Revised retirement age

dtaylor84

atush wrote: »

Personally, as a medical research scientist, I don't consider side effects of drugs (including teratogenic effects) to be 'deleterious effects of medical advances. I consider them drug side effects, which can be either managed or negates use in certain populations (such as teratogenic drugs Not being used on pregnant mothers).

The harm caused by side-effects is clearly an effect, and is clearly deleterious! Yes, where the side-effects are known and managed without causing harm, there is no deleterious effect. But they aren't (and can't possibly be) all known and managed in advance.

atush

But it is not an 'effect' of Medical advances, merely of not considering side effects when prescribing, or prescribing to the wrong cohort (such as pregnant females).

Side effects of drugs are well known today, and researched thoroughly. It is up to doctors and patients to consider them before use. Many don't look into them enough (esp patients).

jamesd

atush wrote: »

Personally, as a medical research scientist, I don't consider side effects of drugs (including teratogenic effects) to be 'deleterious effects of medical advances. I consider them drug side effects, which can be either managed or negates use in certain populations (such as teratogenic drugs Not being used on pregnant mothers).

For me, deleterious effects would be effects of actual medical advances, not individual drugs/therapies.

How I consider them depends on the context. In this case the context is life expectancy, so if a medication for say morning sickness increases death rates I'd consider it to be a deleterious effect of that particular advance and the drug that resulted. I won't care for that context whether it's due to teratogenicity or any other factor that reduces life expectancy. But I will consider the net effect on life expectancy, not just the adverse effects.

That means in part that a medication for low level pain that caused an increase in death rates due to circulatory disease would be negative in the life expectancy context even though it may be positive in QALY terms.

atush wrote: »

One that I can think of (but caused by human error not the advance itself) has been the rise of antibiotic resistance in some disease agents due to misuse (over prescription and not finishing a course) of antibiotics.

But the huge number of lives saved annually and in t he past from antibiotics means the overall effect on LE was greatly positive.

Yes, a clear positive net effect on life expectancy there. The resistance problem is a reduction in net benefit, not a net cost. But in the context of life expectancy change, widespread resistance could end up reducing life expectancy by decreasing the positive effect of antibiotics. Not due to the advances but just due to adaption by the organisms. So it's a potential life expectancy negative by reducing the existing benefit.

atush wrote: »

But I also don't feel there is need to worry about 'deleterious effects of medical advances' either ;-)

I expect LE to continue to rise, unless obesity continues to rise (esp in the young).

I expect life expectancy to increase even with that particular negative increasing.

atush wrote: »

But it is not an 'effect' of Medical advances, merely of not considering side effects when prescribing, or prescribing to the wrong cohort (such as pregnant females).

Side effects of drugs are well known today, and researched thoroughly. It is up to doctors and patients to consider them before use. Many don't look into them enough (esp patients).

Thalidomide was marketed specifically for that wrong cohort, so it's not really sensible to suggest incorrect prescribing. Like the COX-2 inhibitors, the side effects were not known or not sufficiently known at the time of prescribing. Researchers do good jobs but good isn't perfect and there are always going to be some failures that show up only in post-marketing studies. At least that should impose some cap on just how rapid and bad the potential effects can be, if it genuinely takes a large population for them to become visible and isn't due to abusive practices, like selective study publication.

I assume that you're not really going to argue that the adverse effects of Thalidomide and some COX-2 inhibitors were well known before initial drug approval was given? Though for new Thalidomide uses today they clearly are now well known.

Thanks for your job choice - it's one I consider to be in general a good thing for humanity as a whole and I appreciate those who make that choice.

While I agree with you about many not reading, my personal practice is to try to find data on such things as pharmacokinetics and prescribing information rather than relying solely on patient information sheets. But a someone with a science degree, such things as half life or routes through the body aren't particularly challenging for me to follow. Many patients would have a lot more trouble and no choice but to rely on the professionals.

atush

It is also not really realistic to compare Thalidomide (and the lack of proper testing of drugs way back then) to today's much more rigorous standards. I am also not so sure how badly LE was affected over the relatively short time the drug was prescribed. If sickness is severe enough, the pregnancy could fail as well.

The lessons learned through drugs used in the wrong way and not being tested thoroughly have caused major changes. Not that I worked int he drug industry, but it is one reason that drugs are so expensive as the costs are so high.

It also means no money is invested where there is no gold gravy train at the end (such as anti Malarials) as they don't affect the more affluent areas of the world.

jamesd

There clearly have been changes as a result of the Thalidomide problem, but are you really going to argue that the COX-2 inhibitors didn't have modern pre-marketing testing and regulation, given how recently those were introduced?

Consider the effect of the COX-2 inhibitors on the patient population. The newspaper story I mentioned earlier gave the circulatory disease death rates as 1.8 per thousand per year for men and 1.1 per thousand for women. The MHRA gives a rate of 3 thrombotic events per thousand patients per year for those using the affected products (mostly heart attacks according to the source paper). The study estimated that this corresponded to an increase of about 1 death per thousand patients per year - just over a 50% increase in death rate from that cause.

The underlying paper is interesting in part for noting increases from use of high doses of the non-specific NSAID Ibuprofen as well, but finding that there wasn't a comparable increase for Naproxen.

My conclusion from that and other things is that there remains a significant risk of widespread and substantial adverse effects from medicines even with the current testing processes in place. But probably not sufficiently large to have major effects on life expectancy unless the effects take decades to first become visible in post-marketing testing. Which is a real risk, even if a low probability one.

atush

Thalidomide was marketed specifically for that wrong cohort, so it's not really sensible to suggest incorrect prescribing.

I doubt this is correct, It was my understanding that the use was spread by word of mouth as it was used as anti nausea relief for other cohort groups and never tested for teratogenic effects in humans.

These days if previously tested medicines that are used for another purpose to that originally tested and not tested on different genders/cohorts, etc it must be retested although it tends to be fast tracked as many of the original steps have already been done.


yes, agreed, medicines can cause LE events for the short period of time until articles with research are published in such publications as you mention. I personally did not read that one as A, I no longer work in the industry, and 2 was not in that area specifically. And 3 can't be bothered now just to debate it with you ad nauseam.

But I don't consider individual profit making products such as licensed drugs to be the same as 'medical advances' in the more general sense of the word.

These (ie drugs) to me are a completely different kettle of fish to actual medical advances. From hygene/sterilisation and the discovery of disease agents, to blood typing, to transplants, to diagnostic procedures from xrays thru to MRIs, and most importantly improving surgical procedures etc. Even vitamins/diet etc.

The discovery of antibiotics was such a huge medical advance, and was not a for profit discovery in general (although now is an industry in and of itself). And problems with their use only began in the profit making era.

But side effects of individual licensed drugs to me is not something I consider when looking at overall LE in populations. These side effects are now known, and should be taken into account before prescription. And I feel make little to no effect on LE.

More effect is made by not treating the elderly for normal conditions (such as say hernias) as they are felt to not be up to the rigors of surgery and are instead left to die slowly of infection as it does not adversely affect hospital death rates. Not to mention the whole Liverpool (hidden) Pathway.

jamesd

If you do look into Thalidomide more you'll find that it was wrongly believed at the time that the placenta was an effective barrier, so there was no need for teratogenic tests because there was no potential for harm. That belief no longer holds so this particular risk is hugely reduced these days.

I'll leave it to kidmugsy to disagree further with you about the meaning of medical advances, since that's really kidmugsy's argument more than mine, which is more about recognising that there are risks, which I think are pretty well controlled. I agree with you that there's more to medical advances than just drugs and the non-drug ones tend to have pretty positive effects.

The Liverpool Pathway is interesting. Both useful and potentially harmful, though I can't fault it for things like recommending ending medication for conditions that would only have long term adverse effects in a patient who's clearly dying. Withdrawing water without very high levels of confidence is a very different matter.

Since you're tiring of it I'll stop because we're actually mostly in agreement when it comes to the big picture on life expectancy.

atush

I don't really want to spend my time evaluating the failures of doctors in prescribing Thalidomide w/o testing.

It is historic, and not repeatable in this day and age, and quite frankly depressing that the post war obsession with providing mothers from relief of pain and nausea during pregnancy/birth to those who could pay (form the US and germany to the UK with the national health service).

I understand that giving birth used to be a quite LE limiting event in most women's lives before then (esp before penicillin and the derivatives) as many would die in pregnancy/childbirth them post birth infections. it was the highest risk for limited LE in the entire female population for those between 12-50 or so. I myself would have died during either both or one of my deliveries had not modern technical assitance been available. And came close once even with.

Your obsession with drug side effects bored me before, and now exhausts me as you cannot see those are different from true medical advances so I have no more to say on this subject.

My opinion is, individual profit making drugs are not the same as Medical Advances.