More treatment isn’t always the best option

Our health care system sometimes seems like a runaway train. We all know it’s out of control, but no one can figure out how to stop it.  Here’s one example:

A man in his mid-80s, quite frail, had managed to survive two surgeries for lung cancer but the disease had now spread elsewhere in his body. His oncologist was pressing him to start chemotherapy, and he was seeking a second opinion from me. Now, understand that there was zero chance the chemo would cure him. At best, it had about a 10 percent chance of extending his life for six months beyond what would be expected without it – but he would be sick most of that time with nausea, vomiting, and weakness, and would be unable to travel away from home. After weighing the tradeoffs, he decided to skip the chemo. I have since left my position at the hospital where this conversation took place, but the last time I saw him, about six months later, he was still alive and feeling reasonably well. He had spent quality time with his family and even traveled over the holidays.

Conversations like this don’t take place often enough.  Too few consumers and doctors challenge the belief that “more treatment is always better.”  There are many reasons that we have come to believe this. Medical breakthroughs and heroic treatments are always news, whereas failures and horrible side effects are often not. Drug and device manufacturers spend billions to promote the idea that the shiniest, costliest new treatments are better than the old ones, even when there’s no solid evidence for this. High-tech treatments are moneymakers for doctors and hospitals.

I don’t see the situation getting better without some significant changes in the way we deliver and pay for health care. We need more doctors to do what I did with that man—talk through the risks and benefits of treatments, especially expensive, invasive ones. We need better research comparing old and new treatments. Right now, the incentives are in the wrong direction. Doctors earn very little for sitting down and talking to patients, but a lot for delivering costly interventions, whether they’re needed or not.

If you or someone you care about is facing decisions about treatment for a serious illness, keep the following in mind:

• You don’t have to accept the first recommendations you receive
• Insist on a meaningful conversation with your doctor, spelling out the risks and benefits of tretament
• Make sure you understand the side effects and success rates of the treatments you’re offered
• Balance those side effects and success rates against your own quality of life preferences
• Seek a second or even third opinion if necessary

—John Santa, MD, MPH

We are interested in hearing from you about your experiences. Have you ever received high-tech treatment that you later regretted because of side effects or lack of effectiveness? Have you ever turned down treatments that your doctor recommended? Did you have a tough time navigating the complexities of our system when deciding on treatment options? What and who helped you the most? What information was most useful to you? 

Share your story with us.

Older, cheaper drugs best first choice for high blood pressure in people with pre-diabetes

We’ve long recommended diuretics—the oldest, cheapest class of blood-pressure lowering drugs—for most people with high blood pressure. But one exception has been in people who have type 2 diabetes. In that case, newer and more expensive drugs called ACE inhibitors, such as enalapril (Vasotec and generic) and lisinopril (Prinivil and generic), offer special benefits, since they not only lower blood pressure but protect the kidneys from diabetes-related damage. Many doctors have long assumed those benefits also held true for people with the metabolic syndrome, a precursor to diabetes that multiplies the risk of heart disease. But a new study, published in the January 28 issue of the Archives of Internal Medicine, shows that those individuals should usually start with a diuretic too.

The trial, an influential study sponsored by the National Heart, Lung, and Blood Institute  called the "Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial", found that diuretics were also a better first choice than several other classes of medication, including alpha-blockers and calcium channel blockers. The diuretics were at least as effective as all those drugs in lowering blood pressure and preventing heart attack, and better at preventing heart failure or stroke. The benefits were especially striking in black people.  Generic diuretics can cost less than $5 a month, a fraction of what the other drugs cost.

Most people with high blood pressure—including those with signs of the metabolic syndrome, such as high triglycerides, a low level of HDL (good) cholesterol, and lots of abdominal fat—should now start with a diuretic.

Read more about:

• High blood pressure
• Blood-pressure lowering drugs

Trouble sleeping? Try this ad...

Consumer Reports has just posted the second in our series of CR AdWatch videos that add commentary and context to widely seen pharmaceutical advertisements. You’ll recognize this ad immediately: It’s the one that has Abe Lincoln and a talking beaver offering consolation to an unfortunate insomniac.

The ad—the latest in a series—is memorable not only for its quirky cast of characters, but also because the drug it promotes (Rozerem) does not appear to pose the same risk of chemical dependency as other prescription sleeping pills. Yet as our commentary notes, that doesn’t mean your first move after a sleepless night should be to beg for a prescription. I’ll let the AdWatch crew tell you the rest themselves.

Credit for the video belongs to our host, Associate Editor Jamie Kopf Hirsh, to CRTV News producer Ann Burr Tenthoff, and to the rest of the Consumer Reports Health team. And by the way, here’s a link to their earlier AdWatch video on a remedy for restless legs syndrome. We hope you’ll find them interesting and thought-provoking.—Kevin McKean, Editorial Director

Learn more

• Read about non-drug approaches to insomnia.
  
• CR Best Buy Drugs assesses drugs by effectiveness and cost. What insomnia drugs are the best overall buy?
  
• Not sure whether you've got insomnia or not? We'll tell you the symptoms, how common it is and how all treatment options compare in our Insomnia Treatment Center.

Q&A: Safe antibiotics for nursing moms?

My doctor recommended I not take an antibiotic for an infection I developed because I’m nursing and it may harm my baby. Are any antibiotics safe when nursing? —Y.Y., Colrain, Mass.

Some appear safer than others, though the risks haven’t been well studied. There’s concern that ingesting antibiotics through breast milk may cause infants to develop diarrhea, nutritional deficiencies, or other problems. But the amount of antibiotic that passes into breast milk varies by drug, so you can limit your baby’s exposure by using the ones least likely to leach.

The safest appear to be the cephalosporins, such as cefaclor (Ceclor and generic), cephalexin (Keflex
and generic), or cefdinir (Omnicef); macrolides, such as clarithromycin (Biaxin and generic), azithromycin (Zithromax and generic), or erythromycin (E-Mycin and generic); and penicillins,
such as amoxicillin, ampicillin, and oxacillin. Antibiotics to avoid include metronidazole (Flagyl and generic); quinolones, such as ciprofloxacin (Cipro and generic); and tetracyclines, such as
doxycycline (Vibramycin and generic) or minocycline (Minocin and generic).

Taking medication right after nursing may also minimize exposure.

Some animal venom can boost health

Not many people would willingly be stung by a bee or bitten by a snake. But in some cases, venom from animals, insects, and reptiles can help, not harm. And you wouldn’t think of ingesting urine from a pregnant mare, yet that’s the source of the estrogen in Premarin, used to treat severe symptoms of menopause.

Researchers are now exploring the potentially curative powers of many animal secretions. A compound based on scorpion venom, for example, may allow doctors to deliver drugs to brain tumors without harming neighboring tissue. An enzyme in snake venom holds promise as an adhesive in oral surgery. Snail toxin may ease nerve pain stemming from advanced diabetes. And fly larvae may one day help heal wounds caused by the superbug methicillin-resistant Staphylococcus aureus (MRSA).

What are some of the other “creature cures”?

Leeches
These bloodsuckers, long an icon of the medical dark ages, are making a comeback. Surgeons reattaching accidentally severed fingers now sometimes place leeches on the tip of the appendage to stimulate blood flow. Or they circle wounds with leeches to keep blood from pooling. Scientists harnessed the powerful anticoagulant properties of leech saliva to develop the blood-thinning drug lepirudin (Refludan). And some preliminary research suggests that leeches might help relieve knee pain stemming from osteoarthritis. But don’t try leech therapy on your own: The critters used in medical treatments are raised in carefully controlled laboratories, not harvested from lakes or swamps.

Gila-monster saliva
Exenatide (Byetta), a synthetic form of a hormone that occurs naturally in the reptile’s saliva, is an injectable drug for people with type 2 diabetes who can’t adequately control their blood sugar with other medications. Some evidence suggests that the drug may also help those people lose weight.

Bee venom
People who have severe allergic reactions to bee stings are now treated with tiny amounts of bee venom to desensitize them to the poison. That immunotherapy treatment provides almost complete protection from systemic reactions to bee stings.

Snake venom
Investigators are testing ancrod (Viprinex), an anticoagulant derived from the venom of the Malayan pit viper, to see if it can help restore blood flow to the brain when given within six hours after the onset of an ischemic stroke, the most common type of stroke.

This article first appeared in the February 2008 issue of Consumer Reports on Health.

Folic acid and cancer links—what should you do?

Recent research has raised the unsettling possibility that too much folic acid might increase the risk of colon cancer. That’s scary, since obstetricians tell pregnant women to take supplemental folic acid to prevent birth defects, and food manufacturers now add the vitamin to flour, pasta, cereals, and other enriched-grain products. Does that mean you should throw away those pills and avoid those foods?

No. And here’s why.

In one of the worrisome studies, of 607 people with a history of precancerous polyps, 30 volunteers who took 1,000 micrograms of folic acid every day for five years developed multiple new growths, compared with 13 of those who took a placebo. And a recent observational study found that rates of colorectal cancer began to rise in the late 1990s, about the same time manufacturers started fortifying enriched grains with folic acid.

While those findings raise some cautionary flags, our medical consultants say it is too soon to give up on folic acid. Considerable previous research suggests that folic acid helps prevent cancer, including colon cancer. And many causes, such as changes in dietary or exercise patterns, could contribute to the increase in colon cancer incidence seen in the observational study. Even if folic acid does promote colon cancer, that risk may be limited to high doses or people who already have cancerous growths.

Women who are pregnant or thinking about becoming so should still take prenatal vitamins containing folic acid, since the vitamin’s proved benefits against birth defects greatly outweigh any possible colon-cancer risks. And the evidence isn’t strong enough to justify avoiding enriched grains. But you may want to pass on supplements with high doses of folic acid, especially if you have a history of colon polyps or cancer. Instead, aim to eat foods naturally rich in folic acid, including beans, leafy green vegetables, citrus fruits, and whole grains.   

This article first appeared in the February 2008 issue of Consumer Reports on Health.

Make this your year to reach your health goals

The media is saturated this time of year with models and celebs promising you’ll lose weight or develop sculpted abs quickly and with no effort. No matter how appealing the idea is, most of us know in our logical minds that there’s no magic bullet to help us be healthier. Reaching your goals takes planning and a conscious commitment, but it doesn’t have to involve deprivation and discomfort.

So think about realistic health goals and make 2008 your year to achieve them. We’ve brought together the best of our latest health ideas to help you, so make this your year to:

Lose weight

• Winning diets and diet books
• 8 dieting strategies that work
• Find out how supplements and prescriptions drugs rate for weight loss in our Treatment Ratings
• More about diet & nutrition

Get fit

• 10 health benefits of exercise
• Be safe, prevent sports injuries
• Minimize fatigue and try interval training
• We rate the top gyms
• Do infomercial fitness gadgets work?

Eat healthier

• Should you see a nutritionist?
• "Super" foods: Do you really need them?
• When buying organic pays (and doesn't)

Go green

• 20 free ways to save energy
• Animal feed: You are what they eat
• Chemicals in cosmetics
• Being green can save green
• Green product ratings from Greener Choices

Prioritize your health

• Get better care from your doctor
• Ensure you’re getting the best health plan you can
• Make the most of your health insurance
• How are we working to improve your health care?

Quit smoking

• Quiz: What can help you quit?
• Smoking treatment ratings

Q&A:Will Chantix help me quit smoking?

I want to quit smoking. Is it true that the new drug varenicline (Chantix) is more effective than other treatments? —A.G., Seattle

Possibly. Varenicline eases cigarette cravings by providing mild nicotine-like effects, while potentially blocking some of the satisfaction cigarettes provide when you do smoke. Several manufacturer-funded studies have shown that it may work a little better than the antidepressant bupropion (Zyban and generic), often used for smoking cessation. (Research hasn’t compared varenicline with counseling or nicotine-replacement products, both of which appear comparable in efficacy to bupropion.) While the side effects reported for varenicline are relatively mild, the drug is too new to judge its safety definitively. So try the more-established treatments first and consider varenicline if they don’t work.

When the going gets tough: Constipation causes and treatments

Remember summer camp? Carefree days of new friend-ships, arts and crafts, swimming and boating, noisy mess halls, sing-along campfires, and the quiet time at the end of the day, followed by “Taps” and lights out. But not before the camp nurse, in her starched white uniform, made her appearance, clipboard and pencil in hand, and directed the question of the day to each, in turn: “Soft, medium, hard, or none?”—and she wasn’t taking egg orders for breakfast. A teaspoon of castor oil was the unwary respondent’s reward. Although that barbaric ritual has gone the way of public hangings, America’s obsession with daily bowel movements has persisted, largely due to persistent misconceptions. One myth is that waste products can accumulate and contaminate the rest of the body. Another is the belief that constipation can cause colon cancer. Patients have varying ideas about what constitutes constipation. One survey of nearly 600 constipated patients found that the main complaint of 79 percent was straining to pass the stool. Hard stools were a problem for 71 percent, while 57 percent complained of infrequent bowel movements. (Some had more than one complaint.)

The standard medical definition of constipation includes both of the following: 1. Infrequency (less than three bowel movements per week); and 2. Difficult passage of hard, dry stools. Most everyone agrees that anything between three times a week to three times a day can be considered normal. Constipation, as defined above, affects as many as one of every four Americans at one time or another, occurs more than twice as often in women as in men, and is more frequent among older people. Laxative sales in the U.S. are projected to exceed $850 million annually by 2010.

The cause may vary
Most of the time constipation is transient and related to changes in diet or schedule. Going on vacation, starting the Atkins diet, cutting out your usual exercise routine, or ignoring the morning urge in order to catch a train can play havoc with your bowels. A host of medications can cause constipation, including iron and calcium supplements, antidepressants, painkillers, and some blood-pressure drugs. Constipation can occur in pregnancy or be caused by serious conditions, such as an underactive thyroid, elevated blood-calcium levels, Parkinson’s disease, multiple sclerosis, irritable bowel syndrome, and actual blockages of the intestine by colon cancer. All can cause difficulty in moving one’s bowels.

Loosening up
Although a lack of fiber in the diet and dehydration can cause constipation, treating the problem by increasing dietary fiber and drinking eight glasses of water a day lacks the certainty of evidence-based medicine and often results in bloating, flatulence, abdominal distention, and increased urinary frequency. As long as you’re consuming adequate amounts of fiber (at least 25 grams per day) and drinking enough fluids to keep your urine a pale yellow, increases are not likely to help. Resuming your usual lifestyle after a vacation or switching the medication that was the cause usually does the trick. You won’t suffer permanent harm from a few days of constipation, but there’s nothing wrong with the temporary use of a laxative if you’re truly uncomfortable. But how to choose from the myriad products that line the shelves of your pharmacy?

The trick is to select a single-ingredient product that matches your particular complaint. If your main symptom is straining to pass hard, dry stools, try docusate (Colace and generic), an emollient type of laxative better known as a stool softener. If your problem is infrequency, choose a bulk laxative such as methylcellulose (Citrucel and generic), polycarbophil (Equalactin, FiberCon, and generic), or psyllium (Fiberall, Metamucil, and generic). If you have both complaints, take both kinds. Despite lore to the contrary, both types of laxatives are relatively safe for long-term use, but check with your physician. For more stubborn cases, as can occur in seniors with aging bowels, the occasional use of a stimulant laxative such as bisacodyl (Correctol, Dulcolax, and generic) may be necessary. Drawbacks are painful cramping and diarrhea with urgency. As with any symptom treated with an over-the-counter medication, if constipation persists longer than a week or two or recurs after treatment, it’s time to see your physician to find out if something more serious is going on.—Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.