November 16th, 2009

Niacin best for raising good cholesterol

Posted by Dana Blankenhorn @ 5:42 am

Categories: Aging, Consumer Information, Drugs, Finance, General, Home Health Care, Medical Equipment, Research, Wellness

Tags: Cholesterol, Dana Blankenhorn

Want more of that good HDL cholesterol?

(Picture from Costco.com.)

Try a timed-release niacin, and be skeptical if your doctor gives the sales pitch for Zetia or Vytorin.

The authority for this is a study dubbed ARBITER-6, which was stopped suddenly this summer, with the study’s authors insisting safety had nothing to do with it.

It was a question of efficacy.

The results, described in the New England Journal of Medicine, make clear that niacin does better at the main job, keeping arteries open.

“The use of extended-release niacin causes a significant regression of carotid intima–media thickness when combined with a statin and that niacin is superior to ezetimibe.”

Ezetimibe is the generic name for the active ingredient in Zetia, while Vytorin combines the same drug with a generic statin, simvastatin.

This does not mean ezetimibe is worthless. It works. It just doesn’t work as well as niacin.

This has important implications for anyone who, like me, has a family history of hypertension and high cholesterol. But if you want to save some serious money, look further.

The ARBITER-6 study compared ezetimibe with Niaspan, a drug form of timed-release niacin. But you can get similar dosages, for a lot less, with a supplement containing the same stuff. I use something called Slo-Niacin.

On most insurance plans you’ll pay $10/month for a generic statin and $30/month for Niaspan, or $30 for Zetia, “saving” $10 by using Vytorin (which contains the statin).

But Costco offers 150 Slo-Niacins for about $10, so even if you double your dosage to 1 gram (as many doctors recommend, taking one in the morning and one at night to prevent flushing), that’s $14/month for simvastatin and niacin, or $30/month for Vytorin.

Last time I got checked out, my combination of simvastatin and 1 gram of SloNiacin per day was working like a champ. Total cholesterol under 150 and a ratio of bad to good that had my doctor putting exclamation marks on my chart.

The paragraphs above, combined with the results of ARBITER-6, represent the heart of comparative effectiveness, and the way we old-timers can interpret those results to stay healthy for less.

As health IT begins collecting hundreds of millions of health records over the next several years studies like this will become easier to do, and they will be more accurate, given the larger number of records being studied.

But this is bad news for drug-makers. You not only have to prove safety, not only prove that your drug does what it claims, not only prove you’re better than a placebo, but you now have to prove you’re better than alternatives before you’re going to get the big money.

Bad for drug companies, good for patients. That’s what comparative effectiveness studies are all about.

November 11th, 2009

Why not pay for what works?

Posted by Dana Blankenhorn @ 11:44 am

Categories: Drugs, Gadgets, General, Government, Home Health Care Equipment, Hospital Equipment, Insurance IT, Medical Equipment, Medical IT, Medical Office Equipment, Rehabilitation, U.S., state government

Tags: Patient, Health Care, McCaughey, Insurance, Financial Planning, Vertical Industries, Benefits, Healthcare, Business Operations, Corporate Insurance

In all the hullabaloo over health reform, Charles Silver and David Hyman write at The Health Care Blog, a key point of cost control has been lost.

Paying only for what works.

Silver and Hyman are law professors, not doctors. They point to a RAND Corp. study saying that “one-third or more of all procedures performed in the United States are of questionable benefit.” (The illustration is from the study.)

What happened to this simple idea?

The way to enforce it is through comparative effectiveness. Analyze data from millions of patients, develop best practices, and move physicians toward the most cost-effective solution.

This is what every other country does, regardless of how they pay for care. Formularies drive care, based on cost effectiveness. Anyone who wants to go outside what works had better have a good explanation. Often, going outside what works is simply forbidden, or patients are told to buy it with their own money.

Isn’t that how you set priorities? Why should governments or insurance companies act differently?

Unfortunately this was one of the first dominoes to fall in the debate. Reform opponents like Betsy McCaughey called this “getting between a patient and their doctor.”

This happened in conjunction with the debate over the Obama stimulus, and the subject was health IT. The purpose of the HITECH Act’s $19.2 billion in stimulus was to collect the data that would drive decisions on what to pay for.

McCaughey’s scare worked. Explicit promises were made not to use comparative effectiveness in any way to deny care, not to use evidence to decide what we should pay for.

The alternative to evidence is politics. Silver and Hyman note that millions of insurance dollars are spent annually on entirely non-medical treatments like Christian Science, but there’s more:

Lobbying from providers and supportive patients explains why many states already mandate coverage of elective services like in-vitro fertilization, massage therapy, and visits to athletic trainers. Concerns about the efficacy and cost-effectiveness of treatments are washed away by a stream of campaign contributions, and sad stories about patients who can only obtain the “necessary” services if the insurer will pay for them.

This is what is wrong with the present system. State regulation of insurance is based on politics, so your coverage includes any procedure that becomes politically powerful in your state. That’s why insurance costs are rising through the roof.

There is nothing wrong with paying for prayer but it’s not medicine, they write. There’s nothing wrong with in-vitro fertilization but it’s optional, not something everyone should have to cover.

Thus, by tossing away evidence as a way to rule-out certain coverages, you pay for a lot of stuff you don’t need.

Silver and Hyman wrote to argue against a politically-motivated individual mandate. Any mandate should be based on science, not politics, and by giving up on comparative effectiveness early in the process, it became impossible to set that standard, either through the federal government or through the states.

If this was Betsy McCaughey’s intent, she is fiendishly clever. Health care will remain a growth industry, because Americans will keep having to pay for stuff that doesn’t work, regardless of whether reform passes or fails.

October 29th, 2009

Diabetes can be kept at bay

Posted by Dana Blankenhorn @ 6:23 am

Categories: Aging, Consumer Information, Drugs, Ethics, General, Home Health Care, Research, Wellness

Tags: Diabetes, Dana Blankenhorn

Want to save billions of dollars on America’s health bill?

Cut the rate at which people come down with diabetes.

(The site from which this illustration was taken, at Doctorsecrets.com, has a great page on diabetes, explaining the cause, the symptoms, effects and treatment in plain English.)

Right now 24 million Americans have diabetes and another 57 million are in a “pre-diabetic” stage. The latter group’s risk can be cut in half, over 10 years, with self-discipline on diet and exercise, along with a generic drug called metformin.

The latest study, published in The Lancet’s Online First journal, was a follow-up to the Diabetes Prevention Program, an earlier study which showed diet and exercise reduced onset of the disease 34% over four years, and metformin cut it by 18%, compared with rates using a sugar pill.

In the follow-up people who had been on the placebo or metformin were offered the lifestyle program, since it was proven to have benefits.

While some media reports pushed the lifestyle angle exclusively, the study made clear that those who exercised and ate right but also took the drug maintained their weight loss, while those who made the changes without it gained some weight back.

On average, losing weight alone delayed the onset of diabetes by four years, drug therapy alone reduced it by two years. Those over 60 did even better with lifestyle changes than younger patients.

The American Diabetes Association maintains an online test to assess your risks of Type II diabetes.

While it is fun to say “it’s their fault,” meaning the patients (and it is to an extent), the refusal by society to treat a chronic condition like diabetes runs against medical ethics. It’s not going to happen.

Preventable deaths in the tens of millions to suit your ideology are not in the cards.

Prevention costs a lot less than treatment, and much of the savings expected from health reform is based on studies like this which prove that prevention works.

October 23rd, 2009

Could diabetes fight the obesity epidemic?

Posted by Dana Blankenhorn @ 11:03 am

Categories: Consumer Information, Drugs, General, Home Health Care, Medical Equipment, Research, Wellness

Tags: Diabetes, Novo Nordisk, Hormone, Dana Blankenhorn

People who become obese have a high risk of diabetes. People with diabetes are often told to lose weight.

A new Novo Nordisk drug called liraglutide, which it’s marketing as Victoza, may provide an answer to both problems.

A study conducted in Denmark found today that it’s safe and effective as a treatment for Type II diabetes. (Yes, it beat the placebo, too.)

In higher doses it also helps patients lose more weight than a standard weight loss pill, Xenical. Plus it reduced blood pressure.

Novo Nordisk is based in Denmark, and while its stock rose in response to the news it fell back to pre-announcement levels within a day.

The drug is given once a day by injection. While many Type I diabetics are accustomed to injecting themselves with insulin, many Type II diabetics are given pills as a first-line treatment.

Still the idea of a single treatment for both early-state diabetes and weight loss drew enormous media interest.

Arne Astrup, who conducted the study, told the BBC the drug mimics the behavior of a natural hormone called GLP-1, which is released by the small intestine after you eat. The hormone tells the brain you’re full and the body to produce digestive insulin, but the effect dissipates quickly.

The drug allows your body to feel the effects of GLP-1 for a full 24 hours, making it resistant to the body’s natural self-destruct mechanism.

Critics will note that this is an injected drug, while Xenical is a tablet. Some are also questioning its use in weight loss.

Want some?

October 1st, 2009

Health IT prevents heart attacks?

Posted by Dana Blankenhorn @ 2:00 pm

Categories: Curioisities, Drugs, General, Home Health Care, Insurance IT, Research, Wellness

Tags: Health Care, Attack, Health IT, Heart Attack, Healthcare, E-health, Vertical Industries, Benefits, Human Resources, Dana Blankenhorn

Kaiser Permanente is pushing a study in today’s American Journal of Managed Care as proof that health IT saves lives.

It proves to me my pill regimen may be keeping me alive.

In the study 68,560 people with diabetes or heart disease were given a combination of generic statins and hypertension drugs, resulting in 1,271 fewer heart attacks and strokes.

But what’s the health IT angle?

• KP HealthConnect, the insurer’s Electronic Health Record system, was used to identify the patients at risk.
• The findings validate a computer-created model predicting that the bundled drugs would cut heart attack and stroke in the target population by 71%.
• Kaiser researchers conducted the study.

The medical case for statins and hypertensives seems more compelling. Some 23 million Americans have diabetes, and heart attack is the chief cause of death in this country. The study shows that a generic drug therapy can cut the costs of those conditions dramatically.

But, more than EHRs, the study also seems to show that getting your blood pressure and your sugar checked, then doing something simple to control both, actually keeps you alive.

My own condition was found in 2000 with a manual blood pressure meter and a simple blood test.

Get yourself checked today.

September 15th, 2009

Pharmacist pushback against insurer drugs-by-mail plan

Posted by Dana Blankenhorn @ 7:29 am

Categories: Drugs, Finance, General, Home Health Care, Medical Equipment

Tags: Insurance Company, Pharmacist, Insurance, Business Operations, Corporate Insurance, Dana Blankenhorn

Almost every month, I get a letter or a call from my insurer asking if I would like to sign up for a plan to “save money” by having them mail me the drugs I need.

I hang up out of loyalty to my pharmacist. If my prescription is running out he warns me. He has even called my doctor to get emergency refills. He warns of side-effects. The personal service is valuable.

He can’t compete on price. Most pharmacists can’t.

But WalMart can.

(The picture, from CBS, is of my actual pharmacist, Ira Katz of Little Five Points Pharmacy. You also saw his counter in a classic Good Eats episode. I think it was Herbal Preservation.)

After several years of offering generic refills in its stores of $4 for a month’s supply and $10 for three months, WalMart is taking the plan nationwide by mail. Other major chains, like CVS and Walgreens, should be expected to follow suit.

The question may be asked whether this will kill small pharmacies, but that train left the station long ago. When chains move in pharmacists become employees, glorified clerks. I have never gotten real personal service from one, even though the chains constantly advertise it.

But if price is the issue, the drug store industry has now leveled the playing field against the big insurers and it will be interesting to see what comes next.

September 3rd, 2009

We ferret out the latest flu questions

Posted by Dana Blankenhorn @ 6:21 am

Categories: Drugs, General, Home Health Care, Research, genetics

Tags: Vaccine, Flu, H1N1 Flu, Healthcare, Dana Blankenhorn

While parents eagerly await word of whether their college kids are infected with H1N1 “swine” flu, the news elsewhere is pretty good.

(Picture from the blog Billmelater.)

On the vaccine front Novartis says their MF59 vaccine may be able to deliver patients immunity from the bug in one shot. Chinese officials say they have also approved a one-shot vaccine.

The fear this spring was multiple shots would be needed, stretched out over time, so some folks might get the first and forget the second, giving the bug a chance to fight back.

There is even good news here for swine. Pigs don’t really have the swine flu, although they could get it from people. Still, Pfizer is developing a vaccine for pigs from the “master seed virus” given it by the Department of Agriculture.

The big news today is on the transmission front.

University of Maryland researchers write at PLoS Currents: Influenza that patients infected with both swine and seasonal flu are not becoming martini glasses of super flu bugs.

The bad news is these patients are ferrets.

The process by which viruses can mix is called reassortment, and it happens when two viruses meet in the same host cell. That didn’t happen to the ferrets Maryland infected, and ferrets are usually good analogs to humans for this kind of work.

What seems to be happening, the researchers note, is that the new strain is crowding out the normal, seasonal strain. It’s more fit, like a python in a Florida swamp or a gray squirrel introduced into a wood filled with red ones. Or a killer bee.

You get sicker from swine flu than from seasonal flu, and it’s possible that swine flu may replace seasonal flu as a threat, but we can deal with it.

Bottom line is don’t panic. But stack up on the Kleenexes, designate a sick room and get some chicken soup on the stove. It’s going to be a bumpy night.

August 26th, 2009

How bad will swine flu be, really?

Posted by Dana Blankenhorn @ 11:16 am

Categories: Consumer Information, Drugs, Ethics, General, Wellness

Tags: Flu, H1N1 Flu, Dana Blankenhorn

The pendulum between panic and dismissal regarding H1N1 “swine” flu has swung back to panic.

Harold Varmus, who co-chairs the President’s Council of Advisers on science and technology, turned the panic back on Monday, pushing a report that 90,000 Americans may die of the disease this coming winter.

Almost immediately the CDC called the figure overblown, but the estimate may be low if people won’t take precautions or decide, as many have, that the vaccine is worse than the disease.

Normal, old-fashioned, run-of-the-mill seasonal flu kills 36,000 Americans each year, and people don’t take that very seriously. Why worry about this one?

Especially since famous people like Landon Donovan (pictured) are apparently contracting, and recovering from this flu quite nicely?

Because if you don’t, that 90,000 number will look low. The advice is to get the shot if you’re eligible, to stay home at the first sign of symptoms, to wash your hands thoroughly at every opportunity, and (yes) to wear those stupid masks if you’re in an outbreak zone.

How many people will do that? It just takes one idiot living in self-denial to spread this flu to an entire office building, subway system or school.

Another factor that could raise the toll exponentially is the over-use of anti-virals like Tamiflu. (Donovan was reportedly given a 10-day course of the stuff.) How many of those idiots you think will demand the anti-viral once they get out of self-denial? And stop taking it once they feel better? That can cause the flu to mutate into something even nastier.

I wish I could feel more hopeful about this, but let me leave you with some final points. This flu is more dangerous to the young than the middle-aged. You need to plan now to live later. Care cures and panic kills.

Good luck.

August 19th, 2009

Media divides politically on Gardasil

Posted by Dana Blankenhorn @ 5:16 am

Categories: Consumer Information, Drugs, Ethics, General, Internet, Research, U.S., Wellness

Tags: Vaccine, Women, Media, Merck & Co. Inc., Healthcare, Dana Blankenhorn

What is an editor to do when a medical story crosses the desk that can be spun either way?

Spin it the way your politics tell you to.

The subject here is Gardasil, an HPV vaccine by Merck that needs to be given to women years before starting sexual activity to be effective.

A report in the Journal of the American Medical Association calls the science behind Gardasil sound, but notes it does not protect against all HPV viruses that might cause cancer, and that it’s tough to do a study linking such a vaccine to cancer rates 20-40 years later.

JAMA then offers two studies, one covering the marketing of the vaccine, ethically questionable due to close relations between medical societies and Merck, the vaccine maker, and another covering side effects. The second study is inconclusive, noting that most side effects reported so far are “not serious” but more rigorous study is needed.

Merck, of course, put out an all-clear news release. Some states, like Virginia, are pushing the vaccine for girls as young as 12. Merck is also rolling out a big back to school marketing campaign for the vaccine.

Thus we have headlines like this from Medical News, “side effects as expected.” It “seems safe”, writes HealthDayNews. It’s deemed safe, writes dbTechno.

But what if you want to spin the same facts the other way? What if it’s in your business interests to keep up the scare or your politics leans to not wanting girls’ lady parts protected against cancer for fear it might lead to teh sex.

No problem. “CDC Report Stirs Controversy for Merck’s Gardasil Vaccine,” thunders ABC News, followed by an anecdotal lead of a mother who is convinced the vaccine killed her 21 year old. (Note that it’s not recommended for women who have begun having sexual relations.)

Or you can play the false equivalence game, emphasizing any risks or uncertainty in the JAMA articles.

Additional questions on Gardasil, writes The Wall Street Journal. The vaccine still faces additional questions, writes the Philadelphia Inquirer. Benefits despite some risks, writes The New York Times.

HPV vaccine safe but doctors still wary, writes Time. Vaccine may be going to the wrong women, writes USA Today, noting that upper class girls are getting it but lower class girls at greater risk are not.

Want a real political spin? Here’s a good one. “Gardasil controversy puts real moms vs. actor moms,” from an outfit called Flesh and Stone. Who are you going to believe, Madison Avenue science or real moms’ imagined fears?

The mothers of at-risk girls aren’t going to be convinced by what the radio is putting out. Should your daughters get the HPV vaccine, asks KPBS. (It’s the transcript of a call-in show and the answer is a definite maybe.)

In fact the science is pretty clear.

There are side-effects and risk with any vaccine, and those with Gardasil are within the normal range. It targets the most-likely sources of HPV infection and is most effective if taken years before starting sex. Coordinating marketing is not a problem if the medical society agrees with the message.

But since we’re talking girls and sex politics is going to win out. As a result a lot of women are going to die decades from now because their parents demanded absolute certainty and science does not give those kinds of answers.

August 14th, 2009

Aspirin really is a drug

Posted by Dana Blankenhorn @ 5:32 am

Categories: Aging, Drugs, General, Home Health Care, Wellness

Tags: Aspirin, Tablets, Strategy, Security, Hardware, Notebooks & Tablets, Management, Dana Blankenhorn

There are a lot of drugs we take so reflexively we don’t even know they’re drugs.

One such drug is aspirin.

The natural substance from which it was first derived was known to Hippocrates. The first aspirin tablets were sold in 1900. An aspirin is part of the shield for the Bayer Leverkusen soccer club in Germany, founded in 1904.

But aspirin is a drug. I take a little one every night to cut my risk of a heart attack. The Journal of the American Medical Association this month links aspirin use and colon cancer survival.

This doesn’t make aspirin harmless. Aspirin can cause bleeding in your gut or in your brain. Even half a “baby aspirin” (the 83 mg. dose I take) caused a 40% higher risk of digestive tract bleeding requiring transfusion in one study.

Part of the problem, I think, may lie in how we package aspirin and other pain relievers. As with many other substances, it has been super-sized. Until aspirin it was common to see bottles with 1,000 aspirin at a very low price.

Aspirin is relatively safe, and effective for many conditions, some of which we are just learning about. It is, as Bayer advertises, a wonder drug. But aspirin, like many drugs, can also kill you and needs to be treated with respect.