Re: Drug therapy decision course misleading

In the letter “Drug therapy decision course misleading” [BCMJ 2011;53:259-260], the author expresses concern with the content and messages he took from some of the presentations at our 22nd Annual Drug Therapy course that was held at the beginning of April this year. While thoughtful criticism and academic debate is very much welcome, we feel this letter unfortunately went much further than that in its overall tone.

We very much appreciate the editor of the BCMJ providing a written apology for not asking us prior to publication to provide a response to the criticisms raised by the author and also for not editing out the unprofessional comments at the end of the letter.

Nonetheless, we are glad to have the opportunity to respond. Our Drug Therapy Course has been an annual event for 22 years and attendance is typically in the 300 to 400 range (two-thirds family physicians) and in fact sold out this year. Our course receives no sponsorship, with the entire course cost covered by the attendees—something that is somewhat unusual in the area of health care education. The overall rating for the course this year was 4.6/5.0, indicating that not everybody had the same experience as the author of the letter.

To address each one of the author’s criticisms/concerns/misrepresentations and lay out the evidence and our thought process behind each would require thousands of words. However, in general, it appears one of Dr Mudaliar’s main concerns was how we addressed and discussed decisions surrounding surrogate marker thresholds (A1C, LDL, CHADS2 score, etc).

The key message we try to get across in all our presentations, not just the Annual Drug Therapy course, is while guidelines are to some degree useful as a guide, they rarely reflect patient values and preferences.1 Guideline surrogate marker breakpoints typically have not been developed based on the results of RCTs so we suggest clinicians not treat them as dogma.

In all our teachings, we try to provide clinicians with a synopsis of the best available evidence, another thing guidelines minimally provide,[1] so they can engage patients in the concepts of shared-informed decision making.

As a specific example, Dr Mudaliar expressed concerns and suggested we said “In atrial fibrillation with a CHADS2 score of 1, 2, or 3 treatment with an oral anticoagulant is debatable.” What we did say and what we provided to our audience was a synopsis of the best available evidence for the benefits and risks of using oral anticoagulants in atrial fibrillation. 

We showed the benefit (annual percent reduction in the risk of a stroke) to a patient with atrial fibrillation of using an anticoagulant over an antiplatelet is roughly equivalent to the patient’s CHADS2 score. In other words, for patients with a CHADS2 score of one, the annual stroke absolute risk reduction is roughly 1% greater if one uses warfarin/dabigatran versus ASA. If their CHADS2 score was two, the annual absolute difference is 2%, and so on. 

In addition, there are additional risks of bleeds and a cost (both monetary and time) associated with taking oral anticoagulants. Once this information has been communicated to a patient, whether he or she wishes to take an oral anticoagulant should be equally supported by the clinician. We have far too often heard from patients that the reason they take a medication is “because their doctor told them they needed it.”

In regard to intensive glucose lowering, one only has to go as far as a very recent BMJ article and look at the results of the largest meta-analysis done on this topic. The overall impact, if in fact there even is one, of intensive glucose lowering on important clinical outcomes is not tremendously impressive, to say the least.[2]

We understand when we present information this way to clinicians who have, with the best of intentions, been “target shooting” with their patients for many years, it often brings up some cognitive dissonance. 

If clinicians are interested in this sort of shared-informed approach to therapeutics, we encourage them to listen to our weekly TEC podcast (one of the most popular medical podcasts in Canada), where we discuss these and many other issues we feel may be of interest to primary care clinicians. The podcast can be found at therapeuticseducation.org. 

Finally, we offer an open invitation to Dr Mudaliar, along with a modest (remember we have no sponsorship) honorarium, should he wish to present his views and interpretations of evidence in any topic area at next year’s Drug Therapy Course, which will be held 20 and 21 April 2012. We truly hope he takes us up on this invitation as we feel the best way to discuss any of these issues is via an open and friendly discourse.
—James McCormack, BSc(Pharm), PharmD
—Robert Rangno, MD
On behalf of the Drug Therapy Course

References

1. McCormack JP, Loewen P. Adding “value” to clinical practice guidelines. Can Fam Physician 2007;53:1326-1327.
2. Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: Meta-analysis of randomised controlled trials. BMJ 2011;343:d4169 doi: 10.1136/bmj.d4169.