Top Left then Clockwise: Kate and Cyril; Kate and Perveen; All the team; Kate and Richard

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Kate interviews Jaggy

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Do you remember the Aesop’s Fable about the Fox and the Grapes?

A FAMISHED FOX saw some clusters of ripe black grapes hanging from a trellised vine. She resorted to all her tricks to get at them, but wearied herself in vain, for she could not reach them. At last she turned away, hiding her disappointment and saying: “The Grapes are sour, and not ripe as I thought.” (1)

The above is a fable about persistence. Might the outcome have been different if the Fox has been more persistent? One would never know. See how easy it was for the Fox to despise what seemed unattainable.

..

You may wonder where I am going with this but bear with me. A number of things happened in the last few weeks that makes me ask the question: Why would you not want to know? Why would you not want to know why all of a sudden you feel lousy?…Why all of a sudden you feel tired all the time?…Why all of a sudden you simply stop feeling ‘right’? Something is wrong but you are reluctant to investigate what it is. In my experience, I am unaware of any serious medical condition that would not benefit from early diagnosis. Well, don’t trust my experience; let us examine the facts together. Table 1 is a pool of the effect of early diagnosis on some medical conditions:

Table 1 - Effect of Early Diagnosis

These are just some examples and there are lots more. The prognosis (positive or negative) of any one disease can only be made after diagnosis. Armed with such fact, why might you not want to know if something is wrong? Any of the following could perhaps be possible reasons?

• The fear of the worst case scenario. Because you fear the worst, you might not want to know. I will say this: if you already have the worst case scenario, you have just raised the stakes without adequate treatment or intervention. If you take the example of prostate cancer, then you are denying yourself the chance of a near 100% cure by not acting soon.
• You are not insured. If you are in a society where you have to pay for healthcare and you are not insured (or cannot pay), then you might be at a loose end and might feel the best option is to not know since you will be in no position to deal with the financial consequence of knowing. I will advise you to carefully consider your options before making such a drastic decision. Helps are sometimes available from unlikely sources. Now let’s say you live in the UK, with the NHS and its characteristic free access to urgent medical treatment. Why would you still not want to know?!
• You knew someone who wanted to know but ‘what good it did him! He was dead before you could say fetch!’ You need to understand that people are different and diseases may affect people differently. What makes you think you have the same condition anyway? You are better off knowing, even if you are likely to die before you could say fetch! I bet you wouldn’t.

Now to my main point: If you consider all the really serious conditions, the early signs and symptoms may appear innocuous. Take Multiple Sclerosis, a common neurological condition affecting 1 person in 600 in the UK. One of the common non-specific symptom is fatigue ‘…associated with specific neurological symptoms, fluctuates with heat, exercise or as the day proceeds, and is alleviated by short period of rest’ (6). Now will you associate this symptom with MS straight away? No one can. Diagnosing these conditions can be a challenge in itself. Not everyone with fatigue will have MS! However, if after all explanation are exhausted and you still feel unwell, then you must not be the Fox in Aesop’s fable. Keep going back for further investigation and you may even buy yourself valuable time.

Have a merry Christmas and a Happy New year.

(1 votes, average: 4 out of 5)

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Reference

1. http://www.aesopfables.com/cgi/aesop1.cgi?2&TheFoxandtheGrapes

2. ME Diagnosis: Delay Harms Health; Early diagnosis: why is it so important? A report from the ME Alliance; http://www.afme.org.uk/res/img/resources/ME%20Diagnosis%20Report%20master.pdf

3. Early Diagnosis of Alzheimer’s Disease: Clinical and Economic Benefits; Bennett P. Leifer, MD; J Am Geriatr Soc 51:S281–S288, 2003; http://www.blackwell-synergy.com/doi/abs/10.1046/j.1532-5415.5153.x

4. New Perspectives in Multiple Sclerosis: An Expert Interview With Mark S. Freedman, HBSc, MSc, MD
http://www.medscape.com/viewarticle/546714

5. http://www.articlehere.com/Article/Prostate-Cancer-Symptoms—Benefits-of-Early-Diagnosis/14242

6. Making the diagnosis of Multiple Sclerosis: J Palace: J. Neurol. Neurosurg. Psychiatry 2001;71;3-8, doi:10.1136/jnnp.71.suppl_2.ii3
http://jnnp.bmj.com/cgi/reprint/71/suppl_2/ii3.pdf

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Districts:

1. Exeter
2. East Devon
3. Mid Devon
4. North Devon
5. Torridge
6. West Devon
7. South Hams
8. Teignbridge
9. Plymouth (Unitary)
10. Torbay (Unitary)

image courtesy of Keith Edkins

Devon County Council

Devon is the third largest of the English counties. The county town is the cathedral city of Exeter. Discover Devon (URL: http://www.discoverdevon.com) is the website to visit for information on where to stay, things to do and areas to visit.

As part of our project strategy, we will find a day to pay a visit to Devon and identify which charity, the devon project will support. We will make sure we pay the Dartmoor National Park a visit.
The moor, as is commonly called, has a number of qualities which include remarkable landscape, heather-covered moorland and deep wooded gorges, beautiful lake-like reservoirs and tumbling rocky rivers, thriving market towns and villages, patchwork farmland and craggy granite tors. Dartmoor National Park is the largest, and wildest, area of open country in southern England.

(1 votes, average: 3 out of 5)

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In this podcast, Kate describes the background to the project. As we move closer to the launch of the BETA version of the project, we will use a series of 3 podcasts to describe what has been happening with the project.

…and finally, Kate will discuss an item on our webBlog. The article was entitled: Why withdraw Exubera? and was written by Kazeem in October 2007.

go to: http://www.iforg.com/podcast.asp

REFERENCES:

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I hope we do more than this though!

courtesy of nousernamesarefree channel

- Kazeem

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We also describe here the structure of our monthly podcasts so that you can find items more readily.

..and finally we discuss an item on our blog: The power of observation – the pill counter example, published in March 2007.

Kate Penhaligon-Project Facilitator and Podcaster General!

http://www.iforg.com/podcast.asp

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As part of this process, we have decided to take down the site [www.healthcare-events.info] until we launch the new site.

We apologize to our users for any inconveniences. This is a necessary upgrade to add more functionality to this site. We aim to complete this project in 3 months.

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Pfizer has decided to withdraw its novel inhaled insulin, Exubera..not because of safety problems…not beacuse of negative response from patients but because ‘too few patients are taking EXUBERA’ (1)

How could this be? Diabetic patients have been crying for a less painful way of administering insulin for years..Here is a product that requires no injection but prescibers are not using it.

Low take up should have been anticipated

If you examine the datasheet for this product closely you will find that there are specific reasons why the low take up of this product is not surprising. I have identified these below:

The prescriber will always play safe

Diabetes mellitus occurs because of a lack of insulin or resistance to its action. The decision to put someone on insulin is generally the last resort for type 2 patients and the mainstay for type 1 patients. The effect of inappropriate control of blood sugar can result in serious consequences for the patient - retinopathy, neuropathy and nephropathy to mention a few.

Let us forget about the evidence for one moment (these are undoubtably important). Exubera is inhaled - yes. Another class of drug which are administered by inhalation are drugs for relieving asthma and other respiratory conditions. The evidence here for the appropriate use of inhaled medication is not good. It has been suggested that one of the reasons for poor asthma control is the inappropriate use of the devices. The prescriber has this at the back of his mind.

Diabetes is a strong risk factor for cardiovascular disease. A significant proportion of patients presenting with Diabetes (especially type 2 ) probably have other risk factors such as smoking, hypertension and obesity. Well you can’t use Exubera if ‘You smoke, start smoking, or if you quit smoking less than 6 months ago; You have an unstable or poorly controlled lung disease (such as unstable or poorly controlled asthma, chronic obstructive pulmonary disease, or emphysema)’ (1)

That rules out a lot of candidates then.

When you put all of these in the pot…the patient is either excluded or the prescribers will stick to tried and tested interventions.

Getting the pricing right

If Pfizer accepts that this is not going to be a drug for everyone, it must price the product appropriately. Less volume, more expensive drug. With tight squeeze on NHS drug budgets, it will be difficult, if not impossible, to allow an expensive inhaled insulin to be freely prescribeable. PCT will watch the pattern of prescibing this drug like a hawk (well…understandably!). In actual fact, I feel Exubera is reasonably priced considering the time and costs of developing this delivery system (table 1):

Undoubtedly, this drug will not be for everyone. It will only be suitable for a niche patient group. Hence Pfizer pricing model should have reflected this. I don’t have the facts but I suspect, Pfizer was less conservative with its estimations of target patients (why else will there be a need to withdraw the product now?). Should the price have been set higher, with the proviso to reduce price or even refund some cash to the NHS if take up of drug prove to be higher?

General Practitioners want new ways of treating conditions which will bring benefits to the patients and I suspect they will actively look for patients who will benefit from the use of a particular new drug.

My Concern

You lure patients into the promise of a novel intervention and then have to withdraw it because not enough people has taken it up! What happens to the patients already stabilised on this therapy? I am sure we all agree that this is a useful drug…why not give it a chance.

My challenge to pharmaceutical companies is this…when pricing a new drug, be realistic about the potential take-up of the product and price the products appropriately. This threat of withdrawal or intention to withdraw is no good to anyone.

(2 votes, average: 4.5 out of 5)

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