I would like to use this blog post to discuss a medical case in order to reflect on the current state of health care.
Recently a family member Sam* had a transient ischemic attack (TIA or mini-stroke). Sam had a previous stroke and has a stent in the intra-cerebral portion of one of his arteries to help keep the artery patent. Sam has the usual risk factors for cardiovascular disease including high blood pressure, diabetes, and high cholesterol but the patient he is compliant with his medications.
During this last TIA, Sam had atypical, transient symptoms and did not think much of them but at my behest contacted his interventional neurologist. The neurologist asked him to come to the hospital for additional testing. During the hospitalization, Sam had a battery of invasive and non-invasive imaging done to assess the viability of the stent. These tests were inconclusive and Sam was monitored for 24 hours on telemetry where he remained asymptomatic and was discharged. While Sam’s care was relatively efficient and integrated (considering the current fragmented state of health), I would like to discuss a few points from this admission.
Firstly, although the hospital as an integrated electronic health record, and thus all the past labs and imaging studies are easily accessible to the providers, Sam’s metabolic syndrome was not addressed even once. Although his cholesterol values were within normal range, his triglycerides and his hemoglobin A1C (marker for diabetes control) were above the normal range. The focus of his care was on expensive imaging studies and medication adjustments, rather than the dietary interventions that could mitigate the progression of his metabolic syndrome.
Providers and patients get lulled into a false sense of reassurance and complacency by looking at medication controlled partially normal lab values and imaging studies that do not show a blockage. However, they overlook the fact that these TIAs are warning signals of an impending vascular catastrophe. To further exacerbate the problem, the in-hospital food consisted of a sugar-laden brownie, high glycemic index pasta, and a nutritionally bereft piece of chicken breast. In my opinion, an hospital must set the example with respect to providing fresh, nutritionally dense, low glycemic index food choices. This is especially important for a hospitalized patient because these patients are often times the most motivated to change their habits at the time of hospitalization.
With respect to medication adjustment, Sam’s neurologist was considering changing Sam’s medication regimen from Aspirin to Clopidogrel. These are two ‘blood-thinners’ that are prescribed extensively to patient with stents to prevent the stents from re-occluding. However, approximately 15-20% of Asian patients have a genetic polymorphism that is unable to metabolize Clopidogrel to its active substrate and renders the medicine ineffective. At my behest, I asked the physicians to test for Plavix resistance and Sam was in fact found to be a non-responder.
The 20th century has brought us a broad arsenal of therapies against diseases ranging from infectious and cardiovascular diseases to neoplastic and mental diseases. However, drug therapy often fails to be curative and often times causes substantial adverse effects. Furthermore, the use of these drugs has revealed substantial inter-individual differences in therapeutic response. Any given drug can be therapeutic in some individuals but ineffective in others, and some individuals experience adverse drug effects whereas others are unaffected. Moreover, many drugs are effective for only about 50% of patients, often leading to the switching or intensification of therapy that requires multiple office visits. Often, distinct molecular mechanisms underlie therapeutic and adverse effects. Current concepts in drug therapy often attempt to target treatment of large populations as groups, irrespective of the potential for individual genetically based differences in drug response. In contrast, pharmacogenomics seeks to identify variant genes affecting the response to drugs in an individual patient. It will focus effective therapies on smaller populations which although demonstrating the same disease phenotype are characterized by different genetic profiles.
More than half of all medicines are influenced by a handful of biomarkers and pharmacogenomics will enable better prescribing for a range of widely prescribed drugs such as statins, anti-inflammatories, anti-coagulants, and anti-depressants. It is expected that the number of tests will increase exponentially over the next five to ten years, with pharmacogenomics becoming a major component of medical practice by the end of ten years.
Modern medicine has become so infatuated by drugs and imaging tests that simple but key measures of prevention such as dietary modification is often overlooked. In my opinion, prevention is paramount at every stage of the disease process and must be emphasized by the provider. This is the only way (for the foreseeable future) to overcome the massive burden of chronic diseases. Medications should be viewed as transitional with the ultimate goal (when possible) of eliminating the need for these products. Furthermore, the patient must recognize that medications are sometimes ineffective, are laden with side effects, and rarely reverse the disease process. As we enter the era of genomics, medicine must refine genomic technology to tailor drug regimens based on an individuals metabolic and genetic profile.
*Sam is a pseudonym used for the purpose of patient confidentiality.