I know my patients and readers to be smart, analytical and information driven; frankly they are canny people. It is no self-flattery to say they would not be in a practice like mine or reading this if that were not true. So, with my audience in mind, I want to set a problem for you. One I very much hope you can help me understand.
First I want to rehearse with you three recent studies that will set the stage for the problem I would like answered. Help, please.
This from the BMJ (Green J et al. Oral biphosphonates and the risk of cancer of the esophagus, stomach, and colorectum: Case-control analysis within the UK primary care cohort, BMJ2010 Sep 2; 341:c4444)- British don’t you know: The U.K. General Practice Research Database was queried to identify nearly 16,000 adults with cancers of the above mentioned areas. Each cancer was matched to 5(!) control patients without such cancers. Of those who had used such drugs- examples: Fosamax, Boniva, Zometa- 3 or more years there was a 2-3 times increased incidence of cancer of the esophagus. Bad, very bad. Esophageal cancer occurs about 1 in 1000 per 5 years. On the medication the incidence became 2-3 per 1000 per 5 years. A fairly rare cancer becomes less rare. And by the way it does not help the body make any new bone.
Next, again from the BMJ (Bolland MJ et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: Meta-analysis. BMJ 2010 Jul 29; 341:c3691): Summary; the study showed treating 1000 people for 5 years with calcium supplementation would cause 14 additional heart attacks. Other data, from other studies, would conclude this same supplement use would prevent from 0 to 26 fractures in the same population for the same duration of use. Roughly 1 heart attack for at best preventing 2 fractures. From other data I believe the heart attack to prevented fracture score is more likely 2 to nothing (0).
Finally there is this:(The Lancet Oncology, Volume 11, Issue 7, Pages 627 – 636, July 2010 doi:10.1016/S1470-2045(10)70106-6): This looks at cancer incidence in those taking a very common class of blood pressure medicines called ARBs (angiotensin receptor blockers). Simple version of the study is: Number Needed to Harm (NNH) 143 people taking the drug for 4 years yields 1 additional fatal cancer; looks like mostly lung cancer. What is your risk if you have been on the drug for 20 or 25 years?
Now keep in mind all of these therapies have been around for more than 30 years; biphosphonates have been around in one capacity or another for over a hundred years! The ARB cancer risk probably implicates ACE inhibitors as well; my favorite class of blood pressure medications, when tolerated. Now I could expand on these studies, draw distinctions, criticize their experimental design and appear as sophisticated as the study’s critics; or at least I could try. I would fail and look ridiculous in the process. The problem is the studies are pretty well done and must be dealt with. The three examples I offer could be multiplied several times over. The number of black box warnings added to legal drug labeling is skyrocketing. The number of cases discovered of cancer, metabolic and more general problems associated with common medications is exploding. Old time beta-blockers used for high blood pressure increase the incidence of diabetes; another case.
Help me decode this encryption: drugs that have been around for many years, taken by millions of people and advocated by almost every medical professional organization are only now being seen to have problems associated with them. How is this possible? Why is this happening? I am open to conspiracy theories, new versions of intellectual history, accounts of greed, stupidity and just human folly. But something is going on. Has the whole enterprise of modern pharmaceutical medicine been some kind of crazy boondoggle? Well, my at least partial answer must be ‘no’ as so much has been achieved by antibiotics and some cancer therapies. Well even one of the most powerful classes of antibiotics- fluoroquinolones- has had at least 3 of its exemplars removed from use due to adverse events; events like death.
At each point in the decision tree of therapy for disease ‘lifestyle intervention’ is given lip service. High blood pressure: eat less salt, lose weight, exercise more is advocated. Diabetes: eat less sugar, lose weight, exercise more. You get the idea but there is no point of turnaround; once you start down the medication road there is no turning back.
I do not want to start my litany, my mantra of what you can do if only you will and how you do not need any of these medications if you are serious; I believe that and see it daily in my patient’s lives.
But something is missing. Please help me understand this. Something doesn’t make sense. Our medications are killing us. Keep in mind if you factor out, actually normalize, violent death, inner city youth violence, car crashes and the like, Americans have the longest life expectancy in the world. Did you catch that. All of us fat, lazy, Americans actually live longer than any people of any other country in the world. We must be doing something right and it is not ‘take drugs’ no matter how much organized medicine would like to take credit; the numbers don’t crunch.
Help me here. Feedback sought. How many of these drugs we/I have been pedaling are at least as bad as the problems they are ostensibly designed to cure? How did this happen? What’s wrong here? I confess to a small element of rhetorical intent in my questions but my bafflement is real.
Smile, God Speed,
Dr. Mike
