The latest drug isn’t always the answer
When it comes to medicines, the older and well-established are preferable to the new breakthrough
The onward march of medicine, with its ever-expanding range of therapies, should be, one would imagine, a good thing – but not necessarily.
There are, for example, 10 different classes of drug for lowering the blood pressure – thiazide diuretics, beta-blockers, ACE inhibitors, etc – with several variations on each, making more than 80 in total. So, which is best? It might be presumed that the newer (and, inevitably, more costly) are superior to those they displace. But the only trial in which this has formally been investigated favoured thiazide diuretics, the simplest and cheapest first-line treatment.
Or consider the common and benign basal cell cancers of the skin, commonly known as rodent ulcers. The many options here include surgical excision, cryotherapy (freezing), radiotherapy, topical applications of potent creams and curettage with diathermy, by which the cancerous tumour is scraped away and the wound sealed with heat. They all work, but, again, the evidence as to their relevant efficacy is, according to a recent review, “sparse”… and so important issues such as the cosmetic results and rates of recurrence remain unresolved.
This plethora of treatment options is probably most apparent for the relief of the frequency and poor stream associated with benign enlargement of the prostate, almost universal in older males. There is a general impression that the dozen or so different drugs to improve the urinary flow are only modestly useful, so it might be better to proceed directly to one or other of the five “keyhole” procedures that have recently been developed, which include microwave or water therapy and prostate embolisation. Or, better still, one or other of the definitive surgical procedures to reduce the size of the gland: transurethral resection, laser surgery or robotic prostatectomy.
This cornucopia of choice is thus essentially illusory, as it is almost impossible to make an informed decision when the relative merits for one treatment over another are, for the most part, unknown. There are, however, two useful rules of thumb. When it comes to medicines, the older and wellestablished are preferable to the “latest breakthrough”. As for surgical procedures, it is sensible to inquire of the surgeon with which he has most experience.
Dementia therapy
It would seem logical that a stimulating environment would be of value in boosting the mental functioning of those with early dementia, over and above the standard medication that seeks to boost the concentration of neurotransmitters in the brain. And, indeed, a formal evaluation of the most thoroughly researched, known as cognitive stimulation therapy (CST), is certainly favourable.
Twice-weekly sessions of a range of activities – including discussing current affairs, singing, playing word games and practical tasks, such as baking – resulted in a “significant improvement” in the quality of life for two thirds of the participants. “My husband is much more involved and mentally active,” observed one woman. “Following a session, his shortterm memory is sharper and his mood much improved.”
For all that, and despite the reiterated commitment to improve treatments for this group of patients, the provision of CST on the NHS is distinctly patchy. Those who might wish to know more should visit cstdementia.com, which lists the NHS Trusts that provide it.
To go private, contact aimee. spector@sweettree.co.uk.
Take a closer look
Finally, the conundrum of the gentleman whose vision in his left eye goes lighter and darker in synchrony with his pulse has prompted concern. “I experience this effect on a regular basis,” reports a gentleman in whom it proved to be due to a benign tumour of the pituitary gland.
Alternatively, a recently retired radiologist speculates that it may be due to an aneurysm pressing on the optic nerve. “This type of symptom warrants taking seriously,” he notes, and advises, in the first instance, an MRI scan with angiography to visualise the blood vessels.