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Medical Nihilism? By Mrs Vera West

     The book Medical Nihilism (Oxford University Press, 2018) by philosopher of medicine, Jacob Stegenga, is a bit beyond my capacity to review, even to adequately summarise. This highly technical book develops a scientific and mathematical statistical Bayesian critique of modern medicine’s claims to scientificity, attacking the empirical studies, such as metanalyses. While medicine has no problems with simple things, like broken legs, the real issues today are dealing with complex problems, such a depression, heart disease, and the diseases of civilisation, by drugs and chemicals. This is where the numerous difficulties arise, since all drugs have side effects, some that could be worse that the condition treated. Even simple NSAIDS, like ibuprofen, taken over even short periods can raise the risk of heart attacks:

“People who use commonly prescribed non-steroidal anti-inflammatory drugs (NSAIDs) to treat pain and inflammation could be raising their risk of having a heart attack, as early as in the first week of use and especially within the first month of taking high doses of such medication, suggests a study in The BMJ this week. Previous studies suggested that both traditional and COX 2 selective NSAIDs could increase the risk of acute myocardial infarction (heart attack), but the timing of the risk, the effect of dose, treatment duration, and the comparative risks between NSAIDs were poorly understood. An international team of researchers led by Michèle Bally of the University of Montreal Hospital Research Center (CRCHUM), then an epidemiology doctoral student at McGill University in Canada, set out to characterise the risks of heart attack associated with use of oral NSAIDs under real life practice circumstances. For their study, the researchers carried out a systematic review and a meta-analysis of relevant studies from various healthcare databases including those from Canada, Finland and the United Kingdom.

Collectively, they analysed results on 446,763 people of whom 61,460 had a heart attack. The NSAIDs of interest to the researchers were celecoxib, the three main traditional NSAIDs (diclofenac, ibuprofen, and naproxen), and rofecoxib. To provide guidance, the researchers presented their results as probabilities of having a heart attack. They looked at various scenarios corresponding to how people might routinely use these drugs. The study found that taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of heart attack. Naproxen was associated with the same risk of heart attack as that documented for other NSAIDs. With celecoxib, the risk was lower than for rofecoxib (Vioxx) and was comparable to that of traditional NSAIDs. Overall the increase in risk of a heart attack is about 20 to 50% if using NSAIDs compared with not using these medications. To put this in perspective, as a result of this increase, the risk of heart attack due to NSAIDs is on average about 1% annually. The type of analysis the researchers used allowed them to conclude with greater than 90% probability that all NSAIDs studied are associated with a heightened risk of heart attack.

Further analysis suggested that the risk of heart attack associated with NSAID use was greatest with higher doses and during the first month of use. With longer treatment duration, risk did not seem to continue to increase but the researchers caution that they did not study repeat heart attacks such that it remains prudent to use NSAIDs for as short time as possible. This is an observational study based on drug prescribing or dispensing and not all potentially influential factors could be taken into account. Although this means that conclusions cannot be made about cause and effect, the authors say that their study was the largest investigation of its type and that its real-world origin helped to ensure that findings were broadly generalisable. The researchers also emphasise the advantages of sharing ‘de-identifed’ patient data as this helps making healthcare decisions that may improve patient care. They conclude: “Given that the onset of risk of acute myocardial infarction occurred in the first week and appeared greatest in the first month of treatment with higher doses, prescribers should consider weighing the risks and benefits of NSAIDs before instituting treatment, particularly for higher doses.”

     That is bad news for bad backs everywhere, so I guess I will have to stick with emu oil. Oh, and as support for the medical nihilism position, most common antidepressants, simply, are not:

“The most commonly prescribed antidepressant barely relieves symptoms of modern depression, a major study reveals. The largest independent investigation ever undertaken found patients taking sertraline experienced negligible improvements in mood. Published in the Lancet Psychiatry, the study comes amid mounting controversy over increased use of antidepressants by GPs in recent decades, with roughly 7.3 million people in England issued a prescription each year. Its authors said they were “shocked and surprised” by the results, and called for the development of new classes of medication. However, in the absence of better drugs, they do not want current prescribing practice to be changed because the trial also showed sertraline is effective in reducing anxiety, which often accompanies depression. The new trial is by far the largest to be conducted without the involvement of the pharmaceutical industry. It is also the most in-depth examination of sertraline - a type of selective serotonin reuptake inhibitor (SSRI) - in patients with a range of depression severities, rather than just in severely depressed patients in specialist mental health units. The study included 654 people aged 18 to 74 who were given either the antidepressant for 12 weeks or a placebo. The results showed depressive symptoms were five per cent lower after six weeks in the sertraline group, which was "no convincing evidence" of an effect. After 12 weeks, there was a 13 per cent reduction, a finding the experts described as "weak".

     Like all of science, modern medicine needs to be taken with a grain of salt. Wait, salt in excess can cause hypertension!



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Tuesday, 14 July 2020
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