Jason Johnson wrote:

(Disclaimer: Before reading this, bear in mind that I am not a doctor,
and I'm only drawing conclusions from Google searches and personal
experience)

Jason,

When did patient "Y" begin taking the statin, and for how long did he
take it? Did he notice any side-effects or report them to the doctor?

Here is a snippet on statins and rhabdomyolosis from Harvard Health
Publications:


http://www.health.harvard.edu/newsweek/The_Healthy_Heart_Preventing_detecting_an
d_treating_coronary_artery_disease.htm

Severe muscle damage - a condition known as rhabdomyolysis, which can
be deadly unless treated - affects about 8 of every 10,000 people
taking a statin. One popular statin, cerivastatin (Baycol), was
voluntarily removed from the market in 2001 because it was associated
with rhabdomyolysis. Crestor came under fire in 2004 when critics
charged that it was more likely than other statins to cause
rhabdomyolysis and kidney failure. After reviewing the data, however,
the FDA issued a public advisory concluding that Crestor was as safe as
the other statins in most cases, but warning that to reduce risk, the
lowest doses should be prescribed in people older than 65, those who
have hypothyroidism or kidney disease, and Asian Americans.

I have found articles that advise LFTs before beginning statins and at
12 weeks following the start of treatment, because apparently the risk
of liver damage is about 1 in 100.

So far, I haven't found any specific recommendations for routine
testing for Rhabdomyolosis, perhaps because the published incidence of
it is low.

Dr. X should have informed patient Y of all the potential side-effects
of the medication he prescribed, and should have alerted the patient as
to what symptoms to look out for, especially for more serious
complications. In my experience, doctors often prescribe medication
without discussing potential side-effects or drug-drug interactions. I
think this is careless and foolish, but I also think doctors may be
lulled into a sense of false security by the results of published
studies (often underwritten by the drug manufacturer) and drug reps'
assurances that the incidence of serious side-effects is rare.

Imo, a large part of the blame rests on the shoulders of the
pharmaceutical companies, which tend to draw broad conclusions from
very small study samples, and which have been known to suppress data
suggesting lack of efficacy at the least (and perhaps serious
side-effect; who knows?).

I think another issue is that the FDA often approves meds on the basis
of short-term clinical trials, whereas some of a medication's
side-effects only become evident after long-term use. In a way, that
makes the general public unwitting participants in a medication's
advanced clinical trials.

My personal experience with this involved taking Seroquel, one of the
new atypical antipsychotics that is also used as a mood stabilizer for
bipolar disorder. My doctor chose this particular med because published
studies had shown good efficacy with a low incidence of weight gain. I
took the med for 3 years and gained 60-70 pounds while on it. Then the
medical community discovered that, not only does this entire class of
drugs cause weight gain, but it also increases the potential for
developing type 2 diabetes. Doctors were unaware of this this when the
atypicals were first used; they actually appeared to be a miracle drug,
and in some ways they were.

So now I'm off Seroquel and losing weight rapidly, and we'll see about
the diabetes sometime this month (it runs in my family--almost
*everyone* on my father's side of the family develops it). I don't
blame my doctor for this outcome; I believe he was acting in good faith
based on the information available to him at the time the med was
prescribed.

Another example: A friend of mine was on long-term steroid treatment
for chronic sinus disease. She also has munchausen syndrome and/or
factitious disorder, and tends to complicate treatment by doctor
shopping and claiming to have unusual symptoms that are then treated
with various meds. Last time she visited me, she brought TWO large zip
lock bags full of medication, which included three different inhalers
for alleged asthma, prednisone, psychiatric drugs, antibiotics, and who
knows what else. Eventually, she developed avascular necrosis of both
hips and needed hip replacement surgery. She blames this on the ENT who
prescribed the steroids because she feels he should have told her this
was a potential consequence of extended steroid use. It's not clear
whether he would have made different clinical decisions had he known
all the other meds she was taking, or whether these meds contributed to
the problem.

I guess the point of this meandering post is that there is no simple
answer to your question about Dr. "X" violating his Hypocratic oath. If
he prescribed the statin in good faith, had never been advised to
routinely test for rhabdomyolosis, and had no clinical experience of
any patient developing it, there was no intent to do harm. The intent
was, rather, to prevent harm to the cardiovascular system by lowering
cholesterol. That harm occurred is unfortunate, particularly if it
could have been avoided with simple tests, but if the doctor didn't
know the tests were needed, his failure to act is blameless.

My opinion is No, he didn't violate his Hypocratic oath.

Marcia,
Thanks for your excellent--well written--post. You explained your point of
view very well and I agree with most of your points.
I hope that the meds that you are now taking solve the medical problem
that you have without causing any more side effects. It seems that I have
terrible side effects (eg edema) from every blood pressure medication that
I have tried to take. I have had various other side effects that I will
not mention since I get depressed when I think about it.
Related to this issue--there are two blood tests that can check for signs
of muscle related problems--including Rhabdo--and it makes sense to test
statin patients with those two blood tests about every three months. Many
patients that take statins already have to take liver function blood tests
about every three months so the doctors would only have to add two items
to that list. It appears from the posts that most people do not agree with
me. If they do agree with me--they are not stating it in their posts.
I disagree with your last point. I believe that the doctor violated the
Hypocratic oath since harm was caused to the patient that the doctor
may have been able to have prevent if he had conducted the screening
tests. The doctor may not have known the tests were needed--but he should
have known.
Jason

To all...sorry if you get this twice.  My first one did not post at my
end...Pete

Jason...I strongly and vehemently disagree with what you just said.
Obviously you know nothing about doctors in general (I am not talking about
Howard), and give them way too much credit - they are not Gods just because
they went to medical school.

I have been to 75 doctors in my life and I can easily say that I know more
than they do about certain things that I have researched and they have not.
For a doctor to know everything would be like infinity and is ludicrous
(even in the specialty areas).

Now let me pose a simple question.  Suppose a patient (who is not a doctor,
but is reasonably intelligent with a strong technical and science related
background), studies one of his or her ailments or conditions for hundreds
of hours (which I have for several of my problems).  And say his or her GP
studied it for just a few hours during medical school ten or more years ago.
Who do you think is going to know more about the condition.  The answer is
the patient, and I will disagree with any doctor on the planet who wants to
argue the point.

I ask doctors questions all the time and all I get is "I don't know" and
sometimes I get answers that I know are wrong (and can prove it by simple
research) and that are juxtaposed to what another doctor may have said.  It
is friggen amazing.  I am amazed at all the ignorant people in the world who
don't even know what medications they are taking (or maybe why they are even
taking it which is really bad).  And they say "I don't know - my doctor gave
it to me".  Duh!!  Boy that pisses me off.

You give doctors way too much credit Jason.  They are only human beings
limited by the powers of their brains.  And I do not like the majority of
them because of their arrogant prima donna attitudes, and their disrespect
of the patients rights to research their disease or malady.

Pete


Pete,
I agree with you--I should have added--except for Pete and people like Pete.
A great example is myself--I feel that I know much more about various
types of vitamins, minerals and herbs than almost every doctor (except for
alternative doctors) in the world. I read a book that was written by a
kidney specialist that has proved that he can defer dialysis by a change
in the diet--eg eating a low protein diet--. He mentioned in the book that
many kidney specialists continue to encourage their patients to eat a high
protein diet. Even doctors disagree with each other. Also, those nurses
that work in ERs probably know more about emergency medical care than many
doctors. There are lots of exceptions.
Jason

Jason Johnson wrote:

No he did not.

No he did not.

Screening patients does not preclude them from developing side-effects.
You are testing after the fact. The doctor did not prevent anything but
only detected it earlier.
The only way for a doctor to prevent any side effects with any
medication is to not prescribe any medication. Once the medication is
prescribed then risk is assumed. It's a trade off and not against the
Hippocratic Oath. He may test today and find it normal and then the
patient may get it next week. If you test every 6 months how does this
help?
It didn't prevent anything. One would have to test everyday and even
then you did not prevent it from happening.

The vast majority of people with muscle pain taking statins do not
involve rhabdomyolysis.
CK elevations are not specific for rhabdo. Many psychiatric cases
involve elevated CK's. Exercise can cause elevations in CK.
Hypothyroidism can cause elevations in CK. CK isoenzymes adds nothing
to specificity.
There are recommendations on how to deal with elveations of CK in
patients with statins.
Testing every several months does not preclude the patient from having
a severe case of rhabdomyolysis. The cases of rhabdoyolysis mentioned
in relation to statins have been diagnosed at the hospital and not at
the doctors office. The CK testing done routinely are for the more
common muscle problems of a chronic nature. You can have muscle
problems and not have elevations of CK. David mentioned to you that
there are no specific and sensitive tests for statin induced myopathy.

Thanks for your excellent post. I have another question for you:
If a doctor conducted a Serum creatinine and CPK isoenzymes tests
every three months on a patient
and noticed that those levels were much higher
on one of those blood test--do you think that if the doctor told
the patient to stop taking statins that same day that it would be
less likely that the patient would develop
Rhabdomyolysis?
Do you believe that it is a waste of time to
test statin patients for any signs of any statin related side effects?
Jason