Editor, – I was most impressed by the article 'The evidence-relevance gap - the example of hormone replacement therapy' (Aust Prescr 2002;25:60-2) in which Dr Neeskens gives a sensible and pragmatic approach to dealing with complex information thereby allowing the patient to put it in context for her situation. Too often we are confronted with population studies, but what do they mean to the individual person?
There are two other situations, one involving vast expense and the other some serious morbidity, which require similar scrutiny. The first involves the escalating use of 'statins' in the community at a cost which may result in limiting the ability of the Pharmaceutical Benefits Scheme to afford new drugs. Should we really be trying to reduce the cholesterol level to some magic number in every adult Australian, even those who are asymptomatic and without a relevant family history? And if so, for how long do we continue this therapy? I frequently see patients in the 80-90 year-old age group presenting for surgery still religiously taking their prescribed statin. Is this necessary?
Secondly, the prescribing of warfarin with its dangerously low therapeutic index to prevent some perceived morbidity too often results in genuine catastrophes in the form of gastrointestinal or intracranial haemorrhage. Again, elderly patients present as emergencies requiring scarce blood products to reverse the coagulation defect before surgery can be performed. For how long do we keep prescribing this toxic drug? Presumably once patients have these major morbidities they are not started on warfarin again, so could it not be ceased before the disaster actually occurs?
Brian Duffy
Staff Specialist Anaesthetist
Queen Elizabeth Hospital
Woodville, SA
Editor, – Dr Neeskens is to be congratulated for his article 'The evidence-relevance gap - the example of hormone replacement therapy' (Aust Prescr 2002;25:60-2). I hope it will be a forerunner of articles testing the proposition that years of taking pharmaceuticals by basically well (i.e. symptomless people) is a good thing.
I know of no medicine that works which can be taken with impunity by everyone. We are all that little bit different.
The majority of trials are undertaken on people who have a problem (I include Framingham: it is surely not healthy to be under constant medical supervision). They are irrelevant to the majority.
B.W. Griffiths
Surgeon
Crescent Head, NSW
