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Thursday, February 05, 2009

Can we believe guidelines formulated by "expert panels"

The blog, California Medicine Man, written by Dr. John S. Ford, expresses concerns about the recommendations that flow in ever increasing numbers from panels of experts. He expresses some of the same thoughts I have had for some time. My spider antenna quivers when I see a supplemental issue of a journal devoted to a specific topic which contain a panel's recommendation for a given therapy.

He mentions a 2007 supplement to The American Journal of Medicine that discusses hyponatremia and specifically treatment with a new class of medicines that I have briefly blogged about before .

I previously wrote in regard to this particular supplement:

The supplement is sponsored by the drug company that makes conivaptan ( trade name Vaprisol).This is an antagonist to renal vasopressin receptors and is a member of the "vaptan family" which so far has three other members. Vaprisol is approved by the FDA for treatment of euvolemic and more recently hypervolemic hyponatremia and is given IV. It is contraindicated in hypovolemic hyponatremia wherein further volume depletion from the ensuing aquaresis could be disastrous.

The way things work is that when a drug company assembles a "panel" to make recommendations about one of its products and pays to have the results published, usually the opinions tend to be somewhat favorable as was the case with this publication. I have no experience with any of the vaptans but I would be very interested in what the hospitalists (or any of the die hard internists who still treat people in the hospital) bloggers have to say about the role of vaptans in hyponatremic states.

However, as interesting as this new medication may be and as useful as it may or may not be, Dr. Ford's major point was :

The problem is that even before checking out this particular drug's usefulness, I'm already starting from a position of mistrust. With such an undeniable "appearance of impropriety" how can I truly rely on these experts to give me the unvarnished truth? It's one thing to report hard facts. It's something entirely different to render an opinion which is what a guideline is.

Ten years ago, we did not know about medical ghost writing and all the other subtle and so not so subtle techniques used by drug companies to influence physician's behavior but now we do and we cannot go back to an early era of relative innocence and less critical reading of whatever is written about medications and guidelines. From one point of view it is a good thing that physicians have had to become much more critical and skeptical about what we told and that applies to guidelines and not just those apparently encouraged by certain drug company interests. On the other hand, it is so much easier to just do what the experts tell us to.

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