Friday, May 27, 2011

THE ISSUE OF THE POLYPILL. HARM OR HELP?

The medical fraternity as well as the government have realised that diseases are better prevented than cured. This is especially true for chronic lifestyle diseases, like hypertension, diabetes, heart disease and strokes. In particular, cardiac and cardiovascular risk, can be reduced if coronary risk factors can be brought under control, either through aggressive lifestyle modifications ( and few can stomach that ), or through pills. If is very difficult and it would take a very discipline subject ( he is not even a patient, as he is well and not sick ), to work hard to reduce his cardiovascular risk profile. I suppose, if he has seen 1 or 2 of his siblings or relatives fall dead, or undergo CABG or PCI, he may be motivated. The average Johnny around the corner, is unlikely to. They may not mind taking a pill, to reduce their risks. Recently, we are seeing more, and more companies, manufacturing one pill with different drug ingredients, on the basic assumption that should the individual drug prevent CAD, the composite will do better. So now will have the 3 in 1 pill ( aspirin, ACE-I, statin), the 4 in 1 pill ( aspirin, ACE-I, diuretic, and statin ), and I am sure many other combinations, as soon as the patency of the targeted component drug expires. soon we should see combo pills with ARBs, and also atorvastatin.
To emphasize the point, there is an article published in PLoS one, may 25, 2011 online edition, entitled, "An international randomised placebo-controlled trial of a four-component combination pill ("polypill'') in people with raised cardiovascular risk", by the PILL collaborative group. Their 4 in 1 pill includes aspirin ( 75mg), Lisinopril (10mg), hydrochlorthiazide (12.5mg), and simvastatin (20mg). These are people in the moderately high risk group ( about 7.5% CV risk in 5 years by Framingham score ). After 12 weeks of therapy, there was a 10mmHg drop in BP and a 0.8mg/L drop in LDL-C. This may translate to a 60% reduction in CAD and strokes, over 5 years, if the sunjects stay on the drug. However, this came at a cost of almost 50% adverse effects in the treated group.
There comes the question, shall we give assymptomatic subjects a pill, which may contain components that the subject does not need, potentially have a 50% side effect rate, to prevent 6 out of 10 events over 5 years?
This is certainly not how medicine was taught to me. I was taught ( in the good old days ), to identify disease conditions and to treat them with specific therapy, accepting a certain incidence of potential side effects, in the belief that I am able to help him live better and longer. I was not taught to give drugs, where the subjects do not need, because it is in the 4 in 1 pill. Also, how can one size fit all. Some patients may need more than 10 mg of lisinopril or more than 20 mg of simvastatin. aspirin 75 mg is not without its problems in individuals with a history of ulcer disease.
The proponents would argue that by so doing, the polypill will save lives and cutdown healthcare cost in the long term, of course at the risk of some adverse reactions.
What do you think? Would you take a polypill?
There are more and more of these combo pills coming.


1 comment:

doc said...

What is the difference between taking a 4-in-1 pill and four separate pills other than the psychological impact on patients?

I would opt for flexibility in dosage adjustment accordingly rather than swallowing pills with fixed dosages.

For example, if I were to be served coffee from a good restaurant, I like my coffee, sugar and milk separated instead of them serving me 3-in-1s. I prefer to tailor my coffee to my taste instead of them dictating how much sugar I can have in my coffee.