• comment on a post Killing Patients and Bilking Taxpayers over 7 years ago

    There is a real scandal here.  It's huge.  And you, in your oblivious denseness, missed it.  

    It costs the same amount of money to produce a vial of insulin and erythropoietin, both synthetic recombinant hormones.  

    But a vial of generic insulin costs $30.  And a vial of trade EPOGEN costs $18,000.  The reason that Amgen has to conspire to get Medicare to cover the cost, is because if they didnt, people would demand change in the pharmacuetical industry.  

    I know that the Democratic party is hostile to my profession.  Few realize it as much, I suppose, as me and good ole Doc Dean.  But for you to accuse good, ethical doctors who are trying to treat patients, alleviate suffering and save lives, of intentionally killing patients to score a few more buck, well, that's just fucked up.  

  • I read that link in the original post.  I found it completely useless.  

    Here's some information (from Up To Date) if you wanna review:

     The anemia of chronic renal failure is, in most patients, normocytic and normochromic, and is due to reduced renal erythropoietin production (a presumed reflection of the reduction in functioning renal mass) and, to a lesser degree, to shortened red cell survival [1]. However, other forms of anemia can occur, including blood loss from the gastrointestinal tract or via the technique of hemodialysis, as well as folate and B12 deficiency.  

    The use of EPO has essentially eliminated severe anemia as a major cause of morbidity in dialysis patients. In the United States, for example, over 90 percent of chronically dialyzed patients currently receive EPO and over 80 percent have hemoglobin levels greater than 11 g/dL [6]. Only a small percentage of dialysis patients can maintain adequate hemoglobin levels independent of the administration of EPO [7].

    Several general principles govern the administration of recombinant human EPO [1,8]:

    The response to EPO is dose-dependent, but varies among patients.

    The response is dependent on the route of administration (intravenous versus subcutaneous) and the frequency of administration (daily, twice weekly, three times weekly). With subcutaneous administration, frequency is not as important as with the intravenous route. (See "Erythropoietin: Subcutaneous administration").

    The response may be limited by low iron stores, bone marrow fibrosis, inflammation, inadequate dialysis, and other conditions (see below) [9].

    Hypertension may complicate therapy, particularly if the hematocrit is raised quickly. This is primarily limited to patients undergoing dialysis. (See "Hypertension following erythropoietin in chronic renal failure").

    In addition to treating anemia, the administration of EPO may have other hematologic benefits, including correcting the abnormality in platelet function, thereby lessening the risk of uremic bleeding [10]. This may explain in part the reduction in the number of transfusion-dependent patients associated with the appropriate use of EPO. (See "Platelet dysfunction in uremia"). Others, however, have found that EPO has no significant additional hematologic effects [11,12].

    Via uncertain mechanisms, EPO appears to have some non-hematologic beneficial actions, although they are likely directly or indirectly due to increased hemoglobin levels:

    Relief of a variety of uremic signs and symptoms, such as sexual dysfunction in men, and impaired carbohydrate and cortisol metabolism.

    Improved quality of life parameters, particularly vitality and sleep [13,14].

    Increased cognitive function and cerebral blood flow [15].

    Target hemoglobin level -- We recommend that hemoglobin levels in dialysis patients treated with EPO or darbepoetin alfa should be maintained at or above 11 g/dL and should not be routinely maintained above 13 g/dL. This topic is discussed in detail separately. (See "Anemia of chronic kidney disease: Target hemoglobin/hematocrit for patients treated with erythropoietic agents").

    Dose -- Some clinicians have recommended that the starting dose of EPO for hemodialysis patients with adequate iron stores and without underlying active inflammation should be 50 to 100 units/kg (U/kg) given intravenously or subcutaneously three times weekly at each dialysis session; an acceptable response should occur within three months (show figure 1). There is, however, a wide interpatient variability as the dose of EPO required to reach hemoglobin levels above 11 g/dL ranges from 50 to 300 U/kg.

    At a starting dose of 100 U/kg given intravenously three times weekly, ninety percent of patients will attain a hemoglobin level of 11 to 12 g/dL, compared to 70 percent that will reach this level with 50 U/kg. The logic of starting with the higher dose and then titrating down is that a month of therapy may be wasted on the nonresponders if the lower dose is used initially. Titrating up from a smaller initial dose allows the hematocrit to rise more smoothly and more economically than with the titrate down approach.

    Intravenous therapy may also require approximately 30 percent more EPO than with the subcutaneous route. While either intravenous or subcutaneous EPO administration may be acceptable in hemodialysis patients, in whom the intravenous route is more convenient and is currently specifically recommended in the drug package insert, patients on peritoneal dialysis and patients with CKD who are not on dialysis should be treated with subcutaneous administration (see below).

    Treatment algorithms, including those based upon once weekly dosing, have been published to help manage anemia in patients with end stage renal failure [23-25]. However, few if any have been prospectively analyzed for efficacy. A simple algorithm, which was principally administered by nurses, was prospectively evaluated in a study at one dialysis unit [23]. After four to six months, the percentage of patients meeting target values had increased from 27 to 61 percent. In addition, the number with hemoglobin values below desired levels had decreased from 46 to 18 percent, and the weekly EPO dose decreased from 11,200 to 9,400 units.

    Side effects -- The most common side effects of EPO treatment, aside from hypertension and its related problems, are headache which occurs in 15 percent of cases and an influenza-like syndrome affecting 5 percent [28,29]. The influenza-like syndrome is of unknown etiology, but is responsive to anti-inflammatory drugs [30]. (See "Hypertension following erythropoietin in chronic renal failure").

    So.. is this how you get people to do your research for you when you wanna go out on a Friday night?

  • Companies don't prescribe medications, doctors do.  I find it hard to believe that a cabal of cancer and kidney specialists (well paid specialties) would cause harm to patients so they could get some kind of kick back.  

    You can't just make specious claims in medicine.  That's why we call it evidence-based medicine.  Evidence shows that patients who suffer from anemia due to kidney or bone marrow failure (as would happen in renal failure or during chemotherapy) have an improvement in their anemia when treated with this hormone.  

    It is possible that while the anemia is improved with the use of EPO and patients feel stronger, over-all outcomes are worse.  If so, this would represent a huge shift in the understanding of EPO.  In that case, physicians would be ethically obligated to change their use of the drug.  These shifts are not uncommon.

    But before I accept Stoller's premise here, that doctors are intentionally killing patients for some extra cash, I would want to see the peer-reviewed evidence that documents this.  

  • comment on a post The Outreach over 7 years ago

    I suspect that candidates will get better with outreach as the campaign marches on.  When comparing to the French candidates, remember that this is the time of their general election.  We are still a year and a half away.  

  • Patients with Medicare are well insured.  Many patients with renal failure don't qualify for Medicare, and I suspect that for-profit clinics don't accept medicaid or other lower paying re-imbursement programs.  And private insurance companies have clear interest in denying expensive drugs.  (And by expensive, I dont mean $300.. I mean like $18,000.)

    These types of kick back schemes are pretty standard in our disfunctional and collapsing system of medicine, I think.  The entire premise of Medicare Part D is huge government subsidies to the big drug companies, in order to perpetuate drug prices that are so high, they would be unsustainable otherwise.  I can not understand how such overt corruption was allowed to happen.  

    You may not be placing the BLACK BOX WARNING into a proper context.  I have prescribed drugs with the above warning to pregnant women, when other drugs without a 'BBW' posed a greater risk to fetal development.

    EPO was considered quite benign when made available, and was used by professional athletes with normal hemoglobin levels to boost their hgb in order to gain a competitive advantage.  It is now tagged as a disallowed performance enhancing drug, but still widely abused, like anabolic steroids or diuretics (both classes of drug potentially more toxic than EPO.)

    Because naturally occuring EPO is produced by kidney cells, very few patients in renal failure have normal hgb levels.  Do the patients need so much EPO?  Probably not.  People can acclimate to severe anemia, and function quite well.  Will it make most people feel a little stronger and more energetic?  Probably.  Blood transfusions would certainly be cheaper.

    So, what I didnt get from your post is the finding of a peer-reviewed study that concluded that high levels of EPO use, or EPO used in higher doses was "killing patients!"

  • comment on a post Killing Patients and Bilking Taxpayers over 7 years ago

    The story is not that Epogen is over-used.  The story is that it is under-used on people who can't afford to go to for-profit dialysis centers.  

    The story, part two, is that drug companies are allowed to charge such obscene amounts of money for drugs.  

  • comment on a post Second Post-Debate Thread over 7 years ago

    Winner is Gravel.  Winning for him is relative, of course, since he is struggling to break into the third tier.  He might have been able to do so tonite.  We'll see if he breaks out of the 0% margin of error.

    Loser is Clinton.  She appeared to be just one of many candidates, and did not bring the awe of inevitability to the debate.  This was expected, but as these fora increase through the season, her lead will continue to drop.  

    I am interested to know how many people actually watched the debate.  Next state or national poll of likely primary voters should include the question "Did you watch the candidate debate" and I would like to see crosstabs for just this group of likely voters.  

  • comment on a post Democratic Presidential Debate Thread over 7 years ago

    I am considering becoming a Gravel partisan.  

  • Interesting use of the term here.  Bush certainly is Nixonian.  Even Robert Novack said that Bush is more isolated now than Nixon was at the height of Watergate.  Bush's admission that he authorized the executive to ignore the FISA laws alone is an impeachable offense.

    So we have a president who orders torture, perpetual imprisonment without trial or even identification, suspension of habeas corpus, a president who is criminally negligent as a great American city is destroyed, a president who ordered the illegitimate invasion of a sovereign country, from which neither of our countries will recover.

    I guess what we need now is a opposition party that is willing to initiate impeachment hearings.  And save all the strategy speeches, I have heard them all.  

  • The huge halo around Reid's head in the Reuters photo was hard not to notice, and reminiscent of the Bush halo pics.

  • comment on a post Bitch About Your Cell Phone Thread (poll) over 7 years ago

    Does anyone think that Stoller's company has tagged him as a net-neutrality malcontent and activist and is intentionally screwing around with his service?

  • comment on a post Iraq Coalition Military Fatalities By Friedman Unit over 7 years ago

    So now we have the Bowers unit: the number of coalition casualties in a Friedman unit divided by 180.  A far more useful piece of calculus, on the whole, than the FU.

    I talked about the inevitable increase in casualties due to the surge at the beginning of the year in unspectacular DK diary.  The increase in casualties is not simply due to the increase in the occupation army, but a fundamental change in strategy.  

    Prior to the surge, the only coherent and constant goal was force protection.  That's why the commanders at the time testified before congress that they didn't need more troops.  It would just be more troops to defend.

    The point of the surge is not a huge increase in the total number of soldiers; the increase is not all that much.  The term "surge" is itself a misnomer.  

    The point is the change in strategy from force protection to active policing of Iraq.  Force protection must now take a back seat to policing of unstable areas, and that gives insurgents far more opportunites to kill our soldiers.  

  • 12,33,7,8

  • She is very cute.  JG, arent you a gay guy?

  • i agree that that is the premise, like Newt diclosing now  his active adultery during the clinton impeachment.  Brave moves, get the worst out first...but huge riisks.. lets see how it plays out.  


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