Hiding the Truth about Drugs: How Long Are Outcomes Delayed?

It has been a good while since I reported on drugs like epoetin, used to stimulate the body to make more red blood cells to counteract the anemia associated with end-stage kidney disease and cancer. My early post: http://brodyhooked.blogspot.com/search?q=dialysis-- commented mostly on the payment system that tempted dialysis and cancer docs to prescribe more of these drugs than was necessary or safe. But new information now suggests that the truth about the harms and lack of benefit of these drugs could have been known much sooner and many patients saved from bad outcomes. Sadly this is not the first such story in the history of the medicine-pharmaceutical industry relationship.

Dr. Daniel W. Coyne, a kidney specialist at Washington University-St. Louis, has both written a detailed paper and a briefer commentary about his research:
http://the-scientist.com/2012/05/14/opinion-misleading-drug-trials/
http://www.nature.com/ki/journal/vaop/ncurrent/full/ki201276a.html
I'm going to go into some detail about Dr. Coyne's findings as they illustrate several points, both about how scientific studies can be fudged to create a positive drug marketing message, and also how our bureaucracy works (or doesn't) to protect patient safety.

Before more recent research in the mid-2000s showing quite definitively that higher doses of epoetin-type drugs produced more strokes and other bad outcomes, the main research trial informing kidney guideline writers was the Normal Hematocrit Trial, conducted in 1996 and published in the New England Journal in 1998: http://www.nejm.org/doi/full/10.1056/NEJM199808273390903 This study was stopped early because of concerns that the higher doses of epoetin were causing more adverse reactions (more on that later). The journal article reported that on careful statistical analysis, there were no serious safety issues found, but that by contrast, quality of life of patients improved in the groups receiving the higher doses of epoetin (that is, those whose red blood cells achieved higher levels, which usually requires higher doses of the drug).

What Dr. Coyne did was simple. The drug company, Amgen, had to submit its own report of the study data to the FDA. As usually is the case, the FDA is under no obligation publicly to release these data and is indeed usually prevented from doing so by the proprietary nature of a company-sponsored study. Dr. Coyne requested the FDA data under the Freedom of Information Act, and was able to obtain the data after being kept waiting a mere 3-1/2 years (more on that later too).  He then sat down and compared in detail the study data reported to the FDA to the same study reported in the medical journal in 1998.

First the safety data. According to the New England Journal, the primary study endpoint, death or non-fatal heart attack, showed no difference between the high- and lower-dose groups. But the reason that the authors concluded this was that the data monitoring board, that stopped the study early, insisted on a tighter threshold for statistical significance, reportedly to correct for the fact that the same data had undergone multiple prior statistical analyses. The usual threshold is P = 0.05, but with the demand for the stricter level of P = 0.008, there was no statistically significant difference. When Coyne looked at the data the drug company submitted to the FDA, he saw that with the unadjusted significance test, there were more adverse events in the higher-dose group, with P = 0.0119, which would normally be interpreted as quite a significant result.

Time out for a sidebar on early stoppage of clinical trials. As I previous blogged--for example, http://brodyhooked.blogspot.com/2011/03/how-honest-reports-of-research-can.html-- in the past, when drug trials are stopped early because a drug seems superior to the control, it is commonly found with later research that this result is spurious and that had the trial been continued to scheduled completion, there would have been no difference between drug and placebo (or other comparator). What we see in the case of the Normal Hematocrit Trial appears to suggest a double standard for industry-sponsored trials. If the trial is stopped early because the company's drug looks good, then that result is trumpeted as the truth, even if more study would cast doubt on that conclusion. If on the other hand a study is stopped early because the drug causes people to die, then the investigators get to move the goalposts and fudge the statistics, so that it turns out that those people did not really die after all. Without going into all the issues about whether data monitoring boards are truly independent of the study sponsors, and how early stopping can lead to misleading results even of the boards are totally kosher, it would seem a valid take-home lesson that we should authomatically be very skeptical whenever a drug trial is stopped early.

Now, back to the main story and the question of benefits. Dr. Coyne found that the study as reported in the New England Journal indicated benefit in quality of life for patients who had achieved higher red blood cell counts. Reportedly these findings were statistically significant at P = 0.03. When he reviewed the same data as reported to the FDA, he could find no evidence of any statistically significant improvement, with a single exception--it was indeed true that patients getting higher epoetin doses ended up requiring fewer blood transfusions.

So the bottom line--in 1998 the kidney dialysis community was told that higher epoetin doses, leading to higher red cell counts, posed no significant risk of harm and improved patients' quality of life. Based mostly on that one study, the kidney gurus issued several practice guidelines calling for higher levels of red cells, which in turn required docs to prescribe higher doses of epoetin. Around 2006-8, new data emerged suggesting that this was unsafe. In hindsight we now realize that the data from 1996-98 actually show the same thing, and indeed demonstrate lack of any benefit to boot; so between 1998 and 2008, however many dialysis patients were exposed to serious risks of harm, including death, with no corresponding benefit. In total, says Dr. Coyne, Amgen profited to the tune of $37B in total sales of epoetin.

Now for the bureaucracy piece. Dr. Coyne filed his FOIA request for the FDA data in January 2008. He finally received the data in July 2011. Two weeks before he received the data, the FDA issued new labeling for epoetin, calling for lower red blood cell levels. In its warning, the FDA accepted the statistical tests of the data on file, meaning that the FDA now belatedly rejected the statistical fixes that had been published in the New England Journal. He allows us to read whatever we want into the timing of these events.

In his opinion article, Dr. Coyne also reports having contacted some of the academic authors of the New England Journal version of the Normal Hematocrit Trial. They claimed to him that they had tried to insert the information that he later discovered into the published paper, but that the editors at the journal rejected those amendments. Dr. Coyne admits to skepticism, since these same authors published several later papers and also served on the kidney guideline committees, but never made any attempt to alter the impression given by the original publication.

In HOOKED, I mention a couple of other instances where patients suffered due to a delay in revealing the truth about the benefits and harms associated with a drug--Vioxx being the poster child, having caused an estimated 144,000 excess heart attacks during the years when its dangers should have been known. We now have to add epoetin to this dishonor roll.

Many thanks to Dr. Barbara Roberts, author of The Truth About Statins, for calling my attention to this work.

Genetic Test Firms Steal Marketing Ideas from Pharma

Dr. Michael S. Wilkes of UC-Davis (and NPR), who has been eloquent in addressing issues around the ethics and professionalism of drug marketing, widened his gaze in an editorial a while back:
http://www.springerlink.com/content/0798016272844307/

He commented on another article in the journal on the marketing of genetic screening tests. It is generally agreed that while genetic testing can be very valuable for individuals or families known to be at high risk for an inherited disease, genetic screening tests aimed solely at showing a patient's statistical risk of developing multi-gene diseases such as diabetes or heart disease are seldom clinically useful and often quite misleading. Despite this a firm called Navigenics will very happily sell you one of this fishing-expeditiona genetic screening tests for a modest $999. What the research focused on was the fact that a national primary-care practice group, MDVIP, entered into a marketing agreement with Navigenics to promote this test to their patients, and that as part of this relationship, the company offered a free genetic screening test to these primary physicians, 1/3 of whom accepted the offer.

I'll pick up the commentarty from here in Dr. Wilkes's own words:

An offer of an incentive (in this case a free genetic test) from a new “collaborator” should clearly have raised questions for every one of the doctors. Even if any given doctor genuinely believed the test was in the best interest of a patient, it would be difficult to argue that the test ordering wasn’t influenced by a favor provided by Navigenics with an implicit expectation of reciprocity (“we did you a favor, now it is expected you will do us a favor by ordering this test on your patients”)....Is this type of social influence any different than offer of free drugs to doctors by pharmaceutical companies in an attempt to build loyalty?...

I wonder if any MDVIP physicians ever told their patients that they received a free gift by the very company that profited from the test the doctor was about to order—a test that has no proven value to the patient? Similarly, prior to testing, did the physicians include in their conversations with patients a discussion around informed consent? ...

It seems we have been round this issue before with pharmaceuticals and medical devices. As a profession, haven’t we decided that education developed by a company with a vested interest in the physician’s practice outcomes is not ethically or educationally appropriate? ...

Primary care doctors can either be part of the problem or we can be part of the solution by being vigilant and by self policing to avoid any actual or perceived conflicts of interest in order to maintain the trust of our patients and society. We also need to be informed consumers when it comes to our own education and avoid all commercial influence that seeks to promote profit at the expense of patient well being.

The usual hat tip to Rick Bukata and Jerry Hoffman's Primary Care Medical Abstracts for calling my attention to this article.

Bipartisanship in Congress, in Support of Pharma and Device Industries

It's often said today that Congress is totally dysfunctional and cannot agree on anything due to the huge partisan culture war. Well, the good news is that there's bipartisan cooperation on at least one issue. The bad news is that it's all in favor of handing the foxes at the pharmaceutical and medical device industries the key to the FDA henhouse. 

The estimable Merrill Goozner: http://gooznews.com/?p=3914--has blogged about the latest renewal round of the Prescription Drug User Fee Act, where drug firms agree to pay a lot of the freight for running the FDA's drug approval process, and almost always manage to wring out favorable concessions in exchange for their largesse. Among the Christmas list the industry wants this time, and that Congress, well primed by the lobbyists, is apparently ready to hand them, are:

• More use of surrogate markers to approve new drugs, without demanding proof that the actual diseases that affect people get any better (e.g., a drug that lowers blood sugar but does nothing to prevent heart attacks or strokes or blindness from diabetes)
• Complete gutting of the reforms called for in the recent Institute of Medicine report to toughen requirements for testing new devices for safety

Gooz reports that consumer advocacy groups are incensed over these concessions but are getting nowhere with Congress.

The solution, as we have known for a good while, is to stop depending on the drug industry to fund the FDA--though replacing drug bucks with taxpayer bucks won't make that army of lobbyists go away (meaning that at some point or other, campaign finance reform is desperately needed as well).

Abbott Labs, Again–More on Recent $1.6 Depakote Settlement

Okay, I admit that I'm confused. Last November I posted this about a $1.3B legal settlement paid by Abbott Laboratories over off-label marketing of its drug, valproic acid (Depakote):
http://brodyhooked.blogspot.com/2011/11/back-to-standard-form-letter-abbott.html

Now I learn from our friends at the Health Care Renewal blog that Bloomberg News just announced a $1.6B settlement from Abbott over the same drug for the same reason:
http://hcrenewal.blogspot.com/2012/05/abbott-pleads-guilty-settles-for-16.html
http://www.businessweek.com/news/2012-05-07/abbott-to-pay-1-dot-6-billion-to-settle-depakote-marketing-claims

So I have to assume that the article last November was a preliminary announcement and that this recent notice is the final announcement--otherwise Abbott would have paid a total of $2.9B over this one drug which would set a new record and would no doubt have been remarked on in the news media. The amount paid is of interest as previous reports of Pharma settlements often showed that the settlement sum, while in the hundreds of millions of dollars, was still only about 10% or 15% of the annual sales of the offending drug. In this case, $1.6B is the total annual sales figure for Depakote before it became generic. (But don't worry about Abbott, as the company proudly announced that they'd already set aside the funds needed to pay the settlement. Presumably, big drug companies find that sort of loose change under their sofa cushions.)

The settlement is also different from most in that Abbott was forced actually to admit wrongdoing, pleading guilty to a misdemeanor charge. As piddly as that may sound, in past settlements the company has usually been allowed to escape any admission of guilt.

Dr. Roy Poses over at Health Care Renewal focuses (as is his wont) on one aspect of this, which is the responsibility of the company and its CEO for this admitted wrongdoing. The settlement lets Abbott off the hook merely with being on probation for the next 5 years and promising not to do it again. Dr. Poses helpfully gives us Abbott's recent track record that presumably earned it this degree of lenience:

• Obstructing Justice - In 2003, an Abbott subsidiary settled civil allegations and pleaded guilty to obstructing a federal criminal investigation of its marketing practices, resulting in fines of $614 million ...
• Suppressing Reports of Drug Contamination - In 2009, the FDA charged that an Abbott subsidiary failed to report bacterial contamination of an optic product ....
• Blocking Generic Competition - In 2010, Abbott settled with the New York state Attorney General allegations that the company conspired to block generic competition for its lipid lowering drug TriCor ...
• Inflating Charges - In 2010, Abbott also settled with the US Justice Department for $421 million charges that it defrauded Medicare and Medicaid ....
• Paying Kickbacks to Doctors - In 2010, an Abbott subsidiary also settled with the US government charges it paid kickbacks to physicians to prescribe other cholesterol lowering drugs...
• Anti-Competitive Pricing Practices - In 2011, Abbott settled lawsuits alleging that its anti-competitive practices inflated prices of anti-viral drugs...

The Things that You’re Liable to Hear from Pharma Marketers, It Ain’t Necessarily So

I just finished listening to the latest issue of Primary Care Medical Abstracts from my friends Rick Bukata and Jerry Hoffman, which means that I have some more recent articles from the medical literature to comment on. This time the theme is: stuff practitioners believe to be true based on the way that Pharma marketing has flooded the medical airwaves, that may actually not be true at all.

• Chapter 1: Even if the Prozac class of antidepressants are not necessarily more effective than the older tricyclic antidepressants, at least they're a lot safer. A team from Nottingham, England looked at a database of about 60,000 patients 65 or older being treated for new-onset depression. They compared the outcomes for patients on the new-generation (SSRI) vs. older (tricyclic) drugs. They found in virtually every category a higher incidence of adverse reactions among those taking the SSRI-type drugs. The risk of dying within 1 years was 8.1% for people taking the tricyclics vs. 10.6% for the SSRI patients. This is an observational study and not a controlled trial, so you can't exclude the possibility that somehow the sicker patients were given the SSRI drugs and that explains why they had worse outcomes. Still, the huge number of patients included in the study certainly suggests that the safety of SSRIs may have been greatly exaggerated. (Coupland C, Dhiman P, Morriss R, et al. "Antidepressant Use and Risks of Adverse Outcomes in Older People: Population Based Cohort Study." BMJ 343:d4551, 2011)
• Chapter 2: Alprazolam (Xanax) has unique properties as a drug for panic disorder. While alprazolam is a member of the benzodiazepine class (minor tranquilizers like Valium), company marketing has been highly successful in associating it in physicians' minds specifically with panic disorder, so that if you have a patient with that diagnosis, or who even gets excited once in a while, and you try to treat that patient with any other benzo besides alprazolam, you're an idiot. An international team of folks did a systematic review of 8 studies that compared alprazolam to other benzodiazepines in the treatment of panic disorder. They found no evidence that Xanax is superior to any other drug in that class. They did find, however, that Xanax had a worse addiction profile and many additional adverse reactions compared to its benzo cousins. (Moylan S, Staples J, Ward SA, et al. "The Efficacy and Safety of Alprazaolam versus Other Benzodiazepines in the Treatment of Panic Disorder." Journal of Clinical Psychopharmacology 31:647-652, 2011)
• Chapter 3: If you want to prevent Type 2 diabetes, reach for a bottle of pills. There's been a huge interest, almost entirely driven by Pharma marketing, in diagnosing the condition "prediabetes" and then throwing medications at it.  This group from NIH utilized a database of over 200,000 patients who were surveyed for lifestyle factors in 1994-96 when none of them had diabetes, and then compared follow-up data in 2004-6 to see which ones ended up developing diabetes. They looked at smoking, body weight, diet, exercise, and alcohol consumption. Every single one of the healthy lifestyle factors was a significant predictor of not developing diabetes later on, with lean body mass being the single most powerful one. Basically, for every additional healthy lifestyle factor that you had, you reduced your risk of diabetes by about 1/3 compared to what it was previously. The main point here is the immensity of the effect--drug companies would kill to be able to announce a drug that reduced future risk of diabetes by 5-10%. The take home message seems to be that if it takes time and energy to counsel patients on lifestyle instead of reaching for ther prescription pad, it's well worth the effort. (Reis JP, Loria CM, Sorlie PD, et al."Lifestyle Factors and Risk for New-Onset Diabetes: A Population-Based Cohort Study." Annals of Internal Medicine 155:292-299, 2011.)

Avastin Continues to Impress for Eye Use

A while back I posted on the controversy about the drugs Avastin and Lucentis:
http://brodyhooked.blogspot.com/2007/10/retinal-specialists-get-integrity-award.html

Quick recap: Eye specialists found out almost by accident that a drug intended for cancer, Avastin, was really good for a particular eye condition, wet macular degeneration, and was also quite inexpensive. The maker, Genentech, then marketed a newer cousin of Avastin, called Lucentis, which of course they priced up the wazoo, and tried every trick in the book to get doctors to use it instead of the cheaper Avastin, which remains officially off label for eye use. (To their great credit, the retinal community refused to go along.)

In the earlier post away back in 2007, I noted that a trial was just beginning that would provide the definitive scientific answer to whether Avastin was as good as Lucentis for eye use, contrary to the interested claims of Genentech that Lucentis was superior. Genentech, quite naturally, refused to fund a head-to-head comparison trial of the two drugs to find out the answer, so an NIH-funded study was launched.

The first results of that study showed that the two drugs worked equally well, as did a more definitive follow-up report from the same study, as now helpfully summarized at Merrill Goozner's blog:
http://gooznews.com/?p=3892

So in case you wondered, we now have sound evidence for what the retinal specialists had all along believed based on the older evidence plus their impressive clinical experience--a cheaper version of the drug works just as well as the much more expensive version.

If the world were just, the FDA would now revise the labeling for Avastin to make it clear that it's indicated for wet macular degeneration, removing Genentech's claim that Lucentis is the only drug so approved. But to the best of my understanding, the world is not fair, and only Genentech can initiate such a label change at the FDA, which of course they would only do over their dead bodies. (If others know the FDA rules better please chime in.)

Barbara Roberts, "The Truth About Statins"

I recently had the privilege of attending the very important conference in Boston called Avoiding Avoidable Care (about how to both improve quality and reduce costs by avoiding the use of nenbeneficial tests and treatments), and there met Dr. Barbara H. Roberts, a cardiologist who heads the Women's Cardiac Center at Miriam Hospital in Providence, RI. I therefore learned about her new book, The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs (New York: Pocket Books, 2012).

I've not yet had time to read the entire book but zeroed in first on Chapter 7, which is titled, "Big Pharma, the FDA, and the Medical Profession: An Unholy, Very Lucrative Alliance" (for reasons readers of this blog can imagine). Dr. Roberts does a nice job of explaining her own personal experiences with the pharmaceutical industry (she did sponsored talks for a while until the managers decided she was actually telling the audience about the science rather than peddling drugs), and especially in revealing the extent to which organizations in her field, especially the American Heart Association, are in bed with industry and rolling in industry cash--and how that influences the supposedly objective guidelines and food approvals they issue.

I also reviewed what Dr. Roberts had to say about the JUPITER trial, about which I blogged extensively (for a summary see http://brodyhooked.blogspot.com/2010/06/more-on-cholesterol-statins-and-jupiter.html). Her analysis to my inexpert eye is both detailed and cogent.

In short this appears to be a great book for both physicians and patients about how statins for cholesterol have been way too aggressively marketed, and why old-fashioned lifestyle changes are probably a more potent and certainly safer way to reduce one's risk of heart disease.

The Wages of Sin Are Considerable

In an earlier post, I discussed the implications of Kenneth Frazier, CEO of Merck and former company general counsel, serving on the Board of Trustees of Penn State at the time of their recent coaching scandal:
http://brodyhooked.blogspot.com/2011/11/what-could-penn-state-scandal-have-to.html

In that post, I sumarized Mr. Frazier's career at Merck as follows: "So Penn State wants to put its investigation into the hands of a guy who first, did his best (in company with all the corporate leadership) to conceal the truth to assure that a favored brand continued to make profits; and second, once the truth came out, fought like heck to make sure that the human beings who were harmed by those corporate actions didn't get a penny. Sounds like a great plan to restore trust in the university."

The results of Frazier's leadership at Merck thus far have been roughly as follows, as nicely summarized by our good friend Roy Poses over at Health Care Renewal:
http://hcrenewal.blogspot.com/2012/04/spoils-of-scorched-earth-defense-merck.html

Frazier, he tells us, saved Merck megabucks by aggressively fighting all the Vioxx lawsuits. But Merck has since had to pay huge criminal fines for the way it marketed Vioxx,  most recently, a $950M settlement. Merck stock has been in the doldrums as a result.

So how has Merck treated their CEO? According to Dr. Poses (quoting the Dow Jones News Service), "Merck & Co.'s ... leader received compensation valued at $13.3 million for 2011, up 41% from the year before, reflecting his ascension to the drug maker's top post and Merck's ability to exceed certain internal performance targets."

As Dr. Poses has gone blue in the face reminding his readers, this is the norm for corporate America nowadays. Companies are not run for the benefit of their customers, or even necessarily for the benefit of their shareholders, but for the benefit of their top executives, with the full complicity of pliant boards of directors. When this sort of thing happens in the less-developed countries, we call it corruption. As both Dr. Poses' and this site have also blogged about in the past, until individual execs start to suffer real consequences (like how about jail time) for serious misdeeds, we can expect this behavior to continue. (See for instance: http://brodyhooked.blogspot.com/2010/04/cnn-pfizer-too-big-to-prosecute-shadow.html)

Yet More on the Broken Serotonin Model of Depression

A psychiatrist colleague sent me, with his endorsement, an article in the New York Times Magazine on the science of depression:
http://www.nytimes.com/2012/04/22/magazine/the-science-and-history-of-treating-depression.html
--whose author is Dr. Siddhartha Mukherjee of Columbia, whose recent book, Emperor of All Maladies: A Biography of Cancer was very well reviewed.

Since I have previously been dismissive of the serotonin theory of depression, Dr. Mukherjee's account of the history of the science of depression provides some potential balance. Dr. Mukherjee's basic hypothesis is that while it's clear that the idea that serotonin is a sort of magic bullet for depression is deeply flawed, two things are probably true--first, that serotonin plays an important role in at least some cases of depression in one way or another; and second, that drugs that change depression levels have been extremely helpful in our understanding of depression, not as cures, but as chemical probes that help us better understand what's going on in the brain--so long as we understand properly what the probes are telling us.

So I recommend the article, but I did find myself hiccuping at two places where I thought the author deviated from the careful and balanced tone he had established. The first such passage that caught my attention was: "But such a line of inquiry can’t tell us whether the absence of serotonin causes depression. For that, we need to know if depressed men and women have measurably lower levels of serotonin or serotonin-metabolites (byproducts of serotonin breakdown), in their brains."

Now, asking that question gets us a part of the way to an answer, but it's quite misleading if taken to represent the full answer. This is the old confusion between association and causation. Answering this question might reveal an association between serotonin levels and depression, but tells us nothing about whether that association plays a causal role, or whether some other thing is causing both the depression and the serotonin variations. Getting us messed up between association and causation is one of the primary ways that Pharma marketing manages to sell us a lot of ineffective and potentially harmful drugs.

The other passage that disturbed me relates to the newer theory of depression that excites Dr. Mukherjee the most, though he admits that depression is still very complicated and there may be no single "answer." The new theory is that while in most of the adult brain, no new cells grow, there seems to be an exception and new cells can grow slowly in one portion of the hippocampus, which seems to be related to mood. Experiments in mice show that behavior changes that are depression-related can be caused by enhancing or blocking the growth of these cells; and in humans, brain scans seem to indicate some similar function for cell growth in this region. Dr. Mukherjee then states about this cell-growth theory: "Nor does the theory explain why “talk therapies” work in some patients and not in others, and why the combination of talk and antidepressants seems to work consistently better than either alone. It is very unlikely that we can “talk” our brains into growing cells."

This passage seems a retreat back into another mode of flawed thinking that Pharma marketing exploits to mislead us--the old-fashioned mind/body dualism, which persists in treating the mind as foreign from the body and made up of different sorts of stuff, so that things that influence the body cannot affect the mind and vice versa. Dr. Mukherjee had just finished explaining to us that when mice are put in an enhanced environment with fun new stuff to explore, they become more adverturous and less depressed-seeming, and their brains also grow new cells in the hippocampus. He apparently forgets for a moment that if an enhanced environment can grow new brain cells in mice, then the enhanced environment provided by "talk therapy" in humans might have the same effect.

Despite these bumps in the road the article seems thoughtful and I commend it to your attention. I'll await the comments of more expert readers than I as to how good the science is that Dr. Mukherjee refers to.

Yet More on The Broken Disease Model of Diabetes

In the past I've ranted about how in dustry marketing helped to sell both docs and the general public on a flawed model of what "diabetes" is, for example:
http://brodyhooked.blogspot.com/2011/08/controlling-channels-pushing-pharma.html

Again with a hat tip to my esteemed colleagues Drs. Rick Bukata and Jerry Hoffman, I was informed of this study by a multi-national team, one of whom is an excellent person, Dr. James Wright at U-British Columbia, whose work on evidence-based prescribing I have long admired:
http://www.bmj.com/highwire/filestream/388629/field_highwire_article_pdf/0.pdf

These folks looked at 13 randomized controlled trials of type 2 diabetes, involving a total of 34,533 patients, which should be reasonably big numbers to be able to draw conclusions. These studies randomly assigned patients to either standard treatment or super-wonderful-tight glucose (sugar) control. According to our preferred model of diabetes, if you can lower the blood sugar, so that nice little machine Wilford Brimley tries to give away on TV will show better numbers, then of course you'll live longer and be healthier.

So what did these studies show? First, overall death rate was no different in tight sugar control vs. less tight control. Second, deaths from cardiovascular causes (mainly heart attack and stroke) were no different in the two groups.

Was anything different? Two things. First, one good thing-- the tight control people did have statistically fewer non-fatal heart attacks--maybe a 15% reduction in the risk of having one of those. Second, the bad thing-- your chance of having a severe episode of low blood sugar, which could lead to seizures or coma, was more than twice as great in the tight control group. For every one person you'd save from having a non-fatal heart attack, you would have about 5 who suffered severe attacks of low blood sugar.

So what's going on here? We have been brainwashed that diabetes treatment is all about controlling blood sugar, which is certainly the case in juvenile onset or type 1 diabetes. In the much more common adult or type 2 diabetes, the evidence is overwhelming that tight control is not the answer, and that our disease model should be all about blood vessel damage prevention and not about tight sugar control. So what does help in diabetes? First, good ol' diet and exercise. Second, quit smoking. Third, control high blood pressure. In short, treat diabetes as a disease in which you need to prevent further vessel damage. (One drug, by the way, is quite good for type 2 diabetes--metformin, a cheap generic, that helps prevent heart disease and also lowers blood sugar, but the two effects seem to be unrelated.)

But you'll never hear that message from drug companies who make drugs that do a wonderful job of lowering blood sugar, but don't do squat to make patients live any longer or healthier. Or from the device and supply companies that make a mint charging Medicare for the test strips that go in that cute little machine.