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Are Preventive Drugs Preventive Enough.pdf

Are Preventive Drugs Preventive Enough.pdf - n PROFESSIONAL...

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ABSTRACT Objectives – The study aimed to find the threshold of benefit for a hypothetical choles- terol-lowering drug below which the subject would not be prepared to take the drug. We also looked at whether proximity to the target event (myocardial infarction) and the subjects’ views on drug taking affected this threshold. Design – We studied 307 subjects using a written questionnaire and interview. Group 1 (102 sub- jects) had just been discharged from the coronary care unit. Group 2 (105 subjects) were taking cardio-protective drugs but had no recent history of myocardial infarction. Group 3 (100 subjects) had no history of myocardial infarction and were taking no cardio-protective drugs. Results – Median values for the threshold of ben- efit below which the subject would not take the preventive drug were 20%, 20%, and 30% absolute risk reduction for Groups 1, 2 and 3 respectively. Median values for expectation of average prolongation of life were 12, 12 and 18 months respectively. Only 27% of subjects would take a drug offering 5% or less absolute risk reduction over five years. Subjects’ views on medicinal drug taking in general and proximity to the target event were predictors of the accep- tance of preventive drugs. Eighty percent of sub- jects wished to be told the numerical benefit of a preventive drug before starting on it. Conclusion – For the majority, the expectation of benefit from a preventive drug is higher than the actual benefit provided by current drug strate- gies. There is a tension between the patient’s right to know about the chance of benefiting from a preventive drug and the likely reduction in uptake if they are so informed. KEY WORDS: absolute risk reduction, atrial fibrillation, cholesterol, evidence-based medicine, hypertension, myocardial infarction, National Service Framework, patient expectations, preventive drugs, Preventive drug strategies presume that it is the wish of the individual to avoid the target event for which the preventive drug is designed. But they also assume that the reduction in morbidity or mortality is suffi- cient to offset the inconvenience of having to take a drug long-term whose effect on the individual can only be expressed in terms of benefit to a population. For the average individual the chance of benefit is small – normally less than 5% over five years (Table 1). Doctors seldom share these figures with patients, whose acceptance of a preventive drug may be determined not only by the efficacy of the drug but also by their proximity to the target event, their perception of its gravity and their view on drugs in general. In this study we looked at subjects’ views on the limit of benefit below which they would not accept a preventive drug. We used as our model a hypo- thetical cholesterol-lowering drug in the prevention of myocardial infarction (MI). We looked at whether proximity to the target event (myocardial infarction) and the subject’s opinion on prescribed drugs in general influenced their views. Those taking cardio-
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