Medication - does it work?
How effective is it?
Ask your doctor to prove it
“The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge.”
Daniel J. Boorstin
Often wrongly attributed to Stephen Hawking
The Number Needed to Treat
How do you know that the medication you have just been prescribed will do you any good? Where is the evidence? And do you say "yes" just because a doctor says so? Can you trust the information you are being given?
We seem to be experiencing an “epidemic of misinformation” according to a UK consultant cardiologist. (March 2016.)
But first, there is an old joke I found on a website about NNT, the Number Needed to Treat.
It says, “A man, frantically waving his arms in the air, goes to see his doctor.
“What are you doing with your arms”, asks the doctor. “I’m keeping the elephants away,”
says the man.
“But there are no elephants here,” says the doctor. “See. It’s working,” says the man.
The alternate version of the joke, also on the website, goes, “A doctor, believing his patient to
having a deep-seeded fear of elephants, advises him to always wave his arms in the air.
“Why should I do that,” asks the man. “It will keep the elephants away,” says the man.
“But there are no elephants here,” says the man. “See. It’s working,” says the doctor.
According to Dr Aseem Malhotra, a consultant cardiologist in London, GPs and patients are being put at risk because of an ‘epidemic of misinformation’ generated by pharma industry in collusion with the medical community.
In a session on clinical guidelines at Pulse Live on 23rd March 2016, Dr Malhotra said that as a result of biased scientific research and biased reporting in medical journals… ‘The reality is we have an epidemic of misinformed doctors and misinformed patients.’ He also clarified this was also down to “commercial conflicts of interest, defensive medicine and lack of training for doctors in how to interpret the research data.”
Dr Malhotra added: ‘Regulators fail to prevent misconduct by industry, and that doctors, institutions and journals with a responsibility to patients and scientific integrity collude with industry for financial gain.’
Highlighting the recent controversy over NICE’s decision to promote putting millions more patients on statins, Dr Malhotra said there were still huge doubts about the efficacy of the drugs and their real side effects.
He said GPs should advise patients that even on the available evidence, the number needed to treat with statins to prevent or delay one death ‘is infinity’ as no benefit to mortality has been shown, while a recent independent evaluation found the drugs were of no benefit - even for secondary prevention. In America the “need to treat” figure for statins is one in three hundred!
By contrast, Dr Malhotra said that a Mediterranean diet had been shown to have the best evidence for prevention in people with stable heart disease, ‘but nobody knows this’.
Also speaking at the session, Dr Dermot Ryan, a GP in Loughborough and honorary research fellow at the University of Edinburgh, criticised NICE’s approach to developing guidance - in particular for only including evidence from trials that ‘exclude 97% of patients’.
Dr Ryan added: ‘They construct guidelines from abstract evidence and then apply it to a population that was completely excluded from the trials.’
Dr Zoe Norris, a GP in Hull and lead member of the campaign group Resilient GP, warned the guidelines were preventing GPs from using their judgement and driving them to practice ‘defensively’ because of medicolegal fears. She said, ‘Clinical judgment is what we are meant to be using – and that does seem to be stressed more and more - but then our hands are tied by referral criteria. What worries me is that no-one is looking at the system, nobody is looking at the reality of implementing this on the ground.’
GPs in the audience voted overwhelmingly in support of the question posed at the end of the discussion, ‘Is impractical clinical guidance putting patients and doctors at risk?’
What has this to do with you?
Well, the next time a doctor recommends a certain pill for you, if you have not already done
your research (ie pre-empted what s/he might recommend) and are in any way doubtful ,
then engage a conversation on NNT – the Number Needed to Treat.
I did this with Statins; I was concerned that Statins were being mass-prescribed, we were being
mass-medicated, and I intuited there was little solid evidence for their benefits.
(See end of this article for evidence.)
I asked my doctor for the NNT effectiveness figure. He either would not or could not give
it to me and instead went down the road of, “Oh they’re very safe. No need to worry.
They would help you a lot.”
That response simply told me:-
He is either not listening or if he has, he has decided not to answer and so is disrespecting my question.
My question was deliberately being ignored.
He was making the agenda his, not mine…and in these days of patient centredness, that is not acceptable.
I have never taken statins since. Why should I when evidence on effectiveness is flimsy or just on the say so of a doctor?
The NNT – what is it?
The NNT (the number needed to treat) is a statistic that summarises the effectiveness of a therapy, or a preventive measure, in achieving a desired outcome. It is one way to indicate the clinical significance of an intervention. In more common parlance, the NNT result represents the total number of people who must receive a given drug or procedure for any one individual to benefit.
No treatment works for everybody, so, essentially, how many do you need to treat to benefit one person? That is to say, what is the number of patients with a condition who must follow a treatment regimen over a specified time in order to achieve the desired outcome for one person.
The key to understanding the potential benefit of any preventative drug or procedure is to focus, not on the widely publicised measures of relative risk reduction, but on the less well known and seldom publicised measures of absolute risk reduction.
As an example:- a study of the benefits of an anti-cholesterol drug indicated close to a 30% reduction in heart attacks experienced by those using the drug daily over the multi-year study period. The 30% is a relative risk measure and, on the surface, appears substantial. Or does it?
Looked at in another way, for every 100 people taking or not taking the drug, 93 wouldn’t have had any heart attacks. Of the remaining seven, five would have had a heart attack whether they were taking the drug or not. Effectively, that meant that the absolute reduction in heart attack risk for the drug’s users was two people out of a hundred, or one in fifty.
So, for every 50 people taking the drug, one less person would have had a heart attack. Yet it would cost the NHS to medicate 49 out of 50 with an expensive drug (and subjecting themselves to possible quite serious side effects), ie 49 who would not statistically benefit.
Over to you
So when being prescribed medicines, be radical, ask and ask again until you are told how effective it is and what its side effects are. Get aware. Inform yourself.
Study - Statin Drugs Given for 5 Years for Heart Disease Prevention (to patients without Known Heart Disease)
Details and references: - find here
Summary - result for those who took the statin for 5 years:
Benefits in the Numbers Needed to Treat
98% saw no benefit
0% were helped by being saved from death
0.96% were helped by preventing a heart attack
0.65% were helped by preventing a stroke
None were helped (life saved)
1 in 104 were helped (preventing heart attack)
1 in 154 were helped (preventing stroke)
Harms in NNT
1 in 10 were harmed by muscle damage
1 in 100 were harmed (develop diabetes*)
By any standards, the above surely calls into question the wisdom of a Government policy, slavishly followed by our NHS, to mass medicate senior people with statins when statin medication has such a poor track record.
But the same could be said for diabetes, depression and so many other conditions. Find out NNT statistics, details, and references here for drugs you are on or illnesses you have.
If not there, ask for them.
This is about your body, mind and soul – so why pop a pill in your mouth unless you can be satisfied that it will do you some good?