Which doctor knows best?
Medicine is, for the most part, a highly successful enterprise. The everyday practice of sorting out what is amiss and putting it right is not difficult. The assessment of its efficacy is similarly straightforward – either the treatments work or they do not. What then to make of the following?
Five years ago two sisters, A and B, had bone density (DEXA) scans showing that both had evidence of thinning or osteoporosis, warranting the bone-strengthening drug Risedronate in the anticipation that this would reduce their risk of a fractured hip.
A few weeks ago sister A received a letter from her family doctor advising her that recent research had shown the drug to be ‘’ineffective’’ – and she should discontinue it accordingly.
Meanwhile, sister B also received a letter from her doctor advising that she should not only continue the Risedronate but also take the calcium and vitamin D supplement Adcal D-3. This recommendation, she learnt, had been prompted by a review of the records of all the patients on the practice’s osteoporosis register – funded by the drug company ProStakan, which markets Adcal D-3. “We are,” sister A writes, “a bit confused.” This scenario illuminates the difficulties faced by patients with new drugs. Neither doctor could have had any direct experience of the merits of Risedronate in preventing fractures. In deciding to prescribe it, they were deferring to “experts’’ whose interpretation of evidence from clinical trials had resulted in them drawing up protocols to recommend it to sisters like A and B whose abnormal bone scans indicated that they would benefit from taking it. This can be a complex matter based on assumptions, extrapolations and arcane statistical methods. It is also perhaps relevant that the market for bone-strengthening drugs is worth billions worldwide and that their GPs would have had a financial incentive as “the treatment of osteoporosis’’ is a government target and earns a modest fee.
Now, Risedronate certainly works in the sense that it prevents thinning of the bones, but that does not necessarily mean it protects against fractures – especially in the older age group for whom other factors such as a tendency to fall is the primary cause.
Anyhow last year, the professor of orthopaedics at Helsinki University, Teppo Jarvinen, along with 10 colleagues, looked at the evidence and found it rather underwhelming – or, as he put it, “fraught with gaps’’. At best, he estimates that 175 women must take Risedronate, or its equivalent, for three years to prevent a single fractured hip. Further, these potent drugs may have side effects (nausea and vomiting etc) and can even, if paradoxically, predispose to “atypical’’ fractures – so the pay-off between the likelihood of good versus the chance of harm is highly problematic. Hence, sister A’s letter.
As for sister B, the combination of calcium and vitamin D is commonly prescribed in addition to bonestrengthening drugs on the assumption that it further reduces the risk of fracture – but that is disputed. Meanwhile, a GP in recommending she continue the Risedronate should have at least brought to her attention the recent doubts about its efficacy.
Rough cure
To the recently featured cure of a frozen shoulder thanks to a boisterous surrendering of Auld
Lang Syne, the Rev Anthony Appleby, former vicar of All Saints in Dulverton, writes of a comparable experience when chaplain to a group of young cadets on Dartmoor. One of them, ‘‘a large and heavy solder’’, injured his back after a bad fall, requiring him to be stretchered back to camp in an army lorry in great pain and unable to move.
An hour later and several miles down the road, the Rev was surprised to see him standing chatting to friends. ‘‘He explained that one of the many cures he received was being driven at speed over numerous pot holes which had clicked his back into place.’’ Though still sore, he was fully mobile.
A sight of sore eyes
This week’s query is courtesy of Mrs KP from Norwich who decided to dispense with her coal fire in winter in favour of a less bothersome electrical device. The first evening her eyes became very sore and red and so it has continued ever since.