Pills, pills & even more pills

LA times Health section Aug 6th, 07 Under the influence states - FOR many Americans, a doctor's decision to prescribe medication is something of a sacred transaction. A physician considers the patient and symptoms and chooses the best drug for the job, drawing upon years of training and clinical experience. It is an exchange conducted in a hushed sanctuary, far from the heat and noise of the marketplace -- a place where cool judgment reigns. That sanctuary has been breached. Today, drug manufacturers do everything in their considerable power to ensure that their brand-name prescription medications are on the lips of patients and in the minds of physicians every time the two meet across an exam table. In 2006, drug-makers spent almost $5 billion to reach out to consumers with direct advertising. The world's pharmaceutical companies spend an estimated $19 billion annually to woo doctors (the US market size itself is 300B$).

The sales strategies are complex and enticements to doctors are many. More than all this, the worrying fact is that 40-100% specialists in panels & groups who write drug advisories have extensive financial ties with drug companies.

With that in the background, Let us take a look at a couple of examples

Peptic ulcers, H Pylori & antacids

Doctors Warren & Marshall were ridiculed for decades after they published papers stating that H Pylori a common bacterium is the cause of Peptic ulcers. Unlike others, they did not give up. After many years of struggle to get heard, fights with peers in the medical world & the highly profitable antacid drug industry hovering in the background, Dr Robin Warren & Barry Marshall were finally awarded the Nobel Prize in 2005.

New Scientist states -
Working at the Royal Perth Hospital, Barry Marshall and Robin Warren established beyond all doubt in the 1980s that Helicobacter pylori causes stomach ulcers by infecting and aggravating the gut lining. Moreover, they showed that ulcers could be cured altogether by killing the bacteria with antibiotics. Hitherto, ulcers had been considered incurable. Instead, patients' symptoms were treated with a lifetime of drugs to reduce the acidity of the gut. The pair’s claims provoked a fierce backlash from the medical establishment, which held to the dogma that ulcers were brought on by stress and lifestyle, and could not be cured. By revealing a simple cure, the researchers also threatened to destroy huge and lucrative global markets for the existing anti-ulcer drugs, which simply eased symptoms. At conferences, the two scientists were subjected to abuse and ridicule. Notably, Marshall proved in 1985 that the bacteria caused gastric inflammation by infecting himself, then curing his condition with antibiotics. Since their discovery, it has been accepted beyond all dispute that H. pylori causes more than 90% of duodenal ulcers and 80% of gastric ulcers.

Note the following - A peptic ulcer is a sore in the lining of the stomach or duodenum. The majority of peptic ulcers are caused by the H. pylori bacterium. Many of the other cases are caused by NSAID’s. None are caused by spicy food or stress. Treatment is still complex, antacids & acid suppressors & lining shields are required for acid reduction, antibiotics for the bacteria. Treatments could very well be double, triple or quadruple combinations of the above.
Although the idea that bacteria cause chronic inflammatory disease was seen as heresy back in the 1980s, there is now increasing evidence that bacteria might be to blame for other conditions, such as Crohn’s disease, rheumatoid arthritis and even the clogging of arteries that leads to coronary heart disease.

Peridontitis and CHD (Coronary heart disease)

This particular discussion has both supporters and detractors and proof is not absolute. Colgate for example has a
white paper establishing the connection. The national advisory I thought agreed with this. AHA journal paper affirms - Periodontitis, which would lead to frequent bacteremia from the oral lesions, has been implicated as a risk factor for the development of cardiovascular disease. BTW I must state here that CHD has multiple causes and oral ill health is only one of them!!

Chronic inflammation from any source is associated with increased cardiovascular risk," Dr. Wolfgang Koenig, of the University of Ulm Medical Center, Germany, and colleagues write. "Periodontitis is a possible trigger of chronic inflammation."

In 1996 Dr. Joseph B Muhlestein at the University of Utah reported a startling discovery. His research team found a bacterium called Chlamydia pneumoniae in 79 percent of patients undergoing coronary bypass surgery. Now a report from Johns Hopkins says other studies have also implicated Chlamydia pneumoniae. In addition, the bacterium H pylori that causes the majority of stomach ulcers has been linked to CHD along with infectious agents that cause periodontal disease. Many laughed when it was first announced H pylori triggered stomach ulcers. How can bacteria cause heart attacks? Harvard researchers believe chronic infection, such as periodontal disease, causes inflammation that often goes unnoticed by patients. Inflammation is usually a helpful reaction because it sends an army of white cells to fight the infection. The Harvard report claims these inflammatory cells also secrete a substance called C-reactive protein (CRP). This, they believe, promotes the growth of atherosclerosis. Researchers also found men with the highest levels of CRP had three times as many heart attacks as those with the lowest levels.

On the other hand,
A Swedish study by Dr Ahmadreza Parsa does provide another explanation for an association between periodontitis and cardiovascular disease, i.e. that chronic inflammation in the mouth leads to elevated levels of cholesterol in plasma. "

Statins – The miracle drug of the century

Serum cholesterol is a fat-like substance found in the blood (serum) and produced by the liver. The body needs a certain amount of cholesterol to build cell membranes and for other uses. However, the liver makes enough cholesterol to meet these needs. A diet high in saturated fats, trans fats and cholesterol tends to raise total blood cholesterol, while a diet low in those fats and dietary cholesterol helps to lower it. The risk of heart and blood vessel disease rises as blood cholesterol levels increase. Statins are a class of drugs that lower the amount of cholesterol in the blood. Lipitor and Zocor are examples.

Would it turn out that bacteria are a primary cause of CHD and that reduction or elimination of those would result in improving cardiac health? Most definitely!!

So then, what could happen to the highly profitable and growing Statin industry (The Statin industry is over 25Billion US dollars in size) in such a case?

Would it grow or decline? Food for thought!!!

I must add that I am neither from the anti Statin lobby nor am I against periodontal treatment, just wondering about all this!!

Something interesting - do you remember the much hyped bird flu hysteria?? How many of you know that the chairman of the Tamiflu (the only medicine for Bird flu) company Gilead Sciences Inc was Donald Rumsfeld till he became US defense secretary. They own the license though marketing is sublet to Roche.
Maneka Gandhi’s article on how the hysteria was whipped up makes very interesting reading.

By the way here is something new for those medically inclined -
Gut check RFID smart pills - This $500 device doesn't deliver drugs; rather, it provides information about acidity, pressure, temperature, and digestive activity from inside your intestines. The data is transmitted wirelessly via RFID to a receiver worn around the patient's neck or waist; from there it can be downloaded to a doctor's laptop.

I tell you guys - Soon we are going to have embedded phones in our body – or maybe they will call them ‘distance communicators’, You can tell yourself – I need to talk to ‘so and so’ now and it will dial out or establish wireless communication through the net to somebody thousands of miles away..


Ottayan said…
To take your idea about distance communicators- a time will come, when an organ or a cell will diagnoise itself and call up the doctor to get medicines prescribed.
narendra shenoy said…
Medicine has indeed come a long way from being a Florence Nightingale kind of profession -minstering angel, healing the sick - to some real hard-nosed commerce. H. Pylori can't be the cause of ulcers because our bottomlines would be eroded.

Lovely post, as usual.
narendra shenoy said…
I read Maneka Gandhi's article, which was excellently written, by the way, and reassured myself, if such reassurance is required, that Donnie Rumsfeld and several other Bush sidekicks are rats. How low can can these guys stoop?
Read the entire blog sir. I think some of our Karntaka Bio text books need serious updating. Even my Bio teacher in college. Wait till i tell him that! Oh, they've made me write down 'The cause for peptic ulcers' to be:
1) Stress
2) Untimely food
3) Spicy food
4) Beverages like coffee and tea!
And they're making me mug up stuff like that. Cures? 'Ignore beverages like coffee and tea...' somewhere else, they mention caffine stimulates the nerves and is good the neurotrasmitters! So what do I believe? The only text book is excellent publications which excellently explain the cause for stomach ulcers is mainly Helicobater Pyroli and Campylobacter Pyroli. (The book was suggested by the author himself who also happens to be my Bio teacher in tution--in the beginning I thought he was bragging). I've been troubled by mouth ulcers ever since childhood. I searched the net and it sweetly says there is no cure to it. Doctors state the causes, and nobody gives anwers. Is there a sure medicine to this thing? They appear all over my toungue and mouth, sometimes even on the lips making them look swollen and quite aweful.
Happy Kitten said…
Very true....

recently Hubby went for a normal cold and fever and the doctor gave a medicine titled foreverliving.. some natural stuff.. but very costly.. i am sure these Doctors are paid well
Maddy said…
Ottayan - credittably the body actually signals problems already in a fascinating way with the technique called 'pain'. Ensuring that a doctor is summoned in due time!! but i see your point..

narendra - doctors are still better off compared to many others when it comes to ethics like lawyers, businessmane....only issue i take is on the relatively slow & miniscule development in the field of medicine - i.e in my opinion..

Lakshmi - yeah text books we have are pretty corny. I looka t some ofmy sons text books and marvel at the quality & explanation. But the good thing is by & far we have better teachers in india and text books are after all but one tool in the quest for learning.

as regards what you complain about - canker sores, as they are believed viral you may not really find a surefire cure, but only something topical for reduction or alleviation of symptoms. Take a look at these sites.

HK - forever living reminded me or amrut...it is a US company selling grandmas alo vera remedies nicely bottled. it seems to be a bonuis based multi level marketing company based on buyers selling to others. like those plastic dabba's..wont hurt I guess!!
harimohan said…
Dear Maddy ,
a good post where you have got good sources but unlike the comments seen in this post mine is of an insider ,being in the medical profession iam quite used to this fad of people calling that medicine today has been hijacked by matireal temptations and physicians are mere puppets in the hands of multimillion medical companies .
Not true ..
The percentage of doctors being lured by seductive sirens of pharmaceutica may be a sizeable one but there is also a great magnitude of doctors who are concerned on ethics and will allow no such thing to happen ,the laymans view comes mostly from magazines and health journals which are not hardcore techincal journals.
The dictums and standards laid down by scientific bodies and conferences are not fragile and are strictly monitored by hard nosed professionals and no company can project or profess thier wares by lucre alone .
now coming to the two examples written in your post of h pylori and bacteria causing ischaemic heart disease i do not deny thier presence but they are conrtributory factors alone and disease occurs when so many factors merge and meld ,medicne isnt as simple as it looks and there is more to it .
the role of medical companies in research has been enormous though thier motive is profit ,medical research is costly and tediuos ,scientists can work only with funds and such work has yielded its results too, for with all the talk of alternate medicines and the curses on modern medicine one has to accept the success story in conquering diseases ,today a man with cancer has a 70 % five yr survival rate while in 1960 it was a mere ten percent !today emergency and critical care medicine have saved millions ,surgical skills and finesses have transplanted hearts ,livers marrow ,kidney and other organs and given life and hope to millions.
the charading of modern medicine being a fashon one fails to understand the acceptance of quackery and unscientific alternate medicnes as natural ,herbal and with other fashionable labels going unquestioned ,but whattever be the questions medicine will continue to progress in its pace and reward humanity but also with its own share of black sheep who cannot be wished away as in any other profession .

copied two articles from medline related to the post below .....
Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and cause an erosion in the mucosal wall.
While we no longer believe that lifestyle factors cause ulcers, we do believe that they play a role. Some types of medical therapy also can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach. This increases the chances of getting an ulcer and slows healing of existing ulcers.
Aspirin, nonsteroidal anti-inflammatory drugs (such as ibuprofen and naproxen), and newer anti-inflammatory medications (such as celecoxib [Celebrex])
Stress - Physical (severe injuries or burns, major surgery) or emotional
Cigarette smoking
Radiation therapy - Used for diseases such as cancer
Ulcers can be linked with other medical conditions.
People who worry excessively are usually thought to have a condition called generalized anxiety disorder. This disorder has been linked with peptic ulcers.
A rare condition called Zollinger-Ellison Commentary
Association of infection with coronary artery disease
Indian J Med Res 125, February 2007, pp 112-114

below article breaks the myth of papers that came suggesting that infections may cause coronary artery disese.....

The possibility that various microbial agents
may trigger a cascade of reactions leading to
inflammation, atherogenesis, and thrombotic events
in vascular system has been raised in last two
decades. Chronic infection with various agents like
Chlamydia pneumoniae, Helicobacter pylori,
Mycoplasma pneumoniae, anaerobic periodontal
organisms, etc., have been implicated in the
pathogenesis of coronary artery disease (CAD)1.
However, there are various issues yet to be resolved
before making a final cause and effect relationship
between infection and CAD.
Among the various infectious agents,
C. pneumoniae has been shown to have a strong
association with CAD. Various epidemiological and
pathology based studies have demonstrated its
association with atherosclerosis2. On the basis of
serology3 and atherosclerotic plaques pathology4,
positive correlation of C. pneumoniae infection has
been shown with CAD. The article in the present
issue5 also found a significant serological association
of C. pneumoniae in young CAD patients. We have
also reported a significant association of anti-IgG
C. pneumoniae antibody in CAD patients6. However,
Danesh et al7 in a prospective study and also on metaanalysis
did not find a strong association of
C. pneumoniae after adjusting confounding variables
like smoking and socio-economic status. In the article
by Goyal et al5 the confounding variables as above
were not compared between the cases and healthy
controls, which might have favourably affected the
results of the study. In another meta-analysis
of 38 studies a strong association of
C. pneumoniae IgG antibody with clinical
atherosclerosis was shown8. Finally, the question
arises- Is the seropositivity sufficient enough to
explain the inflammatory pathogenesis in CAD? The
reliability of serological association of
C. pneumoniae is challenged by high prevalence of
C. pneumoniae IgG antibody in normal healthy adult
population, increasing prevalence with advancing
age, difficulty in obtaining serial serum samples and
lack of sero-epidemiological studies regarding
normal antibody titres in studied geographical
population9. There is also a lack of a standardized
serological testing method, for which Centers for
Disease Control and Prevention (CDC) endorsed
micro-immunofluorescence assay as the serologic
testing method of choice for diagnosis of
C. pneumoniae infection10. It also recommends a
4-fold increase in IgG titre or a single titre of >1:512
for diagnosis of acute C. pneumoniae infection. A
single IgG titre between 1:16 and 1:512 indicates
previous infection, and it does not differentiate
between chronic persistent infection, recurrent
infection and past resolved infection. High C.
pneumoniae IgA antibody which has shorter half-life
than IgG antibody, is present in chronic active
infection10, as reported in few studies11. However,
this association again requires the confirmatory
evidence in relation to CAD.
Animal studies have documented the ability of
C. pneumoniae to induce atheroma-like inflammatory
lesions in vascular tissue12, and also to accelerate
atherosclerosis13. In human beings, the organism has
been identified in atheromas of the coronary, carotid,
iliac arteries and aorta9. However, the true prevalence
of C. pneumoniae either in atheromatous or carefully
matched normal tissues is still unknown, hence it is
not clear whether the organism is an innocent
bystander aboard atheromas or is actively involved
in initiation/progression of atherosclerosis. The
molecular mechanism of atherosclerosis
pathogenesis can be explained by upregulation of
expression of heat shock protein 60 (HSP-60) by
C. pneumoniae infection, which induces production
of atherogenic tumour necrosis factor-a (TNF-a) and
matrix-degrading metalloproteinases (MMPs) by
macrophages14. Despite these pathophysiological
explanation and strong association of C. pneumoniae
with atherosclerosis, the direct link between the two
is yet to be proven.
The presence of C. pneumoniae in
atherosclerotic lesions raises the possibility that
antibiotic treatment might have a favourable effect
on the course of CAD. However, few of the large
randomized antibiotic trials like Weekly
Intervention with Zithromax for Atherosclerosis and
its Related Disorders (WIZARD)15, Azithromycin
and Coronary Events (ACES)16 and Pravastatin or
Atorvastatin Evaluation and Infection Therapy
(PROVE-IT)17 and also meta-analysis18 did not show
any beneficial effect of long term antibiotic therapy
in patients with established acute or chronic CAD.
After failure of antibiotic trials, it was postulated
that C. pneumoniae has a pathogenetic role in early
development of atherosclerosis and once the process
is established with the appearance of cholesterolladen
plaque and inflammation, anti-chlamydial
antibiotics are not effective18. The effective
antibiotics penetration and eradication of
C. pneumoniae from in vivo atheroma is also
questioned. At present, with the available
sufficiently powered data from above trials and the
meta-analysis, there is no role for long term
antibiotic treatment in secondary prevention of
In conclusion, though there is a strong association
of C. pneumoniae with atherosclerotic CAD, there
is lack of sufficient data to establish an aetiologic
relationship between the two. Pathogenetically, the
association between the various infectious agents and
CAD can be explained by common inflammatory
reaction in both conditions. The authors’ postulation
of infection as a cause for premature CAD in small
sample size of 30 cases5, without studying the
conventional risk factors like smoking, hypertension,
LDL and HDL cholesterol (criteria for metabolic
syndrome diagnosis) and family history of CAD may
not be a correct statement.
Rajesh Vijayvergiya
Department of Cardiology
Postgraduate Institute of Medical
Education & Research
Chandigarh 160012, India
e-mail: rajeshvijay999@hotmail.com
syndrome causes
Maddy said…
Hari - like most others, you missed the point I was trying to allude to. It was not all about Ulcers & CHD, which of course I used to lay the premises - considering good sources, as u yourself agreed.. The point I was coming to was - if at a later date, specialists come to the conclusion that bacteria are responsible for CHD, then what would hapeen to the lucriative Statin business?? As an aside I must add that the antacid business has not crashed even though basic antacid therepy has progressed to combination drug therapy for peptic ulcers!!
Pradeep said…
I guess it is a sign of times... I wonder if medical profession can remain aloof. I also find many people, in spite of their education, have a liking to pop the pills even when it is not necessary.
diyadear said…
gosh.. so much technology does sound scary!!
narendra shenoy said…
There is a gentleman named Dr. B. M. Hegde, a doctor of great distinction and Dean of a Medical college, who argued that very often, the right medicine is no medicine. His has been a lone voice against the drug companies and the technology companies - the ones that make MRI machines and the like. These days your physician is quite likely to require you to take a scan if you complain of a headache.
Nanditha Prabhu said…
it was a nice article maddy sir! pharmacutical comapanies trying to allure the mob and the medical field is indeed frightening! I better go back to the nattu vaidyam!:)
Maddy said…
Pradeep, narendra, Naditha, Diya -

While there have been very useful drugs and cures, the pace of development is pretty slow and dictated by economics. I have always felt that a good amount must be spent in aggressive R&D with lesser regard for profits - at least in the life sciences and health fields!!

I wonder if y'all remember the times when Indian companies were under threat for trying to supply cheap AIDS drugs to an ailing Africa!! It was a time when economics was upheld rather than the need of the sick.