Suboptimal Treatment Plans


The Journal of the American Medical Association last week had two articles that have implications for the proactive patient.   By that I mean that patients who want to take an active role in their own care or care of loved ones had lessons to be learned from these publications.


The first article dealt with a phenomenon known as the treatment-risk paradox.   This study showed that the greater the risk of disease, the lower the probability that optimal treatment was initiated.   This was a Canadian study in the Province of Ontario of 400,000 patients aged 66 years or older.   These patients already had cardiovascular disease or diabetes.   When calculated risks of future events and mortality were analyzed, the investigators found that statin prescriptions paradoxically diminished as risks increased.


The benefits of statin therapy in high-risk patients are no longer questioned.   And certainly patients who already have cardiovascular disease or diabetes are amongst the highest risk patients.   Readers of this column have contacted me in the past with recounts of bad experience with statins and I clearly recognize that adverse effects may occur and we all must be vigilant in monitoring patients by both symptoms and laboratory data.   Nonetheless, when the body of evidence is viewed objectively, the beneficial role of statins in high-risk patients clearly outweighs the risks.   It was the feeling of the investigators that physicians underestimated the potential benefits of statins and overestimated their potential harm.   There was no suggestion that there was any correlation with the Canadian national health care system.


There are now compelling data from European and North American clinical trials that statins should be prescribed not only in patients with elevated cholesterols, but in patients with even clinically “normal” (even though physiologically these levels may still be too high) lipid values if they are at risk.   These would include not only patients who have already had a cardiac event, but those with diabetes or combinations of risk factors such as smoking and high blood pressure.   For the known, but small, risks of statin therapy, the payoff is a 25% or more reduction in heart attacks, strokes and heart failure.


Although lower treatment target cholesterol levels are better than higher levels, the exact statin or drug used to achieve those goals is not the issue.   Combined with prudent dietary and lifestyle modifications, any given statin or drug combination that gets the bad LDL-cholesterol below 100 mg/dL will be beneficial.   But there is a trend now to drive cholesterol levels considerably below that target as I have done for many years.   Indeed, I have received letters in the past from HMO drug “benefits” managers suggesting I be less aggressive in treating patients and thus I could reduce the statin dose I was using.   Perhaps it was more related to reducing the HMO's cost of providing that dose that prompted their letters.

The second article reiterated a more valid point with regard to cost of treatment of high blood pressure.   Americans may be paying $1.2 billion annually more than necessary because we physicians are prescribing higher priced brand drugs more than lower priced generic agents that may have equal efficacy.


The recommendations from the high blood pressure experts on the Joint National Committee VII provide guidelines on treatment levels and treatment approaches.   In this study of 133,000 members of a Pennsylvania drug-assistance program for elderly patients, higher cost non-first line recommended agents were being used disproportionately.   The less expensive yet equally efficacious agents were not being prescribed as first line treatment.   The result may be higher costs of medications for elderly patients and exacerbating the ability to provide affordable prescription drug benefits to the Medicare population.


Although major advances have been made in the understanding and management of high blood pressure, initial treatment strategies based on sound evidence-based guidelines promulgated by expert consensus committees are extremely effective and cost-efficient.   The more elegant strategies, many of which are entirely justified when tailored for the individual patient, can still be implemented using generic versions of those otherwise more expensive brand names.   Given the realities of this broken health care financing and delivery system, I have evolved strategies that have become increasingly dependent on generic equivalents.


The proactive patient needs to ask the health care provider if the appropriate treatments are being implemented given the patients risk profile, and once treatment is initiated, ask if the most cost-efficient agents are being used.   You can help the provider and yourself by doing all that you can to avoid needing the medication in the first place by making all the lifestyle changes you can, and then take the medications reliably.


Dr. Irving Kent Loh is medical director of the Ventura Heart Institute in Thousand Oaks, CA.   He can be reached by e-mail at