Vaccine Fears: What is the Pharmacist’s Role?

Anti-vaccination rally at Toronto City Hall, 1920

It’s Pharmacy Awareness Week. You’re probably not aware of this, neatly illustrating  the challenge pharmacists have in raising their professional profile with the public. Despite what you may read here in this blog (written by me), pharmacists do a lot more than sell unproven supplements. Beyond their important role in ensuring safe and effective prescription drug therapy, pharmacists are gaining expanded professional responsibilities.  Some jurisdictions are allowing pharmacists limited prescribing privileges, and the right to modify prescription therapy without the need to consult a physician. But it’s the right to administer vaccines that is among the most interesting new acts being given to to pharmacists. And it makes sense. Pharmacists are the most accessible health professionals, and are well positioned to support vaccination programs. And vaccination programs need support.

British MPs Tell Gov’t: Stop Funding Homeopathy

In a clear statement on the absurdity of public funding and regulation of homeopathy, British MPs instructed government to stop paying for homeopathy, shut down homeopathic hospitals, cease all homeopathy clinical trials, and to crack down on homeopathic efficacy claims.

Committee chairman Phil Willis MP said; “We were seeking to determine whether the Government’s policies on homeopathy are evidence based on current evidence. They are not.”

Homeopathy doesn’t work. It can’t work. If it did, physics, biochemistry and pharmacology as pharmacists know it would be false. Yet this elaborate placebo system persists, supported in part by the pharmacy profession, which seems comfortable selling products with no active ingredients and no evidence of efficacy.

I have blogged previously about the British inquiry into homeopathy, the public relations disaster for Boots the Chemist (selling their own store brand of homeopathy), and the effectiveness of the “10-23″ protesters, who staged a mass homeopathic overdose, where, not surprisingly, nothing untoward happened to anyone.

The final report from the British inquiry has been released. It scrutinized government policies on homeopathy, and gives direction to the National Health Service.  But the recommendations apply to any country (like Canada) that legitimizes homeopathy.

Does Coenzyme Q10 Relieve Statin-Induced Muscle Pain?

Editor’s Note:

Today’s guest post is from a pharmacist who blogs under the pseudonym Avicenna, who looks at the evidence supporting the use of Coenzyme Q10 to treat statin-related muscle pain.

My pharmacy stocks plenty of natural health products (NHPs) and ensuring they can be used safely is challenging, given the limited information available on safety, quality, purity, and efficacy. Answering patient questions is always interesting and often very challenging, as they can often be non-specific. A typical question like “Is product ‘X’ good for treating condition ‘Y’?” can be difficult to answer without gathering some further information.  My usual response is, “Let’s talk about this. I want to make sure I give you an answer that is right for you, given your medical conditions.”

I recently spoke with a patient taking atorvastatin (Lipitor), a cholesterol-lowering medication from the “statin” family, who was complaining about muscle pain, and asking about Coenzyme Q10 (CoQ10) for treating that pain. Treating or preventing statin-related muscle pain is a common question, given the popularity of statins and the frequency of the complaint: About 1 in 15 develop this symptom. Before diving into the efficacy of CoQ10, let’s review statins.

Statin Benefits

If you have high blood pressure, are overweight, diabetic, or sedentary, you should know your cholesterol levels: Keeping them in the normal range will lower your death risk in the short and long term.[1] If you need drug therapy to reduce your cholesterol levels, you’re probably on a statin. Statins are a class of highly effective cholesterol-lowering drugs that work to inhibit HMG-CoA [3-hydroxy-3-methyl-glutaryl-CoA] reductase. Statins work by lowering cholesterol points (e.g., low-density lipoprotein (LDL), triglycerides) and/or moderately increasing good cholesterol (i.e., high density lipoprotein (HDL)). High levels of “bad” cholesterol is a contributor to heart disease and other negative cardivascular outcomes. It clogs the arteries that feed oxygen to the heart, and is involved in the process of blood clot formation.

Part Fills for February 12

In pharmacy-speak, “part fills” allow a pharmacist to divide a prescription into smaller amounts. In the case of Science-Based Pharmacy, I’m going to use the label to highlight hot topics, related reading, and relevant material on other blogs. I hope you find these links informative:

Homeopathy: After the 10-23 protests that I’ve already blogged about, the pressure on pharmacies to stop selling homeopathy continues to intensify. Complaints have been lodged with Britain’s national health regulator about references to homeopathy on the Boots pharmacy website. Meanwhile, the UK pharmacy regulator hides behind the fact that homeopathy is federally approved to justify the ongoing sale. And from New Zealand, they’re asking What are homeopathy remedies doing in New Zealand pharmacies? As a compromise, the Quackometer proposes a possible labelling system for homeopathic remedies in pharmacies.  The pressure on pharmacies is not going to let up. It’s increasingly clear that 2010 will be the year that pharmacies worldwide will have to justify why they profit from ‘remedies” with no evidence of efficacy and no active ingredients.

Vaccines: Following findings that Andrew Wakefield’s actions were “irresponsible and dishonest,” the Lancet has now fully retracted the paper that set off the “vaccines cause autism” manufactrovery, drove vaccination rates down, and made measles an endemic infection again in the United Kingdom. Dr. Steven Novella sums up the debacle at Science-Based Medicine, and Anthony Cox gives a UK pharmacist’s perspective at Black Triangle.  Liz Ditz has a complete compilation of articles, from those applauding the retraction, to the antivaccinationists that consider Wakefield a martyr.

For more about Andrew Wakefield, listen to Skeptically Speaking next Friday, February 19, where I’ll be joining Dr. Chris MacDonald and Dr. Nancy Walton with host Desiree Schell as we discuss the ethics, controversy, and public health consequences of the Wakefield paper.

Natural Health Products: In January, I blogged that the Ontario College of Pharmacists has ordered unapproved natural health products off pharmacy shelves. To my dismay, pharmacists and pharmacies seem to be taking this directive lightly – some are calling it a “suggestion” and refusing to pull products.  It’s an embarrassment to the profession: putting profits before patients. The directive caught the National Post’s attention recently with an article by Tom Blackwell.  The comments are worth reading, for a mix of Big Pharma conspiracies, complaints about a nanny state (hint: you can still buy unapproved products elsewhere), and cries for “health freedom” (freedom to sell unapproved products, it seems).

Vitamins: With a handful of exceptions, vitamin supplements are unnecessary and offer no meaningful health benefits. This quick overview by Get Better Health explains. Look for some in depth reviews over the next few months on this blog.

Understanding Evidence: Tips for Understanding Drug Studies: Association versus causation. An excellent article the explains why, in an observational study, you cannot draw a link between cause and effect. This a very common mistake in the media, and this article explains how to look for it and what to do about it.

Skeptic North: If you’re not following the Skeptic North blog, check out these excellent posts: The Naturopath Identity Crisis, Picking Apart Raw Food, the 10-23 Homeopathy Protests, and the pH Balancing Myth. Also check out my posts, Mass Homeopathic Overdose Kills No-One, Victory Declared, and When it Comes to Libel Chill, it’s Good to be a Canadian.

Neti Pots for Sinus Congestion: Validated science?

Neti pots have moved from the fringe to the mainstream over the past few years. Traditionally used to treat sinus problems, their popularity exploded in 2007 when Oprah covered them on her show. Requests flooded the pharmacy I worked at. The pharmacy’s owner ordered in a case, and they  disappeared in days. Given Oprah’s poor record at identifying credible sources of medical information, I was skeptical. But given the limited efficacy of drugs for congestion, physical removal with water seemed reasonable, whether with a neti pot, or simply snorting water out of the sink. It was clear to me that uncontrolled sinus congestion problems were not rare, because pouring a cupful of water into your nostril isn’t something one will do on a whim.

Pharmacies Targeted in Mass Homeopathy Overdose

Hundreds of protesters will gather outside Boots pharmacies on January 30 to swallow entire bottles of  homeopathic remedies and embarrass a profession that sells them in the absence of any evidence of efficacy.

A few weeks ago, I blogged about the 10:23 protest which was gathering momentum in the United Kingdom. Recall that in late 2009, a senior executive from Alliance Boots, a UK pharmacy chain, admitted that there is no clinical evidence to support homeopathic products, yet Boots sells these products strictly because of consumer demand.

Homeopathy is an elaborate placebo system of “remedies” with no active ingredients.  Based on the absurd notion of “like cures like”, proponents of homeopathy believe that any substance can be an effective remedy if it’s diluted enough: raccoon fur, the sunlight reflecting off Saturn, even pieces of the Berlin Wall are all part of the homeopathic pharmacopeia.  And when I say dilute, I mean dilute. The 30C “potency” is common – it’s a ratio of 10^-60.  You would have to give two billion doses per second, to six billion people, for 4 billion years, to deliver a single molecule of the original material. That’s dilute.

On Mentors and Memes

As we meander through life, there are inflection points – decisions and events that dramatically affect our future. It may take years to recognize them.  In 1993, I found out I’d been selected for a hospital pharmacy residency at Victoria Hospital in London, Ontario. I didn’t realize it until years later, but this was one of those events. In London, I had the privilege to spend a year learning from Dr. Charles (Charlie) Bayliff, the residency coordinator. I’ve been reflecting on Charlie’s impact on my life over the past few days. On Sunday evening, Charlie passed away after a battle with cancer.  I’m proud to call Charlie a mentor and a huge influence on my career, and philosophy towards pharmacy practice.

Unapproved Natural Health Products Banned from Ontario Pharmacies

In a stunning move, the Ontario College of Pharmacists has prohibited Ontario pharmacies from selling health products that are not approved for safety and efficacy by Health Canada. This directive, which takes effect immediately, banishes some of the most questionable “alternative” health products from pharmacy shelves. This message was sent to all pharmacies and pharmacists on January 20, 2010:

New UK Campaign: “Homeopathy: There’s nothing in it”

http://www.1023.org.uk/

A few weeks ago I blogged about some very public criticism of pharmacy practice in the United Kingdom. I noted that pharmacies were being publicly criticized for selling homeopathy, and this was causing a public relations disaster for Boots, one of the UK’s leading pharmacy chains, and a proud vendor of homeopathy.  The mockery of Boots has continued. And there’s now a new public campaign to raise awareness of the fact that homeopathy is an elaborate placebo system, and has no place in pharmacies.

Cleverly (but somewhat confusingly) called “10:23″  (Remember what that number means?) the campaign has the following goals:

The 10:23 campaign aims to raise awareness of the reality of homeopathy – how it can be proven not to work, how it can be shown to be impossible, and why it’s important to give patients the right information to allow them to make an informed decision on their healthcare.

The campaign starts in a few weeks – and they’ve already posted their open letter to Boots - here’s an excerpt:

We call upon Boots to withdraw all homeopathic products from your shelves. You should not be involved in the sale of ineffective products, because your customers trust you to do what is right for their health. Surely you agree that your commitment to excellent patient care is better served by supplying only those products whose claims can be substantiated by rigorous scientific research? Or do you really believe that Boots should be in the business of selling placebos to the sick and the injured?

The support lent by Boots to this quack therapy contributes directly to its acceptance as a valid medical treatment by the British public, acceptance it does not warrant and support it does not deserve. Please do the right thing, and remove this bogus therapy from your shelves.

If you’re interested in the campaign, you can sign up and find out more.  And follow the chatter on Twitter.  I suspect the PR problems for homeopathy-selling pharmacies may be just beginning.

Forget to take your Ginkgo biloba? Turns out, it doesn’t matter

Among the natural products on pharmacy shelves, I was rooting for Ginkgo biloba for the prevention of dementia. For one, dementia is a horrible illness. Secondly, currently available drugs for Alzheimer’s disease (AD) have little meaningful effect. Thirdly, preliminary data with ginkgo for AD looked encouraging. I recall reading this systematic review back in 2000. One sentence jumped out at me (the bolding is mine):

We conclude that for selegiline, vitamin E, lecithin, linopirdine, and propentofylline the published data do not provide support for efficacy. Based on the evidence we reviewed, it is our conclusion that donepezil, metrifonate and rivastigmine, however, all provide statistically significant modest benefit on cognitive performance and global functioning to the elderly with probable AD who are eligible for inclusion in clinical trials. The magnitude of the effect is similar for all of the medications. The results from the trials of ginkgo biloba are promising but the effects are smaller than those from the above mentioned therapies.

So the effect, while weak, was just about as bad as the prescription alternatives. For a “natural” remedy, that’s pretty good. But as with most small clinical trials, what appears to be clinically and statistically significant usually disappears when larger, more rigorous trials are conducted. And that seems to be the case now, with a publication in the December 23, 2009 issue of the Journal of the American Medical Association. But before we dive into the trial, let’s look at why ginkgo is even being studied at all.