Can pranayama help set the right lung diseases

Cochrane
Germany

Too much medicine can make you sick - making good decisions together against overdiagnosis

Questioning the familiar is often not easy, especially in medicine. Steep hierarchies, lack of time and lack of information often prevent lasting changes. However, studies show that they are urgently needed. A lot is done in Austria's health care facilities, which is unnecessary at best, and to the disadvantage of patients in the worst case. And last but not least, our health system is financially burdened. Using evidence-based methods and in a language that laypeople understand, the team of the initiative “Decide well together - Choosing Wisely Austria” provides information about which examinations and treatments do more harm than good.

Does a lot help a lot?

If you are a woman, when was the last time you had a cancer smear for early detection of cervical cancer - also known as a PAP smear - from a gynecologist? It is very likely that it was no more than a year ago. At least that's what the statistics say. However, one test per year is neither necessary nor useful unless you belong to a high-risk group, say specialist societies (1). In 2016, a study attempted to provide an overview of high-risk and cost-intensive examinations and treatments that are carried out unnecessarily frequently. Among other things, the excessive use of the PAP smear in Austria became clear: In 2012 and 2013, a total of 124,582 women had a smear. 83,686 women had two a year, almost 10,000 women even five (1). Inconsistent or incorrect results of this test create fear and, in the worst case, lead to unjustified operations. This makes the PAP smear an excellent example of overdiagnosis and overtreatment.

Unjustified surgical interventions can have even more far-reaching consequences. What has to be, has to be and what has to go has to go - one should think. What is considered necessary depends not only on the state of health, but also to a decisive extent on the place of residence. Using the example of back pain, the Bertelsmann Stiftung published a study in Germany that examined how often patients in which parts of the country end up on the operating table - with one and the same diagnosis. It shows a somewhat unified picture. In some regions the same disease was operated on thirteen times more often than in others (2). Shouldn't there be universal, objective guidelines based on the latest medical knowledge and what is best for patients?

A complex problem

Most of the time they exist and they are not communicated well enough. Sometimes, however, they are formulated vaguely, contradictory or they are missing entirely. Too often, however, the “domestic use” of a hospital or the personal preferences of the doctor also determine the treatment. On closer inspection, however, the problem is even more complex: doctors are often forced to give in to pressure from patients who want certain treatments. One example is antibiotics in the case of influenza infections, which are mostly viral. Unfortunately, the time to explain why these don't work is often missing in everyday clinical practice. And last but not least, the fear of treatment errors on the part of doctors also plays a role.

Out of these problems, the initiative “Make good decisions together - Choosing Wisely Austria” emerged in 2017. In cooperation with Austrian professional societies, the five most important recommendations of the respective subject area are selected by experts. This happens in the democratic Delphi process and is repeated until the five most important recommendations have been agreed. The team of scientists from "Decide well together - Choosing Wisely Austria" then checks these for their reliability and backs them up with facts and figures. This results in clear top 5 lists in the end. These should also be understandable for laypeople and support doctors in informing their patients. The top 5 in geriatrics and the top 5 in general medicine have already been completed and are available as brochures and on the Internet, with other specialties to follow.

The model for “Making good decisions together” is the initiative Choosing Wisely in the USA, which has already inspired 18 other countries to take similar initiatives.

The top 5 lists and more information about the initiative can be found at www.gemeinsam-gut-entscheiden.at.

 

Text: Dr. Jana Meixner


Dr. Jana Meixner is a doctor and medical journalist and works at the Department for Evidence-Based Medicine and Clinical Epidemiology at Danube University Krems in Austria.

 

 

Making good decisions together in Switzerland and Germany

In Switzerland, a sponsoring association "smarter medicine - Choosing Wisely Switzerland" was founded in 2017, with the aim of promoting early treatment planning, interprofessional agreements between medical, therapeutic and nursing care providers and public information in addition to the publication of lists of unnecessary treatments. Several medical societies have already published top 5 lists with useless treatments in their specialist area since the sponsoring association was founded, and more are constantly following. In addition, “smarter medicine - Choosing Wisely Switzerland” launched a broad campaign for patients in October 2018.
Text: Annegret Borchard

In Germany, an ad hoc commission on the subject of “Making Smart Decisions Together” was founded in 2015 by the Working Group of Scientific Medical Societies or AWMF. The working group aims to improve the quality of care through selected recommendations on priority topics and emphasizes, among other things, better decision-making by doctor and patient and joint care across disciplines and occupational groups. For this purpose, it focuses on patients or aspects of care for diseases, and not the specialist areas. The Commission also supports the professionalisation of doctors and the empowerment of patients to better participate in participatory decision-making.
Text: Andrea Puhl

1. Sprenger M, Robausch M, Moser A. Quantifying low-value services by using routine data from Austrian primary care. European Journal of Public Health. 2016; 26 (6): 912-6.
2. Fact check back. Hospital stays due to back pain and surgical interventions: Bertelsmann Foundation; 2017 [117]. Available from: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/VV_FC_Rueckenoperationen_Studie_dt_final.pdf.

Movement exercises prevent falls in the elderly - but does this apply to all types of exercise?

In this blog post, Cochrane Review Group Leader and Review Author Helen Handoll writes on new evidence that exercise can prevent falls in the elderly, and what it could mean for her mother and other elderly people like her.

There are many opportunities for my mother to fall. She has meanwhile also stopped climbing ladders. Otherwise, however, she leads an active life with the determination to remain independent and to live in her own house with a wonderful garden. Every time she falls, it hits me in the heart ...

Each time it falls in a different place and for a different cause. It's also getting harder and harder for them to get back on their feet. Getting up is also problematic, which is why the cell phone my brother insisted on buying has already been used several times. There has been some spectacular bruising, but there have also been more serious injuries. Including a vertebral fracture that was very painful and restrictive for several weeks.

Small part of my mother's garden

My mother is one of the millions of elderly people - including more women than men - who fall every year around the world. The consequences of falls are a significant health problem. In a 2018 World Health Organization (WHO) fact sheet, it is estimated that over 37 million falls in adults and children each year are serious enough to require medical attention. Older people can also fall fatally; far more often, however, they are at least life-changing, in that they lead to greater dependence, self- or imposed restrictions on activities for fear of further falls, and increased frailty and disability. These changes may result in moving to a nursing home, so preventing falls in the elderly is a priority for the public health system and the focus of extensive research.

New evidence for the prevention of falls through physical exercise

A new Cochrane Review (Sherrington 2018) was recently published on the effects of "exercise to prevent falls in the elderly".
The review provides high trustworthiness evidence that well-designed exercise programs can reduce the total number of falls per year (the fall rate) by almost a quarter and the number of elderly people who fall one or more times by almost a sixth.

The fact that movement exercises reduce falls was already known from an earlier Cochrane Review, which summarized the evidence for all measures to prevent falls, including movement exercises, for the same target group (Gillespie 2012). The insights gained from the careful categorization of the exercise programs examined in the 108 included studies are new. 81 of them compared an exercise program with a control measure (with no measure or one that is assumed not to reduce the number of falls).

On the basis of the studies, the authors * came to the conclusion that effective exercise programs are those that mainly contain balance and function training or combinations of different forms of exercise (typically balance and function training combined with strength training). Tai chi may also prevent falls.

The evidence, based on a few studies, on exercise programs that primarily consist of strength training, dancing, or walking was inconclusive. There have been no studies comparing exercise programs that consist primarily of flexibility or endurance exercises with a control measure.

What else does the evidence say?

Far fewer studies looked at results that go beyond the actual fall, such as the number of people who suffer falls and then need medical attention. Overall, this was insufficiently documented. However, the limited evidence for adverse events from exercise programs was particularly encouraging. None of these occurred in 14 of the 27 studies that reported adverse events, and the events reported in the remaining studies were generally harmless and limited to the musculoskeletal system. Only two major events occurred (a pelvic stress fracture and a hernia (hernia)).

Another important message of this review is the general applicability of the results to elderly people living independently with or without assistance. The few exceptions include people recently discharged from hospital who are undergoing rehabilitation (there have been very few studies on this) and people with specific clinical pictures such as strokes or Parkinson's disease (these have been assessed in other studies). It is also noteworthy that most of the evidence comes from studies conducted in high- and middle-income countries. The review also found that exercise reduced the number of falls regardless of whether a person was previously at high risk of falling or not. However, people at higher risk are likely to benefit more in absolute terms.

This is illustrated in the following table, which relates to data from the review. The data shows that physical exercise is estimated to result in 139 fewer falls per 1000 elderly in the general population annually. For people with a high risk of falling, the number of falls is reduced by almost half.

What type, form of implementation or dosage?

As previously reported, the review identified good evidence for the effectiveness of three types of exercise. He also found that exercise programs are effective regardless of whether they are performed individually, in groups, or under the guidance of a medical or non-medical professional. However, these results are based on observational data based on subgroup analyzes. There have not been enough studies that directly compared the various dosage forms or dosages to be able to make a statement about them.

The duration of exercise programs is perhaps another aspect to consider. Most exercise programs in the included studies lasted 12 or more weeks; in almost a third of the studies it was a year or more. However, as individuals, exercise must be done continuously to be effective. The review authors therefore suggest that physical activity should be part of “lifelong activity to maximize physical performance in old age”. It seems that you can't start early enough.

What does that mean for my mother now?

We talked about all of this after she sent me some photos of her garden. She told me that after her last fall, her physical therapist showed her a few more exercises to complement her daily routine. However, some of these exercises turned out to be unworkable for them. After several attempts, she and the physiotherapist sat down on a bench laughing, which seems to me to be a success of its own. In addition, however, it is a pretext to add a picture painted by her, which has been renamed for the occasion.

“Coming up Daisies” - in oil by Sue Handoll

Text: Helen Handoll

Translated from English by Cordula Braun and Andrea Puhl:
To the Cochrane Special Collection for Falls Prevention

* For reasons of better readability, the simultaneous use of male and female language forms is not used. All personal designations apply equally to both sexes.

1.8 More is not necessarily better

This is the eighth in a series of 30+ blog articles relating to the key concepts for better assessing claims about treatments developed by the IHC (Informed Health Choices) project. Every blog article explains one of these key concepts in order to better understand and classify statements about the effects of treatments.

It seems logical to think that if a treatment is effective, one More this treatment has an even better effect. However, when it comes to treatments, there can actually be "too much of a good" thing. Because finding the right amount for a treatment is like setting the right water temperature in the shower ...

Too little treatment - and the health problem is not resolved; - you feel just as uncomfortable as under a cold shower. On the other hand, too much treatment can cause damage - just like scalding yourself in a shower that is too hot. Just the right amount of treatment and the problem may go away - you'll be better. Just like taking a shower with the right water temperature.

Antihistamines

Unfortunately is a Too much Sometimes more problematic in treatment than scalding in the shower. For example, oral antihistamines can be effective in treating seasonal allergic rhinitis, also known as hay fever. Taking the correct amount, i.e. the correct dosage and duration of treatment as prescribed by the doctor or pharmacist or as instructed in the package insert, can relieve itching of the eyes and help with a stuffy nose [1] [2].

But taking more of it can be dangerous. Taking too many antihistamines can lead to heart problems and affect coordination [3]. In severe cases, the resulting heart problems can even be fatal [4]. And that's exactly why it's so important to test treatments. If antihistamines had never gone through clinical trials, one would not know which doses are useful and which are harmful.

Vitamins

What about other non-medicinal products? For example, vitamins - they are essential for the normal functioning of our body.But does it make sense to take vitamin supplements and can you consume too much of them?
After examining the evidence available for this by the Scientific Advisory Committee on Nutrition (SACN), vitamin D came into particular focus [5]. The review suggests that some people may need vitamin D supplements to ensure their bones and muscles are getting the best possible care. A recently published Cochrane Review found that vitamin D supplementation is likely to reduce the number of severe asthma attacks when taken in addition to normal asthma medication [6].

As with medicines, you can take too much with vitamin supplements. Too much vitamin D can, over time, cause too much calcium to build up in the blood. This can damage the bones rather than benefit them. High calcium levels can also damage the heart and kidneys [7].

Breast cancer

The view that one More Better treatment has resulted in many breast cancer patients receiving treatment that causes preventable harm [8]. In the early days of breast cancer treatment, doctors believed that cancer slowly spread from one place to another. Surgical removal of a larger area around the breast, they believed, would make the operation more successful. Some surgeons even went so far as to remove the patient's ovaries and sometimes arms on the same side as the breast tumor, just because they thought the more surgically removed, the better.

Thanks to the research that has been carried out since then, it is now known that these disfiguring operations are unnecessary and less extreme treatments are effective. The “more is better” mentality, however, has probably meant that this finding from the evidence has only slowly gained acceptance, because 150 radical breast operations were carried out in Japan in 2003. It is important that healthcare professionals and the public alike are aware of the dangers of the “more is better” mentality in order to avoid unnecessary harm.

As the above examples clearly show, it is of great importance to know exactly what dosage and duration of treatment is required. Testing treatments allows us to determine what amount is needed to have a good effect while avoiding the harm of too much. It is important to always be aware that increasing the dose or amount of treatment often increases the harm without increasing the benefit.

Text: Ed Walsh

Translated by: Brita Fiess

Click here for references.

Click here for more study materials explaining why "more is not necessarily better".

You can find the other blog articles in this series under the tags: #key concepts #key concepts

https://www.wissenwaswektiven.org/wp-content/uploads/IHC-Key-Concept-1.8-Die-Erhöhung-des-Umfangs-einer-Behlungs-erhöht-nicht-unbedingt-ihren-Nutzen-und-kann- harmful-effects-have.mp4

1.7 Be aware of existing conflicts of interest

This is the seventh in a series of over 30 blog articles relating to the key concepts for better assessing claims about treatments developed by the IHC (Informed Health Choices) project. Every blog article explains one of these key concepts in order to better understand and classify statements about the effects of treatments.

Conflicts of interest are a pretty hot topic in healthcare. This problem is often dealt with too easily, too ignorantly, or simply too carelessly. What are conflicts of interest and why are they a problem?
Where exactly is the danger here?

Conflicts of interest are “circumstances that present a risk that a professional judgment or corresponding action or measure relating to a primary interest may be inappropriately influenced by a secondary interest.” Our primary interest - as future healthcare professionals - must be the best Make decisions about treatments. This requires of us: 1) the best scientific evidence available; 2) the wishes of our patients; 3) to take into account our clinical judgment. A "disinterest" (i.e. not being influenced by considerations that serve a personal gain) is the hallmark of good research and practice.

However, numerous factors can influence a scientist's * or doctor's judgment and make it difficult for them to remain impartial. These include, for example, income, rewards or gifts from pharmaceutical companies or sponsors of drugs and medical products. Career prospects and power can also be sources of conflicts of interest. Conflicts of interest do not always have to be specific. They can also arise from obligations, gratitude, respect, loyalty, ideologies, political or religious beliefs. All of these reasons are problematic as they can affect the decisions scientists and doctors make. And this can harm patients.

Conflicts of interest can lead to a skewed evidence base

Conflicts of interest can lead to bias or systematic distortion of sponsors (companies that sponsor studies) and / or scientists. There are countless ways in which decisions can be made for your own benefit. This can range from overt scam to a more subtle, unconscious tendentious bias. In fact, intentional or unintentional, biased scientists can use other types of bias to advance their personal interests. The other types of bias include, for example: 1) Through the Study design induced bias (the study here is built in favor of treating the sponsor); 2) Analysis-induced bias (the analytical methods are chosen in favor of the treatment of the sponsor); 3) and / or Bias in reporting („Reporting bias“: Here the researcher 'twists' the results of a study in order to emphasize the benefits of a treatment, or he downplayed possible damage).

Biased sponsors or scientists may also not publish their study at all if their results do not favor a particular treatment. If you consider that there is often considerable uncertainty about the most beneficial treatment anyway, existing conflicts of interest can certainly cause even more confusion.

The confessions of a Finnish medical student

When I was studying medicine, a pharmaceutical company bought me some nice dinners and breakfasts. Now I am no longer accepting these invitations. I feel that this is an unnecessary and terrible business model.

The accompanying lectures revolved around the company and some of its products. A company representative asked us to buy shares in the company. A big selling point was that the company is Finnish. She tried to appeal to our patriotism. So the company representative not only tried to create a financial link through stocks and shares, but also wanted to convince us that the country in which the treatment takes place should also be important to us. Another conflict of interest.

At the time, it didn't seem so wrong to accept dinner invitations and free samples. But in the end it is the patients who pay for it.
The most critical point of view on this quite common practice was shared by an instructor in the clinic who warned that “there are no free meals”. However, many people might ask themselves the question: How exactly is all of this causing unacceptable harm?

Well, what my instructor meant by that was, by attending events like this, you enable marketing professionals with obvious interests to manipulate their own emotions and memories when the real interest is only in their own patients. The goal of such events is clear: we should have a positive attitude towards the company's product or products. However, we should only have a positive attitude towards your product if, in a fair, systematic review, evidence could show effectiveness, and it is therefore a useful product!

If you put the whole thing in a larger framework, the pharmaceutical industry drives its marketing strategy in a variety of ways. And companies are often punished for their illegal marketing practices.

What evidence is there?

How can you actually know whether the evidence base is distorted by conflicts of interest, to what extent conflicts of interest influence decision-making, and what effects this can possibly have? In short, the evidence shows us that:

Industry funding in research with industry friendly conclusions(that is, studies that are industry-funded are far more likely to have conclusions in favor of the drug or medical device than studies that are not sponsored).
Industry-funded studies are more likely to have restrictions on publication and sharing of data than independent studies.
A systematic review of pharmaceutical company advertisements in medical journals found that some of these pharmaceutical product advertisements made misleading and ambiguous claims. When information on risks was given, these advertisements usually only listed the relative reductions in risk (and not the absolute risk reductions). This is misleading.
• One study examined the relationship between industry payments to doctors and prescribing behavior for branded statin products compared to generic statins for lowering cholesterol. It found that industry payments were associated with a higher number of prescriptions for the branded statin products. That is, the higher the company payments to doctors, the more branded statins doctors prescribed.
• Some clinical guideline writers thought that their own connections (for example with pharmaceutical companies), especially those of their co-authors, had an impact on guideline development.

There are endless examples of studies where conflicts of interest skew the evidence base and influence healthcare decision-making. Ultimately, we should all be careful not to be misled by claims made by people with a conflict of interest.

Text: Eero Teppo

Translated by: Brita Fiess

Bibliography

Click here for more learning materials that illustrate Key Concept 1.7. Be aware of any existing conflicts of interest.

You can find the other blog articles in this series under the tags: #key concepts #key concepts

* For reasons of better readability, the simultaneous use of gender-specific language forms is dispensed with. All personal names apply equally to all genders.

https://www.wissenwaswektiven.org/wp-content/uploads/IHC-Key-Concept-1.7-Interessenkonfligte-können-zu-irreführenden-Aussagen-über-die-Wektiven-von-Behandlungen-führung.mp4

Over-medication in the elderly

Many elderly people take up to nine medications a day. However, these can not only contribute to healing, alleviate pain or improve the quality of life of those affected, but also lead to undesirable effects. In Switzerland, a new program by the Swiss Patient Safety Foundation is intended to remedy the situation. The scientific results of an updated Cochrane Review are also to be incorporated into the program.

The older people get, the more medication they take - often up to nine different drugs per day. Some of these are not really necessary and so-called over-medication occurs. This problem is now being tackled internationally with various measures. This is also the case in Switzerland: As part of the “progress! Safe medication in nursing homes ”of the Swiss Patient Safety Foundation, various processes are to be optimized in selected retirement and nursing homes over the next two years, for example relating to medication prescriptions and therapy monitoring. The collaboration between doctors, nurses and pharmacists is to be strengthened. For this purpose, aids, such as a list of drugs that may do more harm than good, should be used and the specialists should be trained. Proven measures should then flow into concrete recommendations for action.

Effects of over-medication

Even if drugs are generally useful to heal illnesses, alleviate pain or improve the quality of life of those affected, they are also associated with increased undesirable effects - especially in older people. These often arise when several drugs are taken at the same time for different chronic diseases. The elderly often suffer from multiple diseases, so they take a variety of drugs at the same time. Often, however, the medication plans are not coordinated with one another, although interactions can occur between the individual medications. If the doctor does not recognize these as such, there is a risk that other drugs will be prescribed to treat the side effect. “The more drugs are taken, the more side effects there are,” says Liat Fishman, head of the “progress! Safe medication in nursing homes ”of the Swiss Patient Safety Foundation. A so-called prescription cascade is created.

Physiological peculiarities of the elderly

The altered metabolism of older people already favors the occurrence of side effects: They break down active pharmaceutical ingredients more slowly and accumulate them in the body. In addition, the performance of the kidneys is reduced, so that drugs are eliminated from the body more slowly. Many drugs are therefore only suitable for older people in lower doses or for a short period of time or should only be prescribed in exceptional cases. These “potentially inadequate drugs” include, in particular, psychotropic drugs such as neuroleptics and benzodiazepines. These drugs can lead to confusion, falls and cognitive deficits, addiction, and even premature death. Nonetheless, patients often take these drugs longer than recommended.

Possible remedies

Over-medication can be prevented if the family or home doctors carefully and regularly check the medication and adjust it if necessary. It is important to determine why a drug was prescribed in the first place and whether the dosage is still appropriate. Many a drug can be replaced by a more tolerable alternative or even discontinued entirely if it is no longer absolutely necessary. A decision diagram can help with this. But even with such aids it is not that easy: “Checking the individual drug list is complex and time-consuming. Often there is not enough time in the doctor's office or in the nursing home, ”says Liat Fishman. From the point of view of patient safety, the additional effort for a structured drug review would have to be reimbursed. Depending on the situation, it can take up to an hour. It is often time-consuming to even find out a patient's full current medication. For example, if there is no or only an incomplete list of medications when entering a nursing home, it is out of date, prescriptions are unclear or the patient does not know exactly. “The knowledge of the pharmacists must also be included in the medication review,” says Fishman. This is already the case in Switzerland in the outpatient sector. Patients who take at least four medications over a period of three months can ask their pharmacy for advice on the dosage or undesirable side effects. "Unfortunately, not enough chronically ill people know about this very low-threshold offer, which is covered by basic insurance," says Fishman. In some cantons there are already models in which pharmacists are jointly responsible for the medication of home residents.

A nurse can also monitor the patient's state of health during the daily dispensing of medication, report any deterioration or side effects to the attending physician and thus contribute to the quality of care for older people. The patients themselves can, for example, use a medication plan to ensure that their medication is taken correctly.

Cochrane evidence

An updated Cochrane Review also looks at over-medication in the elderly.This included 32 studies from 12 countries - including Germany, the USA, Ireland and Canada - which compared the effectiveness of measures to improve the use of drugs with the usual use. The total of 28,672 participants were over 65 years old and suffered from at least one chronic illness - such as asthma, diabetes, lipid metabolism disorders, high blood pressure, cardiovascular diseases (including heart failure) or dementia. Measures included, for example, computer-aided decision-making aids or training for family and home doctors, pharmacists or nursing staff, with whose help the drug lists were regularly checked and the therapy monitored.

However, these measures did not clearly contribute to a clinically significant improvement in the participants. The number of stays in hospital was not reduced, or only barely, as a result of the medication checks. The same was also found in the quality of life: This improved little or not at all. However, the authors were able to show that potentially fewer drugs were prescribed. However, this could only be assessed in two studies, so that the results must be interpreted with caution.

Cooperation between all parties involved

We already know why older people often take too many medications and what interactions can occur. Some measures to prevent over-medication have already been introduced and implemented in various countries. Nonetheless, more research needs to be done to determine which measures are actually effective and practicable. One thing is certain, however: it requires the cooperation, strengthening and sensitization of all those involved - from the general practitioner or home doctor and the nursing staff to the pharmacist to the patient and their relatives.

 

Measures in German-speaking countries to improve drug safety:

Germany: The action plan of the Federal Ministry of Health to improve drug therapy safety (AMTS) in Germany has existed since 2008 and comprises a total of 42 measures. An important element is the introduction of the nationwide medication plan since October 2016. All legally insured patients are entitled to this if they take at least three prescribed medications at the same time.

Austria: This is where the patient safety platform advocates the safety of patients. The independent, national network has existed since 2008. In cooperation with medical societies, the Austrian social security started an information campaign “Beware of interaction!” For doctors and patients in 2014. In the future, the electronic health record with an electronic list of medications should also help to maintain an overview of the prescribed medication and to better identify whether medication is compatible. This should include all drugs that are prescribed within a year and be accessible to treating physicians, pharmacists and patients. The e-medication plan will be gradually introduced in Austria.

Switzerland: The Swiss Patient Safety Foundation has been involved in various programs for patient safety since 2003. With regard to drugs, the foundation is involved with two pilot programs: “progress! Safe medication at interfaces ”and“ progress! Safe medication in nursing homes ", as well as with various research projects (see e.g. https://www.patientensicherheit.ch/forschung-und-entwicklung/doppelkontrolle/).
Whether and how a nationwide medication plan will be introduced is currently being discussed in Swiss health policy.

Text: Anne Borchard

* For reasons of better readability, the simultaneous use of gender-specific language forms is dispensed with. All personal names apply equally to all genders.

1.6 The opinion of experts is not always correct

This is the sixth in a series of over 30 blog articles that focuses on the key concepts for better assessing claims about treatments developed by the IHC (Informed Health Choices) project. Every blog article explains one of these key concepts in order to better understand and classify statements about the effects of treatments.

Whenever anyone makes a claim about treatment, a healthy dose of skepticism is always advisable. This is also appropriate if this person is a so-called expert.

We need to distinguish between people who are experts because they consider the best available scientific evidence and people who pretend to be - or are considered to be - experts but who ignore the evidence. One thing is clear: an “expert opinion” can only be correct if it is based on the best available evidence.

James Lind

Medicine cannot be a dumb doctrine memorization - where the opinion of experts is taken as the absolute truth. Rather, proactive, critical thinking is required here. Claims made by experts need to be challenged and the reasoning and evidence underlying the claims assessed.
Let's look at a few examples of why we can only trust expert opinions when they are based on the best available evidence.

From fruit to avoiding unnecessary knee surgery ...

Classic evidence of how wrong experts can be - and how only rigorous scientific research can be the basis for claims about treatments - dates back to 1747. At that time, people were not sure how to treat scurvy (vitamin deficiency disease, which should be treated best when there is a persistent lack of vitamin C in the diet in humans. The “expert opinions” fluctuated: some experts recommended vinegar, others sulfuric acid. Finally, it was the surgeon James Lind who found the solution with an appropriate test He carefully compared 6 treatments and was able to show that fruits (lemons and oranges) were more effective than the alternative treatments the professionals supported at the time.

And 260 years later, even in surgery, it is no different ...

An arthroscopic partial menisectomy (a type of knee surgery) is one of the most common orthopedic treatments performed. The theory (that is, the explanation of why this procedure is effective) and the perceived effectiveness of this treatment is widely recognized by and practiced by physicians. However, a few years ago some teams of surgeons began to have doubts about its effectiveness, so they began comparing the treatment to sham surgery.

A comprehensive analysis of all available evidence produced robust results that prove that the doubters were right. The corresponding average effect of a menisectomy is maximally small. This finding has important implications, especially for doctors. A more conservative approach to treatment (i.e., waiting without operating) could not only save money, but could save patients an operation that may not be necessary.

Why expert opinions on the effects of treatments alone are not sufficient ...

The basic idea of ​​evidence-based practice is that you can only achieve the optimum in healthcare if you take into account the best clinical evidence, the best clinical experience, and also the wishes of the patients. Expert opinions alone do not provide a sufficiently reliable basis for medical decisions, not even knowledge of the effects of treatments.

Here are three major ideas in a nutshell:

1. It's not about who declares something to be true, but how someone evaluates something as true

The source of an assertion is not decisive for the veracity of the assertion. Only the process that leads to the acquisition of knowledge - through extensive research - guarantees reliable statements. It's about understanding the evidence behind a claim, not just accepting the claim.

For example, why should a layperson believe the claim that the universe is approximately 14 billion years old instead of thousands or trillions of years? The claim should not be accepted simply because it is claimed to be true, but because extensive calculations have been carried out to answer the question.

The more you research how a particular conclusion was reached, or why a particular claim was made, the less you have to “just” “rely” on the claims of others.

2. Experts can have different opinions ... so who is right?

Doctors, scientists, patient organizations and other organizations often disagree about the effects of treatments. Some disagreements and controversies about treatment guidelines are difficult to avoid (for example, when there is no scientific work on a particular treatment or health problem). However, if there are other disagreements, it may simply be because the scientists, doctors, etc. do not adequately consider systematic reviews of reasonably comparing treatments.

Unless all of the evidence available about a particular treatment is considered, disagreements about the safest, most effective treatments are inevitable. And like other people, can. Being experts biased and prone to thinking mistakes. So, if doctors just do what they think is right instead of basing their decisions on all of the available evidence, they may not be implementing the best treatment policy. And deviating from the current best treatment guideline can be harmful.

3. Don't jump to conclusions ...

There are clues that can help predict whether experts (or people in general) will make a reliable claim. For example, you may be more inclined to believe a claim made by someone who has no conflict of interest. (Conversely, if you realize that the person making the claim has financial ties to the pharmaceutical industry, you may be skeptical of a claim about a new miracle cure!).
However, there is no real substitute for a claim based on a systematic review of the evidence. So one should not jump to conclusions and assume that an "expert" is right just because he is considered an "expert". Do not rely on expert opinions about the effects of treatments unless their claims are based on a fair, systematic evaluation of treatments.

Text: Eero Teppo

Translated by: Brita Fiess

https://www.wissenwaswektiven.org/wp-content/uploads/IHC-Key-Concept-1.6-Die-Minations-von-Experten-oder-Autoritäten-allein-stellen-keine-zuicherige-Grundlage-für-Entscheidungen- to-benefits-and-harmful-effects-of-treatments-dar.mp4

Click here for references
Click here for more learning materials that further explain and illustrate the key concept 1.6 “The opinion of experts is not always correct”
You can find the other blog articles in this series under the tags: #key concepts #key concepts

Brushing your teeth: electrically vs. by hand

We all do it, most twice a day. Often half asleep it almost works by itself. I am talking about brushing your teeth. It is a matter of course part of our daily routine, very few of us think about it. But we should, as the dentist emphasizes on every visit. And it seems to be very important to use an electric toothbrush. Nothing is more effective against plaque. What does science say about it? Who is better at cleaning, man or machine? For a current Cochrane Review, researchers went looking for hard facts about high-tech in the mouth.

I still remember well. It was two or three decades ago - I was just a kid back then - when everyone suddenly had a toothbrush that was buzzing and had to be charged overnight. Recommended by dentists, advertised on television, there is nothing better for plaque. You could “clean like a dentist” with her. I was a pretty good kid and scrubbed my teeth twice a day, but by hand, with my colorful children's toothbrush with the extra small head. But suddenly that wasn't enough!

Although I was a bit offended that I was assumed to be inadequate in cleaning my teeth using good old hand craftsmanship, I tried one of these devices two or three times in adulthood. Especially early in the morning, the noise when cleaning was definitely too loud for me and the vibration felt like ants were in my head. I soon switched back to the manual version.

But now I finally want to know. Am I missing something? Do I Owe Better Care of My Teeth? Science has an answer.

Cleaning for science

A current systematic review article by authors of the Cochrane Oral Health Group summarized 56 studies on the question of mechanical vs. electric toothbrushes. All of these studies compared brushing with a manual toothbrush to brushing with an electric brush. A total of 5,068 test persons, mainly from the USA and Europe, cleaned for science. The question: which toothbrush removes plaque more thoroughly and can reduce gingivitis?

For everyone who only knows plaque from toothpaste advertising: It is bacteria that stick to the tooth and together form a so-called biofilm. Plaque is the most common cause of gingivitis and the dreaded periodontal disease.

When the dentist warns of periodontitis, she means an inflammation of the gums. Over time, this can destroy the surrounding bone, causing the teeth to loosen and, in the worst case, fall out.

Bacteria feel particularly good at the transition between tooth and gum and between teeth. So where the toothbrush can't go. The manual toothbrush. Because that electric toothbrushes “go where no manual toothbrush can” is one of the promises made by manufacturers.

Vibrate, rotate, oscillate

But not all electric is always electric. Sideways, rotating, ionic and ultrasonic - toothbrush manufacturers are creative when it comes to the technology of their products. In the systematic review, the investigated models were therefore divided into different groups.

The work only included studies that examined cleaning under real conditions; test subjects were not allowed to receive professional cleaning instructions during the study. Subjects of all age groups who were randomly assigned to one of the two “cleaning groups” were included.

Some of the studies examined the short-term effects of cleaning after one to three months, some the long-term effects after more than three months, some both. The yardstick for cleaning success was how severely the test subjects were affected by plaque and gingivitis, with the various studies using different scales to measure the results.

The result: electric cleaning actually appears to be more effective than manual cleaning. Electric toothbrush users experience less plaque and less gingivitis. The front runners in cleaning were brushes with an oscillating rotating head, i.e. a brush head that rotates and constantly changes direction.

High tech wins

After one to three months, test subjects using electric brushes had around 11 percent less plaque compared to manual cleaners, and after more than three months around 21 percent less plaque (measured using the Quigley Hein plaque index). Bleeding gums were 6 percent less common after one to three months when brushing was done electrically (measured using the Löe-Silnes index). Both results were statistically significant, so there was a high probability that they were not due to chance.

Brushing with the electric brush reduces plaque and gingivitis, which in turn are responsible for periodontal disease and tooth loss. One could conclude now that electric brushing protects the teeth from these problems in the long term. Although this seems likely, the existing studies cannot confirm this. At least not yet. Only very long-term studies that do not yet exist could do this reliably.

Nevertheless, the electric toothbrush emerges as the clear winner in the race for the cleanest set of teeth. That's why I will personally think again about whether I will not let the technology work for me in the bathroom in the future ...

Text: Dr. Jana Meixner

Dr. Jana Meixner is a doctor and medical journalist and works at the Department for Evidence-Based Medicine and Clinical Epidemiology at Danube University Krems in Austria.

 

Literature:

Yaacob, M., Worthington, H.V., Deacon, S.A., Deery, C., Walmsley, A.D., Robinson, P.G., & Glenny, A.M. (2014).Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews, (6).

Wilder RS, Moretti AJ. Gingivitis and Periodontitis in Adults: Classification and Dental Treatment. Uptodate 2018.
Available from: https://www.uptodate.com/contents/gingivitis-and-periodontitis-in-adults-classification-and-dental-treatment?search=parodontitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Crazy Vegan - Is Taking Vitamin B12 Effective For Vitamin B12 Deficiency?

Some people, especially vegans *, are familiar with this condition. Both tiredness and weakness are increasingly widespread and occasionally there is a slight feeling of dizziness. The way to the doctor and the subsequent blood test bring certainty: anemia due to vitamin B12 deficiency. So what?

Medical treatment for B12 deficiency depends on the severity of the deficiency and the underlying causes. In the case of very severe deficiencies and / or existing absorption disorders, the doctor will administer the vitamin B12 intramuscularly, i.e. he will inject it directly into a muscle. Occasionally, but much less often, he prescribes high-dose vitamin B12 preparations, provided there are no absorption disorders. Treatment of a vitamin B12 deficiency is always recommended, although it is up to those affected to take action against a mild to moderate deficiency. As a rule, the next route for those affected is to the pharmacy or drugstore to buy vitamin B12 capsules, drops or appropriate juices. There is enough choice. But what is vitamin B12, are oral supplements effective and what should the daily dose be?

What is Vitamin B12?

Vitamins are organic compounds that the human organism needs for vital functions. Vitamin B12 or cobalamin is one of the water-soluble vitamins and is involved in a large number of biological processes in the organism and is therefore vital. In the body, vitamin B12 plays a central role in cell division and the formation of red blood cells. In addition, vitamin B12 is involved, among other things, in synthesizing DNA and in forming and maintaining protective layers of the nerve cords (myelin layer).

Where does vitamin B12 occur?

With the exception of vitamin D, the human body is not able to produce the necessary vitamins itself, but rather relies on taking in sufficient quantities from food. In nature, vitamins are made either by plants, bacteria or animals.

Vitamin B12 is synthesized by microorganisms that are primarily found in the intestines of ruminants. Humans therefore mainly take in vitamin B12 through animal foods such as offal (liver, kidney), muscle meat, fish, eggs, milk and dairy products. Plant-based foods can be produced through bacterial fermentation, such as B. Sauerkraut, also contain traces of vitamin B12. It is unclear whether the contained form of vitamin B12 is just as useful for humans as that which is ingested with animal products. In addition, the amounts that can be ingested through plant-based foods such as sauerkraut, beer or algae (nori, chlorella) are so small that they cannot be consumed to meet the needs.

How does a vitamin B12 deficiency arise?

A vitamin B12 deficiency can arise, for example, if insufficient vitamin B12 is absorbed through food. This can happen to vegans, but also to pregnant women, for example, whose daily requirement is generally higher. In addition, there are other causes, such as absorption disorders in the small intestine, which mean that vitamin B12 cannot be absorbed by the body in sufficient quantities.

A deficiency in vitamin B12 should not be underestimated and, if severe, can manifest itself in symptoms of anemia such as weakness, tiredness, dizziness and even lead to nerve damage.

Is There a Recommended Daily Allowance for Vitamin B12?

According to the WHO, the recommended daily intake for adult men and women is 2.4 µg vitamin B12. A daily dose of 3.5 µg is recommended for pregnant women in order to ensure adequate supply. For adults, this daily dose can usually be achieved with a balanced diet, since 100g beef, for example, already contains 5µg and 100g Gouda 1.9µg vitamin B12. A detailed table with information on the vitamin B12 content of various foods can be found here. However, should vitamin B12 deficiency symptoms occur, the respective cause must be investigated and, if necessary, taken into account.

In a Cochrane Review from March 2018, Cochrane authors examined whether vitamin B12 supplements to be taken work as well as intramuscularly administered vitamin B12 in the presence of a vitamin B12 deficiency.

Study characteristics

Three randomized controlled trials were included in this review. All studies were conducted within the framework of tertiary health care in the United States, Turkey, and southern India. The total of 153 adult study participants were between 39 and 72 years old and had a vitamin B12 deficiency that required therapy (vitamin B12 concentration in blood serum <148 pmol / L). 74 patients (48.3%) who received oral vitamin B12 were assigned to the intervention group and 79 patients were assigned to the control group who received vitamin B12 intramuscularly. The duration of the study varied between studies and ranged from 3 to 4 months.

method

The included studies differed with regard to the duration of therapy, the daily dose and the total amount of vitamin B12 administered during the therapy period. In two studies, the patients in the intervention group received 1000 µg of vitamin B12 daily, which were taken as drops. In the third study, the patients in the intervention group were prescribed 2000 µg of vitamin B12 in tablet form per day.

All control groups in the studies received a daily dose of 1000 µg of vitamin B12, which was administered intramuscularly to the patients. The total amounts of vitamin B12 administered to the intervention and control groups varied between studies because the duration of the therapy varied.

In order to determine the difference between the routes of administration, the patients were examined during and after the treatment with regard to the following parameters: (1) Vitamin B12 concentration in the blood, (2) Clinical markers and symptoms of vitamin B12 deficiency, (3) Side effects (4) Socio-economic effects.

Results

Both the daily intake of vitamin B12 (1000 μg / per day) and the intramuscular administration of the same dose led to a normalization of the vitamin B12 concentration in the blood of the patients in two studies. In the third study, the intervention group who received oral vitamin B12 had higher levels of vitamin B12 in the blood after therapy than the control group. However, the intervention group in this study received twice the amount of vitamin B12 (2000μg / per day) compared to the control group. In addition, the therapy of the intervention group lasted 30 days longer, which in turn led to large differences in the total amount administered. The authors point out that oral vitamin B12 therapy is more cost-effective than intramuscular therapy.

Conclusion

Both routes of administration are suitable for increasing the concentration of vitamin B12 in the blood and thus successfully treating a vitamin B12 deficiency. It should be noted, however, that the small number of included studies and patients limits the informative value of the results. The Cochrane authors therefore rated the quality of the evidence as low or very low.

Text: Maren Fendt

The full review can be found here: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004655.pub3/full/de#CD004655-abs-0004

* For reasons of better readability, the simultaneous use of gender-specific language forms is dispensed with. All personal names apply equally to all genders.

1.5 New is not automatically better

This is the fifth in a series of over 30 blog articles that addresses the key concepts for better assessing health claims developed by the IHC (Informed Health Choices) project. Every blog article explains one of these key concepts in order to better understand and classify statements about the effects of treatments.

How new or how expensive a treatment is can affect our attitude towards treatment. We all make certain assumptions rather unconsciously: The latest drug or a new treatment is certainly better than an existing treatment! And treatment that is expensive is sure to be effective! Well, not necessarily ...

Some interesting (and alarming) examples show that expensive and new drugs are not necessarily better than already established therapies!

Arbitrary price increases

The price of EpiPens (simply injectable adrenaline products) for severe allergic reactions has only recently become very controversial. Their price has increased more than 450% since 2004. What justifies this price increase? Well, you might think that EpiPens have been significantly improved during this period and that this price is justified. Unfortunately, this is not the case. In fact, the rise in price was essentially because there was only one company, Mylan, that was selling the EpiPens at a time when demand for it was growing. With little government regulation, Mylan was relatively free to raise the price of the EpiPens several times, while the company used targeted marketing (or "awareness") to increase demand for EpiPens.

Pharmaceutical company Turing took a similar approach, increasing the price of Daraprim, a drug used to treat parasitic infections such as malaria, by over 5,000% in 2015.

"Me-Too" products

In Finland, a science journalist publicly criticized doctors * for prescribing too much esomeprazole, a medicine that reduces the production of stomach acid. Why? This drug was just a new, slightly modified version of the omeprazole that was already on the market.

Esomeprazole is an example of a so-called “me-too” drug: here the industry is developing several very similar drugs that are not necessarily an improvement on the drug already available. In Canada, Morgan et al. Based on their 2005 analysis, found that “Most (80%) of the increase in drug spending in British Columbia from 1996 to 2003 was explained by the use of new, patented drug products that did not offer significant improvements over cheaper alternatives that were available before 1990. ”“ Me-Too ”products are often a large, unnecessary financial burden and can raise false hopes in patients.

These are just a few examples, but they clearly show that just because a drug is expensive, it does not necessarily have to be effective. It also does not necessarily represent an improvement over an existing alternative to the preparation.

New, expensive brands of treatments also need to be tested accordingly ...

The common assumption that new and expensive treatments are better than older, cheaper, pre-existing treatments is wrong. How do we know?

Brand new, attention grabbing results turn out to be less promising than initially expected upon further review. For example, in 2003 scientists looked at 101 studies published in prestigious scientific journals between 1979 and 1983 that claimed a new therapy or medical technology was very promising. They found that only five of these therapies or products had been brought to market within a decade.
As for the industry, one might mistakenly assume that the driving force behind a development and the price of a treatment is the effectiveness and safety of that treatment. Let's get that straight: The main goal of pharmaceutical companies and other companies in the healthcare sector is economic success. (It is therefore not surprising that you spend more money on marketing than on research). For pharmaceutical companies, very minor changes to the main molecules of a drug can generate more returns than risky, large-scale new developments. It is not really difficult, through a clever marketing strategy, to convince doctors and patients that a slight change in a drug can make a meaningful difference in its effectiveness and safety. Companies can also increase or decrease prices in a relatively arbitrary manner.
When properly tested, new treatments are rarely much better than existing therapies. New treatments should therefore be compared with the best existing alternatives in well-designed studies (ideally randomized controlled trials (RCTs)). What do you think the likelihood is that any new treatment will be better than its established alternative? Equals zero? Almost 100%? The best estimate in this regard comes from a team of researchers who, based on their analysis in 2012, concluded that “Society can assume that slightly more than half of the new experimental treatments in RCTs have been shown to perform better than the established treatments, but only a few are fundamentally better.
Within the existing regulatory system, the market approval ** of a new treatment does not require that the new treatment is more effective than an already existing, alternative therapy. In addition, some treatment-related side effects and damage may take longer to occur. This in turn means that the long-term safety of a new treatment is often not really known until the treatment is brought to market for widespread use. This is especially the case with rare side effects.

In order for the safest, most effective and most tolerable treatments to be selected, doctors, health insurers and patients must not be distracted from the essentials by the excitement surrounding the price and novelty. Because we have to compare all treatments appropriately and fairly.

Text: Eero Teppo
Translated by: Brita Fiess

Click here for references.
Click here for more learning materials that further explain and illustrate Key Concept 1.5 “Newer is not necessarily better”
You can find the other blog articles in this series under the tags: #key concepts #key concepts

https://www.wissenwaswektiven.org/wp-content/uploads/IHC-Key-Concept-1.5-Neue-mit-einem-Markennamen-versehene-oder-teurere-Behandlungen-sind-nicht-immer-besser-als- available-alternatives.mp4

 

* For reasons of better readability, the simultaneous use of male and female language forms is not used. All personal names apply equally to both genders.

** In Germany the situation looks like this: “The price of a drug without additional benefit must not be higher than that for the existing drug that has been determined as an appropriate comparative therapy according to scientific criteria. Because not every new drug is automatically better or closes supply gaps ”. Source: https://www.gkv-spitzenverband.de/krankenversicherung/arzneimittel/verhandlungen_nach_amnog/rabatt_verhandlungen_nach_amnog.jsp

COPD: breathe freely in the lungs?

Chronic obstructive pulmonary diseases or COPD impair the lung function and thus the breathing capacity of those affected and require drug therapy. In addition, 'alternative' methods are increasingly being used to support drug therapies. Alternative forms of therapy are often aimed at improving the breathing rhythm or supporting breathing. What does the evidence say about some of these options?

We stay human until our last breath. This is what my father last told me in one of his wise moments. That's right - and even more: It shows how important the breath is for us, and also how vulnerable we can be when we catch our breath. People with chronic obstructive pulmonary disease are also often short of breath. If there is shortness of breath or shortness of breath - also known as dyspnea - the person concerned has the feeling that they cannot get enough air and cannot breathe deeply enough. As a result, they breathe very quickly and it takes a lot of effort to breathe. Based on this, it is reasonable to assume that breathing training or gymnastics also has a positive effect on existing shortness of breath.

Breath therapy for longer?

As early as 2012, Cochrane authors * investigated whether breathing exercises could reduce shortness of breath, improve physical performance and improve the general well-being of people with COPD. The breathing exercises examined were carried out for more than 15 weeks and were aimed at strengthening the breathing rhythm.
The authors included 16 studies with 1233 participants in their review. Most of the participants had severe COPD. The breathing exercises that were examined included brake lip (exhaling through 'half-closed lips'), diaphragmatic breathing (deep breathing into the lower abdomen), pranayama (yoga breathing exercises focusing on exhalation), changing the breathing pattern, to slow your breathing rate and lengthen your exhalation, or combinations of these techniques. The authors were unable to determine any significant adverse effects.

The results showed that pranayama exercises that were done over a period of three months, as well as diaphragmatic breathing and also exercises with the brake lip, significantly increased the distance that sufferers could walk within six minutes. According to four studies, the distance could be increased from 35 to 50 meters on average. The effects of breathing exercises on shortness of breath and general wellbeing were not clear, however.
When breathing exercises were used in addition to other physical exercises, they did not seem to have any additional effect. Another Cochrane review published in 2016 on the Chinese martial arts Tai-Chi and COPD shows very similar results in this regard.

Sing your lungs free?

Singing supports breathing, especially abdominal and diaphragmatic breathing, and thus increases the volume of the lungs and therefore has at least the potential to support the health of people with COPD. While exhaling is a more passive process in normal breathing, it is active in singing and is supported by the abdominal, intercostal and pelvic muscles. A Cochrane review published in December 2017 looked at whether singing had an effect on the quality of life or shortness of breath in people with COPD.

The authors found only three studies with 112 participants who were either in a singing class or in a comparison group without singing, e.g. B. in a handicraft group. Participants were on average between 67 to 72 years old and the hour-long singing lessons were held once or twice a week for at least six weeks.
The studies were difficult to compare because of their different designs and the endpoints examined. Thus, based on the evidence given, the authors were only able to state that singing is unlikely to pose any risks to people suffering from COPD and that the activity generally has positive effects on health. They did not find any specific effects on shortness of breath or quality of life related to improved breathing. There is no de facto evidence on the long-term effects of singing on people with COPD.

This result doesn't say much, one might think. And yet it is important because the small number of studies available indicates an evidence gap and invites funding for more studies in this area.

Conclusion

Pharmacotherapies for COPD are supported by non-pharmacological therapeutic measures, including forms of therapy that are designed to support breathing. Although the benefits of these forms of therapy are not always clear or can be associated with improved breathing ability, it is clear that the risks associated with them are low. They also seem to have at least some positive effect on the health and stamina of people with COPD.

Text: Andrea Puhl

* For reasons of better readability, the simultaneous use of male and female language forms is not used. All personal names apply equally to both genders.

Further sources:

Gillissen Adrian. (2016). Update COPD therapy. Medicinal prescriptions in practice. Issue 2, April 2016. https://www.akdae.de/Arzneimitteltherapie/AVP/Artikel/201602/062.pdf. Accessed March 20, 2018.

 

COPD: what treatment options are there and how effective are they?

Chronic obstructive pulmonary disease, or COPD, is affecting more and more people around the world. By 2030, an increase to 7.9 million people with COPD is expected in Germany alone. There are different treatment options, usually drug and non-drug therapies are combined. In addition to quitting smoking, drug treatment is usually mandatory. Which drug groups are there and which combination is most effective for treating COPD? This was the question of various Cochrane reviews.

Michael, one of my best friends, is a long-term smoker. Since I've known him, he has been coughing constantly - to me it sounds like a 'whistling and crashing' sputum - and this has been increasing lately. 'Stupid smoker's cough' has long been his usual excuse. Cough, sputum and steadily increasing shortness of breath (the so-called AHA symptoms) can also indicate COPD. So, in my opinion, it would make sense for Michael to have his cough examined by a doctor. All the more so since COPD is in most cases the result of years or decades of exposure to cigarette smoke.

Diagnosis of COPD and what then?

GOLD - the global initiative for COPD - publishes annual recommendations on the diagnosis, treatment and management of COPD. These three different diagnostic aspects, on the evaluation of which the classification of the severity of COPD should be based, are named: 1) the current lung function 2) the risk factors to which the patient is exposed and 3) the symptoms that can be quantified using questionnaires.

A detailed assessment of these three aspects leads, according to the GOLD approach, to an individualized assessment of the severity of the disease. This in turn serves as the basis for the selection of medicinal and non-medicinal measures. Drug recommendations aim to alleviate symptoms and the frequency of phases in which the disease worsens significantly, also known as exacerbations, and to improve the state of health and physical endurance of patients. Usually this requires taking medication on a daily basis. The most important drug groups are briefly presented below.

Drug therapy options for COPD

Medicinal treatments are usually long-term treatments, i.e. In other words, they must be taken permanently from the first use and consist of drugs that expand the airways (so-called bronchodilators) and anti-inflammatory drugs (e.g. drugs containing cortisone). People with little or no symptoms are usually recommended bronchodilators with a short-term effect (12 or 24 hours). For the treatment of COPD sufferers with more severe symptoms, there are three classes of drugs that are prescribed either individually or in specific combinations: 1) long-acting beta-2 sympathomimetics (LABA) and 2) long-acting anticholinergic (LAMA) are usually the first choice; 3) Inhaled anti-inflammatory corticosteroids (ICS) are mostly used when there is an increased risk of exacerbation.

What does the evidence say? Comparison of the 3 drug classes (standard therapy)

A Cochrane network meta-analysis compared these three drug classes. The aim was to compare their effectiveness in terms of quality of life and lung function in people with COPD who require more than short-term bronchodilators for treatment. Studies were only included in the Cochrane Review when they compared one of the following treatments with a second for a period of at least 6 months:

• LABAs (e.g. the drugs formoterol, indacaterol and salmeterol)
• LAMAs (aclidinium bromide, aclidinium, glycopyrronium, tiotropium)
• ICSs (budesonide, fluticasone, mometasone furoate).
• Combination therapy LABA + ICS

Most studies compared drug interventions with dummy drugs (placebos).