Blog entry by Meguid El Nahas
Blog By Dr Sherif AlHammady (Edited by Prof El Nahas)
My advice to you if you are optimistic about the era of guidelines is to read the BMJ article:
WHY WE CAN NOT TRUST CLINICAL GUIDELINES?
The BMJ in a series of article on Guidelines, and their value as well as issues with transparency and conflict of interest, highlights the ways the pharmaceutical industry influence the thrust of many guidelines. It often starts with the selection of panellists on guidelines committees; the overwhelming majority of committee chairs and co-chairs have ties to industry, and selection of panellists with industry-friendly viewpoints can make a desire outcome a foregone conclusion. Committee stacking may be one of the most powerful and important tools to achieve a desired outcome. Although guidelines are usually issued by large panels of key opinion leaders (KOL), the BMJ articles highlight to their careful selection by the industry as well as the choice of single issue fanatics (SIF) who are uncritically wedded to a dogma to which they steer the guidelines panels towards. A recent survey found that 71% of chairs of clinical policy committees and 90.5% of co-chairs had financial conflicts (2).
Take the LIPIDFS GUIDELINES as an example:
(a) In 2004, cholesterol guidelines greatly expanded the number of people for whom treatment is recommended. A firestorm broke out when it was learnt that all but one of the guideline authors had ties to the manufacturers of cholesterol lowering drugs (4).
(b) In 2013, the situation doesn't seem much better, as the new lipids guidelines released by the American College of Cardiology–American Heart Association (ACC-AHA) Task Force on Practice Guidelines seem to lower the threshold for prescribing statins based on an unvalidated cardiovascular scoring system.
(c) In 2013, KDIGO also seem equally indiscriminate as to who should receive statins amongst CKD patients…it seems as if statins for all is the flavour of our times…although evidence is seriously lacking…this is often acknowledged by the guidelines themselves awarding 1C or even 2C (NO EVIDENCE) to some of their recommendations; but all too often unaware physicians take the guidelines at face values and don't seem too concerned about their level of validity or utility…
IF WE SEE HOW GUIDELINES PANELISTS AND CHAIRS ARE CHOSEN…
IF WE SEE HOW KOL ARE GROOMED…
IF WE SEE HOW THE GUIDELINES PROCESS IS MANAGED…
IF WE SEE HOW NEGATIVE TRIALS ARE RE-ANALYSED AND POSTHOC AS WELL AS SUBGROUP DARTED PROMOTED BY KOL AND INDUSTRY AS FACTS... http://www.ncbi.nlm.nih.gov/pubmed/24038560
IF WE SEE HOW NEW THRESHOLDS ARE RE-DEFINED FOR TREATING MORE PATIENTS...
IF WE SEE HOW NORMALITY IS SLOWLY CONSIDERED A DISEASE...WITH LOWER THRESHOLDS...FOR PRE-DIABETES, PRE-HYPERTENSION, PRE-CKD, ETC...ALL AIMED TO MEDICALISE NORMALITY AND AGE RELATED INCREASED FASTING BLOOD SUGAR, BLOOD PRESSURE AND FALLING GFR...AND TREATING MORE PATIENTS...
AFTER ALL THAT HOW COULD I TRUST GUIDELINES?!
1-Jeanne Lenzer, medical investigative journalist Why we can’t trust clinical guidelines
BMJ 2013; 346 doi: dx.doi.org/10.1136/bmj.f3830 (Published 14 June 2013) Cite this as: BMJ 2013;346:f3830
2- Kung J. Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med2012;172:1628-33.
3-Lenzer J, Epstein K. The Yaz men. Washington Monthly2012 Jan 9. www.washingtonmonthly.com/ten-miles-squa...of_fda_pan034651.php
4-Abramson JE, Barnard RJ, Barry HC, Bezruchka S, Brody H, Brown DL, et al. E.petition
to the National Institutes of Health seeking and independent review panel to re-evaluate
the national cholesterol education project guidelines. 2004. cspinet.org/new/pdf/
finalnihltr.pdf. Cite this as: BMJ 2013;346:f3830© BMJ Publishing Group Ltd 2013