Monday, October 31, 2011

More ways to take charge of your health

kw: book reviews, nonfiction, medicine, self help

I long ago realized I'd have to be a very active participant in my own medical care and health, as I have written in several previous blog posts. My latest concern is about my wife's heart condition, or rather her lack of a condition. She has slightly high total blood cholesterol (TBC), around 230. A few years ago she was asked by the doctor to get a HeartCam test (see Philly HeartCam for the one out here). The test showed a few tiny spots of calcification in two coronary arteries, on the low side of "normal" for her age and sex. But based on that, the doctor prescribed a daily dose of 10 mg of Crestor. She doesn't like being medicated, and because this amount lowered her cholesterol quite a bit, she demanded to be prescribed a lower dose, so he prescribed 5 mg, a little grumpily. As it turns out, for Crestor specifically, the recommended starting dose is 5 mg for persons who are hypothyroid, over 65, or Asian. My wife is all three! Very recently, she began cutting the pills in half, so as to take 2.5 mg. Take it or leave it, Doc.

The literature makes it pretty clear: Crestor does increase life span for people with active, symptomatic heart disease, but it does not do so for people with no symptoms of disease. I discussed this matter with a friend who is a doctor, and he agreed, she has no symptoms; the HeartCam test indicates a very early stage in a process that proceeds slowly and she is likely to live into her 80s or 90s with no heart symptoms. We may decide to drop the Crestor entirely. And last year there was a study reported in Age and Aging, reported on page 151 in the book I'm reviewing, that states in older people, an optimum level of TBC is about 230! It seems my wife may be best left alone!!

The book is Top Screwups Doctors Make and How to Avoid Them by Joe Graedon and Teresa Graedon, a husband-and-wife team that has worked with hospitals for decades to improve patient safety. I read it at an uneven pace. I find it a bit of a downer to read so much bad news all at once, even though I learned a lot. For example, there is also a link between Crestor and its statin relatives and cataracts. My wife's family is already prone to cataracts, so perhaps it is best to avoid that added factor.

In Introduction is followed by twelve substantive chapters, each built around a Top Ten list. While there are many more possible items on each list, a list of ten major items will get you past the worst errors that are likely to be made. This is not a book that slams doctors. A few doctors deserve slamming, but most are at least conscientious. They are just overwhelmed. For example, there are more than 13,600 diagnoses in their arsenal, if any individual could manage to remember them all. My doctor friend confirmed that, even with computer help, it is hard to diagnose many conditions, or even to ask the right questions. Many doctors are too proud to look up stuff in a patient's presence, so we have to prod them to do so.

A key section of the book is a chapter detailing how the situation has changed regarding generic drugs. The authors were early promoters of generic medicines, but now that they are big business, and now that there are thousands of overseas labs making most of them, it is less certain that they are always the right idea. The FDA does not have the resources to monitor them, to be sure that the generic drug is medically identical to the branded drug or that it meets purity standards. Many times, "medically identical" does not mean "chemically identical", and the odd term "bioequivalent" used in FDA literature is even more troubling.

For example, if I want pain relief, I usually use Ibuprofen (branded as Advil or Motrin). The generic, Ibuprofen, is chemically identical to the branded products. But I can get the same level of pain relief if I take twice as much aspirin. The aspirin dose, by FDA rules, would be called bioequivalent. This in spite of the fact that it causes much more stomach bleeding than the Ibuprofen, and may cause dizziness at a high dosage.

There is a secondary problem. A certain substance may be off patent (such as Wellbutrin), but a timed-release version may be still under patent (as Wellbutrin XL). A generic using a different timed-release method may be released differently, causing more side effects, sometimes quite damaging side effects that the branded timed-release drug will not cause.

The authors contend that untimely death due to diagnostic errors, prescription errors, dosing errors, and unrecognized drug interactions may together reach at least 600,000 yearly in the U.S., making doctor-caused death the second leading cause of death. There is reason to believe the number is twice this, making doctors the leading cause of untimely death. Thus the reason for the book. Several doctors are quoted as saying or writing that there is on average one error committed per day per patient in U.S. hospitals.

If you are in the hospital, the best thing you can do for your own well-being is to have an alert helper with you as much of the time as possible, to double-check everything that is done to you while you are there. The helper(s) should not fear offending doctors or anyone else. They may be the only barrier between you and damaging or deadly errors.

The book contains several helpful resources. All the Top Ten lists are repeated in an appendix, and well explained in their respective chapters. There is a two-page listing of Dr. Beers' List of "bad drugs" on pp. 154-5. A Drug Safety Questionnaire is found on page 85. And there is another list of anticholinergic drugs (p. 164), because these are so ubiquitous and can interact with so many other medications.

An odd omission is an appendix listing web resources, so here are the major ones the authors mention:

The Cochrane Collaboration - Health experts evaluate what works, and what does not.
SkinSight - Insight from experts about treating and caring for your skin. It includes a self-help diagnostic tool.
American Geriatric Society - Includes a referral service to those rare geriatric specialists.
PubMed - A government sponsored resource for research documentation. - Independent evaluation of products, particularly OTC.

I probably used the book inappropriately by reading it all. It is a great resource, and is better used for looking stuff up.

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