Education with an angleBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1548 (Published 16 April 2009) Cite this as: BMJ 2009;338:b1548
All rapid responses
Dear Jane Smith,
I am happy that things are slowly changing in the “so called”
evidence based medicine which, in reality, is only evidence burdened
medicine. Over enthusiastic reduction of blood sugar being dangerous was
referred to in your editorial according to the ACCORD study.
A new large study of a cohort of 16,600 diabetics followed up to 27
years , just out this week, (1) has, in addition, shown that lowering
blood sugar to such low levels might be associated with another danger of
precocious dementia which might make life miserable for elderly Type II
diabetics. Very tight control of blood sugar is associated with episodes
of hypoglycaemia, any way. The above mentioned study did show that one
attack of such hypoglycaemia might be associated with a good chance of
early dementia, with more than one episode of hypoglycaemia the risk of
dementia goes up exponentially!
Another significant study shows the futility of routinely checking
for asymptomatic coronary artery disease in Type 2 diabetics with our
“evidence base” predicting that diabetics run an extra risk of CAD. The
study did show that this was not true and that the whole exercise is a
waste of money and time for the patient. (2)
One more dangerous practice is to give small doses aspirin to healthy
people in the fond hope of warding off an impending heart attack. I was
doubtful about the basis of this advice and had written about it in the
past. Now a large study shows that this practice leads to multiple micro-
bleeds in the brain. The risk increases when aspirin is added to other
blood thinners that the patient might be on already! (3)
If one keeps his/her eyes open there are bad news coming in almost
daily about our evidence base falling apart! Educating physicians is a
continuous and difficult process in the midst of the pharmaceutical
lobby’s efforts to sell their wares at any cost. There are more things not
to do in this field. Primum non nocere.
1) Rachel A. Whitmer; Andrew J. Karter; Kristine Yaffe; Charles P.
Quesenberry Jr; Joseph V. Selby. Hypoglycemic Episodes and Risk of
Dementia in Older Patients with Type 2 Diabetes Mellitus. JAMA.
2) Lawrence H. Young; Frans J. Th. Wackers; Deborah A. Chyun; Janice A. Davey; Eugene J. Barrett; Raymond Taillefer; Gary V. Heller; Ami E. Iskandrian; Steven D. Wittlin; Neil Filipchuk; Robert E. Ratner; Silvio E. Inzucchi; for the DIAD Investigators. Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 Diabetes: The DIAD Study: A Randomized Controlled Trial.JAMA. 2009;301(15):1547-1555.
3) Meike W. Vernooij, MD; Mendel D. M. Haag, PharmD; Aad van der Lugt, MD,
PhD; Albert Hofman, MD, PhD; Gabriel P. Krestin, MD, PhD; Bruno H.
Stricker, MB, PhD; Monique M. Breteler, MD, PhD. Use of Antithrombotic
Drugs and the Presence of Cerebral Microbleeds. The Rotterdam Scan Study.
Arch. Neurol. 2009;66(6):(doi:10.1001/archneurol.2009.42).
Competing interests: No competing interests