FIRST DO NO HARM

I have come across 2 articles that would exemplify what all of us physicians believe in when we treat patients, be it medications or angioplasty or surgery. Safety is always our first concern.

1. The first article has to do with " Stop smoke" campaign. As we all know, smoking is an important medical risk factor for coronary artery disease, cancer of the lungs, the stomach, and many other ails, so that stopping the cigarettes have become an important strategy for good health. The Malaysian government has also spend millions of dollars on their "Tak Nak" campaign with limited success at best. Anyway, there is this drug out there called Varenicline ( Champix ), which was promoted by the pharma, to help people quit smoking. Of course, I was spoken to, and they came to declare all the good that Champix can do for my cardiac patients who smoke. As always, using first principles, I told them that this drug will do more harm then good, as it works centrally to reduce the desire for nicotine. Using a drug that acts centrally will always either boost or damp a neurological reaction.
The last online issue ( 2nd Nov 2011 ) of PLoS One carries an article by Dr Thomas J Moore of the Institute of Safe medication Practices, Horsham,PA. They have studied 13,000 adverse reactions over 13 years in people who were taking smoking cessation drugs. 90% of those reaction involving self injurious behaviour or depression involved the use of Champix ( varenicline ). This suggest that Champix does have a problem with abnormal CNS behaviour including depressions and suicides, an issue I highlighted to them when they came to promote this smoking cessation drug. No, this is not an attempt to say, "I told you so". This posting is to say that we should use champix very selectively and only in those patients whom you can monitor well, and who have no pre-morbid personality, that would make them more prone to depression and suicides. But there again, which patient, addicted to smoking, does not have such a pre-morbid personality. I would certainly not wish to fly in an airplane pilotted by a pilot on Champix to stop smoke.

2. The second article is on a more cheery note. I see more and more articles on Pharmacogenomics ( the genomics to predict the persons response to drugs and medications. Dr Dan Roden and his colleagues from the Vanderbilt University Medical Center, are enrolling patients who consent, to do genetic studies on them, to find the genetic variants that will make them more prone to drug sides effects. In this study, they were studying the two variants of gene SLCO1B1, which will make the carriers of these gene variants more prone to drug drug interactions, especially with the use of warfarin, clopidogrel, and also myopathy with the use of simvastatin. This study is aptly called the PREDICT study. They aim to enrol 10,000 patients who may be taking these drugs to identify those with these gene variants and try and predict the possibility of the side effects. So far, they have been successful with predicting myopathy with the use of simvastatin.
This study is important to allow us to target patients who may best respond to certain tretament or who my not respond well to certain treatment. In fact over the last 2 years, we have seen more and more of such studies coming out. It is certainly a step in the right direction. maybe we should call it pharmacogenomics for targeted therapy. I would also like to see the accuracy. We should not simply assume that all genetic studies must necessarily be accurate and so true. I am sure that with commercialisation, we will begin to see a spread of results, giving us levels of predictability and accuracy.
As usual, the final question is cost? How much will these targeted therapy cost?
But it is a step in the direction of " First do no harm".