Does money or patient welfare drive our profession?

An extremely well-written and thought provoking book is The Truth About The Drug Companies: How They Deceive Us And What To Do About It, by Marcia Angell. Dr. Angell is a former editor of the New England Jounrnal of Medicine and a respected authority in the field of medical and pharmaceutical matters. Her book tackles what she has termed the takeover of the pharmaceutical field by 'big pharma'

Dr. Angell opines that the massive profits generated by the leading pharmaceutical companies are no longer morally justified and sustainable. She argues that truly innovative and socially profitable drugs are now few and far between, and that the current system of patent protection and profit taking is being manipulated by pharmaceutical companies, to the detriment of the general public. Her arguments are well reasoned and backed up by fact and lead one to give a certain credence to her thesis.

In this light, an introspective view at the manner in which we conduct our profession is warranted. Do we, as Dr. Angell so well describes in her writing, take every word and advertised fact proposed by drug companies as being incontrovertibly right? Do we question research we are quoted and probe the efficacy of newer and more costly medicinal products? Do we consider the financial implications that pharmaceuticals have on the daily well-being of our patients? Are we placing our own motives for profit, financial or otherwise, before those of the public we are obliged to treat impartially?

The above questions are not easily answered, and as in most situations in life, the pragmatic response is a grey line somewhere down the moral middle. Considering them and applying the consequent thoughts to our daily professional practice can only lead to better application and patient benefit. The above mentioned book is also worth a read as it portrays the pharmaceutical industry in a manner few have had the courage to.

Watch what you drink!!

The study below, from the American cardiac journal Circulation, raises some very troubling points. In short, the study concludes, to a high level of significance, that one sugary soft-drink a day increases the risk of CHD (Coronary Heart Disease) by 20%!

The implications of such a discovery are far reaching. If the findings are substantiated and replicated in further studies, then steps should be taken to have health warnings on the products in question and also to initiate public awareness campaigns. There might also be the possibility of introducing a tax on the raw material for sugar containing drinks, as apart from this new link to CHD they are also directly connected to the increase in the incidence of diabetes mellitus, both locally and also world-wide.

These statements may be considered idealistic in view of the financial clout and lobbying power wielded by the soft-drinks industry, however this must not deter us from pursuing the best course of action required for optimum public health. As with the tobacco industry in the past, no interest is too potent to surpass that of society as a whole.

From Heartwire

A Soda a Day Raises CHD Risk by 20%

Lisa Nainggolan

March 12, 2012 (Boston, Massachusetts) — Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by Dr Lawrence de Koning (Children's Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].
"Even a moderate amount of sugary beverage consumption — we are talking about one can of soda every day — is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors," senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) told heartwire . "The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries."

 

The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda.

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. "Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn't been substantiated in our study," says Hu. "The problem with diet soda is its high-intensity sweet taste, which may condition people's taste. It's still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. "
Hu says water is the best thing to drink, or coffee or tea. Fruit juice is "not a very good alternative, because of the high amount of sugar," he adds, although if diluted with water, "it's much better than a can of soda," he notes.
And Hu says although the current results apply only to men, prior data from his group in women in the Nurses' Health Study [from 2009] were comparable, "which really boosts the credibility of the findings."

Inflammation could be a pathway for impact of soda upon CHD risk
Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.
Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.
There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend < 0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.
Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda "may impact on CHD risk above and beyond traditional risk factors," say the researchers.
Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).
Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors — including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1) — as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p < 0.02).
"Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk," say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change
Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks "ridiculously cheap" and helping explain why consumption is so high, particularly in lower socioeconomic groups.

 

Doctors should be advising people with heart disease or at risk to cut back on sugary beverages; it's almost a no-brainer.

"Doctors should set an example for their patients first," he stresses. "Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it's almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change."
And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.
"It has been shown for minority groups — such as African Americans and Asians — that they are more susceptible to the detrimental effects" of sugary drinks on diabetes incidence, he notes.
The authors report no conflicts of interest.

Statins in the dock

The FDA has updated statin labelling and literature to include prior screening for hepatic function. Also included in the release is the information that statins are implicated in a higher incidence( 8-13%) of diabetes in patients on them, especially with higher doses. Also highlighted is the connection, though tenous, between statin therapy and cognitive disorders.

The full article is here http://www.medscape.org/viewarticle/759588?src=cmemp.

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John Vella B.Pharm. (Hons.) M.Sc.(Pharmacoeconomics)

8, Islets Promenade, Bugibba, SPB2502, Malta

+356-21571649, +356-27571649, +356-99497510

http://www.stsimonpharmacy.com

Well done to all!

The Pharmacy Symposium 2012 has been a run away success. The quality of the work on offer is a credit to students and department staff alike, taking into account the limited resources avaiable. All involved deserve a slap on the back and congratulations for a job well done. John

Owen Farrugia

Owen's passing is a loss for all of us within local pharmaceutical circles, and also to all those he touched throughout his brief but worthy life. My thoughts are with his family at this hardest of times.

May he be with us in spirit, always.

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The benefit of a healthy lifestyle and pharmaceutical consumption

We have become accustomed to turning to our very well-stocked medicine chests or if that fails us, to our friendly pharmacist for immediate  relief to all our ailments. This tendency has led us to be symptomatic  in our treatment of disease, rather than attempting to get to the root of the problem. 

It is unfortunate that this attitude has crept into  the manner in which health professionals approach most medical  problems presented by patients. The quick fix consists of а prescription, or in the case of a pharmacist a recommendation for а particular drug or referral to a certain physician. This has led to an  increase in the demand for medical services and pharmaceutical  products, with a concomitant increase in the financial pressures on  the payer, whether the cost is state-financed or paid out-of-pocket.

It is quite likely that a percentage of patients being treated with  lipid-lowering pharmaceutical therapies and anti-hypertensive  medication, would achieve the same or improved treatment outcomes, without treatment(or at least at a lower dose and variety), if induced  to adopt lifestyle changes that are conducive to better health. In  other words, if the patients on the above mentioned drugs are  overweight, smoke and possibly consume amounts of alcohol that аре above the recommended limits, then there is room for improvement. Persuading these people, indeed the whole of the Maltese population  that lifestyle and positive health outcomes are inexorably linked, would be beneficial to all of society as a whole.

In fact, not only would patients be better off if they required less  or no medication, they would also reap the benefits of an improved  well-being and healthy outlook. Society at large would gain, and the  state would also see a reduction in the increase in pharmaceutical  expenditure that is threatening to derail the whole public healthcare  system.

The subject requires a much deeper and considered discussion, but one  cannot discount and ignore the positive effects of combining health  promotion and prevention together with treatment. It is unfortunate  that, especially locally, we are dedicating most of our efforts and  funding towards the latter, and ignoring the long-term benefits that  the former could provide.

Professional morals and education

It is all so easy for members of the health professions to forget the true reason for their daily work routine. All health professionals are inexorably linked to the principles of patient primacy and the over-riding moral authority derived from the Hippocratic oath and related philosophies. Unfortunately financial matters and other conflicts have come to exert ever increasing pressures on practitioners in various fields. This has lead to a situation where the health of the patient is no longer the primary concern, but takes second place to career advancement, profiteering or a combination of both.

It is imperative that institutions of higher education place great emphasis on the creation of graduate professionals, that are not only of a high academic standard, but also of strong moral fibre. Such a task is no mean feat, as persuading students who are just about to attempt to establish a foothold in the societal rat-race, that principles are worth more than financial reward, is a tall order.

The first step in achieving the above is to have educators that practice and hold themselves to the same standards that students aspire to. As is often the case, remuneration within the academic world does enable universities to hold on to,or attract the best talent available. In certain cases it might make sense to utilise a system of visiting lecturers from various specialities, or create a pool of volunteers from leading professionals who would dedicate a certain amount of time to mentoring.

Attaining a high level of moral standards and ethical practice within the pharmacy profession will enable the possibility of self-regulation with respect to a multitude of issues that need to be approached. This in turn will create the opportunity to negotiate with other stakeholders and indeed patients themselves, from the vantage point of moral high ground.

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