Clinical Inertia: It Can Be Good For Your Health

This article cites a fascinating study in JAMA that looks at the benefits of the "less is more" approach to certain aspects of medicine. The authors "Phillips et al¹ intended to limit the discussion of inertia to disorders in which abnormal values may be the only manifestation of the disease, such as diabetes, hypertension, and dyslipidemia." This is a key characteristic of the conditions that can be treated to the point of danger in the name of prevention.

October 20, 2011, 10:20 am
When Doing Nothing Is the Best Medicine
By DANIELLE OFRI, M.D.

“Don’t just do something; stand there!”

It’s one of those phrases that attending physicians will spout off to their medical students while on rounds, trying to sound both sagacious and clever at the same time. It sometimes grates, but it does make a valid point, because so much of medicine is about “doing something.”

Sore throat? Prescribe an antibiotic.

New headache? Get a CT scan.

P.S.A. at the upper limit of normal? Get a biopsy.

Blood pressure still high? Add on another medication...

Of course, every “thing” a doctor does also has side effects — rampant bacterial resistance from antibiotic overuse; major increases in radiation exposure from unnecessary CT scans; incontinence or impotence from prostate cancer treatments that may do nothing to prolong life; toxic drug interactions from multiple medications, particularly in the elderly.

The admonishment “Don’t just do something; stand there!” reminds us that we should stop and think before we act, that there are many instances in which doing nothing is greatly preferable to doing something...

They focused on three common medical conditions — diabetes, elevated cholesterol and hypertension — for which there are established clinical guidelines for doctors to follow and “quality measures” that evaluate medical care. For all three illnesses, “lower is better” is the dominant mantra.

But while “lower is better” is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying.

Of course there are myriad situations where aggressive intervention is required, but it is helpful to have the reminder that sometimes less harm is done if you leave "well enough" alone.
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Cholesterol Drugs (Statins) Linked With Diabetes Risk

Who could have predicted that a highly lucrative drug might turn out to have some unpredicted nasty side effects? I have posted before about statins, since I've seen cases in my clinic of people with new muscle aches and pains, or back pain, or shoulder pain, etc... that started when they started taking statins. The part that irks me the most is the wide spread and inflexible denial on the part of the medical community to scrutinize these drugs more closely. If you read through the article, you will notice how these findings, also, are summarily dismissed. I have posted about statins here. In the letter to the editor in the Economist (not mine) their dubious efficacy is mentioned here. (For more information about my practice please click here.)

Cholesterol Drugs Linked With Diabetes Risk
By TARA PARKER-POPE

Cholesterol-lowering drugs called statins, which have been shown to lower a person’s risk for heart attack, can also slightly increase a patient’s risk for developing diabetes, particularly at higher doses, new research shows.

The findings, based on new analyses of five clinical trials involving 32,752 patients, raise new questions about how much we really know about the long-term effects of statins, which are the most widely prescribed drugs in the United States. The focus on the link between statins and diabetes comes at a time when some medical experts and pharmaceutical companies have pushed to broaden the use of the drugs beyond the 40 million at-risk patients who already use them to healthy people who would take the drugs for prevention of heart disease.

Doctors cautioned that patients should not overreact to the diabetes news, saying that the increased diabetes risk is very small, and that the benefits of statin therapy still far outweigh any side effects.

“I don’t think it’s very clinically important,’’ said Dr. Steven E. Nissen, chairman of cardiology at the Cleveland Clinic, who consults with drug companies that make statins but requires his fees be donated to charity. “What I worry about here is that people will read this story and say, ‘I don’t want to get diabetes so I’m going to stop my statin,’ and then they have a heart attack.’’

Last year, the medical journal The Lancet published an analysis of major statin trials involving 90,000 patients that showed statin users had a 9 percent higher risk of developing diabetes than those who didn’t take statins. But questions remained about whether the effect was real or something that may have just been due to chance.

However, the latest analysis, published today in The Journal of the American Medical Association, makes the strongest case yet that statins can trigger diabetes in some people. The report focused on differences in diabetes risk among moderate-dose and high-dose statin users, and found that those taking high doses had a 12 percent higher risk of developing diabetes compared to moderate-dose users. That translates to a 20 percent overall increased risk of diabetes for high-dose statin users, compared to those who don’t take the drugs, according to the study’s senior author.

Even so, medical experts, including the study authors, argued that while more study is needed to understand the diabetes link, the increased risk doesn’t eclipse the strong health gains achieved with statins, which in some studies have reduced heart attack and stroke risk by half.

Based on the data in the study, a total of 498 people would need to take a statin before triggering one extra case of diabetes. By comparison, just 155 people would need to take a statin to prevent one heart attack.

“The net benefit favored the statins overall,’’ said Dr. Kausik Ray, professor of cardiovascular disease prevention at St. George’s University of London and senior author on the paper. Dr. Ray says he has consulted for drug companies that make statins.

Exactly how statins may increase diabetes risk isn’t entirely clear, though animal studies suggest that statins can increase muscle resistance to insulin, resulting in higher levels of circulating blood sugar. Dr. Kausik notes that the patients in the studies were diagnosed with diabetes because of elevated blood sugar levels, but that the long-term consequences of higher blood sugar levels triggered by statin use aren’t known.

“Diabetes is defined by blood glucose levels, but none of us are absolutely certain if this is going to carry the same risk as if you traditionally developed diabetes,’’ Dr. Kausik said.

In addition, Dr. Nissen says the statins don’t cause blood sugar to shoot up rapidly but instead can slightly elevate blood sugar enough to push borderline patients across the threshold into diabetes.

“It doesn’t take much to tip a few people over that boundary to the point where we call them diabetic,” said Dr. Nissen. “We can’t dismiss it, but I also don’t want to scare people who need these drugs. They are the best thing we’ve got going to prevent coronary disease events.”

HDL, "Good" Cholesterol May Lower Alzheimer Risk

At Columbia University’s Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, they've done a study looking at Alzheimer risk and HDL, the "good" portion of cholesterol. If your HDL cholesterol is very high, this may be protective. In fact patients with high levels of HDL were less than half as likely to develop Alzheimer's Disease.

(To read more about acupuncture and my practice, please click here.)


‘Good’ Cholesterol May Lower Alzheimer’s Risk
By RONI CARYN RABIN

The people who reaped the benefit had very high HDL blood levels that exceeded 56 milligrams per deciliter of blood, the study reported. They developed 60 percent fewer cases of Alzheimer’s disease than people with the lowest HDL levels, of 38 milligrams or below...
But the HDL was only protective at extremely high levels, Dr. Reitz said. “It really only makes a difference if you’re higher than 56 [milliliters],” she said.

The report, published in the Archives of Neurology, is not the first to find that what’s good for the body may also good for the brain. Numerous studies have found that older people who walked the most were at lowest risk of developing vascular dementia, possibly because the regular exercise improves cerebral blood flow and lowers the risk of vascular disease.

Regular physical activity, in general, is believed to improve brain function, both by increasing blood flow to the brain and by stimulating the production of hormones and nerve growth factors involved in new nerve cell growth. Exercise also raises levels of “good” HDL cholesterol. Studies have found that animals that are kept physically active have better memories and more cells in their hippocampus, a part of the brain critical for memory. And exercise can help stave off or keep in check diseases like Type 2 diabetes, which increase the risk of developing dementia...

Some medications, like niacin and fibrates, may help raise HDL levels, Dr. Reitz said. But she recommends a Mediterranean diet rich in healthy fats from nuts, fish and olive oil, along with exercise, adding, “Aerobic exercise helps a lot.”

In a previous post, I discussed a study that looks at insulin resistance and acupuncture and how acupuncture can help with this aspect of metabolic syndrome and Type 2 diabetes. I hope it's not a stretch to think that acupuncture might help increase HDL cholesterol by increasing insulin sensitivity. Maybe it is a bit of a stretch, but for sure acupuncture can help to get you walking again if you have knee, back or hip pain!

Some sanity, at last, on Statins

I just attended the annual UCSF conference on Controversies in Women's Health. This conference is well done, in that it alerts practitioners to issues that are being discussed at the "Task Force" level. For example when I was at the conference 2 years ago I first heard about the mammography controversy, that the science was showing that there was no added benefit to mammography in younger women and that there were increased harms. Of course this caused a huge uproar in the subsequent two years. I won't go into the particulars of either side. But this was one of the first times I had actually been aware of the medical community admitting that there might be a downside to too much intervention.
This year, Professor Rita F. Redberg gave a thoughtful and informative talk on cardiovascular disease entitled "Prevention and Treatment of Cardiovascular Disease in Women:When is Less More?" Any readers of this blog know that this is an approach that I take seriously; to evaluate interventions carefully to make sure there is no harm being done, and to be highly suspicious of new, lucrative, and highly touted treatments. Dr. Redberg has a column in the Annals of Internal Medicine entitled "Less is More" and solicited contributions to the column via Deborah Grady, MD, section editor, Less is More, Annals of Internal Medicine. She asked specifically for cases, commentary, original investigation. What a great concept!
So as to the topic of Statins, I've been suspicious of them since the beginning because of the triad I just mentioned, new, lucrative and highly touted. My patients were coming in saying that their physicians were extremely enthusiastic about these medications, many even saying that they wished that they were in the water supply (!) (No worries, they probably are in our creeks and rivers by now, just like Prozac and antibiotics.) I also heard from patients that since they started taking them they had muscle problems and backaches. They were sure that they were from the statins, but their doctors insisted that they were fine. From Dr. Redberg's presentation, statins do cause muscle aches and pains, weakness, and memory loss. Her unequivocal position was that there is no data that statins reduce cardiac events or chronic heart disease mortality in women. Furthermore, there is no data that statins reduce all cause mortality in men or women.
She has a quote from one of her patients saying,

"Since stopping the Welchol, my leg muscle weakness has stoppend and I am able to walk down the stairs normally. I am also not experiencing memory loss. My thinking feels sharper."

First do no harm. Hopefully, with this latest consensus, people will feel more comfortable taking themselves off the statins, and physicians will not be so gung ho prescribing them. Dr. Redberg also said that cholesterol levels are clearly related to diet and physical activity, and it is unclear if the same benefits accrue via cholesterol lowering by medications.

(To read more about acupuncture and my practice, please click here.)