Friday, December 21, 2007

The Appropriateness of Chronic Self-care

A lot of over-the-counter products, many of them derived from herbal sources and others as specially-formulated multivitamin supplements, are advertised to treat (or help treat) various chronic disease states. AmealBP is a new product for patients with high blood pressure. Saw palmetto shows great promise in relieving symptoms of benign prostatic hyperplasia, or BPH (non-cancerous enlargement of the prostate), and it may have similar efficacy to finasteride, a prescription drug used for the same purpose--but with fewer reported side-effects (though that doesn't necessarily mean it actually has fewer side-effects). And though trials have generally shown that it is ineffective for the purpose, black cohosh has gotten a lot of press for reducing symptoms of menopause, namely hot flashes.

Let's momentarily ignore the issue of efficacy for all of these products and assume that they work as advertised with minimal risks or side-effects. Would that make them good products?

There are many pros to self-care, or therapy with over-the-counter products without the intervention of a physician. Self-care helps reduce healthcare costs, largely because physician's office visits are expensive. The convenience and ease of access to self-care promotes the seeking of treatment by patients who might otherwise do nothing. And symptomatic relief of common ailments, such as colds, helps reduce the number of sick days taken by employees, increasing workplace productivity. Some do-it-yourselfers love the idea of treating all their ailments via Google diagnosis and OTC purchases.

The question is whether or not these are really illnesses that should be self-treated. Is BPH really an illness that should be self-diagnosed and self-treated? The major symptoms of BPH are related to urination. But there are many problems that might cause difficulty urinating or "leakage" in men, including the anticholinergic effects of many medications, especially since BPH is a problem of old age and older people are more susceptable to these side-effects. And while BPH is a "wait and see" illness, not typically requiring a biopsy, BPH may not be BPH--it may be cancer. Which means that these medications are likely best used under the supervision of a doctor, significantly reducing the monetary savings of self-treatment.

Mevacor, otherwise known as lovastatin, has been considered as an over-the-counter or perhaps a "behind-the-counter" drug. Lovastatin is a "statin," used to lower cholesterol and a member of a class of drugs that is estimated to have saved 83,000 lives since the '80s. Like low-dose aspirin, statins are clearly a life-saving therapy for patients at risk for cardiovascular disease. Wouldn't improving patient access to statins--by making them over-the-counter, or perhaps behind-the-counter--save lives as well? Maybe. Maybe not. Statins are effective, but must be used judiciously. And because statins can cause both liver damage and rhabdomyolysis, or breakdown of muscle tissue, patients on statins need to have regular lab tests and monitoring. So OTC statins don't save patients from regular doctor visits--one at the initiation of therapy to establish a baseline for liver enzymes and follow-up monitoring every three to six months depending on the patient, not to mention lipid panels to confirm that the therapy is actually working. The drug may be more accessible if moved out of the pharmacy, but will it really be any more convenient? And how many patients are going to cut corners, putting off lab tests and appointments they don't think they need in order to save time and money? I really don't think OTC statins are a terribly good idea.

If lovastatin shouldn't be OTC, why should saw palmetto or AmealBP? All three are intended to be used to treat chronic conditions that require monitoring by a primary care physician. The only reason the latter two escape scrutiny is the DSHEA. Putting aside questions of efficacy--and even safety, at least in the sense of drug side-effects--is it really a good idea for patients to be treating these conditions without the intervention of a professional? And don't even get me started on the notion of these products as "complementary" therapies; saw palmetto is theorized to work via the same mechanism as finasteride, which is the blockade of enzymatic conversion of testosterone to the more potent dihydrotestosterone. No sane physician would prescribe finasteride and dutasteride simultaneously, as they have the same mechanism of action. Why take saw palmetto alongside finasteride? Patients may unknowingly do so, especially if they do not discuss the herbal supplements that they use with their physician.

I apologize in advance to the do-it-yourselfers, but some things just aren't conducive to that kind of attitude, and healthcare is frequently one of them.

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