Clinical controversies to watch in 2015
A review of clinical uncertainties to look out for in the new year
Are gastric bands the best treatment for people with obesity?
Repeated studies have shown the difficulty that people who are overweight or obese have in losing a substantial amount of their body weight and especially in keeping that weight off, through diet, exercise and medication. Studies of bariatric surgery, on the other hand, show gastric banding and gastric bypass work quickly and effectively to reduce weight. Even more exciting, they seem to prevent type 2 diabetes in people at high risk of the condition, and even reverse diabetes in some patients.
Gastric banding is drastic treatment for a condition which should, at least theoretically, be treatable by lifestyle measures. It comes at a risk of serious complications and has a big effect on lifestyle after the operation. Many people are left with excess skin from rapid weight loss, which may require additional cosmetic surgery.
What’s the latest?
NICE guidelines published in November 2014 recommended offering bariatric surgery to people with a body mass index of 35 or over who have recently developed type 2 diabetes.
Are antidepressants overprescribed?
Prescriptions for antidepressants have risen sharply since the financial crisis of 2008 and represent the biggest increase in volume of prescribing by therapeutic area. Critics say depression is defined too loosely and many people diagnosed with depression are simply unhappy, in a rational response to their circumstances. Even for those correctly diagnosed, a Cochrane review found antidepressants helped only 1 in 7 people. Guidelines promote the use of psychological therapies such as cognitive behavioural therapy (CBT), but in many areas CBT is underprovided and people have to wait weeks or months for treatment. As a result, antidepressants are being used to plug the gap in the absence of potentially more appropriate therapy.
Depression is a serious and debilitating illness, which is under-recognised and undertreated. The rise in prescriptions is driven by longer duration of antidepressant prescription, not by an increase in diagnoses of depression. Antidepressants are as effective for treating depression as drugs in other branches of medicine, which don’t help everyone but do help some people. Antidepressants are not prescribed instead of psychological therapies but are compatible with them, and prescription rates do not reflect the availability of therapists in an area.
What’s the latest?
Changes to the diagnostic criteria for major depressive disorder caused controversy in 2014, when the new DSM-5 criteria broadened the definition to include persistent low mood two weeks after a bereavement. Critics say this medicalises human sadness as a normal response to events.
Should most people over 50 take statins?
Statins have proven their worth in reducing the chances of a heart attack or stroke among people who already have heart disease or who have a high chance of getting it within the next 10 years. Until 2014, advice from NICE was to offer statin therapy to people with a 10 year risk of 20%, calculated using risk calculators. After re-evaluating the evidence, NICE proposed this risk threshold should be lowered to 10%, based on their cost effectiveness analysis.
This new risk threshold could take in as much as 25% of the adult population and would mean most people over 50 should be offered a statin. This amounts to medicalising the well, exposing people to a side effect risk that experts do not agree upon, for a potential benefit of uncertain size.
What’s the latest?
Researcher and writer Ben Goldacre said treating a quarter of the population with statins on the grounds they had a 10% risk of cardiovascular disease over 10 years made clinicians “less like doctors and more like a life insurance sales team,” offering potential benefits many years away, for a small inconvenience and cost now.
Read more about The BMJ’s campaign to make the data from clinical trials of statins to be made available for independent scrutiny here: www.bmj.com/campaign/statins-open-data.
Do too few women receive hormone replacement therapy?
Hormone replacement therapy (HRT) fell abruptly out of favour in 2003, when big randomised controlled trials were published showing the treatment increases the risk of breast cancer and of heart disease and blood clots. But some think the risks are overstated and that women with troublesome menopausal symptoms are not being offered therapy that would make a significant difference to their quality of life. In addition to helping with symptoms such as hot flushes, women taking HRT have some protection against osteoporosis.
HRT is now thought to increase risk of ovarian cancer as well as breast cancer, stroke, pulmonary embolism and even dementia. For women with severe symptoms, the increased risk may be worth taking HRT in the short term, but for most women, doctors are right to be cautious.
What’s the latest?
The most recent report of long term outcomes from randomised controlled trial of HRT concluded that risks outweigh benefits for chronic disease prevention, especially for women who had not undergone hysterectomy and who took oestrogen and progesterone. The researchers conclude HRT is a “reasonable option” for women in early menopause with moderate to severe symptoms.
Should governments continue to stockpile oseltamivir (Tamiflu) against a flu epidemic?
Oseltamivir is the only antiviral drug available in tablet form that has been shown to have an effect on flu symptoms. Governments should ensure they have enough to mitigate the worst effects of flu, should there be another outbreak like the H1N1 outbreak of 2009.
There is no good evidence that oseltamivir reduces transmission of flu or reduces the chances of complications. A Cochrane review published in 2014, after full data was finally obtained from Tamiflu manufacturers Roche, found no evidence that it reduces the chances of serious complications from the disease.
What’s the latest?
Bird flu among poultry emerged again in the UK at the end of 2014. Government preparations for an epidemic still rely on the antiviral medications oseltamivir and zanamivir (Relenza), yet evidence suggests this may not be an adequate response.
Read more about The BMJ’s open data campaign to make the data from clinical trials of Tamiflu available for independent scrutiny here: www.bmj.com/tamiflu.
Should men be screened for abdominal aortic aneurysm?
While big abdominal aortic aneurysms are rare, they can kill if they rupture. About 93% to 97% of aneurysms are successfully repaired by surgery. However, most people don’t know they have an aneurysm until it ruptures. Screening by ultrasound means large aneurysms can be picked up and repaired before they cause damage.
Screening will find many smaller aneurysms, where the case for treatment is less clear. Men with smaller aneurysms are usually offered monitoring, but will have to live with the knowledge they have a condition that could kill them. While surgery is usually successful, some people die during the operation. Screening could mean some men die from surgery that they would not have needed, had they not been screened.
What’s the latest?
The NHS abdominal aortic aneurysm (AAA) Screening programme offers screening to men over 65 in England. In 2011/12, the latest year for which figures were available, 75% of invited men attended screening, 190 men underwent surgery to repair an aneurysm, eight men experienced a rupture and three of the men died postoperatively as a result, which is a mortality rate of 1.6%.
Should GPs diagnose more people with dementia?
What NHS England describes as “timely” identification of dementia and referral to support services will help patients and their families to plan their lives better, get treatment and support, and will improve their quality of life.
The NHS Screening Programme currently recommends against population screening for dementia. The evidence that an early diagnosis of cognitive decline or dementia will actually lead to treatment that makes a difference to people’s prognosis is unclear. Critics point out that services are already stretched and have proposed that any money available for dementia should be spent on research and support, rather than in diagnosing new cases.
What’s the latest?
NHS England’s enhanced service specification for dementia identification met a storm of criticism when it was unveiled in October. A large group of doctors and other healthcare workers asked for it to be withdrawn, saying that the scheme undermines trust and the doctor-patient relationship.
Is tight glucose control best for people with type 2 diabetes?
Diabetes is a leading cause of morbidity and mortality and is an independent risk factor for cardiovascular disease and microvascular complications such as retinopathy. Keeping blood glucose as close as possible to the levels found in people without diabetes (tight control) should reduce the chances of cardiovascular and microvascular events.
The effect of tight glucose control on the rate of cardiovascular events or microvascular complications is uncertain but carries a significant risk of severe hypoglycaemia. Any putative benefit from vascular protection could be outweighed by this risk.
What’s the latest?
Research published in The BMJ in 2013 found that severe hypoglycaemia itself carried a higher risk of cardiovascular disease. This suggests that the potential benefit of intensive glucose control could be diluted by the impact of episodes of hypoglycaemia.Anna Sayburn, freelance journalist, London
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Booth H, Khan O, Prevost T, Reddy M, Dregan A, Charlton J, et al. Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study. Lancet Diabetes Endocrinol 2014;2:963-8.
- National Institute for Health and Care Excellence (NICE). Obesity: Identification, assessment and management of overweight and obesity in children, young people and adults. NICE guideline draft for consultation. July 2014.
- Health and Social Care Information Centre (HSCIC). Prescriptions dispensed in the community, statistics for England 2003-2013. July 2014. www.hscic.gov.uk/searchcatalogue?productid=14988&q=title%3a%22Prescriptions+Dispensed+in+the+Community%22&sort=Relevance&size=10&page=1#top.
- Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009;3:CD007954.
- Reid IC. Are antidepressants overprescribed? No. BMJ 2013;346:f190.
- Spence D. Are antidepressants overprescribed? Yes. BMJ 2013;346:f191.
- National Institute for Health and Care Excellence (NICE). Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. July 2014. NICE guidelines CG181. www.nice.org.uk/guidance/cg181.
- Goldacre B, Smeeth L. Mass treatment with statins. BMJ 2014;349:g4745.
- British Menopause Society. Women’s Health Initiative—restoring the balance a decade on. Press release, July 2012. www.thebms.org.uk/newsitem.php?newsid=71.
- Wise J. HRT risks outweigh benefits for chronic disease prevention, research confirms. BMJ 2013;347:f5885.
- Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. Cochrane Database Syst Rev 2014;4:CD008965.
- Department of Health. UK Influenza Pandemic Preparedness Strategy 2011. www.gov.uk/government/uploads/system/uploads/attachment_data/file/213717/dh_131040.pdf.
- NHS Abdominal Aortic Aneurysm Screening Programme. Information for the public. 2013. http://aaa.screening.nhs.uk/treatment.
- NHS Abdominal Aortic Aneurysm Screening Programme 2011-12 Summary. http://aaa.screening.nhs.uk/reports.
- NHS England. Enhanced service specification: dementia identification scheme. October 2014. www.england.nhs.uk/wp-content/uploads/2014/10/dementia-ident-schm-fin.pdf.
- Brunet M, McCartney M, Murphy K, Heath I, Britton B, Chand K, et al. An open letter to Simon Stevens, NHS chief executive, and Alistair Burns, national clinical lead for dementia. BMJ 2014;349:g6666.
- Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, Lafont S, Bergeonneau C, Kassai B, et al. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ 2011;343:d4169.
- Goto A, Arah OA, Goto M, Terauchi Y, Noda M. Severe hypoglycemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ 2013;347:f4533.
Cite this as: Student BMJ 2015;23:g7489