Integrative Medicine and Family Practice

[deleted87716]

A 2009 trial published in NEJM compared ezetimibe + statin to extended-release niacin + statin. Both lowered LDL. Niacin reduced artery wall thickness, but ezetimibe increased artery wall thickness. Bad news.

ARBITER 6-HALTS was really a pretty mediocre study.

The study was supported by Abbott, the maker of Niaspan. It was not powered or designed to investigate major cardiac events. It was a small study. Only 208 patients finished after 14 months because it was terminated prematurely, possibly giving Niaspan an advantage. Patients on Niaspan were taking 2 grams a day (if you can get your patients to tolerate 2 grams per day without flushing, God bless you). Patients enrolled in the study already had very low LDL (most <100, hardly your typical patients). The Zetia arm showed greater LDL reductions than the Niaspan arm.

I'd be hesitant to draw any firm conclusions from this trial.

More info here: http://www.medpagetoday.com/MeetingCoverage/AHA/17067

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[facetguy]

ARBITER 6-HALTS was really a pretty mediocre study.

The study was supported by Abbott, the maker of Niaspan. It was not powered or designed to investigate major cardiac events. It was a small study. Only 208 patients finished after 14 months because it was terminated prematurely, possibly giving Niaspan an advantage. Patients on Niaspan were taking 2 grams a day (if you can get your patients to tolerate 2 grams per day without flushing, God bless you). Patients enrolled in the study already had very low LDL (most <100, hardly your typical patients). The Zetia arm showed greater LDL reductions than the Niaspan arm.

I'd be hesitant to draw any firm conclusions from this trial.

Does anyone have any tried-and-true tricks to reduce flushing?

 

[deleted87716]

Does anyone have any tried-and-true tricks to reduce flushing?

The usual. Take the Niaspan in the evening (hopefully, you'll flush while asleep and not know it). Avoid spicy foods and alcohol in the evening (yeah, right). Take the Niaspan with a fiber-containing snack (a couple of wheat crackers, for example). Take an aspirin 30 min. before taking Niaspan.

I usually tell patients that they're going to flush, it's just a question of how much/how often. It's usually worse in the beginning. I start at 500 mg and gradually titrate up over several weeks. Still, I've hardly been able to get anyone >1000mg/day, and many refuse to stay on it at all.

The lipidologists I've talked to say the same thing, but seem to have better luck with higher doses. I think their patients are simply more motivated. You have to be pretty motivated to go to a lipidologist in the first place.

It probably helps when you're paid to participate in a study, too.

 

[deleted87716]

Keep in mind that lack of evidence of benefit is very different from evidence of no benefit.

Right now, this would apply to the use of Zetia as well, although there's ample evidence that lower is better where LDL-c is concerned.

 

[facetguy]

The usual. Take the Niaspan in the evening (hopefully, you'll flush while asleep and not know it). Avoid spicy foods and alcohol in the evening (yeah, right). Take the Niaspan with a fiber-containing snack (a couple of wheat crackers, for example). Take an aspirin 30 min. before taking Niaspan.

I usually tell patients that they're going to flush, it's just a question of how much/how often. It's usually worse in the beginning. I start at 500 mg and gradually titrate up over several weeks. Still, I've hardly been able to get anyone >1000mg/day, and many refuse to stay on it at all.

The lipidologists I've talked to say the same thing, but seem to have better luck with higher doses. I think their patients are simply more motivated. You have to be pretty motivated to go to a lipidologist in the first place.

It probably helps when you're paid to participate in a study, too.

Financial compensation helps cool the burn a bit, I agree.

 

[facetguy]

Right now, this would apply to the use of Zetia as well, although there's ample evidence that lower AND FLUFFIER is better where LDL-c is concerned.

.

 

[deleted87716]

Recent data shows there were no deaths attributable to vitamins or minerals, which is remarkable considering over half of Americans use supplements.

http://www.cpsc.gov/cpscpub/pubs/5051.html

"According to poison control center data, iron supplements are responsible for 30 percent of pediatric poisoning deaths from medications."

The effectiveness of antioxidants has been called into question in numerous trials, and some even show an increase in the risk of death with use of these supplements.

http://www.webmd.com/news/20070227/antioxidant-supplements-up-death-risk

Furthermore, many supplements interact with prescription medications, which can cause a variety of complications, including death.

The only thing that's 100% safe is an inert placebo.

 

[facetguy]

http://www.cpsc.gov/cpscpub/pubs/5051.html

"According to poison control center data, iron supplements are responsible for 30 percent of pediatric poisoning deaths from medications."

This is kids getting ahold of iron-containing supplements and overdosing. Blame the parents, not the iron.

The effectiveness of antioxidants has been called into question in numerous trials, and some even show an increase in the risk of death with use of these supplements.

http://www.webmd.com/news/20070227/antioxidant-supplements-up-death-risk

From the article:
Taking vitamin A supplements increased the risk of death by 16%.
Taking beta-carotene supplements increased the risk of death by 7%.
Taking vitamin E supplements increased the risk of death by 4%.

There is emerging data that vitamin A blocks vitamin D absorption and mechanisms. Perhaps that explains the increased risk of death, as we have seen over and over now that vitamin D reduces the risk of death. We'll see more on this in the near future I'm sure.

I'm willing to bet that the beta-carotene risk was in smokers.

On vitamin E, I hope future studies do a better job of separating out alpha-tocopherol-only supplements from those with mixed tocopherols.

It was also suggested in the article that many studies showing benefit were left out. I'd guess that these studies didn't meet the authors' criteria for one reason or another, but it does raise a bit of a flag.

Furthermore, many supplements interact with prescription medications, which can cause a variety of complications, including death.

There are interactions, sure. However, I think you might be overstating this a bit.

The only thing that's 100% safe is an inert placebo.

Never underestimate the power of the mind.

 

[deleted87716]

This is kids getting ahold of iron-containing supplements and overdosing. Blame the parents, not the iron.

Not really the point. The point is that saying there have been "no deaths attributable to vitamins or minerals" is grossly inaccurate.

There are interactions, sure. However, I think you might be overstating this a bit.

How so?

http://www.personalhealthzone.com/vitamins_supplements/side_effects_interactions.html

 

[facetguy]

How so?

http://www.personalhealthzone.com/vitamins_supplements/side_effects_interactions.html

Again, not that they don't exist. Just overblown.

And, it works both ways. Drugs commonly deplete key nutrients, yet this goes virtually unaddressed. There are a few books detailing this, but for now there's this article:
http://www.lef.org/magazine/mag2006/mar2006_report_drugs_01.htm

 

[VQuick]

http://www.cpsc.gov/cpscpub/pubs/5051.html

"According to poison control center data, iron supplements are responsible for 30 percent of pediatric poisoning deaths from medications."

That seems questionable given the raw data (Annual Report of the American Association of Poison Control Centers' National Poison Data System) that shows 1 death from vitamins and 1 death from minerals in 2007 (see pp 1024, 1026-7). The single death under the "other" vitamin category seems to be a case where a 71-y-o died subsequent to IV vit. K infusion but it hardly seems certain that he wouldn't have died without it (see case study p. 1056). The single death attributed to magnesium was a mag hydroxide overdose, which is used a laxative and not a nutritional supplement. Meanwhile, there were 1,597 fatalities from drugs and toxins. 1 or 2 versus 1,597 is a pretty huge discrepancy. The 2008 report is shows 0 vitamin fatalities and 3 deaths attributed to sodium. Not sure what the story is there, but I don't think anyone takes sodium as a nutritional supplement.

The effectiveness of antioxidants has been called into question in numerous trials, and some even show an increase in the risk of death with use of these supplements.

Sure, and the effectiveness of drugs has been called into question in numerous trials, and some even show an increase in the risk of death with use of these drugs.

Regarding increased risk of death shown in a few studies, it's likely that taking too much of one supplement (especially if there other nutrient deficiencies) can be harmful. Indiscriminate use of either drugs or nutritional supplements is never a good idea.

Furthermore, many supplements interact with prescription medications, which can cause a variety of complications, including death.

So do many drugs, and drug-drug interactions are a bigger deal.

The only thing that's 100% safe is an inert placebo.

I agree. Even though there are a negligible number of deaths from vitamins and minerals, they can indeed cause harm. However, it's clear to me that in general they are safer to use than drugs. (I am not including all "natural" therapies under this umbrella. Certainly there are some out there that have killed people.)

 

[deleted87716]

So do many drugs, and drug-drug interactions are a bigger deal.

It's not a "bigger deal" if somebody bleeds out because they took Coumadin and Levaquin rather than Coumadin and fish oil.

They're dead either way.

 

[EdibleEgg]

I think reading this thread is giving me fibromyalgia.

I don't understand the logic.

Why should magic beans get a free pass? Why should there be a separate standard for traditional medicine and one for "alternative" treatments. Shouldn't they both be held to some standard?

 

[facetguy]

I think reading this thread is giving me fibromyalgia.

I don't understand the logic.

Why should magic beans get a free pass? Why should there be a separate standard for traditional medicine and one for "alternative" treatments. Shouldn't they both be held to some standard?

I understand where you're coming from. But you have to admit that drugs have WAY more potential for harm than supplements. Sure, supplements can occasionally cause problems, extremely rarely serious or fatal ones. Prescription drugs kill people everyday, even when used as directed. Having said that, drugs obviously also have the potential for dramatic life-saving actions.

 

[deleted87716]

I understand where you're coming from. But you have to admit that drugs have WAY more potential for harm than supplements. Sure, supplements can occasionally cause problems, extremely rarely serious or fatal ones. Prescription drugs kill people everyday, even when used as directed. Having said that, drugs obviously also have the potential for dramatic life-saving actions.

Supplements are drugs.

Sure, most of them are pretty ineffective drugs, but then...that's really the point, isn't it?

 

[facetguy]

Supplements are drugs.

Sure, most of them are pretty ineffective drugs, but then...that's really the point, isn't it?

I don't look at supplements as direct replacements for drugs, as I think you might. Integrative care should go beyond "take red yeast rice in place of Zocor".

 

[deleted87716]

I don't look at supplements as direct replacements for drugs, as I think you might.

I didn't say "direct replacements." I said "drugs."

Anything you put in your body to do something is a drug.

Don't kid yourself otherwise.

 

[facetguy]

I didn't say "direct replacements." I said "drugs."

Anything you put in your body to do something is a drug.

Don't kid yourself otherwise.

That bowl of Ben & Jerry's I just housed is a drug?

I disagree that a substance found in foods is equivalent to a synthetic drug purposely designed to alter physiology.

 

[deleted87716]

I disagree that a substance found in foods is equivalent to a synthetic drug purposely designed to alter physiology.

Whether or not something is "found in foods" is irrelevant. It's the intended use that's the key.

I'll leave it to Merriam-Webster: "a substance other than food intended to affect the structure or function of the body."

This encompasses all "drugs," natural and synthetic, regulated and unregulated, prescription and non-prescription.

 

[facetguy]

Whether or not something is "found in foods" is irrelevant. It's the intended use that's the key.

I'll leave it to Merriam-Webster: "a substance other than food intended to affect the structure or function of the body."

This encompasses all "drugs," natural and synthetic, regulated and unregulated, prescription and non-prescription.

OK. You win on semantics. But we all know that vitamin C for example is nowhere near, say, Coumadin on the potential-for-disaster scale. Even if we looked at a "safe" prescription drug and a "dangerous" nutritional supplement, the drug has a greater side effect profile.

 

[VQuick]

I think reading this thread is giving me fibromyalgia.

haha, I'll take the bait. So because modern medicine can't treat it, it doesn't exist, right?

I don't understand the logic.

Why should magic beans get a free pass? Why should there be a separate standard for traditional medicine and one for "alternative" treatments. Shouldn't they both be held to some standard?

Yes they should, which is what I've been arguing.

 

[VQuick]

I'll leave it to Merriam-Webster: "a substance other than food intended to affect the structure or function of the body."

This encompasses all "drugs," natural and synthetic, regulated and unregulated, prescription and non-prescription.

That is but one of many definitions that M-W lists. The term "drug" is ambiguous enough that it can include or exclude supplements. So your point that "drugs are supplements" is moot and is only serving to obfuscate the issue.

To make things clearer, let's talk about xenobiotics versus substances that are normally found in the body. Both can be used therapeutically to treat medical conditions. However, xenobiotics are not necessary for normal functioning in healthy individuals and must be detoxified by the body. Not so for naturally occurring substances such as vitamins. Thus, in theory and in reality xenobiotics tend to have more adverse effects on the body.

The vast majority of drugs are xenobiotics. One exception I can think of is L-DOPA, which you could argue is a supplement used at pharmacologic doses (and thus having potential side effects). Whichever you choose to call it is a matter of semantics, i.e., beside the point.

Bottom line: it is a fair generalization to say that administering a xenobiotic substance is less safe than administering a substance that is has normal physiologic roles in the body.

 

[deleted87716]

To make things even more confusing, let's talk about xenobiotics versus substances that are normally found in the body.

Fixed that for you.

it is a fair generalization to say that administering a xenobiotic substance is less safe than administering a substance that is has normal physiologic roles in the body.

Oh, you mean like...potassium?

 

[thedon35]

I just listened to this.... and immediately thought of this thread

http://www.forgoodreason.org/harriet_hall_science_based_medicine

 

[EdibleEgg]

haha, I'll take the bait. So because modern medicine can't treat it, it doesn't exist, right?

Yes they should, which is what I've been arguing.

Actually, there are quite a few effective fibromyalgia treatments.

I haven't picked out your statements, but the general feel I've gotten from some on this thread is that alternative therapies don't cause harm so it doesn't matter that there is little evidence of benefit.

 

[VQuick]

it is a fair generalization to say that administering a xenobiotic substance is less safe than administering a substance that is has normal physiologic roles in the body.

Oh, you mean like...potassium?

Pointing out an extreme exception doesn't refute my generalization.

 

[VQuick]

Actually, there are quite a few effective fibromyalgia treatments.

I haven't picked out your statements, but the general feel I've gotten from some on this thread is that alternative therapies don't cause harm so it doesn't matter that there is little evidence of benefit.

I agree completely that any therapy used should have good evidence of benefit. However, would you agree that for any treatment there should be an inverse relationship between potential for harm and willingness to prescribe/administer it? Something with weak evidence of benefit but minimal safety concerns may be worth trying if more conventional treatments have failed.

What I've been trying to fight here is the attitude that lack of evidence is proof of inefficacy. We have little evidence of efficacy for many non-conventional treatments simply because they haven't been studied very much.

 

[deleted87716]

Pointing out an extreme exception doesn't refute my generalization.

"All generalizations are false. Including this one." - Mark Twain

 

[EdibleEgg]

I agree completely that any therapy used should have good evidence of benefit. However, would you agree that for any treatment there should be an inverse relationship between potential for harm and willingness to prescribe/administer it? Something with weak evidence of benefit but minimal safety concerns may be worth trying if more conventional treatments have failed.

What I've been trying to fight here is the attitude that lack of evidence is proof of inefficacy. We have little evidence of efficacy for many non-conventional treatments simply because they haven't been studied very much.

The treatments that have little evidence of efficacy usually have little evidence of safety.

 

[VQuick]

And little evidence of harm.

Further study of promising therapies is needed to produce all this evidence.

 

[jl lin]

I didn't say "direct replacements." I said "drugs."

Anything you put in your body to do something is a drug.

Don't kid yourself otherwise.

Does this mean food is a drug? I mean I get what you are saying from one perspective, since too much water or oxygen can harm someone. But extreme excess isn't the defining measurement of what is a drug per se.

Anything in excess can harm. It doesn't mean anything is necessarily a drug. Something in excess may act like a drug or produce effects that act like drug effects. That's why sound education is essential.

I personally disagree about supplements not being effective. It really depends if the person is correctly guided or properly educated on the various supplements.

 

[EdibleEgg]

And little evidence of harm.

Further study of promising therapies is needed to produce all this evidence.

By your own logic, lack of evidence of harm is not the same thing as evidence of safety.

By all means, study away.....

 

[deleted87716]

Snake oil chart...

...in static:
http://www.informationisbeautiful.net/visualizations/snake-oil-supplements/

and interactive versions:
http://www.informationisbeautiful.net/play/snake-oil-supplements/

The chart is a pretty simple idea: Items toward the top of the chart have strong scientific evidence supporting their health benefits (when taken orally by an adult with a healthy diet), while those toward the bottom have the least evidence supporting their worth. Each item also lists the supposed health benefit of said supplement. The larger a supplement's circle, the more popular it is as a solution for a problem. Using green tea as a cholesterol helper is popular and strongly supported, for example, while the chart illustrates that although Vitamin E is popularly believed to help your heart and fight prostate cancer, there's little evidence to support it.

Here's some of the evidence to support the chart: http://spreadsheets.google.com/ccc?key=0Aqe2P9sYhZ2ndFRKaU1FaWVvOEJiV2NwZ0JHck12X1E&hl=en_GB

 

[notinkansas]

It's not a "bigger deal" if somebody bleeds out because they took Coumadin and Levaquin rather than Coumadin and fish oil.

They're dead either way.

Very true!!!


And wasn't digitalis originally made from foxglove, a "natural" substance? Lots of potentially dangerous effects there, too.

 

[digitlnoize]

Snake oil chart...

That chart is pretty awesome, Blue. Thanks.