are making money out of him. He's suspicious. He's seen his mate on ten different pills not doing very well. He wants no more pills thanks all the same doctor. Patient non compliance is a major factor. It's not just the doctors fault. And yes many doctors are non complaint too - especially when it comes their turn to take pills - many of them don't even check their own blood presssure.

There's another problem with guidelines - how things work in trials with motivated and relatively healthy patients and ambitious researchers/doctors is very different to the real world. Many trials are done on younger and fitter groups than coal face doctors deal with. An 80 year old diabetic with hypertension may have arthritis heart failure reflux and a whole pile of other complaints. By the time each condition is treated they are on a sack load of pills. Polypharmacy is not a good idea! It's bloody nuts unless a particular patient is highly motivated and well supported it just isn't going to happen. And anyway are the findings in that study relevant to this particular person?

The HDC , my personal bete noir, a government opinion generating organisation, that sits outside normal due process, passed judgement on me on a couple of issues. It took them three years. One of these issues was a dose of valium I prescribed. This ...... (words don't fail me.It's just what I want to say could land me in hot water) anyway this ........ decided I had used more than a therapeutic dose. How did she know this? She looked in New Ethicals. She blindly accepted what was in that book. She was wrong. Was there anyway of correcting her? Of course not. This opinion, garbage, still sits on my records.

In a few years time guidelines will be used this way too - they probably are already.

Bottom line any system that imposes from top down will in the end fail!! When the boys and girls at the coal face no longer love their work those at the top won't last very long - a couple of generations maybe. They will go out of fashion just like their dreams, visions, ideals, missions and so on. If they want monkeys that's what they will get.





Okay time to stop. I'll get back to the HDC again one day.

Cholesterol

Thanks to OverdosedAmerica and Dr Abramson.

The Framingham Heart study began in 1948. They enrolled 5,000 people. The association between high cholesterol and heart disease was found in 1957. HDL and LDL cholesterol and their effects came to light in 1977.

When I started GP work in 1976 Atromid S was the big thing. After many years of use it was discovered that it increased the overall death rate by 47%. Yes fewer people died of heart attacks but cancer and violent deaths more than made up for this drop. Didn't take long for a replacement to be discovered, statins in 1987. It took a while for the fashion to kick in - it's in full swing now! How bad will be this awakening?

Cholesterol is an essential molecule. It plays a major role in the brain, hormones, cell membrane and nerones.

Data from Framingham show higher cholesterol levels significantly correlate with an increased risk of death from coronary heart disease 'through the age of 60'. This does not extend to 70 and beyond. The over all risk of death correlates with high cholesterol till 50 and not beyond.

If the above surprises you what about the following. The risk of death from non coronary artery diseases increases significantly the lower the total cholesterol level for men and women after they reach the age of 50.

The most active third of the Framingham people have a 40% lower death rate than the least active third.

Modern guidelines are based on five major studies. Two terms you need to know - primary and secondary prevention. Secondary is for folk with coronary artery disease or CAD. Primary is for those who haven't got CAD.

Primary prevention in men younger than 65.
Men is this group with very high cholesterol levels may benefit from statins but the benefits are not miraculous. In one study 100 men have to be treated for 2 years to prevent one heart attack. To prevent one death 100 men would have to be treated for 5.5 years. In another study of people with moderate levels of cholesterol treatment with statins did not alter the over all mortality. In order to prevent one death, in those with moderate levels, from heart disease 100 people would have to be treated for 25 years. To prevent an episode of heart disease 100 would have to be treated for two and a half years.

Women under 65
A review article in 1995 in JAMA concluded " there is no evidence in primary prevention trials that statins affect total mortality in healthy women". Studies with these women show that statins may lower risk of recurrent CHD but they do not affect over all death stats.

Over 65
Remember that total cholesterol is not significantly related to mortality from CAD beyond the age of 60. There is no increase in the risk of heart attack with higher cholesterol levels in the elderly. In those 70 and above without heart disease statin therapy does not reduce risk of stroke or heart attack. It does increase their risk of cancer. By the fourth year of taking statins there is one extra cancer for every 100 elderly people taking statins that year and eacah year after.

Men with CAD
166 need to be treated to prevent one heart attack.

Women with CAD
Statins lower the risk of recurrent CAD but do not lower the over all mortality.

Abramson states .... it stretches credulity beyond reasonable limits to recommend statin therapy for primary prevention of heart disease in women, people over 65 and men with only moderately elevated cholesterol.

Few trials of statin therapy last more than five years. We have evidence of cancer with statin therapy in the elderly and in animal studies. If the maxim is first do no harm, then maybe some caution is appropriate here especially when the numbers to treat are pretty high and especially if we are going to treat people for many years. It takes a few years for smoking to produce cancer of the lungs.

There is a very rare condition with statins that leads to break down of muscles and kidney failure. My brother a gp in England knows of a man in his 50s who took statins without any history of CHD and died from this condition.

Statins have a small but statistically significant negative effect on cognitive function.

One study showed about 50% of men on statins have sexual dysfunction.

Statins should be used with caution in those with a history of liver disease or with a high alcohol intake (use should be avoided in active liver disease). Hypothyroidism should be managed adequately before starting treatment with a statin (see Lipid-regulating drugs). Liver-function tests should be carried out before and within 1–3 months of starting treatment and thereafter at intervals of 6 months for 1 year, unless indicated sooner by signs or symptoms suggestive of hepatotoxicity. Treatment should be discontinued if serum transaminase concentration rises to, and persists at, 3 times the upper limit of the reference range. Statins should be used with caution in those with risk factors for myopathy or rhabdomyolysis; patients should be advised to report unexplained muscle pain (see Muscle Effects below). Statins should be avoided in porphyria (section 9.8.2) but rosuvastatin thought to be safe. Interactions:

Contra-indications
Statins are contra-indicated in active liver disease (or persistently abnormal liver function tests), in pregnancy (adequate contraception required during treatment and for 1 month afterwards) and breast-feeding

Side-effects
The statins also cause headache, altered liver-function tests (rarely, hepatitis), paraesthesia, and gastro-intestinal effects including abdominal pain, flatulence, constipation, diarrhoea, nausea and vomiting. Rash and hypersensitivity reactions (including angioedema and anaphylaxis) have been reported rarely.

I have heard people describe lethargy and tiredness too.

The picture isn't quite as rosy as we are led to believe.

Medsafe information sheet on lipex

New Zealand guidelines
These present a more optimistic outlook.

Statins, Asprin and treated hypertension is the way to go, is the message.

The problem is polypharmacy. This was a no no a few years back. It's all go now. Often lowering BP requires 3 drugs. Patient haved other problems too - arthritis, asthma, diabetes, indigestion and so on all needing yet more pills.

Do they do these controlled trials on elderly people taking a zillion pills?? I doubt it.

Do a survey of docs and find out how many would swallow their own medicines.

Guidelines

One of the preconceived ideas medical folk have is that their guideline creators are objective and honorable women and men. One of the preconceived ideas that our guideline creators have is that they are honorable men and women.

In 2002 JAMA published a study that found that four out of five experts who participate in the formulation of guidelines have on average 10 money related arrangements with drug companies. 59% of the experts had deals going with the companies whose drugs were dealt with in the guidelines they were authoring.

I got this bit of information out of OverdosedAmerica.

With regards to statin guidelines little old New Zealand has been less hoodwinked than the rest of the world according to some Canadian researchers.

Back as GP after 15 years

This time last year my wife and I were here. It's Milford Sound in the South Island of New Zealand. Click on it and get a fuller sized picture.

May the 8th, 2006, I started back as a general medical practitioner. I hadn't seen a patient for a year and a half and I hadn't been in a GP surgery for 15 years. It's now August. I am no longer drowning but I am concerned. I have spent a zillion hours catching up and I have a zillion more hours to go. The steepness of the learning curve has been steep and is now a wee bit less so.

Guidelines have been my saviour. They are everywhere and on every subject. Most of them bang up to date - well compared to textbooks. And they are free. Anyone can get their hands on these if you know where to go. Have a poke around this site. It's the New Zealand guideline website.

Now that the curve isn't so steep I can take my time. Look here. And then take a look in here and before you go to far take a look at the members of this organisation. There are a lot of MDs and PHds with major concerns about where we are going with cholesterol. Maybe the whole theory is suspect. Is this going to turn out to be a major embarrassment?

There are similar issues around diabetes and hypertension - truths being stretched and stretched so more people are included in various treatment guidelines. So much work and skill required to sniff out the BS.

I still have a lot to learn. My diagnostic skills are reasonable and getting better. I enjoy this bit - interacting, taking a history, examining and finding out what is going on.

But treating people in a paint by picture manner, this I find distasteful. We will, in time, regret this top down, treat all to benefit a few approach. When the benefit is perceived to be huge - immunisation - about 80% cooperate. But when a relative risk benefit of 40% is found to be an absolute benefit of 1% - hmmm - I somewhat doubt anywhere near 80% will be coming to the party.

Take a peep at the table below - click on it to enlarge it. How convinced are you now? Yup the author may well have an agenda - check him out. He is in one of the sites I gave you above.



Take a few moments to read this table. I am not a stats man. Read it and you'll get it. There's a lot of effort going on for little gain.

What about the 50 year old man, I saw today, visibly deteriorating as he waits and waits in pain for an operation to replace his hips. We can fix him but by the time we do, he may only be half the man he used to be. He tells me he reckons his wait will total a year or more. His surgeon tells him he could have it done in two weeks if he paid for it. Pain has a soul destroying impact on folk and so does an ever decreasing mobility and a system that tells this man he has little value - suck it in and wait Buster.

Treat 100 of these folk and benefit 90% - now that's a worthwhile treatment. Why deny it to those who need it? Why pump and pomote hugely expensive treatments that will only benefit a few - maybe!