Doctors “Bending” Ethical Norms to Best Serve Their Patients who can’t Bend their Joints

ethical-medical-dilemmasRheumatic diseases, such as rheumatoid arthritis and lupus, are a common cause of disability. they affect all sectors of the population, diminish quality of life and have a significant social impact.

Yet, despite the benefits of early treatment and effective therapies, access to rheumatologic services may be difficult, involving long wait times, even difficulties finding providers.

C. Ronald MacKenzie, MD, a rheumatologist at Hospital for Special Surgery in New York City conducted a survey among rheumatologists entitled “Bending’ Ethical Norms to Serve Patients’ Interests:Tensions in Medical Professionalism,” to examine the medical, moral and ethical dilemmas doctors face when trying to do what’s best for their patients in the current health care environment.

The study was published in the October issue of the journal Arthritis and Rheumatism. When people receive a diagnosis, the cost of effective treatment may render it unaffordable for many,” says Dr. MacKenzie. “While an optimal or fair system would mitigate these impediments to care, our survey of the American College of Rheumatology members suggests that this is often not the case. In fact, physicians report they frequently find themselves in situations of ethical conflict in an effort to best serve their patients.”

The survey consisted of 14 closed-ended and two open-ended questions and was sent to 5,500 members of the American College of Rheumatology.

Physicians reported ways in which they see themselves as ‘bending’ ethical standards and presented justifications for doing so. Examples included ‘embellishment’ of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain diagnostic tests and necessary medications and or physical therapy.

rheumatismThe delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed.”

Medicine is not merely the scientifically based treatment and care of illness. It also involves ethical issues of right and wrong. In some cases, tough ethical dilemmas force doctors and other health care providers to make difficult decisions, all while upholding the Hippocratic oath to which all doctors are bound.

In today’s health care world, where the number of health care options can be great, medical ethics is of particular concern.Awareness of this problem and its consequences is only the first step in finding solutions to the challenges that physicians face.

Fixing the system in which physicians feel they have to ‘bend’ ethical norms and compromise ethical principles in order to provide the care their patients need, is clearly what’s so desperately needed.

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NSAID’s in the News (again)

Medication - Over the Counter - otcLet me start by saying, that despite spending the last 20-something years in or around the pharmaceutical industry, I don’t like taking pills. That said, I’m not particularly partial to pain either. So when my knees or back hurts or I’m doubled over with dysmenorrhea, like many other people, I’ll reach for the ibuprofen.

But that may be about to change. Results from a new, large international study of non-steroidal anti-inflammatory drugs (NSAIDs), showed that high doses of them increase the risk of a major vascular event such as heart attack, stroke or death from cardiovascular disease by around a third.

In other words, for every 1,000 people with an average risk of heart disease who take high-dose ibuprofen for a year, about three extra would have an avoidable heart attack, of which one would be fatal, the researchers said.

vioxxThis puts the heart risks of generic NSAIDs on a par with Vioxx – the painkiller that U.S. drugmaker Merck famously pulled from sale in 2004 because of links to heart risks.

The study team from Oxford University in the UK, gathered data, including on admissions to hospital, for cardiovascular or gastrointestinal disease, from all randomized trials that have previously tested NSAIDs.

This allowed them to pool results from 639 trials involving more than 300,000 people and re-analyze the data to establish the risks of NSAIDs in certain types of patients.

In contrast to the findings on ibuprofen and diclofenac, the study found that high doses of naproxen, another NSAID, did not appear to increase the risk of heart attacks. The researchers said this may be because naproxen also has protective effects that balance out any extra heart risks.

Researcher, Colin Baigent stressed that the risks are mainly relevant to people who suffer chronic pain, such as patients with arthritis who need to take high doses of for long periods. “A short course of lower dose tablets purchased without a prescription, for example, for a muscle sprain, is not likely to be hazardous,” he said.

He also warns patients not to make hasty decisions or change their treatment without consulting a doctor.

For many arthritis patients, NSAIDs reduce joint pain and swelling effectively and help them to enjoy a reasonable quality of life,” he said. “We really must be careful about the way we present the risks of these drugs. They do have risks, but they also have benefits, and patients should be presented with all those bits of information and allowed to make choices for themselves.”

Donald Singer, a professor of clinical pharmacology and therapeutics at Warwick University, who was not involved in the study, said its findings “underscore a key point for patients and prescribers: powerful drugs may have serious harmful effects.

In the meantime, I for one, will be revising my pain versus pill-popping habit, or switching to naproxen.

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The biggest-selling drug in 2018 will be…

EvaluatePharma, a UK based company specializing in pharma and biotech analysis has been gazing long and hard into its crystal ball.

Having scrutinized the world’s leading 3,500 pharmaceutical and biotech companies they have come up with a list of what, they believe, will be the top 10 selling drugs in 2018.

  1. Januvia       (diabetes) – $9.7 billion
  2. Humira        (arthritis) – $8.2 billion
  3. Avastin        (cancer) – $7.5 billion
  4. Enbrel          (arthritis)  – $7.2 billon
  5. Revlimid     (myelodysplastic syndrome) – $6.75 billion
  6. Prevnar 13  (pneumococcal vaccine) – $6.72 billion
  7. Rituxan         (cancer) – $6.3 billion
  8. Lantus           (diabetes) – $5.9 billion
  9. Remicade     (arthritis) – $5.8 billion
  10. Advair            (COPD)  – $5.7 billion

Surprised?  No conventional molecules, no cholesterol lowering agents, no blood pressure meds and not a single new drug among the top ten.  However, they predict the #11 best seller will be GS-7977 – the much anticipated oral hepatitis C drug from Gilead Sciences .

Not so surprising, given the obesity epidemic sweeping the western world that 2 of the front runners are diabetes drugs. Likewise, given the globally aging population – 3 are for arthritis.

#5 may be a surprise to many. Few people had ever heard of myelodysplastic syndrome before ABC news anchor Robin Roberts announced last week that she has the disease.  Still, it’s predicted number 5 status doesn’t mean that an epidemic is expected – it’s still relatively rare with only 10,000 or so new cases detected each year. Its lofty status on the list is more to do with the price. It costs a staggering $10,000 or so for a 28 day supply of the pills.

Other predictions from the EvaluatePharma World Preview 2018 report:

  • Worldwide prescription drug sales are forecast to total $885bn in 2018 an increase of 3.1% from 2011
  • Over $290bn of pharmaceutical sales are at risk from patent expirations between now and 2018
  • Pfizer was the top company for prescription drug sales in 2011, but  Novartis will top the list by 2018
  • Global pharmaceutical R&D spend forecast will grow by 1.5% per year to $149bn in 2018
  • Anti-coagulants (blood thinners) are set to record highest growth of major therapy categories to 2018

Interesting stuff. But the problem with such long term predictive models is that they are but a snapshot  trying to project out six years.

In reality, life is a movie, with a frequently changing plot. For example if J&J’s canagliflozin can reduce obesity and improve blood sugar levels better than Januvia then the projected No. 1 ranking is suspect, at best.

Steroid Side-Effects & Seven-Fold Suicide Risk

Steroids are used to treat a variety of conditions such as rheumatoid arthritis, systemic lupus erththematosus (lupus), myositis (inflammation of the muscles) and vasculitis (inflammation of the blood vessels).  They work by decreasing inflammation and reducing the activity of the immune system, thereby minimizing  tissue damage and organ failure.  At times they can be life-saving.

However, they are always prescribed with caution due to the long list of well-documented physical side-effects such as:

In addition, steroids are known to cause psychological problems such as sudden mood swings, nervousness, restlessness, and depression.

Now a new study reveals another worrisome side-effect.  According to a group of French researchers, patients prescribed oral steroids are nearly seven times more likely to commit or attempt suicide.

In the largest study of its kind, researchers followed 372,696 adult patients treated with oral steroids between 1980 and 2008 and compared them to patients with similar conditions who were not prescribed steroids.

The results of the study were published last month in the American Journal of Psychiatry. They showed that patients taking oral steroids were seven times more likely to commit or attempt suicide compared with those with the same underlying medical disease not treated with oral steroids.

The steroid treated group was also twice as likely to suffer from depression and more than four times as likely to suffer mania.

The authors of the study concluded primary care physicians should educate patients and monitor oral steroids closely. Lead author Dr Laurence Fardet, a consultant in internal medicine at Saint-Antoine Hospital, Paris, called for caution in prescribing oral steroids: “Where it is essential to prescribe a glucocorticoid, patients and their families should be informed about the possibility of these severe adverse events.”

Have you or your loved ones suffered physical or psychological side-effects from oral steroids? Share your stories with us.

Joint Treatment for Asthma?

Once again, Word on Health brings you news of a potential breakthrough in the treatment of asthma.  Researchers in Australia believe that a drug used to treat rheumatoid arthritis could also help patients with asthma. According to a paper published in the Lancet the scientists from Down Under have identified two mutant genes that may predispose a person to asthma. After comparing 58,000 DNA samples of people living in Australia, Europe and the United States they found two regions of the DNA that are consistently different between asthmatics and non-asthmatics.”  One of the genes is also linked to rheumatoid arthritis (RA) and the researchers suggested that the drug tocilizumab, which is used to treat RA, may also work for asthma. Tocilizumab, marketed under the brand Actemra by Genentech, targets a certain molecule in the body called “interleukin-6 receptor” and reduces inflammation in RA patients. “Targeting interleukin-6 receptor may be a good strategy to reduce or prevent inflammation (in asthma) in the same way that it is used to prevent or reduce inflammation in rheumatoid arthritis,” suggests lead author Manuel Ferreira at the Queensland Institute of Medical Research. Word on Health awaits further research to confirm if and how the drug may help asthma patients. We’ll bring you further news as we hear it.