December 21, 2012 | 1:59 pm

Niacin: Ineffective, and Now with Fewer Side Effects!

Posted by Albert Fuchs, M.D.

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Photo credit:
Wikimedia commons

I haven’t written about niacin for over a year, and like a misunderstanding of the Mayan calendar that won’t go away, niacin is in the news again this week.

You can catch up on the old news by reading my previous posts (links below) but here’s the story in a nutshell. People with high levels of a cholesterol molecule called LDL tend to have more strokes and heart attacks than people with normal LDL levels. People with low levels of a cholesterol molecule called HDL tend to have more strokes and heart attacks than people with normal HDL levels. (Does that mean that LDL causes strokes and heart attacks or that HDL prevents strokes and heart attacks? Nobody knows.) We've long known that taking niacin raises HDL and lowers LDL. That should be good, right? And in fact a study called the Coronary Drug Project in the 60s and 70s showed that in patients with a previous heart attack, taking niacin modestly reduced the risk of another heart attack.

More recently, many other medications have been proven to prevent strokes and heart attacks – aspirin, statins (a family of cholesterol reducing medicines), and beta blockers (a family of blood pressure medicines). These medicines are now in widespread use. Statins especially have very solid evidence that they greatly decrease the frequency of strokes and heart attacks, and now that some of them are available generically they are used extensively. Last year, the AIM-HIGH trial tried to discover whether patients with a history of cardiovascular disease and low HDL had better outcomes by taking niacin with a statin than by taking a statin alone. They didn't  The rates of strokes and heart attacks were the same in both groups, strongly suggesting that in the age of statins, niacin has no additional benefit.

Now, when faced with a medication that has no benefit, I typically decide not to prescribe it, but not the folks at Merck. They were thinking “How can we decrease the side effects?” Why it would be valuable to decrease the side effects of a medicine without benefit is a mystery that only Mayan astronomers are likely to solve. In any case, the most common and bothersome side effect of niacin is facial flushing, so Merck came up with a tablet in which they combined niacin and a second drug, laropiprant, which prevents the flushing. This combination medicine, called Tredaptive, has been in use in Europe since 2007.

A large trial designed to win FDA approval for Tredaptive ended this week. The results won’t be formally published for some time, but Merck has already released some important tidbits. The study randomized over 25,000 patients to Tredaptive and simvastatin or to simvastatin alone. The patients were monitored for over four years. There were no differences in rates of strokes or heart attacks between the groups, but the Tredaptive group had an increase of a “serious adverse event” the details of which Merck has yet to release. In an unusual move, Merck has asked European physicians not to start new patients on Tredaptive.

This new finding should throw a wet blanket on the few remaining niacin enthusiasts. Niacin use has declined since the AIM-HIGH study and now should decline further. It has no benefit in the vast majority of patients who can tolerate statins.

Learn more:

Why Merck's Niacin Failure Will Scare Drug Researchers (Forbes)
Merck Says Niacin Drug Has Failed Large Trial (New York Times)
Merck: Niacin Drug Mix Fails To Prevent Heart Attacks, Strokes (NPR Shots)

My previous posts about niacin:
Niacin Much Less Helpful in the Age of Statins
Niacin Does Not Prevent Strokes or Heart Attacks

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

December 7, 2012 | 5:10 pm

Flu Season Hits Earlier than in Recent Years

Posted by Albert Fuchs, M.D.

Flu incidence by week
(CDC)

This year’s flu season seems to be starting earlier than usual and is getting more intense by the week. The Centers for Disease Control (CDC) reports in its weekly summary of flu surveillance that flu cases are increasing across the country. California still is showing only sporadic flu activity, but 8 other states report widespread activity and 15 others report regional activity.

The CDC reminds us that it’s not too late to protect yourself and those around you by getting a flu shot. The vaccine is recommended for everyone over 6 months of age. And the CDC also has other helpful suggestions for preventing flu transmission. If you’re sick, stay home and limit contact with others. Avoid touching your eyes, nose, and mouth. Cover your coughs and sneezes with a tissue. And wash your hands frequently.

I've seen no randomized studies suggesting that lighting candles, singing songs, or eating latkes decreases transmission of flu, but I recommend it anyway. Happy Hanukkah!

Learn more:

Unusually Early Flu Season Intensifies (NPR Health)
Situation Update: Summary of Weekly FluView (CDC)
Google Flu Trends for Los Angeles
Key Facts About Seasonal Flu Vaccine (CDC)
CDC Says “Take 3” Actions To Fight The Flu (CDC)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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November 30, 2012 | 6:41 pm

When it Catches on They Won’t Call it Concierge Medicine

Posted by Albert Fuchs, M.D.

Photo credit: Liz Ramos-Prado
One more illustration

The idea that patients are better off paying their doctor directly and using their insurance only for unaffordable catastrophes is gaining some traction. With implementation of the Affordable Care Act looming in 2014 many patients are looking at their doctor’s already crowded waiting room and wondering how their care will be impacted when their doctor is responsible for even more patients. And doctors who even now are swamped and frustrated with insurance bureaucracy are wondering how much worse things will get when they have less time for more patients.

Yesterday Bloomberg Businessweek published an article which asks “Is Concierge Medicine the Future of Health Care?” The headline lifted my spirits because of its happy presumption that healthcare has a future. The article interviews several concierge doctors. It makes the important point that practices in which patients pay doctors directly are now thriving at many different prices. From practices charging tens of thousands of dollars a year targeted to the very affluent to practices charging $50 per month for blue collar workers, doctors have found that they can take better care of patients by caring for fewer of them and by concentrating on practicing medicine the way they were trained, not by focusing on what’s covered by a policy.

The article brings up some very common criticisms of concierge medicine that deserve to be answered.

One objection is that concierge medicine leads to a two tiered system in which the affluent get attentive care and everyone else doesn't  That’s nonsense. The whole point of the article is that direct-pay care is working at many different prices and that some of the practices are targeted to middle class patients. There are already many more than two tiers of healthcare – the County system and Medicaid for indigent patients, private HMO insurance, staff model HMOs, PPOs, direct-pay practices, etc. How many tiers are there in other marketplaces, like food, housing, or clothing? A practically uncountable number. One characteristic of robust marketplaces is that they offer goods at widely varying prices. That means that those who need to save can still afford some access to the marketplace but those who can afford more can get better comfort, or better quality, or more reliability. I can get across town for the price of a bus ticket or the price of a BMW. (I ride my bike.) How many tiers is that?

Another objection is that by shrinking their practices to only those who can afford them, doctors who switch to the concierge model are exacerbating the coming primary care physician shortage. Of course the opposite is true. The physician shortage in primary care is fueled by the fact that people aren't choosing to go into primary care. Nothing will attract more students into primary care than examples of happy doctors who are making a living practicing in a way that is both ethical and enjoyable. Concierge doctors are not the cause of the shortage; we’re the fix. What would the critics prefer? That we stay in the insurance model and tell medical students how miserable a career in primary care is? That we drop out of medicine all together?

I think the main barrier to even faster growth of concierge medicine is the name. Another problem is that the insurance model is so entrenched in our understanding that we now think of getting routine care through insurance as the “regular” way it works. We don’t have a name for it anymore. If someone says “I saw my doctor” we just assume that someone else paid for it. If she says “I saw my concierge doctor” we understand that she paid herself. But it should be the other way around. We don’t have a word for an accountant or a plumber or a lawyer who gets paid directly by his clients. They’re not concierge accountants or concierge plumbers or concierge lawyers. We need to get to the point that paying a doctor directly doesn't deserve an adjective before the noun “medicine”. Paying your doctor is just medicine. Having someone else pay for you is insurance medicine.

The Buisnessweek article quotes Josh Umbehr, a concierge doctor in Whichita.

“Health insurance should work more like car insurance,” says Umbehr. “We have car insurance for all the big stuff, but we pay for gas, tires, and oil changes ourselves.”

He's right. I wish I’d thought of that.

Learn more:

Is Concierge Medicine the Future of Health Care? (Business Week)
Dealing With Doctors Who Take Only Cash (NY Times)
Dollars to doughnuts diagnosis (My 2008 op-ed in the LA Times that explains why I got out of the insurance model) 

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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November 21, 2012 | 11:21 am

Giving Thanks

Posted by Albert Fuchs, M.D.

I’m grateful that I have a home.

I’m grateful that my home has electricity and heating.

I’m grateful that I have work.

I’m grateful that I love what I do.

I’m grateful that I’m healthy enough to attempt a 77 mile bicycle ride this weekend.

I’m grateful that tomorrow I will be gathering with lots of loved ones to eat more than is prudent and to count our innumerable blessings.

I hope you will do the same. Happy Thanksgiving!

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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November 16, 2012 | 11:48 am

Revenge of the Parasites

Posted by Albert Fuchs, M.D.

Malaria parasites inside
human red blood cells
(Photo credit: Wikipedia)

Malaria is a life-threatening illness marked by high recurrent fever, shaking chills, and severe headache. Though malaria is now treatable, even with treatment it sometimes progresses to coma and death. Survivors frequently suffer recurrent symptoms and can be debilitated. The World Health Organization estimated that in 2010 there were 216 million people infected with malaria. Hundreds of thousands of them died, though precise estimates are lacking.

Malaria has plagued people for tens of thousands of years. It may have contributed to the decline of the Roman Empire. Very little was known about malaria until the late 1800s when the parasite that infects the red blood cells of malaria patients was first observed under a microscope. Later work discovered that mosquitoes were responsible for transmitting the parasite from person to person. Since that time malaria control has involved a combination of mosquito control, avoidance of mosquito bites, medication to prevent infection, and medication to treat infected patients. Despite advances in all these fronts, malaria remains a tough adversary. It was the most dangerous health hazard faced by U.S. troops in the South Pacific in World War II. As many as half a million troops were infected.

In the second half of the twentieth century as developed nations became more affluent, malaria elimination was a marker of their progress in public health. Mosquitoes were sprayed. Standing water was drained. The U.S eliminated endemic malaria transmission in 1949. Greece did the same in 1974. That doesn't mean that there were no cases in the U.S. (or Greece) since then, but that all the cases were imported. People who were infected abroad would travel to the U.S. and become ill here, but no one has been infected in the U.S. since 1949.

Well, forty six years later malaria is regaining lost ground. This week the Wall Street Journal reported that endemic malaria transmission has returned to Greece. That means that infected mosquitoes are infecting people in Greece for the first time since the 70s. In the past two years there have been over 50 endemic cases of malaria in Greece and over 100 imported cases. So far there have been no deaths.

Since its economic collapse three years ago, Greece’s public health system and its mosquito eradication efforts have been hard hit. The nation’s ability to care for patients and to prevent infection has been hobbled by worsening scarcity of resources and financial uncertainty. In response, the U.S. Centers for Disease Control and Prevention (CDC) has released an outbreak notice advising travelers to take precautions to prevent mosquito bites when traveling in Greece. Travelers to the agricultural regions of Evrotas should also take prescription medications to prevent malaria.

My friends who were born in the U.S. sometimes think that human progress is inevitable and irreversible, that the human condition can only improve over time as if propelled upward by some natural law, like water flowing downward. I was born in Romania, so I know that this isn't so. I know that a modern affluent country can be utterly ruined. If you have friends from Iran or Cuba, they’ll tell you the same thing. (If you don’t have friends from Iran or Cuba, make some. Then beg to be invited to their homes for a meal. In both cases, the food is delicious.)

Perhaps the return of malaria in lands from which it was eliminated is a sign of the local cracking of the thin veneer of civilization. Perhaps it is a very late marker of societal collapse or of fiscal profligacy. If that is the case, it may be wise in the next few years to bring insecticide and mosquito nets to Italy, Spain, Portugal, and eventually, to California.

Learn more:

Health Scourge Hits Greece (Wall Street Journal)
Malaria in Greece (CDC Outbreak Notice)
Malaria (Wikipedia)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

November 2, 2012 | 9:57 am

A Reminder about Earthquake Preparedness

Posted by Albert Fuchs, M.D.

Image credit: CDC

The stories and pictures from Sandy’s wake are heartbreaking. The loss of life, the destruction of property, and the prolonged disruption of routine seem overwhelming. I’m sure you join me in wishing for the prompt return of electricity, transit, and normalcy to the millions whose lives have been turned upside down.

This is a good time to make sure that we’re prepared for a natural disaster. In California we know with certainty that we’ll be hit with a major earthquake. We just don’t know when, and unlike with severe weather, we won’t get a warning. The Centers for Disease Control and Prevention (CDC) has a very informative web page about how to prepare before an earthquake, what to do during an earthquake, and how to stay healthy after an earthquake. I urge you to take some time to review it.

Before an earthquake, it’s important to assure that there is drinking water and non-perishable food stored for each person in the household for three to five days. Tall heavy furniture (book shelves, bunk beds) should be secured to walls, as should heavy appliances (refrigerators, water heaters).

I was surprised to learn that what we should do during an earthquake has changed somewhat since I learned these instructions. I’m quite phobic about earthquakes, so my typical behavior when a mild 2.0 magnitude earthquake shakes me awake in the middle of the night is to leap out of bed, stand in a doorway, and scream “EARTHQUAKE!” like a panicked child. This annoys my wife who would have slept through the whole thing, but also, apparently, doesn’t even protect me. In modern buildings doorways are no safer than anywhere else.

During an earthquake, if you are inside do not run outside or to other rooms during the shaking. Drop down to your hands and knees. Cover your head and neck (or your whole body if possible) under a sturdy table or desk or next to low-lying furniture. Hold on to the furniture that you’re sheltering under until the shaking stops.

If you are outside during an earthquake, stay outside and avoid buildings and utility wires.

After the earthquake, avoiding spoiled food and contaminated water is critical. Also, power outages and disrupted natural gas lines will lead to people using camping stoves or charcoal grills for cooking or heating. Remember never to use camping stoves, outdoor grills, or electrical generators indoors. Several people have died of carbon monoxide poisoning on the East Coast this week because of poorly ventilated combustion sources.

The CDC website has much more detailed information. You owe it to your family to make preparations now.

Learn more:

Earthquakes (CDC Emergency Preparedness and Response)
During an Earthquake (CDC Emergency Preparedness and Response)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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October 26, 2012 | 1:24 pm

Many Terminally Ill Patients Believe Chemo Might Cure Them

Posted by Albert Fuchs, M.D.

Image credit:
Flikr, Juni A.

Metastatic (stage IV) colon cancer and lung cancer are fatal incurable illnesses. That doesn’t just mean they are life-threatening. A fatal incurable illness is one which has zero survivors. You don’t know anyone who had metastatic colon or lung cancer who survived and is no longer ill.

Chemotherapy is still occasionally used in such cases and sometimes can prolong life by a few months. Chemotherapy might also help temporarily alleviate some of the symptoms caused by the cancer. But what chemotherapy never does in these cases is cure the disease. The distinction is important because chemotherapy itself frequently has serious and uncomfortable side effects and patients who are considering undergoing it should understand the benefits they may gain.

A disturbing study in this week’s issue of The New England Journal of Medicine suggests that many terminally ill patients misunderstand why they are receiving chemotherapy. The study was a survey of over 1,100 patients with a recent diagnosis of stage IV lung or colon cancer who had opted to receive chemotherapy. The survey asked several questions about their expectations of chemotherapy. One such question was “After talking with your doctors about chemotherapy, how likely did you think it was that chemotherapy would cure your cancer?” Response options were “very likely,” “somewhat likely,” “a little likely,” “not at all likely,” and “don't know.”

“Not at all likely” is the only response that conveys an accurate understanding of what chemotherapy can do for these patients. Yet 69% of patients with lung cancer and 81% of colon cancer patients chose one of the first three responses, reflecting mistaken expectations of their treatment. Though previous studies suggested that some patients are mistakenly optimistic in the face of a terrible prognosis, the very high fraction of patients in these studies who apparently believed they might be cured was surprising.

What could account for this? An accompanying editorial ponders the possibilities. Might the oncologists not be giving patients an honest explanation of their prognosis? Prior studies show that most oncologists give bad news honestly, so that is not likely to account for the majority of patients misunderstanding the goals of treatment. Perhaps patients actually know that a cure is impossible and have discussed this with their doctors and their families but are reluctant to share this painful realism with a researcher who is a stranger. Perhaps many patients heard the bad news and chose not to believe it.

Certainly some selection bias is involved. The study, after all, interviewed only patients who chose to undergo chemotherapy. That would include whichever patients were most likely to ignore bad news or exaggerate the possible benefits of treatment. Those who were mostly likely to accept bad news and minimize the possible benefits of treatment were the most likely not to have pursued chemotherapy and would not have been included in the study.

The distressing possibility is that many of the patients surveyed are fooling themselves. In other facets of life self-deception might be beneficial, or at least harmless. (“I look terrific.” “I think I’ll do great in this interview.”) But in this case patients with limited time are choosing to spend that time in healthcare facilities experiencing side effects instead of at home (or on vacation) with loved ones.

One final worrisome finding is that the patients who reported better scores for how well their physician communicated with them were less likely to give accurate responses for the goals of chemotherapy. That means that patients who best understood that chemotherapy could not cure them reported that their physicians were worse communicators than patients who misunderstood their likelihood of cure. Does telling bad news inevitably strain the physician-patient relationship? Do patients bond best with physicians who misinform them with optimism or allow them to misunderstand important aspects of their care?

As patient satisfaction surveys begin to play a larger role in physician compensation we may ironically find that doctors will be increasingly paid to cater to patients’ unstated desire for misinformation.

Learn more:

Many Terminal Cancer Patients Mistakenly Believe A Cure Is Possible (NPR Shots)
Study: We overestimate how much medicine can do (Washington Post, Wonkblog)
Patients' Expectations about Effects of Chemotherapy for Advanced Cancer (New England Journal of Medicine)
Talking with Patients about Dying (New England Journal of Medicine editorial)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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October 19, 2012 | 3:04 pm

Multivitamins May Slightly Decrease Cancer Risk in Older Men

Posted by Albert Fuchs, M.D.

Vitamin B supplement tablets
Photo credit: Wikimedia Commons

My regular readers already know my deep skepticism about the benefit of vitamin supplements in well-nourished healthy people. My post last year summarized the available studies about many vitamins and ran under the headline “A Reminder to Dump Your Multivitamin”. Thus far, large randomized studies about vitamins have tended to study a single vitamin at a time usually in fairly high doses. That makes a lot of sense. If you want to figure out if vitamin E prevents heart attacks, design a trial in which lots of people get either vitamin E or placebo. (It doesn’t prevent heart attacks.)

This week the Journal of the American Medical Association published the results of the first large randomized trial to study the effects of a multivitamin. The trial began in 1997 and enrolled 14,641 male US physicians aged 50 years or older. It randomized the men to a daily multivitamin or a placebo. The multivitamin used was the same formulation as the formulation of Centrum Silver at the time, which has 30 different vitamins and minerals. The men were followed for an average of 11 years. New diagnoses of cancer (except non-melanoma skin cancer) and deaths were counted for both groups.

It’s important to note that this was part of a larger study to test the effects of a multivitamin on cancer, cardiovascular disease, eye disease, and cognitive decline. The current results publish only the cancer findings. The effects on cardiovascular disease, eye disease, and cognitive decline will be published separately.

Especially to a skeptic like me, the results were interesting. The multivitamin group had slightly fewer new cancer diagnoses than the placebo group. The media is reporting the decrease as an 8% lower risk, which is true, but I don’t think gives us a clear mental image of the magnitude of the benefit. Imagine two groups each of 769 older men. If one group took the multivitamin for a year and the other group took the placebo for a year, the vitamin group would have 13 new cases of cancer and the placebo group would have 14. So for every 769 men taking a multivitamin for a year one new diagnosis of cancer is prevented.

Total mortality and mortality due to cancer were the same in both groups. The study was too small to detect differences in occurrence rates of specific types of cancers (i.e. lung cancer, colon cancer, etc.).

Two objections demand to be raised. First, why would you test 30 different vitamins and minerals together? It’s conceivable that some of the ingredients have synergistic effects and work differently in combination than they do individually, but it seems that the scientific method suggests the opposite approach. First figure out the effects of each ingredient, then test some combination. The current results leave us completely mystified about which of the ingredients (or combination of ingredients) is responsible for the effect. The authors state that the trial studied the effects of multivitamins because so many people take them, but I am left wondering whether the trial was designed to raise our understanding or increase Centrum Silver sales. (Pfizer which sells Centrum Silver, supplied the placebo and the multivitamin for the trial, though it did not design or conduct the study. The study was funded by the NIH.)

The other objection is that the difference between the cancer incidences in the two groups barely rose to the level of statistical significance. Bear with me while I delve into the statistics briefly. Statisticians use a measure called a p value to decide whether a measured difference between two groups might have been due to chance alone and not due to the intervention being studied. The p value answers this question: If the intervention being studied is actually irrelevant (in this instance, if the multivitamin and the placebo have equivalent health effects) how likely is it that the two groups would show such different numbers (in cancer incidence, in this case) by chance alone? By convention, any p value less than 0.05 is considered statistically significant. That is an arbitrary choice agreed on by statisticians, but there is no math or science behind that number. We just need some cut-off point, so we decided that 0.05 is statistically significant and 0.06 is not. That still means that for all the randomized trials we do, if the null hypothesis is true (meaning, if the medicine is just like the placebo) 1 time in 20 we’ll get a result that shows that the two are different in a statistically significant way, meaning we’ll get a false result by chance. The p value in this trial for the difference in cancer incidence for the two groups was 0.04. Yes, that’s statistically significant, but just barely.

So what can we conclude?

First of all, this teaches us nothing about multivitamins in women or in men under 50.

Second, the design of the trial is very solid. It was randomized and blinded. So we should take the result at face value – that for men over 50 taking a multivitamin daily makes a small decrease in the risk of cancer (but not in dying of cancer). This effect is much smaller than quitting smoking. So it makes a lot of sense to quit smoking before you try to figure out whether or not to take a multivitamin.

My suggestion for now is to wait for the rest of the results from the trial. For example, if the cardiovascular results are even slightly negative, suggesting that the multivitamin increases stroke or heart attack risk by a small amount, that may overwhelm the cancer benefit.

For the time being I’m still not recommending a multivitamin for healthy adults, or taking one myself.

Learn more:

Multivitamin Cuts Cancer Risk, Large Study Finds (Wall Street Journal)
Daily multivitamin appears to slightly lower cancer risk in older men (Los Angeles Times Booster Shots)
Multivitamin Use Linked to Lowered Cancer Risk (New York Times)
Multivitamins in the Prevention of Cancer in Men, The Physicians' Health Study II Randomized Controlled Trial (Journal of the American Medical Association)
A Reminder to Dump Your Multivitamin (my post from last year reviewing the current studies about vitamin supplements, with links to my prior posts about vitamins)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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