Guideline recommended treatments in complex patients with multimorbidity
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5145 (Published 02 October 2015) Cite this as: BMJ 2015;351:h5145
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The authors state that with multimoribidity we have 'little to replace them (single disease guidelines)'
My suggestion is the re-invention of competent generalists as a replacement for most guidelines.
It isn't just patients who are 'confused and tyrannised when clinical management is driven by algorithmic protocols, top-down directives and population targets'.
Doctors are in the same boat!
Competing interests: No competing interests
Dear Editor,
I read with interest the article “Guideline recommended treatments in complex patients with multimorbidity” by Muth et al. in The BMJ [1]. There is one aspect worth considering.
More sedentary time was independently associated with higher multimorbidity rates [2-3]. For example, standing up frequently is a simple but highly efficient daily whole-body exercise for patients with multimorbidity, as it would not only increase blood circulation in the brain and strengthen the supportive muscular system as a whole, but also result in beneficial changes in metabolic syndrome components (e.g., 10–15 repetitions, twice a day). In a recent analysis of data from the 2003-2006 NHANES Dankel et al. showed that people participating in muscle-strengthening activities had a 26 percent reduced odds of having multimorbidity [4]. There is an inverse, dose-response relationship between physical activity and multimorbidity risk.
This again reinforces old, timeless sayings such as that from the Jewish physician Moses Maimonides (1138 to 1204). He wrote the following in his work Hilchot Deot more than 800 years ago: “Whenever one exercises and works but is not satisfied with what one eats and one's bowels are healthy, one will not become sick and one's strength will increase, even if one eats bad foods. Anyone who does not exercise, or holds back from relieving himself, or who has hard bowels, will have a painful life and his strength will weaken, even if he eats good foods and looks after himself medicinally” [5].
References
1. Muth C, Glasziou PP. Guideline recommended treatments in complex patients with multimorbidity. BMJ 2015;351:h5145.
2. Loprinzi PD. Sedentary behavior and medical multimorbidity. Physiol Behav 2015;151:395-7.
3. Loprinzi PD. Health-enhancing multibehavior and medical multimorbidity. Mayo Clin Proc 2015;90:624-32.
4. Dankel SJ, Loenneke JP, Loprinzi PD. Participation in muscle-strengthening activities as an alternative method for the prevention of multimorbidity. Prev Med 2015;81:54-57.
5. Hofmeister M. Effectiveness in the obese. Dtsch Arztebl Int 2011;108:612.
Competing interests: No competing interests
I am surprised that a journal such as BMJ which promotes EBM would repeat the urban myth that beta-blockers are not safe in asthma. Cardio selective beta-blockers certainly are safe to use in asthma. Newer evidence suggests that even older medications such as propranolol are also safe to use. http://pulmccm.org/main/2014/asthma-review/beta-blockers-safe-for-most-p... -- accessed October 7, 2015 0945 MST
Competing interests: No competing interests
Re: Guideline recommended treatments in complex patients with multimorbidity
Thank you for your responses. You encouraged us to illustrate further our somewhat abstract terms “doctor’s deliberate choice” (of prescription) and “practice variation”. We felt our example of the treatment dilemma of betablockers in asthma a bit outmoded but Dr. Devitt reminds us about its actuality: betablockers are “contraindicated” or - at least – “must be used with caution” in asthma. That’s what we find in recent summaries of products characteristics (https://www.medicines.org.uk/emc/) – e.g., on metoprolol, bisoprolol, propranolol, or even nebivolol. Recommendations within high quality evidence based practice guidelines are explicit and in line with this directive, as patients with comorbid asthma and reversible airway obstruction were excluded from the trials of beta blockers.1-4 Nevertheless, in individual patients, the potential benefit of betablockers may outweigh the risk of (potentially severe) respiratory dysfunction – as we discussed with our case example (a real patient) in a recent article.5 But the prescription of betablockers in asthma and reversible airway obstruction remains off-label use. Rather than based on good evidence for safe use, physicians (have to) act in a grey zone. Ideally, they are very careful about safety netting and follow up, and this will have an impact on outcomes.
With regard to the study by Tinetti et al., doctor’s deliberate choice of prescribing and further monitoring in individual patients are part of the– from a methodological perspective – unmeasurable confounding of the relation between exposition (guideline recommended treatment) and outcome (mortality). We also thank Dr. Storring for his comment. But rather than ‘replacing’ evidence by eminence our patients need our clinical expertise and competence to interpret and apply the evidence.
Reference List
(1) NICE National Institute for Health + Clinical Excellence, AHRQ Agency for Healthcare Research + Quality. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care (CG108). http://guidance nice org uk/CG108 [ 2010 [cited 2013 Aug. 7]; Available from: URL:http://guidance.nice.org.uk/CG108
(2) NICE National Institute for Health + Clinical Excellence. Hypertension (CG127). http://guidance nice org uk/CG127 [ 2011 [cited 2013 Aug. 7]; Available from: URL:http://guidance.nice.org.uk/CG127
(3) McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33(14):1787-1847.
(4) Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013; 34(38):2949-3003.
(5) Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med 2014; 12:223.
Competing interests: No competing interests