Comments on GeriPal - Geriatrics and Palliative Care Blog: Pharmaceutical Industry Influence on Guidelines an...

"DBs medical rants" is writing a talk ab...

2009-09-07T11:06:03.030-07:00

"DBs medical rants" is writing a talk about this, anyone who wants to give suggestions should go over to his site to give suggestions. DB Medical rants link.

The HA1C target of 7 has become holy writ in some ...

2009-07-21T16:08:45.843-07:00

The HA1C target of 7 has become holy writ in some circles. Physicians with a contrarian view are accused of anti-evidence based blasphemy. However, many of us in the primary care trenches have seen the harms that have occurred (particularly to elders) through slavish adherence to this Big Pharma driven measure and have been heartened by recent papers arguing for a different approach to diabetes management (Montori VV, Fernandez-Balsells M. Glycemic control in type 2 diabetes. Time for evidence-based about-face. Ann Intern Med 2009; 150: 803). It is concerning that the current "quality" driven P4P measures in many practices rely on outcomes such as HA1C which may have numerous, harmful, unintended consequences.

Sei, You're absolutely right - the financing ...

2009-07-21T10:48:00.476-07:00

Sei,

You're absolutely right - the financing and production of practice guidelines by entities with commercial conflicts of interest produces biased guidelines that are bad for the public health as well as the public purse.

What can be done?

First, as your examples point out, everyone should be sceptical of "conflicted guidelines" - i.e., guidelines produced with commercial conflicts of interest.

Second, we should encourage regulation to prevent, or at least reduce, the production of "conflicted guidelines." Regulatory approaches may be limited, however, by free speech considerations.

Third, we can change our culture that accepts "conflicted guidelines" - they are not acceptable - and promote alternative means to produce unbiased guidelines. This builds on the recent IOM report's call to “create incentives for reducing conflicts in clinical practice guideline development” (Institute of Medicine. Conflict of interest in medical research, education, and practice. Washington, DC: National Academies Press,
2009. at http://www.iom.edu/CMS/3740/47464/65721.aspx.)

Seth Landefeld

Sei---I am attending on medicine this month and co...

2009-07-17T21:38:35.374-07:00

Sei---I am attending on medicine this month and copied this post for the residents and students on my team as a compelling statement of how critical we need to be when we read guidelines. We really need to carefully ask who wrote them and what evidence supports them. These guidelines illustrate that guidelines supported by industry may support more aggressive care, and that this more aggressive care will generally be beneficial to industry, but may not be beneficial to patients. It may be even sometimes be harmful.

It is a shame that we have reached an era in which we may even need to be careful about guidelines supported by prestigious professional organizations. Shame on the National Kidney Foundation and the American Diabetes Association for accepting funding from "partners" who stand to profit from their guidelines and clinical recommendations.

I've been thinking about other examples of how...

2009-07-17T12:13:20.571-07:00

I've been thinking about other examples of how big pharma might be influencing our care of the elderly or persons with serious illness. The first thing that comes to mind is the off-label advertising of gabapentin. Seth Landefeld and Mike Steinman wrote a great report about this in NEJM:

The Neurontin Legacy

Since these marketing practices have come to light, I've not been sure to what degree the teaching I received about the use of gabapentin for neuropathic pain is correct, or evidence based. I was taught that gabapentin should be the first line therapy, that other medications such as opioids were less effective to ineffective, and that the dose of gabapentin needed to be aggressively titrated, upwards of 3600mg a day, to achieve effective results. I had many sleepy patients with marginally improved pain control. Andy Billings, chief of palliative care at MGH, always insisted that opioids should be first line therapy for neuropathic pain, and I've started to think perhaps he's correct. Has anyone done more critical thinking/research about this issue?