Tag Archive for: evidence-based medicine

The Bottom Line on the 2018 Cholesterol Guidelines

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In Thursday’s Memo, I talked about the 2018 Cholesterol Guidelines and evidence-based medicine, focusing on the physician side of the treatment discussion. But I believe that’s not the most important part of the discussion; I think the critical part is the patient side. Here’s why.

The Cholesterol Guidelines focus on lifestyle changes first: a healthier diet, exercise, quitting smoking, and weight loss. That’s supposed to be the initial part of the potential treatment plan—lifestyle first. In other words, what will the patients do for themselves before the discussion leads to medications, especially statins?

The guidelines aggressively focus on the use of statins and other medications to get the LDL-cholesterol to desirable levels, so we have a dilemma during the discussion of a treatment plan. Do the physicians assume, based on experience, that the patients won’t do what they’re supposed to do to lower their risk of CVD and immediately prescribe medications? Or do the patients take the lifestyle route seriously and do what’s necessary to change their health?

To be blunt, we patients haven’t done our part. We lose weight and gain it back. We start to eat healthier and don’t sustain it. We start to exercise, but we let life get in the way and stop, or we push too hard and get injured and stop, or the weather turns colder or hotter and we stop. When we agree to change our health habits and then don’t follow through, we make our health issues worse—they’re still in there eating away at our lifespan and not being treated.

Don’t make promises you know you won’t keep; notice I didn’t say can’t keep, I said won’t keep. If you know in your heart you’ll never change your diet or keep up with exercise, the best thing you can do for your health is don’t delay: start taking the meds and start taking care of the problem.

Although I disagree with it, I get why physicians jump to meds. There’s only one way to change that: we have to prove them wrong when they assume we won’t stick to a healthier lifestyle.

The Bottom Line

The 2018 Cholesterol Guidelines put the responsibility for lowering the risk of CVD without medications in our hands—the patients. Work out a timeline with some concrete goals for each lifestyle area with your physician. It won’t be easy: regular exercise for life, eating better from now on, quitting smoking, plus getting to a normal weight and staying there will all take time and consistent effort. That’s okay because even if your risk of CVD is high, it doesn’t mean you drop dead tomorrow. Even if you fall into an at-risk scenario, I know you can do it. There are many tools to help you keep at it: an app, a workout buddy, a Facebook group, and more.

Instead of looking at your health challenge as an obstacle, look at it as an opportunity for better health. If you say you don’t want to take medications, this is your chance to prove whether you really mean it. I can’t guarantee you’ll never need the meds, but you can work your way down to a smaller dosage with fewer side effects.

It all depends on your answer to one question: what are you prepared to do today?

Dr. Chet

 

Reference: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625.

 

2018 Cholesterol Guidelines and Evidence-Based Medicine

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I was encouraged by the AHA’s new cholesterol guidelines for one reason: the promotion of a joint decision between patient and physician on a treatment plan if one was necessary. That’s the basic tenet of evidence-based medicine: any and all treatment plans should take into consideration the wishes and desires of the patient. Many factors can go into that—the age and current physical state of the patient, the financial cost of treatment, and the physical cost of treatment compared to the potential benefit.

The only concern I have is this: will that discussion actually take place as intended or will it be a one-sided conversation with the physician making the decision for the patient? Will the physician listen or ignore the patient’s views? Paula and I have a great primary care physician and specialists who always listen to us, but I know it’s not that way everywhere. It’s easy to say, “If he won’t listen, just find another doctor,” but that isn’t always an option in rural areas or if your health insurance limits your choice.

The physician side of evidence-based medicine is just half the story. I’ll give you my thoughts on the rest of the guidelines on Saturday.

What are you prepared to do today?

Dr. Chet
Reference: www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000625.

 

Guidelines for Type 2 Diabetes: EBM in Practice

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The American College of Physicians (ACP) has established guideline statements for the management of HbA1c in non-pregnant adults using medication. They considered the research behind guidelines set by four other major physician organizations for treating type 2 diabetes. After reviewing that data, they have proposed four guidelines for use when treating patients. These are non binding guidelines; the choice is always left to the physician and the patient. But I think they get back to what evidence-based medicine should have always been about: use the best science and research and work with the patient to see what they want to do. Let’s take a look.

ACP Guideline Statements

These are the statements:

Guidance Statement 1
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

Guidance Statement 2
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3
Clinicians should consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Guidance Statement 4
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

EBM and Guideline Statements

I think the Guideline Statements reflect what EBM was always supposed to be about: consider the patient and what they want. I have spoken to many adults with type 2 diabetes who become frustrated with their inability to reach the HbA1c goals their physician has set. If they can’t reach it, more medication seems to be the only solution, and that’s not what they want.

I think these guidelines bring the patient or their caregiver into the equation. What price does the patient have to pay with their body? How much will it affect their life positively or negatively? Are there real improvements in quality of life if the HbA1c is 6.5% versus 7.0%? What is the cost of emotional stress?

The new guideline statements are a great addition to a physician’s repertoire: treat the patient as an individual. The patient comes before statistics and hazard ratios.

The Bottom Line

While not all organizations are going to adopt these guidelines, they’re important. There has been significant pushback from other organizations, all suggesting that there are new medications that may prevent some of the negative effects of prior treatment. “New medications”—they’ve learned nothing.

The one opportunity I see is that there’s hope for all of us who want to work at getting control of our lifestyle and reduce the dependence on medications as recommended by statement three. You say you don’t want to take medication? Excellent! Here is your chance to prove it.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

What Is Evidence-Based Medicine?

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The term evidence-based medicine (EBM) dominates the scientific literature related to the treatment of disease. In short, the use of EBM is intended to treat patients based on the best available science and research; only the largest, best designed, and strongest studies are used when setting up the standards for treatment. That seems to make sense. That applies to the use of medications for the treatment of type 2 diabetes in adults as well as other diseases.

In the past, physicians primarily depended on their training. It doesn’t mean they didn’t use science to guide their decisions, but where and how physicians were trained influenced their treatment decisions more than research and science. That’s why EBM was developed; the use of solid evidence when considering treatment of patients keeps treatment up to date.

The problem is that the way EBM evolved appears to have excluded one of the primary purposes of how it began: consideration of the values and preferences of the patient. Treating patients should never be a one-way street. Your doctor should be a trusted advisor, not a dictator, and should give you the most up-to-date options for treatment of your condition; then you decide together which treatment option fits your life. The clinical and research evidence guides the physician in what to do along with knowledge of your personal health history, but only in the context of what you want.

For example, if after discussing all the options, a patient decides an earlier death is preferable to extending life by taking medication and suffering horrible side effects, that’s a valid preference that the doctor must respect. Another example: if the patient’s life expectancy is less than 10 years or so, pain management may be a better option than joint replacement when all the ramifications of major surgery are considered. That kind of joint decision-making is what EBM is supposed to be all about.

Saturday I’ll look at the guidelines for HbA1c proposed by the American College of Physicians in light of EBM. It’s a Memo you don’t want to miss.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.