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The Good, the Bad and the Ugly

MagazineFebruary 2014 (Vol. 24 Issue 11)The Good, the Bad and the Ugly

We like to think that medicine works

We like to think that medicine works. Even if it doesn't cure, we hope at the very least it will treat the symptoms that make life difficult or even intolerable. Certainly, we don't expect to come off worse from treatment.


In fact, just 11 per cent of 3,000 treatments and drugs assessed by investigators at the BMJ Evidence Centre are very likely to 'work', whether that is curing or alleviating symptoms.1 Close behind those are the 23 per cent of therapies that are likely to work based on the evidence out there, whether it's a clinical trial or case notes.


So, taking a generous view, just over one-third of medicine will probably help you: that's the good face of medicine.


Then we turn to the ugly. It represents 51 per cent of medicine and is like the dark side of the moon: nobody knows if it works or not because it's never been properly investigated. These are the therapies and drugs used every day, but for which there are little or no data to demonstrate they are actually helping anyone. Put another way, more than half of medicine is unproven.


Finally, there's the bad. This is the remaining 15 per cent of medicine, practised every day: there is enough evidence to show it should be put in medicine's waste basket. These are the therapies that are as likely to do harm as good, or are unlikely to help, or are probably going to harm you.

Before we look in more detail at the good, the bad and the ugly of medicine for some major conditions, it's worth saying this: when the researchers carried out their review, they were looking for at least one good study that would demonstrate that a drug or procedure could work. One solid study that proved benefit, and no studies suggesting harm, would put a drug or therapy amongst the good. But as around 80 per cent of medical research is fraudulent, those solid studies may not be quite so solid after all.2


We can't know what impact this would have on the true picture and, frankly, it doesn't even bear contemplating. Certainly, from a financial viewpoint, it seems a pretty poor return on the lb160 billion annual investment the British taxpayer makes into the National Health Service; the human cost is far greater,
of course.


This is also a critique of conventional medical practices by doctors for doctors. Many alternative therapies haven't even been considered, and most of those (like glucosamine for osteoarthritis) that have been are given short shrift.

References

1

Clinical Evidence Handbook, BMJ Evidence Centre, London. June 2011

2

BMJ, 2000; 321: 1487

How well does your doctor's arsenal of treatments work for the most common conditions? Here's the lowdown on the Good, Bad and Ugly in his medicine bag

KEY

The Good (grade 1): You are very likely to be helped by the treatment

The Good (grade 2): You will probably be helped by the treatment

The Bad:The treatment is unlikely to help, or is a trade-off between doing harm and having some benefit, or is likely to be ineffective or harmful

The Ugly:There is little or no evidence to suggest the treatment may help

CARDIOVASCULAR DISEASES

Angina (chronic, stable)

Symptoms:Discomfort or pain in the chest, arm or jaw usually brought on by exertion. It happens when arteries harden or become blocked by LDL cholesterol (atherosclerosis).

The Good (grade 2):Beta-blockers, calcium-channel blockers, nitrates or potassium-channel openers as single-drug therapy

The Ugly:Beta-blockers or nitrates if you're taking other drugs for angina

Atrial fibrillation (acute)

Symptoms:Rapid and irregular heartbeat lasting for less than two days; treatment may include blood clot prevention before stabilizing heart rate.

Preventing a blood clot

The Ugly:After an episode of atrial fibrillation, doctors often prescribe an anticoagulant or antiplatelet drug to stop a blood clot (embolism), but there's no evidence to suggest the treatment is helpful.

Reestablishing normal heart rate

The Good (grade 2):Applying an electrical current directly to the heart is pretty much the best method medicine has for stabilizing heart rate.

The Bad:There is a range of drugs doctors may use to stabilize heart rate, but there's little or no evidence they work. The drugs include amiodarone, flecainide, propafenone and digoxin.

The Ugly:There are other drug options too, but no evidence either way about them. These include quinidine, sotalol and verapamil.

Heart failure

Symptoms:This is sudden failure of the heart to pump blood at a rate that allows the body to continue healthy functioning. Depending on the severity of failure, symptoms can range from breathlessness, a sudden inability to carry out normal functions, fluid retention and death.

The Good (grade 1):Exercise, ACE inhibitors, angiotensin-II receptor blockers, beta-blockers, digoxin, installing a pacemaker

The Good (grade 2):Aldosterone receptor antagonists, hydralazine

The Bad:Antiarrhythmic drugs (other than amiodarone), calcium-channel blockers

The Ugly:Amiodarone, antiplatelet agents, anticoagulants

Heart attack (myocardial infarction)

Symptoms:Pain, usually in the centre of the chest, that can feel like pressure, tightness or squeezing; pain in other parts of the body; pain that feels as if it's travelling from your chest to your arms (usually the left arm, but it can affect both arms), jaw, neck, back and abdomen; shortness of breath; feeling sick

The Good (grade 1):ACE inhibitors, aspirin, thrombolysis

The Bad:Nitrates, calcium-channel blockers

The Ugly:Beta-blockers

ENDOCRINE DISORDERS

Type 2 diabetes

Symptoms:This 'lifestyle disease', usually caused by poor diet and lack of exercise, is progressive, as blood glucose (sugar) levels rise with the body's inability to produce insulin. Early symptoms include thirst, excessive urination, blurred vision and weight loss.

The Good (grade 1):Metformin, sulphonylureas

The Good (grade 2):Diet, education on lifestyle changes, including weight loss and exercise

The Bad:Insulin

The Ugly:Blood glucose self-monitoring, continuous insulin via infusion

DIGESTIVE DISORDERS

Acute cholecystitis (gallstones)

Symptoms:Almost all cases are caused by a gallstone blocking the cystic or bile duct. Symptoms include constant pain in the abdomen, anorexia, nausea, vomiting and fever.

Good (grade 1):Cholecystectomy (gall bladder removal)

Bad:Observation alone

Ugly:Mini-laparoscopic cholecystectomy (use of smaller surgical instruments to remove the gall bladder)

Chronic pancreatitis

Symptoms:Long-term inflammation of the pancreas sometimes brought on by alcohol and a fatty diet. Symptoms include recurring abdominal pain.

The Good (grade 2):Avoiding alcohol, taking pancreatic enzyme supplements

The Bad:Analgesics, various surgical procedures like decompression and resection

The Ugly:Low-fat diet, calcium supplements

Crohn's disease

Symptoms:This chronic inflammatory condition can affect any part of the gastrointestinal (GI) tract. Symptoms include diarrhoea, abdominal pain, weight loss, blood or mucus in stools, perineal pain.

The Good (grade 1):Corticosteroids, infliximab to help remission

The Good (grade 2):Aminosalicylates, methotrexate to bring on remission, laparoscopic surgery

The Bad:Azathioprine, antibiotics, cyclosporin

Irritable bowel syndrome

Symptoms:IBS is a chronic condition of the lower GI tract. Symptoms include abdominal pain, disordered bowel habits like diarrhoea and constipation.

The Good (grade 2):Antidepressants, antispasmodics, cognitive behavioural therapy (CBT), hypnotherapy, fibre supplements

The Bad:Alosetron, tegaserod

The Ugly:Loperamide

MENTAL HEALTH

Depression

Symptoms:Persistent low mood, loss of interest and enjoyment, and reduced energy. Day-to-day functioning is often impaired.

The Good (grade 1):Antidepressants, CBT, interpersonal psychotherapy

The Good (grade 2): St John's wort, combining antidepressants with psychological therapies

The Ugly:Exercise, problem-solving therapies, lithium

Panic attacks

Symptoms:Sudden onset of intense apprehension, fear or terror, often associated with feelings of impending doom.

The Good (grade 1):CBT, SSRI antidepressants

The Good (grade 2):Applied relaxation, client-centred and cognitive therapies, CBT plus antidepressants

The Bad:Benzodiazepines

The Ugly:Breathing retraining, couples therapy, monoamine oxidase inhibitors (MAOIs)

Post-traumatic stress disorder (PTSD)

Symptoms:Disabling symptoms of reexperiencing a traumatic event, avoidance behaviour and irritability that last for at least a month

The Good (grade 1):CBT

The Good (grade 2):Paroxetine

The Bad:Single-session debriefing, supportive counselling

The Ugly:Antiepileptic drugs, antihypertensives, benzodiazepines, fluoxetine, SSRIs

MUSCULO-SKELETAL DISORDERS

Ankle sprain

Symptoms:These vary depending on the extent of injury to ankle ligaments, which can range from mild stretching and partial rupture to complete rupture.

The Good (grade 1):Functional treatment, such as early movement with the help of external support

The Good (grade 2):Cast and rest

The Bad:Surgery, ultrasound

The Ugly:Cold therapy, diathermy, physiotherapy

Carpal tunnel syndrome

Symptoms:Caused by compression of the median nerve, symptoms include numbness, tingling, burning or pain in at least two fingers

The Good (grade 2):Corticosteroids

The Bad:Endoscopic carpal tunnel release, surgery, wrist splints

The Ugly:Diuretics, NSAIDs, massage

Chronic fatigue syndrome

Symptoms:Severe, disabling fatigue often accompanied by musculoskeletal pain, sleep disturbance, impaired concentration and headaches.

The Good (grade 1):CBT, graded exercise

The Bad:Galantamine, immunotherapy

The Ugly:Antidepressants, corticosteroids

Gout

Symptoms:Acute pain and swelling around bones in the toes and foot caused by deposits of urate crystals. It can also affect the joints, especially in the foot, ankle, knee, wrist, finger and elbow.

The Ugly:Colchicine, corticosteroids, NSAIDs, weight loss advice

Herniated lumbar disc (slipped disc)

Symptoms:Bulging around the midriff sometimes accompanied by pain in the lower back, often following activity.

The Good (grade 2):Surgery such as discectomy, spinal manipulation

The Bad:NSAIDs, bed rest, traction

The Ugly:Analgesics, antidepressants, corticosteroids, exercise therapy, heat or ice, massage

Low back pain

Symptoms:Low back pain affects around 70 per cent of adults at some time. It involves pain, muscle tension or stiffness in the lower back region persisting for 12 weeks or longer (considered chronic). Pain that lasts for less is usually described as acute and often resolves itself.

The Good (grade 1):Back exercises

The Good (grade 2):Acupuncture, CBT, massage, spinal manipulation, fusion surgery

The Bad:NSAIDs, muscle relaxants

The Ugly:Analgesics, antidepressants, epidurals, TENS, traction

Osteoarthritis

Symptoms:This usually affects knee, hip and hand joints, and damages bone and cartilage around the joints. Symptoms include pain, swelling, tenderness and inability to use joints properly.

The Good (grade 1):NSAIDs for short-term pain relief, exercise and physiotherapy, hip replacement (where appropriate)

The Good (grade 2):Corticosteroids, knee replacement surgery

The Bad:Analgesics, corticosteroid injections for medium- to long-term relief

The Ugly:Capsaicin, chondroitin, glucosamine

RESPIRATORY DISORDERS

Bronchitis

Symptoms:Sudden inflammation of the trachea, diagnosed from cough and wheeze and occasionally from sputum

The Bad:Antibiotics, amoxicillin-clavulanic acid

The Ugly:Amoxicillin, analgesics, antihistamines, beta-agonists, expectorants

Asthma (in adults)

Symptoms:Sudden airflow obstruction causing shortness of breath (dyspnoea), cough, chest tightness and wheezing

The Good (grade 1):Inhaled beta-agonists with inhaled corticosteroids

The Bad:Helium-oxygen mix, intravenous short-acting beta-agonists

The Ugly:Magnesium sulphate (intravenous)


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