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Cardiovascular Medicine, Chronic Disease, In the News, Research, Science, Stanford News

How best to treat dialysis patients with heart disease

How best to treat dialysis patients with heart disease

523392_4923732760_zKidney failure patients on dialysis often have other chronic diseases – heart disease topping the list. They’re prescribed an average of 12 pills a day by physicians, according to Stanford nephrologist Tara Chang, MD, and they spend three-to-four hours at a treatment center three times a week connected to an artificial kidney machine.

For Chang, this makes it all the more important that any medication she prescribes for a patient on dialysis is both essential and effective.

The problem is, particularly in the case of treating kidney patients with heart disease, evidence-based treatment guidelines just aren’t available. Kidney doctors are left making best guesses based on guidelines written for the general population.

“Our patients might be different from patients not on dialysis,” said Chang. “Dialysis patients have a lot of heart disease, yet rarely does a cardiology study enroll patients on dialysis, so we just don’t know.”

This was part of the motivation behind Chang’s most recent study examining the use of anti-platelet drugs such as clopidogrel, one of the most commonly prescribed drugs for kidney patients. The researchers looked at the use of anti-platelet medications such as clopidogrel as treatment following stenting procedures to unclog arteries in the heart in 8,458 dialysis patients between 2007 and 2010. The data suggests that longer-duration of drug use may be of benefit to patients on dialysis who get drug-eluding stents but not those who get bare metal stents. Chang told me:

We found that for those who got drug-eluting stents who took the drug for 12 months compared to those who had stopped the drug at some earlier time point, there was a non-statistically significant trend towards lower risks of death and heart attacks. So for this group, following the same guidelines as for the general population may be appropriate. However, we found no indication of benefit with longer duration of anti-platelet drug use for patients on dialysis who got bare metal stents.

About half of the 400,000 patients in the U.S. on dialysis also have coronary artery disease, as referenced in the study. The number of those getting stents inserted to unclog arteries also has increased 50 percent in the past decade, the study states. The results of the study, while not definitive as to exactly how long doctors should prescribe the drug, does stress the need for more clinical research on patients with kidney failure to provide guidance on treatment strategies for heart disease.

“Because our study was not a randomized trial,” said Chang, “we tried to be very measured in how we interpreted the results. What it does point to is the fact that we can’t assume that what works in non-dialysis patients works in dialysis patients. Hopefully our study will help convince researchers to include our dialysis patients in their studies.”

The paper was published this week in the Journal of the American Heart Association.

Previously: Keeping kidney failure patients out of the hospitalStudy shows higher rates of untreated kidney disease among older adults and Study shows daily dialysis may boost patients’ heart function, physical health.
Photo by newslighter

Ask Stanford Med, Health and Fitness

Director of Stanford Runner’s Injury Clinic discusses treating and preventing common injuries

Director of Stanford Runner's Injury Clinic discusses treating and preventing common injuries

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It may surprise you to learn that past studies show that runners have a 50 percent chance of sustaining an injury that disrupts their training, and those that compete in marathons have an incidence rate as high as 90 percent. But don’t hang up your sneakers just yet. Many common aches and pains that nag runners can easily be treated or avoided.

On Thursday, Michael Fredericson, MD, who is director of the Stanford Runner’s Injury Clinic and has been head team physician with the Stanford Sports Medicine Program since 1992, will talk about the latest running prevention and treatment methods during a Stanford Health Library lecture. (For those unable to attend the event in person, you can watch the live webcast starting at 7 PM Pacifiic time.) To kick off the conversation, I reached out to Fredericson to discuss some of the topics of his upcoming talk, including the harms of overstriding, the benefits of cross-training, and remedies for prevalent joint problems. He and Adam Tenforde, MD, a sports medicine fellow at Stanford, responded to my questions.

How can overstriding lead to injury?

The term “overstriding” refers to running with the foot striking the ground too far forward from normal stride length. This results in heel strike pattern that may increase stress in the hip and knee joints. Research has shown that forefoot strike patterns tend to reduce stress on the knees and hips, although this may lead to greater stress on the foot and ankle. We conduct a clinic called RunSafe, where we evaluate gait of runners using video and markers. More efficient stride frequency is 90 strides per leg per minute. When a runner overstrides, this may result in a lower stride rate and an inefficient gait. We evaluate for the causes of overstriding, including poor hip extensor strength (weak gluteal muscles), decreased flexibility and technique and encourage correction of these biomechanical contributors. Also, we may suggest shoes with reduced weight, such as ‘minimalist shoes’ as these tend to encourage a runner to run with a more mid-foot strike pattern. However, we caution any changes in shoe type or technique be introduced gradually to decrease risk of developing an injury from changes in gait pattern that stress the body in a new way.

Why is it important for runners to cross-train?

Cross-training refers to forms of aerobic exercise that do not involve running. Doing exercises that do not involve the repetitive ground-impact experienced during running help to rest tired muscles and decrease stress on bones, assisting in recovery while building aerobic capacity. There are no established forms of cross-training to prevent injuries, but performing exercises that do not involve impact loading through the legs, such as elliptical trainer, cycling or deep water running may be helpful.

Many runners select shoes that compensate for how their foot pronates. But recent research shows that pronating too much or too little may not actually increase a runner’s risk of injury. How important is pronation and foot type in preventing injuries?

We evaluate foot type and pronation during our RunSafe clinics. Pronation is a normal motion that helps to distribute forces while landing through the foot and ankle, reducing stresses through the lower extremities. If the foot abruptly stops moving from too much or too little pronation, the other joints and lower limbs may absorb these forces and can become injured. Foot type (having too high an arch or too flat a foot) may also result in higher forces in the legs and joints through associated biomechanics. Foot type and concerns of pronation need to be put into context of prior injury history, as recent research has suggested that foot type and pronation do not necessarily predict future injury risk.

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Autoimmune Disease, Chronic Disease, Immunology, Stanford News, Videos

Unbroken: A chronic fatigue patient’s long road to recovery

Unbroken: A chronic fatigue patient’s long road to recovery

“Fatigue is what we experience, but it is what a match is to an atomic bomb,” said Laura Hillenbrand, the author of Unbroken, about how it feels to live with chronic fatigue syndrome.

I recently finished a Stanford Medicine story and video (above) about another CFS patient, “Erin,” who asked that her real name not be used. After an acute illness in rural Mexico, Erin went from being an elite soccer player to one of the 17 million people worldwide who suffer from the condition.

Most people who acquire hit-and-run infections go back to their normal lives after a few days. But these patients don’t. They become virtual shut-ins, prisoners of a never-ending cycle of flu-like symptoms, many of them bedridden for years. CFS, also called myalgic encephalomyelitis or ME/CFS, has no known cause or cure, frustrating both patients and physicians.

What makes Erin’s CFS story somewhat rare is its happy ending. With the help of Stanford infectious disease expert José Montoya, MD, and cardiac electrophysiologist Karen Friday, MD, Erin is back to working fulltime and playing soccer.

“Dr. Montoya and doctors like him are heroes for taking up an unpopular disease and patients that most doctors shun,” said Lori Chapo-Kroger, a registered nurse and CEO of the patient charity, PANDORA Org. “He combines his medical expertise and a creative approach with a truly caring heart for suffering patients.”

Dr. Montoya is also collaborating with immunologist Mark Davis, PhD, on the Stanford Initiative on Infection-Associated Chronic Diseases, a research project using cutting-edge technologies to identify the biomarkers and root causes of ME/CFS. Working at the Human Immune Monitoring Center, team members are searching 600 blood samples for infectious microbes, inflammation-related molecules and genetic flaws. In addition, they’re conducting brain scans and physical exams to look for physical abnormalities among these patients.

Early results are promising — the team has discovered a number of measurable biological markers that indicate that ME/CFS patients may be suffering from out-of-control inflammation.

The team’s goal: To find out what is wrong with the immune systems of patients with infection-triggered diseases such ME/CFS and Lyme disease, then figure out how to help them get better.

Previously: Deciphering the puzzle of chronic fatigue syndrome

The HIMC is partially funded by Spectrum, Stanford’s NIH Clinical and Translational Science Award.

Medical Education, SMS Unplugged

Why “looking dumb” in medical school isn’t such a bad thing

Why “looking dumb” in medical school isn’t such a bad thing

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

hands in air - longerIf I had to choose one theme that has stood out in the first weeks of medical school, it would be this: questions, questions, and more questions. In the first class on our first day of medical school, our professor set the tone by laying down the requirement that we ask a minimum of ten questions before the lecture was over. Based on my experience in large undergraduate lectures, where questions were as rare as rain in Palo Alto, I naively thought this would be a challenge for us. To my surprise, we met the challenge and probably asked at least twenty questions in that first class alone.

This first day set the tone for the rest of our time together so far, and my class has quickly gained a reputation among the faculty for the volume of questions that we ask. It’s a common occurrence for a lecturer to be moving along smoothly, only to look up and see four or five hands in the air, of people waiting patiently to ask for clarifications, pose hypothetical situations, or simply admit that the last lecture slide was way too confusing. More than one class session has been derailed and run out of time because of our frequent interruptions. One of our professors memorably poked fun at us by hinting – not very subtly – that our class had no problem with “looking dumb” in front of our peers.

Given the amount of important information and interesting ideas that I’ve learned through my classmates’ questions, I’ve quickly come to feel that learning how to ask questions is an important part of my early medical training. However, this can be a difficult thing. By asking a question in public, you’re more or less admitting to everybody in the room that you didn’t know the answer; that you needed help from somebody else to get the information. Only certain learning environments – namely, with a close group of non-judgmental peers and willing professors – are conducive to this.

With that in mind, what will happen with our class as we move through our medical training? I’m hopeful that our willingness to ask questions will continue, along with the receptiveness of our teachers and mentors. As first-year medical students, we’re not expected to have a vast medical knowledge yet, so admitting “I don’t know” is relatively easy. But what will happen in a few years, when we reach the clinics and are expected to be able to put the knowledge from our first two years to use? Or more importantly, what will happen when we are fully trained physicians, and our patients expect us to have all the answers? When we don’t have the answers, will we be as willing to ask for help as we are now? As a patient, I would certainly hope that my physician would be willing to ask the right questions when needed. Because of this, I think our class can and should aspire to keeping the flood of questions coming.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research.

Image by Kaz

Big data, Research

Using supercomputers to spot drug reactions

Using supercomputers to spot drug reactions

sierraSupercomputer[1]Remember the drugs Avandia and Vioxx? Avandia, an anti-diabetic drug released in 1999, worked wonderfully against diabetes. But it was also shown to increase users’ risk of heart attacks – a devastating side effect that slashed its sales. And Vioxx, an anti-inflammatory drug, was also linked to an increased risk of heart attacks and stroke, leading manufacturer Merck & Co. to withdraw it from the market.

These are just the drugs that grabbed the headlines. Other side effects from drugs kill more than 100,000 patients a year, according to a study in the Journal of the American Medical Association.

To slash that number, researchers at Lawrence Livermore National Laboratory put their supercomputers to work. They developed a program that determines whether a drug will form a bond with any of hundreds of proteins found in the human body. The research, published recently in the journal PLOS One, found that modeling based on the protein’s 3-D structure can pinpoint reactions more quickly than current methods.

From the LLNL release:

“We have discovered a very viable way to find off-target proteins that are important for side effects,” said Monte LaBute, PhD,  a LLNL researcher and the paper’s lead author. “This approach using high-performance computers and molecular docking to find adverse drug reactions never really existed before.”

The team’s findings provide drug companies with a cost-effective and reliable method to screen for side effects, according to LaBute. Their goal is to expand their computational pharmaceutical research to include more off-target proteins for testing and eventually screen every protein in the body.

“If we can do that, the drugs of tomorrow will have less side effects that can potentially lead to fatalities,” Labute said. “Optimistically, we could be a decade away from our ultimate goal. However, we need help from pharmaceutical companies, health care providers and the FDA to provide us with patient and therapeutic data.”

Previously: Mining data from patients’ charts to identify harmful drug reactions, Medical journal wins award for reporting on problems with Medtronic bone product and New research scrutinizes off-label drug use
Photo by Lawrence Livermore National Laboratory

Health Costs, Health Policy, Medicine and Society, Public Health, Research, Stanford News

Competition keeps health-care costs low, Stanford study finds

Competition keeps health-care costs low, Stanford study finds

The term market competition usually sparks a mental image of business suits and ties, not white coats and stethoscopes. Yet even the health-care system plays by the rules of the economic market place.

A new study, conducted by Stanford researchers Laurence Baker, PhD; M. Kate Bundorf, PhD; and colleagues, provides important evidence that less competitive health-care markets are more likely to charge higher prices for office visits. The article was published today in The Journal of the American Medical Association.

There’s a push through the private sector and through Medicare to encourage the formation of larger practices, which could improve the efficiency of the health-care system, said Bundorf.  The researchers sought to understand what effect these larger practices have on health-care spending.

To make the comparisons, the researchers used a database to establish the prices paid by PPOs for the most commonly billed office visits within 10 physician specialties. Next, they adapted a standard economic competition measure to calculate physician practice competition for different U.S. regions.

As I wrote in a release today:

Studying a measure that averaged prices across multiple types of office visits, in their most conservative model, being in the top 10 percent of areas with the least competition was associated with 3.5 to 5.4 percent higher mean price. The researchers point out that in 2011, privately insured individuals in the United States spent nearly $250 billion on physician services. In that context, these small percentage increases could translate to tens of billions of dollars in extra spending.

The study’s findings show the importance of developing policies that will encourage a balance between the quality of care and health-care spending. As Baker explained, “Sometimes it can be tempting to say our goals for the health care system should be only about taking care of patients and doing it as well as possible – we don’t want to worry about the economics. But the truth is we do have to worry about the prices because the bill does come even if you wish it wouldn’t.”

Previously: What’s the going rate? Examining variations in private payments to physicians

NIH, Research, Science Policy, Stanford News

Shake up research rewards to improve accuracy, says Stanford’s John Ioannidis

Shake up research rewards to improve accuracy, says Stanford's John Ioannidis

currencyLab animals such as mice and rats can be trained to press a particular lever or to exhibit a certain behavior to get a coveted food treat. Ironically the research scientists who carefully record the animals’ behavior really aren’t all that different. Like mice in a maze, researchers in this country are rewarded for specific achievements, such as authoring highly cited papers in big name journals or overseeing large labs pursuing multiple projects. These rewards come in the form of promotions, government grants and prestige among a researcher’s peers.

Unfortunately, the achievements do little to ensure that the resulting research findings are accurate. Stanford study-design expert John Ioannidis, MD, DSci, has repeatedly pointed out serious flaws in much published research (in 2005 he published what was to be one of the most highly-accessed and most highly-cited papers ever in the biomedical field “Why most published research findings are false”).”

Today, Ioannidis published another paper in PLoS Medicine titled “How to make more published research true.” He explores many topics that could be addressed to improve the reproducibility and accuracy of research. But the section that I found most interesting was one in which he argues for innovative, perhaps even disruptive changes to the scientific reward system. He writes:

 The current system does not reward replication—it often even penalizes people who want to rigorously replicate previous work, and it pushes investigators to claim that their work is highly novel and significant. Sharing (data, protocols, analysis codes, etc.) is not incentivized or requested, with some notable exceptions. With lack of supportive resources and with competition (‘‘competitors will steal my data, my ideas, and eventually my funding”) sharing becomes even disincentivized. Other aspects of scientific citizenship, such as high-quality peer review, are not valued.

Instead he proposes a system in which simply publishing a paper has no merit unless the study’s findings are subsequently replicated by other groups. If the results of the paper are successfully translated into clinical applications that benefit patients, additional “currency” units would be awarded. (In the example of the mice in the maze, the currency would be given in the form of yummy food pellets. For researchers, it would be the tangible and intangible benefits accrued by those considered to be successful researchers). In contrast, the publication of a paper that was subsequently refuted or retracted would result in a reduction of currency units for the authors. Peer review and contributions to the training and education of others would also be rewarded.

The concept is really intriguing, and some ideas would really turn the research enterprise in this country on its head. What if a researcher were penalized (fewer pellets for you!) for achieving an administrative position of power… UNLESS he or she also increased the flow of reliable, reproducible research? As described in the manuscript:

[In this case] obtaining grants, awards, or other powers are considered negatively unless one delivers more good-quality science in proportion. Resources and power are seen as opportunities, and researchers need to match their output to the opportunities that they have been offered—the more opportunities, the more the expected (replicated and, hopefully, even translated) output. Academic ranks have no value in this model and may even be eliminated: researchers simply have to maintain a non-negative balance of output versus opportunities. In this deliberately provocative scenario, investigators would be loath to obtain grants or become powerful (in the current sense), because this would be seen as a burden. The potential side effects might be to discourage ambitious grant applications and leadership.

Ioannidis, who co-directs with Steven Goodman, MD, MHS, PhD, the new  Meta-Research Innovation Center at Stanford, or METRICS, is quick to acknowledge that these types of changes would take time, and that the side effects of at least some of them would likely make them impractical or even harmful to the research process. But, he argues, this type of radical thinking might be just what’s needed to shake up the status quo and allow new, useful ideas to rise to the surface.

Previously: Scientists preferentially cite successful studies, new research shows, Re-analyses of clinical trial results rare, but necessary, say Stanford researchers  and John Ioannidis discusses the popularity of his paper examining the reliability of scientific research
Photo by Images Money

Behavioral Science, Mental Health, Public Health, Stanford News

“Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention

in-a-lonely-place-fa873a88-0c57-4b11-8f84-58c09aab94acMost people shy away from talking about suicide. Me too – I have some personal ties to the topic that still stab every time the s-word comes up. Yet after the initial reluctance wears off, that pain from grief and anger and fear turns into a motivational jab. Let’s talk about suicide nonstop. Let’s talk to make it stop.

Laura Roberts, MD, who leads Stanford’s psychiatry department, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. And she took it – partnering with the Wisconsin-based Charles E. Kubly Foundation to produce a special package of articles to inform clinicians about the latest efforts to prevent suicide.

Roberts and I spoke recently about the special issue and about suicide prevention:

Why did you want to publish this issue?

Suicide is such an under-recognized phenomenon, and it is an urgent threat to public health. Mental illness affects one in five people. Each year, more than 36,000 people commit suicide in the U.S. That is one person every fifteen minutes. In rough numbers, that’s twice the number of people who die from a violent injury in this country. Really, every life is touched by suicide.

Despite their serious public-health impact and life-threatening nature, illnesses and conditions associated with suicide have received little attention in society. These conditions are poorly understood and so greatly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education — we really wanted to emphasize these topics in this special collection.

New evidence-based models for prevention of suicide are emerging and inspire optimism. Integrating these new models is an exciting challenge for medical educators. Papers in this collection also document the impact of suicide and suicidal behavior among medical students and graduate students. About 350 physicians commit suicide each year in the U.S., and recently two interns in New York City ended their lives shortly after entering residency training. This is devastating.

In our special issue, a systematic review highlights the observation that psychiatry residents commonly experience the death of a patient by suicide, and three articles address coping with suicide professionally. Several articles focus on the development of educational programs that help strengthen suicide prevention, including screening skills and suicide awareness and management. Two articles address the resources and experience of from the Department of Veterans Affairs.

The journal special issue underscores there is much we can do in medical education to foster understanding and strengthen our responses to the phenomenon of suicide. Taken together, the papers also show how important it is that academic leaders better educate other about the prevention and impact of suicide.

What have we learned about preventing suicide?

We have learned a great deal about the prevention of suicide. Population data have shown that certain subgroups are especially vulnerable to suicide, including, for example, older white men who are ill and live alone, Native American youth as they make the transition to adulthood, and people living with serious illnesses that cause great physical and emotional pain. Understanding these larger population patterns has done a lot to help raise awareness of suicide and has allowed for creative interventions to address this problem.

Recently, researchers have been pursuing neurobiological markers that may signal when an individual is most at-risk for attempting suicide. Other studies are connecting other aspects of health — such as healthy sleep and exercise — to protective factors that may help diminish the likelihood of suicide. Such innovative work is very much needed because it will help us understand when a person with latent risk factors for suicide may act on this impulse, or, alternatively, how we can better support and intervene.

Other recent work has focused on psychological and situational factors that may contribute to suicidality among young veterans, and again, this line of inquiry may give us greater understanding on how best to reduce suicide deaths. As you may know, the number of veteran deaths due to suicide have been devastating. The VA has shown immense concern for members of the military and young veterans returning from conflicts around the world. In the course of studying suicide in this population, we have begun to have greater insight into when and whether an individual will act on an impulse to end his life. Three factors appear to be in play: first, a predisposition or vulnerability, for example, the presence of depression or anxiety that increases the general risk of suicide; second, access to a way to end one’s life, such as a gun; and, third an experience or set of experiences that make the individual feel like he is out of place, isn’t part of things, and doesn’t belong — what’s referred to as “thwarted belongingness.”

We are getting parts of the problem figured out, but so much more scientific investigation is needed. Ironically, suicide has been understudied because of concerns that the population is too vulnerable to be included in human research studies and because of the stigma associated with suicide. There have been so many barriers to these studies, and it strikes me as doubly tragic that suicide takes so many lives and yet has been relatively neglected by society and by science. In the Department of Psychiatry and Behavioral Sciences at Stanford, we are working to turn this around.

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Immunology, Infectious Disease, Microbiology, Public Health, Research, Stanford News

Paradox: Antibiotics may increase contagion among Salmonella-infected animals

Paradox: Antibiotics may increase contagion among Salmonella-infected animals

cattleMake no mistake: Antibiotics have worked wonders, increasing human life expectancy as have few other public-health measures (let’s hear it for vaccines, folks). But about 80 percent of all antibiotics used in the United States are given to livestock – chiefly chickens, pigs, and cattle – at low doses, which boosts the animals’ growth rates. A long-raging debate in the public square concerns the possibility that this widespread practice fosters the emergence of antibiotic-resistant bugs.

But a new study led by Stanford bacteriologist Denise Monack, PhD, and just published in Proceedings of the National Academy of Sciences, adds a brand new wrinkle to concerns about the broad administration of antibiotics: the possibility that doing so may, at least  sometimes, actually encourage the spread of disease.

Take salmonella, for example. One strain of this bacterial pathogen, S. typhimurium, is responsible for an estimated 1 million cases of food poisoning, 19,000 hospitalizations and nearly 400 deaths annually in the United States. Upon invading the gut, S. typhimurium produces a potent inflammation-inducing endotoxin known as LPS.

Like its sister strain S. typhi (which  causes close to 200,00o typhoid-fever deaths worldwide per year), S. typhimurium doesn’t mete out its menace equally. While most get very sick, it is the symptom-free few who, by virtue of shedding much higher levels of disease-causing bacteria in their feces, account for the great majority of transmission. (One asymptomatic carrier was the infamous Typhoid Mary, a domestic cook who, early in the 20th century, cheerfully if unknowingly spread her typhoid infection to about 50 others before being forcibly, and tragically, quarantined for much of the rest of her life.)

You might think giving antibiotics to livestock, whence many of our S. typhi-induced food-poisoning outbreaks derive, would kill off the bad bug and stop its spread from farm animals to those of us (including me) who eat them. But maybe not.

From our release on the study:

When the scientists gave oral antibiotics to mice infected with Salmonella typhimurium, a bacterial cause of food poisoning, a small minority — so called “superspreaders” that had been shedding high numbers of salmonella in their feces for weeks — remained healthy; they were unaffected by either the disease or the antibiotic. The rest of the mice got sicker instead of better and, oddly, started shedding like superspreaders. The findings … pose ominous questions about the widespread, routine use of sub-therapeutic doses of antibiotics in livestock.

So, the superspreaders kept on spreading without missing a step, and the others became walking-dead pseudosuperspreaders. A lose-lose scenario all the way around.

“If this holds true for livestock as well – and I think it will – it would have obvious public health implications,” Monack told me. “We need to think about the possibility that we’re not only selecting for antibiotic-resistant microbes, but also impairing the health of our livestock and increasing the spread of contagious pathogens among them and us.”

Previously: Did microbes mess with Typhoid Mary’s macrophages?, Joyride: Brief post-antibiotic sugar spike gives pathogens a lift and What if gut-bacteria communities “remember” past antibiotic exposures?
Photo by Jean-Pierre

Chronic Disease, Health Costs, Infectious Disease, Research

Despite steep price tag, use of hepatitis C drug among prisoners could save money overall

Despite steep price tag, use of hepatitis C drug among prisoners could save money overall

pills-384846_640There’s nothing free about the revolution that’s shaking up hepatitis C treatment. A slew of newer drugs, including sofosbuvir, are nearly eliminating the virus with fewer side effects than the old standbys, pegylated interferon and ribavirin, which had limited effectiveness and caused fatigue, nausea and headaches. But at a cost of $7,000 a week, it seems obvious they are more expensive.

Not necessarily, however, says Jeremy Goldhaber-Fiebert, PhD. Working with colleagues including former Stanford graduate student Shan Liu, PhD, Goldhaber-Fiebert developed a model that examines the overall costs and benefits of treating hepatitis C with sofosbuvir rather than the traditional drugs in prisons. Prisoners are more likely than those in the general population to be infected with hepatitis C, a virus that attacks the liver, because it can be transmitted through intravenous drug use and unclean tattoos.

The researchers found that the high upfront cost saves money in later years by reducing the number of liver transplants and other more invasive treatments needed. In accordance with standard practices, this  study examined the overall societal cost without accounting for the source of the money. For example, the prison system’s are more likely to spend more money upfront, although savings might be recouped by Medicaid or other private insurers several decades later. From our release:

“Overall, sofosbuvir is cost-effective in this population, though its budgetary impact and affordability present appreciable challenges,” said Goldhaber-Fiebert,who is also a faculty member at Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, which is part of the university’s Freeman Spogli Institute for International Studies.

Goldhaber-Fiebert called hepatitis C a “public health opportunity.”

“Though often not the focus of health-policy research, HCV-infected inmates are a population that may benefit particularly from a highly effective, short-duration treatment,” he said.

The research appears in this week’s Annals of Internal Medicine.

Previously: Fortune teller: Mice with ‘humanized’ livers predict HCV drug candidate’s behavior in humans, A primer on hepatitis C and For patients with advanced hepatitis C, benefits of new drugs outweigh costs
Photo by stevepb

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