Saturday, July 23, 2011

The problem with numbers, the curse of intermediate end-points

The curse of treating chronic kidney disease is that one is always treating patients to the numbers:
  • Blood pressure. I need to get my patients below 130/80
  • Cholesterol. I need to get their LDL below 100
  • Metabolic bone disease. I need to keep their PTH
    • KDOQI 
      • Stage 3: 35-70
      • Stage 4: 70-110
      • Stage 5: 150-300
    • KDIGO
      • In patients with CKD stages 3–5 not on dialysis, in whom serum PTH is progressively rising and remains persistently above the upper limit of normal for the assay despite correction of modifiable factors, treatment with calcitriol or vitamin D analogs is suggested. (hey KDIGO, thanks for the guideline)
  • Diabetes. I need to keep their Hgb A1c less than 7
  • Anemia. I need to keep their hemoglobin
But these numbers are all intermediate, and from a patient perspective, pretty abstract. Patients don't get PTH angina. Targetting the numbers is a way to shift the odds toward better patient outcomes, to load the dice in the patient's favor. However we cannot allow the numbers to substitute for the real goals of care. I don't really care about your blood pressure, I just want to prevent the heart failure, dementia, kidney failure, stroke and erectile dysfunction that result from the high blood pressure. If you give me a pill that magically improves the blood pressure but doesn't avoid those end-points I'm not interested.

But as the number game has become a larger part of medicine we are getting medications that are pursued and approved only for their ability to fix the numbers. Some have been super successful, statins have repeatedly and reliably shown their ability to reduce events in lockstep with reducing the cholesterol. Lately however, it is feeling like success of the statins to reduce LDL and also reduce cardiovascular events maybe more the exception than the rule.

The recent experience with ESAs and hemoglobin have been beat to death in the nephrology community. See this post for a deep dive. The core issue, is that low hemoglobins are bad for patients, but using ESAs to improve the hemoglobin does not mitigate the risk. And not only does it not mitigate the risk, it appears that the current agents bring with them novel arterial and venous thrombotic risks.

The experience with A1c seems to be playing out using a similar script. Glitazones were approved based on their ability to reduce blood sugars. They effectively lower blood sugar but Rosiglitazone increased the risk of cardiovascular death by 64% and was associated with increased composite outcome of stroke, heart failure and total mortality compared to pioglitazone.

And June 9th pioglitazone was pulled from the shelves in France for increased risk of bladder cancer. A position validated by the FDA on June 15th.

This comes on the heals of three studies in 2008 and 2009 that question the notion of very tight (less than 7%) hemoglobin a1c targets to improve patient outcomes.

In cardiology, following the stunning success of statins and LDL we have a string of failures, Ezetimibe (Zetia/Vytorin) for LDL and niacin/torcetripib for HDL

I often feel the only reason we still treat PTH is that no one has done the study to show that it helps and when we get around to that trial, I'm looking at you Abbott, we will find that it too, has been a waste of money and attention.
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