Heartfelt with Dr Melissa Walton-ShirleyView all posts »
ATLAS ACS 2-Where do we stop?Nov 13, 2011 22:53 EST
Last week, a patient told me I had cost her an extra $360 per month. She lives on a fixed income and suffers from angina. She has hypertension, diabetes, and dyslipidemia. With the simple stroke of a pen, I added a new medication and I changed her life, but maybe it's not been such a good thing. She can no longer comfortably have a night out with her granddaughter. She will be more careful about what she purchases at the local grocery. Christmas will be different this year because in three months, she'll spend an extra $1080 dollars on her medication. In today's ATLAS presentation, the antithrombotic rivaroxaban lowered mortality when added to aspirin and clopidogrel, and I couldn't help but think about what my patient had said. Although I was thrilled to see a positive result in the world of secondary ACS prevention, just where is all the madness going to end?
During the 1960s, heart-attack treatment and prevention of reinfarction was deplorable. It consisted of bed rest and chicken soup. Then came nitro, aspirin, and later, heparin. Beta blockers and statins were then added to our armamentarium. We lurched light-years ahead with CABG. Finally, the appearance of the mightiest of the mighty therapies: PCI came into our midst kicking and screaming, flexing its muscles and burrowing its way into the world of ACS with balloons, wires, and stents. All of this came at a price, but we physicians are rarely aware of exactly how much of our patient's money we are spending for them.
Like a snowball rolling down hill on a particularly good day for packing and shaping, the veritable laundry list of drugs for our patients potentially adds a new layer of pharmaceuticals each year or two. We now have "add-on" meds like aliskiren, soon the CETP inhibitors, and now potentially low-dose rivaroxaban for its new indication for ACS.
There is little doubt that the planning has been extensive for the sale and marketing of this drug. There is also little doubt that our US patients will likely pay for both the development and the world's supply of this medication. At what point will a battle-worn US patient revolt, weary from the financial burden we have thrust upon them? But aren't they revolting already and not telling us?
Study after study has demonstrated that compliance at its best is around 50%. I used to think it was just hardheadedness, lack of dedication to good health, or lack of education that drove that statistic. Now, in this environment of economic despair, it is also the lack of funds that dictates who buys what and when. Intelligent, sophisticated patients are literally begging for mercy every time I write a prescription.
At some point, someone is going to have to own the process and ask when it's time to go backward and delete things from our medication list that might no longer be needed. Someone has to decide which things are antiquities and which medications have retained their relevance.
In deep winter, on a snowy day, we layer up with coats, shirts, long johns, hats, scarves, and gloves. But when we come inside, into a different environment, we have to shed some of that insulation. If we don't, we could easily overheat to the point of becoming ill. It's time to examine the possibility of shedding some of the old pharmaceutical clothing that is suffocating our patients. Dr Paul Armstrong from the University of Alberta even questioned if one "needs to subtract aspirin" from our patient lists in this era of cardiovascular polypharmacy.
One can never know where they are going unless they know exactly where they have been. We've come a long way to get to this point. ATLAS ACS just might get us thinking in a better direction.
ISAR-REACT 4 on bivalirudin; IC vs IV abciximab in AIDA STEMI; vorapaxar in TRACER; ADOPT: apixaban vs enoxaparin; rivaroxaban in ATLAS ACS 2
Nov 13, 2011 23:25 EST Next post »
After ISAR REACT 4, will bivalirudin remain the 'ex-Mr Kardashian' of the PCI world?
Nov 13, 2011 21:05 EST