Statin Interaction Reference

Your EMR, Epocrates, Lexicomp and your local pharmacy may give you four different opinions on which drugs interact (and how much) with each other.

A week or so ago I did a physical on a patient on simvastatin with chronic gout. My EMR flagged a major interaction between simvastatin and colchicine. Epocrates had something bad to say about the combination of any statin I tried with colchicine. I decided to stew about it for a while.

Today I asked Dr. Google, and he served up what I wished I had heard about it when it was first published: An AHA statement about more than a dozen statin Drug-Drug interactions.

It turns out rosuvastatin has only one pathway for interaction with colchicine while simvastatin and atorvastatin have two, making rosuvastatin “reasonable”.

Whew…

Thanks, AHA, and thanks, Dr. Google!

“Coadministration of colchicine and rosuvastatin, fluvastatin, lovastatin, pitavastatin, and pravastatin is reasonable when clinically indicated. Dose reductions may be considered for atorvastatin, simvastatin, and lovastatin, given the potential for interactions mediated by both CYP3A4 and permeability glycoprotein (P-gp) pathways.”

https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/10/20/21/53/recommendations-for-management-of-clinically-significant-drug

British Doctors Also Suffer

My latest post on A Country Doctor Writes is about a simple, yet radical fix to the crazymaking situation most American primary care physicians find themselves in:

“A better day for medical providers:

1) Encounter Productivity Achieved

2) Charts done on time

3) Inboxes Cleared.

Those are the three basic tasks of a medical provider, yet most medical organizations only schedule providers for one of them, the patient visits, and somehow expect that by pure magic, superhuman willpower or personal sacrifice, the other two things will get done, and continually act surprised when that doesn’t happen.”

The BMJ writes on the same theme, and there is even a British conference on “The Wounded Healer”:

“Rates of mental illness, emotional exhaustion, and anxiety are increasing among health professionals.23 The causes are generally the same across the world and include a lack of time with patients, loss of continuity, erosion of amenities such as on-call rooms and doctors’ messes, shift systems that undermine traditional peer and senior support, unrealistic public expectations of medicine, the industrialisation of healthcare turning it into a production line, a growing burden of administrative tasks, and being expected to deliver more with fewer resources.”

“Doctors increasingly work within a culture of litigation and blame, carrying the full burden of accountability despite a loss of authority and autonomy.”

“The BMJ champions the wellbeing of doctors. To coincide with the tenth annual conference of the Practitioner Health Programme, the wounded healer, on 4 and 5 October, we have curated an online collection of articles published in the past few years (www.bmj.com/wellbeing).”

What’s this world coming to, when the people who are supposed to be healing the sick are themselves sick from the way their work is structured, organized and mandated?

Air Pollution, Blood Pressure and Heart Attacks

Fine particle air pollution is associated with increased cardiovascular morbidity. Air purifier use causes measurable, rapid decrease in blood pressure in urban US elderly populations according to an article in JAMA Internal Medicine:

Effect of Portable Air Filtration Systems on Personal Exposure to Fine Particulate Matter and Blood Pressure Among Residents in a Low-Income Senior Facility –

http://app.jamanetwork.com?doi=10.1001/jamainternmed.2018.3308&utm_source=email&utm_medium=app&utm_campaign=share

The Lancet: A Broken Heart is the Epitome of Mind Body Medicine

Takotsubo cardiomyopathy of the 1990s, described in the 1847 Novel Wuthering Heights, is the topic of one of the typically philosophical essays in the current issue of The Lancet:

“Brontë’s assertion that the mind and emotions have control over the physical body, that Heathcliff can remind his “heart to beat”, is a progressive departure from a traditional biomedical focus on mind–body dualism. She is aware of the toll that despair can have on health. Heathcliff visits Catherine’s grave time and time again until her ghost at last appears. Overcome not by misery, but by happiness, Heathcliff’s heart finally breaks from overwhelming joy. The next day he is found dead in his room, a ghastly smile on his face: his weary heart at last broken with delight.”

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32061-0/fulltext?dgcid=raven_jbs_etoc_email

JAMA: Is US Medical Care Inefficient?

http://app.jamanetwork.com?doi=10.1001/jama.2018.10779&utm_source=email&utm_medium=app&utm_campaign=share

Quality When Nobody is Watching?

Last week’s issue of The New England Journal of Medicine has an article that demonstrates that, in Britain, when incentives for achieving quality targets are removed, doctors’ behavior changes, and they don’t do those things anymore.

But the authors do admit that it may have something to do with the EMRs. It’s one thing to counsel a patient on a myriad of things, yet another to click all the awkwardly placed boxes to actually get credit for it. In my own EMR, there are a half dozen ways to document that BMI counseling was done, but only one shows up in the quality reports. If nobody’s counting, why make all the extra clicks for the bean counters; the office note still says I did it…

What the authors don’t say is that the “quality” parameters they looked at, from 2010 to 2017, include lipid control. I don’t know about the U.K., but in this country, the 2013 lipid guidelines ABANDONED and DISMISSED lipid TARGETS, since some cholesterol treatments have turned out to have little or no effect on cardiovascular mortality.

Quality is really too hard for nonmedical people and even medical administrators to try to measure.

https://www.nejm.org/doi/full/10.1056/NEJMsa1801495?query=featured_home

Suicide: A Silent Contributor to Opioid-Overdose Deaths | NEJM

Not all opioid overdoses are accidental. But how common a method of suicide is prescribed opioid pain medication? And what is the likelihood that suicides by opioid go unreported?

“Perhaps of most relevance, 2006–2011 data from the Nationwide Emergency Department Sample that include information on more than 250,000 emergency department visits by adults for opiate overdose show that only 54% of the overdoses were classified as “unintentional”: 26.5% were deemed intentional, and 20.0% were “undetermined.” The data also document a steady annual increase in opiate-overdose visits to emergency departments. Together, these data suggest that the true proportion of suicides among opioid-overdose deaths is somewhere between 20% and 30%, but it could be even higher.”

https://www.nejm.org/doi/full/10.1056/NEJMp1801417

Treat the Brain to Lessen the Pain

We have successfully helped many of our chronic pain patients reduce their need for opioid medications through our in-house cognitive pain management program. JAMA Neurology just published an article about a similar program with similar results:

http://app.jamanetwork.com/?doi=10.1001/jamaneurol.2018.0492&utm_source=email&utm_medium=app&utm_campaign=share

The Loss of a Sense of Control as a Major Contributor to Physician Burnout

The current issue of JAMA Psychiatry points out that resilience training and mindfulness are strategies to decrease physician burnout only when it comes to dealing with unchangeable circumstances. The most important solution is to give physicians more control and influence about how we should work and how our practices and organizations should evolve.

http://app.jamanetwork.com?doi=10.1001/jamapsychiatry.2018.0566&utm_source=email&utm_medium=app&utm_campaign=share

The Truth About the Discovery of the Smallpox Vaccine

Jenner didn’t discover that cowpox protected against smallpox, a simple Country Doctor did. The story appears in this week’s The New England Journal of Medicine:

Two hundred fifty years ago, an almost-forgotten country doctor made an observation while inoculating a group of farmers against smallpox. Although John Fewster never appreciated the importance of his discovery, he told his colleagues what he had found, setting in motion a process that led to the development of the smallpox vaccine and the eventual eradication of the virus. All immunizations arguably have their origins in this event.

http://www.nejm.org/doi/full/10.1056/NEJMp1715349?query=featured_secondary