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Drugs are great preventive medicine, especially if they are cheap. Why bother with fancy screening tests if we can write a prescription? Low dose aspirin, for example, costs a few pennies a day and can help prevent heart attacks and strokes in high-risk patients. But should we give it to older women to help prevent cognitive decline? Jae Kang and colleagues analyzed data on this question from a substudy of the huge US women's health study (doi: 10.1136/bmj.39166.597836.BE). They could not find evidence of overall cognition benefits in women 65 or over treated with 100 mg of aspirin every other day for up to 10 years.
In a related editorial, Lawrence Whalley and Donald Mowat point out that the study patients were largely healthy white women whose responses may not generalize to a more diverse population (doi: 10.1136/bmj.39204.473252.80). Also, the cognitive assessments were done over the telephone, which may not capture the subtle changes of early Alzheimer's.
Well, how about statins then? Many cardiologists seem to think they should be put in the water so everyone can benefit. Scott Grundy and Malcolm Kendrick debate whether women should be offered statins to prevent cardiovascular disease. Grundy argues that statins have been shown to help women with established heart disease and that studies of asymptomatic women haven't been large enough to prove or disprove the benefits of statins for them (doi: 10.1136/bmj.39202.399942.AD). He thinks we should move to a risk-based assessment system rather than grouping people by whether they have had a cardiac event or not. Women at high risk should be treated. Kendrick states that no studies have found that statins reduce mortality in women (doi: 10.1136/bmj.39202.397488.AD). In addition, they are expensive in aggregate and have significant side effects. He recommends against treating asymptomatic women.
Another controversial prevention drug is erythropoietin. No one argues that it doesn't work—if you take it, your hemoglobin level will go up. The question is who should take it and at what dose. Alison Tonks describes the issues in the US around guidelines for erythropoietin use in chronic renal disease (doi: 10.1136/bmj.39198.510347.AD). Guidelines sponsored in large part by erythropoietin's manufacturer recommend more aggressive treatment than do British guidelines prepared by an independent government agency. And there is not much evidence to support increasing renal patients' hemoglobins to the higher level. This is especially relevant given the scandal that erupted this week about large payments to doctors who prescribe erythropoietin. Is the difference in prescribing regimens due to drug company influence on the guidelines or is it just America's philosophy that if some is good then more must be better?
Speaking of more being better, take a look at Steven Birnbaum's personal view, in which he recounts his horror as a radiologist at the number of computed tomography scans his daughter received after being hit by a car (doi: 10.1136/bmj.39205.757870.47). Another example of too much of a good thing.