Re: serious question


Jason Johnson wrote:

I copied this sentence from the Hippocratic Oath:
"...I will keep [my patients] from harm..."

Doctor X prescribes statins to a patient.
During the following year, Doctor X does not conduct
any blood tests or urine tests to screen for signs
of Rhabdomyolysis which can cause kidney failure. It is
known that statins can cause Rhabdomyolysis.
The patient develops Rhabdomyolysis and loses the use
of his kidneys and has joint pain and muscle pain
for the rest of his life.
Please answer the following questions:

Did Doctor X keep his patient from harm?

Did Doctor X violate the Hippocratic Oath?

Do you believe that doctors that prescribe statins
should or should not screen them for signs of
Rhabdomyolysis?

Before you respond, I suggest that you read this two
page report related to Rhabdomyolysis:

http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm


(Disclaimer: Before reading this, bear in mind that I am not a doctor,
and I'm only drawing conclusions from Google searches and personal
experience)

Jason,

When did patient "Y" begin taking the statin, and for how long did he
take it? Did he notice any side-effects or report them to the doctor?

Here is a snippet on statins and rhabdomyolosis from Harvard Health
Publications:

http://www.health.harvard.edu/newsweek/The_Healthy_Heart_Preventing_detecting_and_treating_coronary_artery_disease.htm

Severe muscle damage - a condition known as rhabdomyolysis, which can
be deadly unless treated - affects about 8 of every 10,000 people
taking a statin. One popular statin, cerivastatin (Baycol), was
voluntarily removed from the market in 2001 because it was associated
with rhabdomyolysis. Crestor came under fire in 2004 when critics
charged that it was more likely than other statins to cause
rhabdomyolysis and kidney failure. After reviewing the data, however,
the FDA issued a public advisory concluding that Crestor was as safe as
the other statins in most cases, but warning that to reduce risk, the
lowest doses should be prescribed in people older than 65, those who
have hypothyroidism or kidney disease, and Asian Americans.

I have found articles that advise LFTs before beginning statins and at
12 weeks following the start of treatment, because apparently the risk
of liver damage is about 1 in 100.

So far, I haven't found any specific recommendations for routine
testing for Rhabdomyolosis, perhaps because the published incidence of
it is low.

Dr. X should have informed patient Y of all the potential side-effects
of the medication he prescribed, and should have alerted the patient as
to what symptoms to look out for, especially for more serious
complications. In my experience, doctors often prescribe medication
without discussing potential side-effects or drug-drug interactions. I
think this is careless and foolish, but I also think doctors may be
lulled into a sense of false security by the results of published
studies (often underwritten by the drug manufacturer) and drug reps'
assurances that the incidence of serious side-effects is rare.

Imo, a large part of the blame rests on the shoulders of the
pharmaceutical companies, which tend to draw broad conclusions from
very small study samples, and which have been known to suppress data
suggesting lack of efficacy at the least (and perhaps serious
side-effect; who knows?).

I think another issue is that the FDA often approves meds on the basis
of short-term clinical trials, whereas some of a medication's
side-effects only become evident after long-term use. In a way, that
makes the general public unwitting participants in a medication's
advanced clinical trials.

My personal experience with this involved taking Seroquel, one of the
new atypical antipsychotics that is also used as a mood stabilizer for
bipolar disorder. My doctor chose this particular med because published
studies had shown good efficacy with a low incidence of weight gain. I
took the med for 3 years and gained 60-70 pounds while on it. Then the
medical community discovered that, not only does this entire class of
drugs cause weight gain, but it also increases the potential for
developing type 2 diabetes. Doctors were unaware of this this when the
atypicals were first used; they actually appeared to be a miracle drug,
and in some ways they were.

So now I'm off Seroquel and losing weight rapidly, and we'll see about
the diabetes sometime this month (it runs in my family--almost
*everyone* on my father's side of the family develops it). I don't
blame my doctor for this outcome; I believe he was acting in good faith
based on the information available to him at the time the med was
prescribed.

Another example: A friend of mine was on long-term steroid treatment
for chronic sinus disease. She also has munchausen syndrome and/or
factitious disorder, and tends to complicate treatment by doctor
shopping and claiming to have unusual symptoms that are then treated
with various meds. Last time she visited me, she brought TWO large zip
lock bags full of medication, which included three different inhalers
for alleged asthma, prednisone, psychiatric drugs, antibiotics, and who
knows what else. Eventually, she developed avascular necrosis of both
hips and needed hip replacement surgery. She blames this on the ENT who
prescribed the steroids because she feels he should have told her this
was a potential consequence of extended steroid use. It's not clear
whether he would have made different clinical decisions had he known
all the other meds she was taking, or whether these meds contributed to
the problem.

I guess the point of this meandering post is that there is no simple
answer to your question about Dr. "X" violating his Hypocratic oath. If
he prescribed the statin in good faith, had never been advised to
routinely test for rhabdomyolosis, and had no clinical experience of
any patient developing it, there was no intent to do harm. The intent
was, rather, to prevent harm to the cardiovascular system by lowering
cholesterol. That harm occurred is unfortunate, particularly if it
could have been avoided with simple tests, but if the doctor didn't
know the tests were needed, his failure to act is blameless.

My opinion is No, he didn't violate his Hypocratic oath.

.

Relevant Pages

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  • Re: serious question
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  • Re: serious question
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