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New high-tech treatment or proven low-tech therapy?

Chris Cairns,

Healthcare communities around the world are excited about recent and forthcoming “high-tech” medicines – major advances in the treatment of a number of common conditions. Some of these innovations are the result of biotechnological research, while others are the consequence of focusing on recently discovered enzymatic and physiological pathways.

Examples include the use of infliximab and etanercept in the management of severe relapsing rheumatoid arthritis. Infliximab has profound effects for patients with severe inflammatory bowel disease, sparing these patients from high-risk surgery.

In cardiology the glycoprotein IIb/lIIa inhibitors lead to improved outcomes in unstable angina and during revascularisation procedures, such as stenting and angioplasty. Newer thrombolytics have been shown to shave percentage points off mortality following myocardial infarction. Until recently many physicians and pharmacists thought that the place of clopidrogel would be restricted to use in patients who could not tolerate aspirin. The HOPE study has changed that, and we are likely to see large numbers of patients prescribed both.

In cancer we have already seen the difference that taxanes have made, particularly in breast and ovarian cancer. The soon to be licensed Glivec will offer the first effective treatment for many patients with chronic myeloid leukaemia. New improved treatments for solid tumours such as bowel cancer are with us in the form of irinotecan and capecitabine.

However, these new and more effective treatments do not come without a price. By this I don’t just mean financial cost, although they are expensive. Expected adverse effects occur, such as bleeding seen with glycoprotein inhibitors and clopidrogel. Unexpected adverse effects have also emerged. Cases of TB have occurred with the use of the anti- inflammatory agents infliximab and etanercept.

These costs are significant, both in financial and toxicity terms. Drugs and Therapeutics Committees will be ­questioning whether they are worth it. Or can we afford it? Or can we use our limited funds more effectively?

There is no doubt that older, proven and cheaper treatments are not always used to their optimal effect. Is thrombolysis given as quickly as possible? The earlier thrombolysis is administered, the greater the mortality reduction. Can improvements in door-to-needle time achieve greater benefit than the use of glycoprotein inhibitors and/or low- molecular-weight heparins? Is every patient discharged from hospital following an MI prescribed aspirin, a b-blocker and an ACE inhibitor? There is strong evidence to support their use so what mechanisms are in place to ensure they are prescribed? Are these drugs and statins given to all patients with ischaemic heart disease for secondary ­prevention or following a coronary event?

Are patients with rheumatoid arthritis put onto disease- modifying antirheumatic drugs soon after diagnosis if non­steroidals show no benefit? Equally, are ACE inhibitors given to all diabetics with IHD or hypertension? Do physicians prescribe antibiotics for all infections or use nonantibiotic therapy for suspected viral and other infections?

The question “new high-tech treatments or proven low-tech therapy?” is not simple to answer. There is definitely a place for using newer and better treatments. However, it is equally important for older proven therapies to be used to their optimal effect. It is not a case of “out with the old – in with the new” but one of using the most effective remedies appropriately, no matter whether they are old or new.

Chris Cairns, Editor

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