Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 23 November 2005

HOW SOON DO YOU BENEFIT FROM A MEDICINE?

            In today’s world, the public is deluged with advertisements and information regarding medicines.  Some of the information is “evidence-based”.  This means that the medication has been tried on a group of people with a common problem such as high blood pressure.  In another group of people with the same kind of high blood pressure, they are not treated with the medication.  The question asked is whether or not the medication makes a difference in the person’s blood pressure.  If the medication does make a difference, how soon does it work?  When can one expect to reap the benefits of taking the given medication for a given purpose?  This question comes up very frequently.

            If a specific medication is being taken to prevent something from happening, how will you know that it worked?  In other words, “How will you know what never happened to you?”  The second question raised is, “If something doesn’t happen to you, how will you know that the medicine you took prevented it?”  The answer to both of those questions has to do with statistics in a branch of medicine called epidemiology.  Using these tools, the healthcare profession can segregate one group of people who appear to have a common problem. When they are then treated in some particular way and another similar group is not treated that way, differences in the two groups will or will not emerge.  As an example, if a hundred people in a thousand of a certain group get a certain disease such as heart attacks, and a treated group only got 50 heart attacks in the same length of time, one would say that the drug cut the rate of heart attack in half.  But for the fifty people in the treated group that had a heart attack, there was no benefit at all and they are asking why did I take this drug?  The answer is medications of this sort are used to put you into a statistically more advantageous group but for any one person in that group, the drug may not work.

            Lastly, one must be very careful about attributing benefit to a given treatment.  “Snake oil” salesmen are out there touting the benefits of all kinds of treatments.  Never was the warning “let the buyer beware” more applicable.

            As a ridiculous little example, I was once told the story about a man who got on the bus every day riding to work.  He would buy a newspaper, tear it up in little tiny pieces and throw it out the window.  He had done this for several months and a lady sitting near him each day had observed him doing this.  Finally, she could stand it no longer.  She asked him what he was doing and why?  He explained that he tore up the newspaper and threw it out of the window to keep the wild elephants off the streets on the way to work.  The lady gasped and blurted out that there are no wild elephants for 10,000 miles from here.  To which the man replied, “This is doing a really good job, don’t you think?”  Many of the treatments in our society today are no better based than this man’s story.

            With the above warnings, below are listed a number of our common medications and what we can expect from their use:

            1.  The statin drugs (Zocor, Mevacor, Pravachol, Lescol, Lipitor, Crestor) to prevent heart attacks and strokes.  In evidence based trials, these drugs have now been shown to prevent recurrent heart attack as soon as one month after the person has had a heart attack.  By the end of two years of use of these medications, there is a clear separation in the rate of heart attack and stroke in the group using these medications.  This family of medications appears to be one of the most beneficial in our society today.

            2.  Blood pressure pills.  Depending upon how high the person’s blood pressure is, the benefit of these medications can be evident within a week.  For individuals with very high blood pressure, the relief of heart failure comes very quickly.  The prevention of heart attack and stroke is evident within two years of starting these medications.

            3.  Diabetes medications.  The most effective treatment for diabetes is clearly lifestyle change.  But from a practical standpoint, this is the least likely treatment to be instituted by people who have diabetes.  Medications such as Metformin, Avandia, or Actos have benefits that are evident by the second year.  The use of insulin does lower blood sugars and by projection thereby saves lives.  But it is very hard to show that insulin treated groups do much better than those who do not use insulin.

            4.  Proton pump inhibitors (Nexium, Prevacid, Protonix, Prilosec OTC, Aciphex).  These are drugs that stop the production of stomach acid and treat heartburn and ulcers.  The benefit from these medications is almost immediate.  Within one to two days, the patient states these drugs really work.  The acid in the stomach is shut off enough so that the burning effect of the acid on an ulcer stops.  The time to benefit here is very fast.  Unfortunately, most of these medications are very expensive.

            5.  The Bisphosphonates (Fosamax, Actonel, Boniva).  These are drugs that are used to prevent osteoporosis.  The rate of hip fracture is decreased by six months after starting these drugs.  The long term benefit seems to get better and better with time.  The best effect of these medications comes from starting them before the osteoporosis occurs.  Many times, the drugs are started in people that already have serious osteoporosis and benefits may not be as great.

            6.  Bladder control medications.  For women, the most common bladder problem is leaking.  For men, the most common bladder problem is urinary retention and difficulty starting their stream. There are two different families of medications to help with this.  One family of medications (Ditropan, Detrol, Enablex, Vasicor, Oxytrol patches) prevents a lady or a man from leaking urine.  The benefits are almost immediate within a few days of starting the medication.  For men, there are series of medications (Hytrin, Cardura, Avodart, Flomax) that relax the opening of the bladder and allow a man to pass his urine more easily.  The benefits from these medications are almost immediate within several days.

            7.  Antibiotics.  The use of antibiotics is so diverse that it is difficult to state a time to benefit.  In cases of pneumonia, fevers will usually break within 24-36 hours.  In the case of sinusitis, and bronchitis, benefit may not come for several days.  If the person takes an antibiotic and continues to smoke cigarettes benefits are not really expected.  The raw surface of the bronchial tree gets no benefit from corrosive chemicals that are present in cigarette smoke.  Taking an antibiotic is really of little benefit in smokers.

            8. Estrogen replacement therapy.  It was originally thought that Estrogen replacement therapy prevented heart attacks and strokes.  That is subsequently shown not to be true.  It is however, also true that estrogen replacement therapy does not cause strokes.  Rather it simply does not prevent them as originally thought.  The only real benefit of estrogen replacement therapy at this time is prevention of osteoporosis and prevention of postmenopausal symptoms.  Prevention of postmenopausal symptoms will begin within the month of the time the lady starts to use the drug.  Controversy regarding the side effects of estrogen replacement therapy has clouded the use of this medication although I personally am not impressed that estrogen is such a dangerous product.

            In summary, drugs that treat disease already present may often work very quickly.  Drugs that prevent disease are more expensive, take longer to show a benefit, and leave the person with an empty feeling of not knowing what they never really got.  But please remember, never getting a disease is the best thing that can happen to you.