Thursday, April 8, 2010

Reassuring Comments from Rang and Dale

With regards to drug treatment options for rheumatoid arthritis:

"The antirheumatoid action of most of these agents was usually discovered through a mixture of serendipity and clinical intuition. When the drugs were introduced, nothing was known about their mechanism of action in these conditions, and decades of in vitro experiments have generally resulted in further bewilderment rather than understanding."
                                   -Rang and Dale's Pharmacology, 6th ed. (2009)

I like the honesty in the statement, though it isn't overly reassuring considering the amount these drugs are prescribed. I guess that a lot of medicine is just knowing that it works, not necessarily knowing how it works...but no ones seems to want to admit that.


OMDG said...

Once you know how little what we do in medicine is either a) evidence based or b) based on an understanding of a biochemical mechanism, it's quite humbling. Quite honestly, it's sort of a miracle we do as well as we do.

Albinoblackbear said...

It's true, and the more I read about statistical 'massage' the less faith I even have in evidence based medicine.

I think I need to stop reading "Bad Science" it is just making me depressed. :)

OMDG said...

There are good studies!!! You just need to be able to spot them.

At least when statistical massage is involved, usually the result isn't that strong, and the studies won't make it into the really good journals.

Cate said...

One of the most frustrating things is when we learn something and I want to know why... and we don't. Guess it just shows the importance of continuing research...

Albinoblackbear said...

I always got a little bit of a rash from always being told (first in nursing school and now in medical school) to do research now now now yet we

a)have no time to sleep let alone take on a research project

b)have no courses or concrete guidance on how to set up a study

I feel the same way as you Cate but it's like, where to begin?

Especially when you come from a non-core science background and have no experience with research projects.

Sigmoid Freud said...

As little as we know about rheumatological agents, it still far exceeds what we understand about psychotropic medications and yet they are some of the most widely prescribed medications. Sure we think we understand the main neurotransmitters involved, but we aside from a few theories, we really don't understand why those neurotransmitters cause the changes we see clinically. As for statistical massage - it seems to be particularly bad in psychiatry. You have to be really perceptive when reading studies to sort out the good from the bad, even if they are in one of the better journals. When you have a 30% placebo response rate, subtle study design features can make a big difference. The incestuous relationship between the pharmaceutical companies and the medical profession, while slowly getting better, is still problematic.

As for research, I was lucky to be at a big research hospital during medical school. If you just thought "research" someone had you helping out in his/her lab. It was mostly basic science research we did, but it's the clinical studies (and how they are marketed)that really drive prescribing patterns.

Albinoblackbear said...

SF--Very good point.

I wasn't meaning to imply that rheumatoid meds were the great mystery of pharmacology. I was just impressed at the flowery wording from a pharm text.

"The incestuous relationship between the pharmaceutical companies and the medical profession, while slowly getting better, is still problematic."

Yep. It's definitely getting to be a little more déclassé to admit you're going on a GSK golf weekend. But society continues to want pills for everything and until that tide starts turning I think it will be a major uphill battle for the medical profession.

At least in Canada advertising by pharma is still greatly restricted, though there are many lobby groups working *very* hard to change that.

I haven't noticed as much pharma advertising here in Ireland, mind you I don't buy magazines or watch TV so I could be missing it right under my nose.

Mark In Mayenne said...

It's how herbal medicines were discovered, after all.

Albinoblackbear said...

Serendipity and intuition yes, and lots of accidents!

Grumpy, M.D. said...

I freely tell patients that we have no idea how some drugs work.

Reps are always telling me about mechanisms of action. I don't care. I'm more interested in whether or not it works.

People have made tea from willow bark long before they knew it has Aspirin in it.

And used foxglove plant for edema long before digitalis was isolated from it.

And Penicillin was discovered by accident.

Anonymous said...

One of the things I very much appreciate about most of my doctors who prescribe things is that they tend to be very frank about not knowing what will work or why, and that it's kind of trial-and-error to see what works with my particular physiology.

I'm a complex patient with a ton of problems and a correspondingly heavy medication load. I won't put up with a doctor who doesn't speak openly about how likely something is to help me, especially versus just leaving things alone and waiting.

As far as pharma advertising, I generally agree with you, however some of the 'scripts that have helped me a great deal were things I saw on TV and asked about. Of course, I saw them and my response was to ask my doctor 'Will this help?' instead of demanding them based on what I saw, and did reading of my own on what the studies say about them, so I suppose I'm not your average patient.


Albinoblackbear said...

Grump--I am sorry but I have a hard time taking any of your comments seriously while chuckling at that profile shot of's true.

One of the things I loved about my med micro class in the days of yore was my profs obsession with medical history. She lectured often about the serendipity/accidental origin of many drugs, vaccines, microbes...etc. Fascinating stuff really.

Kali--I agree that ads can be useful with proactive patients like yourself who look into the literature around them and if they might be of benefit.

The marketing certainly keeps docs on their toes and up to date with new meds--which is a good thing. And I am glad that you have a good team of docs who are honest with you and listen to your requests and input (and are upfront about the mysteries of medications).

I think many people in healthcare are deathly afraid of admitting they don't know everything. Which is ridiculous because clearly, no one can.