TEC: Evidence Based Therapeutics
Therapeutics Education Collaboration
Medication Mythbusters – Home of the Best Science (BS) Medicine Podcast

The BS Medicine Podcast episodes are presented by James McCormack and Michael Allan. We try to promote healthy skepticism and critical thinking and most of the podcasts are presented in a case-based approach. We also try to inject some humour into the whole process to make the learning more interesting. Occasionally we have great guests like Mike Kolber, Tina Korownyk and Bruce Arroll help us out.

Most podcast episodes are available for free until they become archived after about 1-2 months. Every 4th episode or so is a “New Studies You Need to Know About” podcast and these will only be available to our Premium Podcast members. Premium members will also be able to listen to all archived episodes since episode #1.

Episode 12: Getting Hyper Tense about Monitoring

In our 12th episode, we divide and conquer the remaining points around hypertension. In section A, we talk about monitoring blood pressure: frequency, reliability and home monitoring are all discussed. In section B, we talk about the potential side-effects of different hypertension therapies and the need to monitor for biochemical-metabolic effects. In the end, Mike is hyper and James is tense but both need therapy.

Show Notes

1) Effect of home blood pressure monitoring on blood pressure

BMJ 2004;329:145

2) Hypokalemia and metabolic effects of thiazides are dose related

BMJ 1990;300:975

3) Cardioselective beta-blockers in mild-moderate asthma and COPD Cardioselective beta-blockers in asthma

Ann Intern Med. 2002;137:715-725

Cardioselective beta-blockers in COPD

Cochrane library

Other resources

Episode 11: Taking the Pressure off: Other Drugs

In our 11th episode, we discuss the laundry list of the remaining hypertensive medications and their evidence. The issue of blood pressure as a surrogate marker is discussed and we encourage clinicians to focus on hypertensive agents that effect patient oriented outcomes. While the evidence is reasonable for Ca+ Blocker, we put Beta-blockers low down (and Atenolol off) the list with Alpha-blockers and a few others.We have few laughs along the way, primarily at our lack of humor.

Show Notes

1) Atenolol no better than placebo and other drugs are better than atenolol in reducing cardiovascular outcomes in patents with high blood pressure

Lancet 2004;364:1684–9

2) Beta-blockers do appear to increase the chance of developing diabetes

Am J Cardiol 2007;100:1254–62

3) A debate on using or not using betablockers for high blood pressure

Can Fam Physician 2007;53:614-7

4) ALLHAT – the problem with alpha-blockers

JAMA 2000;283:1967-75

5) Data for felodipine and cardiovascular events in patients with high blood pressure

Lancet 1998;351:1755-62

6) Use of low-dose spironolactone in “resistant” hypertension

Amer J Hyper 2003;16:925–30

7) Effect of spironolactone on albuminuria

Diabetes Care 2005;28:2106–12

Episode 10: Taking the Pressure Off: ACE Inhibitors

In our tenth episode, we discuss our second choice of hyperåtensive medication agent, the ACE inhibitor. We review dosing and renal protection (briefly) before agreeing our choice is based mostly on once a day adminstration and costs. We look at substituting with ARBs but not combining with ARBs (with possible exception of co-morbid CHF). Throughout the podcast, James disagrees with Mike on a variety of issues, more on principle than fact.

Show Notes

1) A meta-analysis of ACE inhibitors/ARBs versus other antihypertensive drugs on renal outcomes – in diabetics, no difference in end-stage renal disease or doubling of creatinine – albuminuria was reduced but remember this is a surrogate endpoint

Lancet 2005;366:2026-33

2) Telmisartan produced the same outcome as ramipril in diabetics – the combination did not add benefit but increased adverse events

N Engl J Med 2008;358:1547-59

3) Combining ACEs and ARBs in heart failure did produce a benefit

Lancet. 2003;362:767-71

Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet

In our ninth episode, we interrupt our regularly scheduled podcast to talk about the recently released ACCORD and ADVANCE trials which focus on intensive glucose control (reduction) in diabetes. We discuss the patient-oriented outcomes and harms, ranging from mortality to hypoglycemia, as well as the potential benefits such as preventing microalbuminuria. Evidence regarding patient blood sugar monitoring is reviewed while reminding listeners how much fun monitoring is for our patients.

Show Notes

1) A synopsis of what was reported in the ACCORD and ADVANCE studies.

Download PDF

N Engl J Med 2008 358:2545-2559

N Engl J Med 2008 358:2560-2572

2) Studies of monitoring blood sugar in type 2 diabetics showing no benefit and increased depression scores

BMJ. 2007 Jul 21;335(7611):105-6

BMJ. 2008 May 24;336(7654):1174-7

Episode 8: Taking the Pressure Off: Hypertension Drugs

In our eighth installment, we discuss the initiation of hypertensive drug therapy. In recommending thiazide diuretics, we outline the evidence (e.g. ALLHAT trial) showing equivalence and the significantly lower yearly cost. We debate (politely this time) dosing and attempt to dispel the smokescreen of thiazide metabolic issues (e.g. blood glucose). The usual banter ensues around the challenges of monitoring therapeutic effect and the pseudo-logic of initiating combination drugs.

Show Notes

1) ALLHATno difference in CVD outcomes between thiazides, ACEI or CCBs in hypertensive patients treated for 4.9 years

2) Additional benefits of ACEIs/ARBs on renal outcomes in diabetic patients is unproven

Lancet 2005;366:2026-33

3) No evidence of superiority of CCBs or ACEs over thiazides for hypertenison in type 2 diabetics

Arch Intern Med 2005;165:1401-9

Episode 7: Hypertension: Taking the Pressure Off

In our seventh installment, we discuss the options for blood pressure reduction before adding medications. We first talk about medicines, drug use and dietary factors that may increase blood pressure. We review the approach and potential benefits of varying lifestyle interventions like Exercise (e.g. pedometers), Diet (e.g. DASH) and Salt Reduction. The ever elusive balance between nagging and encouragement is debated (James and Mike pick sides).

Show Notes

1) Using a Pedometer

  • Ask the patient to wear the pedometer for one week
  • Have them calculate their “steps/day”
  • Next add 1000 steps to the day average and that will be their daily goal for each day next week.
  • They repeat this every week.
  • Once at 10,000 steps/day. They can stay stable (and come to see you to brag about their success)

NOTE: This is only one way. There are many and you should feel free to use any safe approach to help you patients increase their activity.

2) Approximately 35% of patients who reduced their salt intake either

had no change in blood pressure (20%)

or an increase in blood pressure (15%)

Hypertension 2003;42:459-67

Episode 6: Hypertension: Coping with the Pressure

In our sixth installment, we begin to discuss hypertension. We review the principles of making the diagnosis of hypertension and confounders in the office. Although the identification of an elevated blood pressure for a certain patient may be new, the hypertension itself is likely not and rarely an emergency. The risks of hypertension are put in context of global cardiovascular risk while we wax poetically around evolving hypertension guidelines.

Show Notes

1) Our 45 y/o 10-year risk

Framnigham
10 year change of CVD
Overall CVD 14.1%
CHD 12.3%
MI 6.4%
Stroke 1.2%
Death of CVD 2.0%
Death for CHD 2.0%

2) Treating a Blood Pressure of 160 /100 mmHg for 5 years –

 

CVD ? 1% (4% to 3%)

3) Diagnosis of high blood pressure

Elevated BP Measured

Episode 5: Swiss Cheese & The Evidence Holes in the Lipid Hypothesis

In our fifth installment, we end our discussion of cholesterol outlining some of the remaining evidence gaps. Areas discussed are primary prevention for women, the use of other cholesterol reducing medicines, and the need for follow-up cholesterol testing for patients on statins. We avoid filling the evidence gaps with theory-based assumptions and close by discussing the endless fun in tests, doctors’ visits and taking medicines.

Show Notes

1) Absolute benefit of statins over approx 5 years

Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
Primary 1-1.5* 8-9 to 7
Diabetes 2 1-1.5 10 to 7
Secondary 4 2 1 20 to 15

* just in males and NO difference in overall serious adverse events

2) Meta-analysis data for mortality benefit with Statins in primary prevention

3) Ezetrol data

4) Fibrate data

5) Torcetrapib

6) Treating to Targets

  • Optimal targets “because all of the trials compared fixed-dose regimens of more intensive statin therapy with less intensive statin therapy and because none provided a breakdown of event rates by the level of LDL cholesterol reduction achieved, the available data cannot be used to define optimal target LDL cholesterol levels.”
  • No long-term data for adding other cholesterol meds to statins in order to hit targets “It is not enough that short-term trials with LDL cholesterol outcomes have demonstrated that other lipid-lowering agents can further lower LDL cholesterol when given along with statins. Large trials are needed to establish the clinical safety and effectiveness of combination therapy.”
  • High vs low dose statins in primary prevention. “the current literature provides limited insight into whether more intensive statin therapy should be used in patients without coronary artery disease but with multiple atherosclerotic risk factors” CMAJ 2008;178(5):576-84

Episode 4: De-constructing Risk (or Benefit)

In our fourth installment, we apply the absolute benefit for statin therapy to our patient. We discuss the absolute benefits in context of the individual risk and acknowledge that when translating pooled literature numbers to individual patients an element of mysterious uncertainty always remains (except for James who knows but won’t tell and Mike who doesn’t know but tells us he does).

Show Notes

Definitions

CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease – fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes – and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease)

Calculating benefit

  1. Change the factor and recalculate the chance of CVD
  2. Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient
  3. Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials

A synopsis of the relative benefit of drugs

  • Statins ? 30%? in CHD (0%? in women)? 5 years
  • BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years
  • Metformin ? 35%? in CHD and stroke ? 8-10 years

A synopsis of the absolute benefit of drugs

Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%)

Absolute benefit of statins over approx 5 years

Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
Primary 1-1.5* 8-9 to 7
Diabetes 2 1-1.5 10 to 7
Secondary 4 2 1 20 to 15

* just in males and NO difference in overall serious adverse events

Episode 3: The Risky Business of CVD Risk Assessment

In the third session, we discuss the advantages and disadvantages of three methods to present “benefit”: changes in risk calculators, using relative risk, or the absolute benefit. We review the challenges of absolute vs relative risk (or relative vs absolute truth) and discuss patient expectations in regards to the medical miracle of prevention. The duration of therapy is put in context of the epoch time frames of risk calculators and studies.

Show Notes

Definitions

CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease – fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes – and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease)

Calculating benefit

  1. Change the factor and recalculate the chance of CVD
  2. Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient
  3. Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials

A synopsis of the relative benefit of drugs

  • Statins ? 30%? in CHD (0%? in women)? 5 years
  • BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years
  • Metformin ? 35%? in CHD and stroke ? 8-10 years

A synopsis of the absolute benefit of drugs

Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%)

  • Therapeutics Letter #62.
  • Absolute benefit of statins over approx 5 years

    Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
    Primary 1-1.5* 8-9 to 7
    Diabetes 2 1-1.5 10 to 7
    Secondary 4 2 1 20 to 15

    * just in males and NO difference in overall serious adverse events

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