What is MedEvidence: Three Major Elements of Decision Making

What is MedEvidence:  Three Major Elements of Decision Making
Risk vs. Benefit

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Kevin Geddings: 0:16

So we're going to spend a little bit of time talking about a really interesting and very useful website, the MedEvidence website. Dr. Michael Koren is here with me and of course, he heads up the show with ENCORE Docs and also helps us get good health care information and medical research information. Dr. Koren, give us the website, the actual address, and then we're going to start talking about it in a little more detail.

Dr. Michael Koren: 0:39

Okay, yeah, thank you, Kevin. It's called MedEvidence. com and it's a platform that we established several years ago to help people understand how to evaluate medical products, services, tests and claims in an objective way and also from the standpoint of somebody who's involved with clinical research, which is the way we actually put things to the test. So we like to call it the truth behind the data, and I'm happy to explore that with you, because there are actually some principles that one should use to understand health claims as well as possible and then ultimately make good decisions for you and your family.

Kevin Geddings: 1:20

Yeah, Dr. Koren. Obviously there's justa flurry of health care information that comes flying at us. It seems like every day there's a little snippet either in the news or on our Facebook feed that says that here's the latest research on Alzheimer's or the effectiveness of statins or whether or not the COVID vaccine latest variation works.

Dr. Michael Koren: 1:39

How do we?

Kevin Geddings: 1:40

How do we use MedEvidence to help us make better sense of all this health care information that kind of blows at us out of a fire hose.

Dr. Michael Koren: 1:48

Yeah, and keep in mind that when you Google something, you're going to get information back that's based on somebody trying to sell you something, and that's fine. I have no objection to capitalism. I'm a capitalist. I think you are too as well, Kevin, but ultimately, people need to get to the truth. And how do you do that? So, again, our bias is only that we believe in evidence-based medicine, we believe that medical claims should be backed up by some scientific information, and we are part of the process for generating that scientific information. So that's what I do day to day. So, when I think about how to advise patients and family members and friends, it comes down to understanding certain elements that will help you think through these things in a much better way, and I like to say that there are three big categories. One, understand how to look at risks versus benefits. Two, understand who you are and how that's relevant to medical decision making. And then, finally, understand issues around value and convenience. And then the fourth thing is that once you've gone through those three major elements of decision making, then you have to know what dose to pick, and the devil is in the details. So we'll get to that and we're going to break down each one, right? So let's start with the concept of risk versus benefit. So, Kevin, what do people usually ask me when they come to my office? Rhetorical question they ask me is something good or bad for me, right? And that's not a great way to think about the world, because everything could be good or everything could be bad. There's nothing intrinsic about things that are either good or bad. It depends on their context. So, for example, is water good for you? Well, we all need water to live, and water and being hydrated is important. But you can drown in water and you can literally kill yourself with water. People have actually drank so much water that they die from water intoxication. So water isn't good or bad. Water is something that has a benefit and a risk and, depending upon what your question is, what your circumstances are, you can assess that risk versus benefit. Obviously, in the doses that we usually use for water, the risk is extremely low, but it doesn't mean it's zero. And actually, when you get into management disease, the amount of fluid in one's body becomes very, very important in terms of how well they'll live their lives. And, of course, this concept of risk versus benefit carries through in virtually every decision we make in medicine. So some of the common ones. I think you and I have talked about this should I take an aspirin a day? Is aspirin good or bad? Well, aspirin is neither good or bad, but aspirin is something that, if used correctly, can reduce your risk for heart artery disease. If used incorrectly, it could increase your risk of having a gastrointestinal bleed, and so we can go into why, in certain circumstances, something should be considered to be high risk and something that should be considered to be low risk.

Kevin Geddings: 4:57

Does that resonate? Yeah, I think I guess I would ask and back up a little bit. When somebody first goes to Dr. Google and they research whether or not it makes sense to take a statin because they've been told their cholesterol is elevated, and they see all these results and depending on how they typed in the search, it could come up with all kinds of stuff, what would you recommend for we laymen out here? I mean, how do we handle that? How do we handle all that stuff that's appearing on our Google search results? What should be step one, as we really look at that, understanding the whole risk reward notion that you just explained?

Dr. Michael Koren: 5:32

Right. You should look at the information based on that risk reward mentality. So, for example, if you're looking at statins and you're just looking up their side effect profile, well, you're going to find lots of reports about side effects, right. On the other hand, if you look at statins and you say what are all the potential benefits? You'll say that they save lives, they reduce strokes, they reduce heart attacks. There's no question about that. And you get more into the risk versus benefit when you start to look at the clinical research elements and you also look at the consistency of all the scientific data. So, if you have heart artery disease or if you've had a stroke, there's nothing that ever has said that, on average, stentons will be bad for you. Obviously, somebody could have an individual side effect, but as a population and you're at that high risk category of having had previous heart disease there's nothing out there that says that stentons are a problem. And there's nothing out there that says getting your LDL cholesterol down to as low as possible is a bad thing. So some people have said in the past oh, you need a certain amount of cholesterol to live Well, that's really not exactly true, and the reason it's not true is because your body is very, very capable of making cholesterol from basic ingredients. So every cell in the body is able to produce cholesterol for its own needs, which are multiple. Cholesterol is a very, very important part of cellular functions but because of that, every cell in your body except your eyelashes, interestingly enough can make cholesterol. And the stuff in your circulation, the stuff that we measure is the extra stuff your body's trying to get rid of, and the stentons help your body get rid of that. So again, getting back to your question is look at the clinical trial evidence or look at a resource like MedEvidence that breaks this down, not from anecdotes or stories, but looking at more global pictures, and then fit yourself into that global picture. Is it relevant to you? So, for example, if you're a 22 year old woman who is a vegetarian and you get a report that your cholesterol is a little bit high, don't freak out. Chances are that that may be "good cholesterol. Quote unquote, meaning that the cholesterol your body is trying to get rid of is in a favorable package called HDL and that person shouldn't be on a statin number one, because they probably don't need it and number two statins can cause birth defects. So if you're a 20 year old woman and you may get pregnant or you may want a baby. You don't want to be on a statin. So, again, this is the concept of one looking at risk, benefits, and then start putting it into step two, which is who you are.

Kevin Geddings: 8:17

And it would seem that Dr. Koren all of us, I guess is layman consumers of health care. We want absolutes right. We want absolute answers. You know that say, okay, this is good, this is bad, this will work 100%, this won't, and that's really totally seems like it's unrealistic to ever look at any health information in that way.

Dr. Michael Koren: 8:38

You're absolutely right, Kevin, is that if you look at anything absolutely, you'll be absolutely wrong. So with that concept let's take a break and in our next session let's talk more about who you are and why that's so important.

Narrator: 8:52

Thanks for joining the MedEvidence podcast. To learn more, head over to medevidence. com or subscribe to our podcast on your favorite podcast platform.

Who You Are

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Kevin Geddings: 0:17

And we're spending time with Dr. Michael Koren today and we're talking about how to get good information about our health care status, all the health information that's out there, all these medical studies, all the research. You know how do we go through all that and make it work for our lives and the lives of our friends and loved ones? And so we're talking with Dr. Koren about that. There's a great resource out there that Dr. Koren and his team direct and are responsible for. It's the MedEvidence website. Go to MedEvidence. com. That's MedEvidence. com, and before we get into the details of what we want to talk about in this podcast, Dr. Koren summarize really quickly what people are going to find when they go to MedEvidence. com.

Dr. Michael Koren: 0:57

So thanks for that great question, Kevin, and MedEvidence is a platform where people can find the truth behind the data. Unfortunately, when you ask Dr. Google for some health information, typically what you get back is what somebody's trying to sell you. Nothing wrong with selling you stuff, but you need to be objective and you need to look at information that's relevant to you. So in our first session, we talked about not thinking about things that are good versus bad. Everything could be either good or bad, and there's nothing that's absolute. You should be thinking about the world as risk versus benefit and, as part of that risk versus benefit analysis, who you are is really, really important. So there are characteristics that are just your characteristics that will ultimately be important in terms of making good decisions about what health care claim you should believe, what product you should use, what service you should use, et cetera. So let's break that down a little bit more, okay, so let me use you as an example, Kevin, who you are. So, as a radio entrepreneur, I would say that when you are making a decision about what antibiotic to use for, let's say, urinary tract infection, you may not want to use something that has a side effect of hearing loss. That's true, right. So that's nothing to do with your race or your sex or gender, but it has to do with what you do for a living and what your personal risk versus benefit is. So we know that certain antibiotics called the macrolides example that would be a Z-Pak or azithromycin or vancomycin in particular that you get in the hospital. One of the side effects of that that's unique to that particular product is hearing problems, hearing loss. That would be a really bad risk for you, Kevin.

Kevin Geddings: 2:52

Yes, it would be.

Dr. Michael Koren: 2:54

So if you look up Google Best Antibiotics for a urinary tract infection, that element of your thinking is not going to be there. But we like to get that element of thinking in the MedEvidence podcast so that people can personalize things. During the break, right before the session, our producer was saying that she took glucosamine for the last 20 years and that it helped the arthritis pain in her knees. And is that good or bad? Well, how should I look at it? Well, glucosamine as a nutritional supplement isn't as well tested as drugs. Obviously, because of FDA mandates and government control over the drug supply, these things have a lot of information before they get on the market. Glucosamine as a nutritional supplement isn't subject to all those rules, but there are actually some studies with glucosamine that showed it has some benefits. And then, of course, there is the old trial and error assessment, which is a bit of a clinical trial, where an individual tries it, then takes herself off of it and tries it again, and you sense whether or not there is some benefit to these things and over time you figure out that this works for you. It doesn't work for you. Well, our producer, or happened to know is a pretty serious athlete and she's running and biking and using her knees all the time. So the who you are elements of it is that she's extremely active and needs some help for the pain in her knees. That will come with her activities and her choices will be taking ibuprofen or an anti-inflammatory like that that could have gastrointestinal side effects, or maybe taking something like glucosamine or some combination thereof. So for the who you are elements of it it's her day to day activities that are important, not her race or her gender, necessarily. We do know that women have more bone risk than men, but in this case, it's more about your day to day activity, and that's true based on your occupation. So, as a cardiologist, my day to day occupation doesn't necessarily put my knees at risk, but I happen to like playing soccer, which has put my knees, ankles, hips and my head at risk on many occasions, and so the things that I choose will be reflection of who I am and what I like to do. Now there's been a lot of focus in the media about race, for example, and what I like to tell people is you know, race is a consideration in terms of health care claims, but probably less than a lot of other things. So I like to remind people that genetically, we are 99.9% identical between blacks and whites, and Asians and whites, et cetera, et cetera. So, on average, things are going to be the same between blacks and whites. Women are men are fundamentally different. We have different chromosomes, so, although we're mostly the same, there are differences that could impact our health. But, having said that, in a lot of situations there's really no difference between the way men and women are going to respond to antibiotics or cholesterol drugs or most things. But there are some things where that would be a consideration, particularly when you get into hormonal issues and things that may affect us differently, or disease predisposition. So, for example, men tend to develop coronary artery disease and atherosclerosis 10 years earlier than women. Doesn't mean that women don't get benefits from the treatments that will help men, such as Statins, but that their risk profile may be different, and this is again the interface between who you are, risk profile and what decisions you make. Family history may be the most important thing, so is there anything in your family, Kevin, that is of a particular concern when you evaluate your health?

Kevin Geddings: 6:41

Well, history of diabetes type two diabetes on both sides of my family, so obviously you have to be somewhat conscious of that.

Dr. Michael Koren: 6:49

Yeah. So something like diabetes is going to be more related to situational things, so physical activity that's going to be related to your diet and things of that nature. So my guess is that if you stay fit and trim the way you are, you'll be okay. But maybe, because of your family history, if you get a little bit overweight, you think this will go in the wrong direction. Big example of that. Obviously we know there are certain cancers that run in families. There are certain other conditions. One that I deal with a lot is called familial hypercholesterolemia, where the function of your LDL receptors these are the receptors that clear cholesterol from your circulation is impaired and these people, genetically, have extraordinarily high risk and they have to be looked at differently than other people that may have high cholesterol just based on eating too much fried food, for example. Another example that you and I have talked about this more than once is lipoprotein-a, which is a type of lipid particle that we couldn't do anything about until very recently, and now we have strategies through clinical trials that expose people to products that can lower their lipoprotein-a by more than 90%. So again, who you are has to do with your genetics and family history. And, by the way, LP(a) affects all races, all religions, it affects all genders, so this is something that crosses those lines, and it's just about what your family tree looks like and whether or not you inherited the gene that causes a high level of this lipoprotein.

Kevin Geddings: 8:26

Well and clearly the takeaway right. Whether we're considering risk versus benefits to some of the health information we get, or who we are, you know, in terms of our genetic makeup or where our socioeconomic status is, or what have you, it makes it really hard just to go to Dr. Google and just start looking at the results of you know, the media talking about some recent health care study. Right, because that information is going to be so synthesized it's not going to consider any of those two issues.

Dr. Michael Koren: 8:50

No, exactly, exactly. And then the other piece of who you are is your belief systems, and I think we should spend a few moments looking at that. So you know, there's certain people that have belief systems that will favor, for example, exercise as their primary way of treating things. And you know, exercise is wonderful, exercise is intimately associated with longevity and prevents a lot of problems. But there are certain situations where you can exercise all you want and it's still not going to change your health course. And then you need to look at other things, and I brought up a familial hypercholesterolemia before, and that's a great example of it is that you can exercise 24 hours a day, if that were possible, and you're still going to have high cholesterol because genetically you're predisposed to it. So belief systems are important. You get into religious belief systems Jehovah's Witnesses, for example that don't want to take blood products. That's always a challenge, and if that's the belief system and that's the trade-off you want to make, then that's fine. We'll do the best we can with treatments that don't involve blood products. But sometimes they're belief systems that are not internally consistent, and I think it's fair for our MedEvidence platform to challenge those belief systems, or for me, as a physician, to challenge those belief systems. So an example of that is I've had people that have rejected the messenger RNA vaccines because they don't want genetic material in their body. So let's think about that for a second. Well, every time you eat a steak, genetic material from something foreign gets into your body. Think about that. Or, if you're really fearful of genetic material in your body, you should be super fearful of viruses. Because what are viruses trying to do? Viruses are trying to get RNA or DNA in your body. Now, fortunately, we have ways of protecting ourselves against that. But the beauty of the messenger RNA is that you're just taking a small little snippet of genetic material that's coding for a protein. You don't even get the whole RNA or the whole DNA, it's just a little snippet, and so that's going to be intrinsically safer. And by producing a protein based on that little email that we get from the vaccine, you're protecting your body against getting RNA and DNA in your body from viruses. So when you think about it in those terms, sure we love to respect patients' belief systems, but let's at least make those belief systems cohesive and internally consistent.

Kevin Geddings: 11:22

It would seem to you that we have an issue with you know, when people see four or five items on a Facebook feed or something and their cousin says it, that's almost assigned the same amount of weight as something that comes from a group of research scientists who've been working on something for 10 years.

Dr. Michael Koren: 11:38

Yeah, Well, again, sometimes the cousin may be more right than research scientists, and you know we all make mistakes, but again, the evidence is what's important. So, again, I don't hopefully I sound credible, but you should trust me. Not because I sound credible, but you should trust me because I'm looking at the data and I'm trying to help people understand the data. And, as we ended our last session, it's not about absolutes, it's about looking at the data and one determining that we know the risk versus benefit and we know how that plays out based on who we are. And with those first two elements, I think people will make much better decisions than just trusting their cousin on Facebook saying you should take zinc because it's good for you, and maybe we'll get into that for the next session.

Kevin Geddings: 12:27

In the meantime, check out the website MEedvidence. com. That's MedEvidence. com.

Narrator: 12:32

Thanks for joining the MedEvidence Podcast. To learn more, head over to medevidencecom or subscribe to our podcast on your favorite podcast platform.

Value vs. Convenience

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Kevin Geddings: 0:17

For spending time with Dr. Michael Koren, of course, with ENCORE Docs, and he also heads up a team that's responsible for a great website, MedEvidence. com. That's MedEvidence. com a great place to go to get just good, accurate information. That's not particularly biased, right, Dr. Koren, it's just information we like to call the truth behind the data.

Dr. Michael Koren: 0:39

Thanks, Kevin, for helping us explore how to get the most out of the MedEvidence platform. It's been a valuable conversation so far. Maybe you can summarize it for people who just are starting with this podcast.

Kevin Geddings: 0:52

Yeah, we've been talking about how the website will help you do deal with issues like trying to determine risk versus benefits, the importance of who you are in terms of your genetic makeup, what your background is, what your socioeconomic status is. All these filters matter when you're looking at health-related information to try to figure out how it applies to you or your loved ones. We also thought we would talk in this segment about value and convenience, because when we see options out there for all the many supplements especially, and other things we can do for our health most people have a budget, right, Dr. Koren. They have to determine what is of true value for them and their loved ones.

Dr. Michael Koren: 1:32

Exactly. Yeah, that was a great summary. So again, the three tiers just to reiterate it for the audience is first, think in terms of risk versus benefit, not just good or bad. Everything could be good or bad, depending on circumstances. Then know who you are and how that's relevant for the medical decision-making. Now to the third tier, which is what's the value to you? The value in terms of dollars, the value in terms of time, the value in terms of other options. So, with all these things, sometimes the easiest way to illustrate the point is through an example. This happens every day in my practice, so literally clinic. Yesterday I talked to a patient. He's like many other patients, some guy in his 70s. He's on probably about 14 supplements. I asked him why are you taking these things? Typically the answer is well, someone told me it was good. Okay, well, we can break it down and say well, there's always a risk versus benefit. In this particular case, let's talk about zinc. That was one of the things that he was on. I asked him why are you taking zinc? He didn't really have an answer. Well, there's actually studies that have looked at zinc. So in terms of the risk versus benefits just a quick overview I can talk about zinc for an hour, but in one minute what I would say is that everybody needs zinc. Zinc is very critical to many biochemical processes in your body, but you can also get zinc toxicity. So a typical element of zinc toxicity is something called a taxia, where you lose your balance or your muscle function is a little bit off, and that's well known to occur for people that overdo it with zinc. The other thing is that zinc interacts with other important elements that your body also needs. So when you take zinc, it's more difficult to absorb iron in copper. So that is a consideration. So if you're anemic and you're taking iron supplements, well maybe you shouldn't be taking zinc because that can affect the absorption of iron and copper. So all these things get into the element of kind of who you are, and then we get into sort of the value proposition. Well, zinc actually has some data showing that it's effective for people with macular degeneration, and so that's an eye condition of the elderly, and I think a lot of ophthalmologists recommend zinc supplements for patients that fall into that category. So if this fellow who I spoke with yesterday had mentioned that his eye doctor recommended it, I would say, okay, that's cool, that makes sense, you have a reason for taking it. Another area where zinc has had some benefits is in trying to reduce the symptoms of oral illnesses. So a number of studies that have looked at using zinc immediately after developing some symptoms of an upper respiratory infection and typically that's going to be a liquid zinc or the zinc losanger that can absorb in your mouth and there may be some ways that those products reduce the severity of the illness and studies have borne that out. So the truth behind the data is, under those circumstances that helps, but there are no data to say that if you take one zinc pill every day, that you can prevent disease, and in fact there's some studies that show that that in fact doesn't happen. So, again, context and the use of it is important, and then you get into value. Well, if you're taking one zinc tablet every day to prevent viral diseases, well, you're probably making your urine very expensive by taking all these nutrients that are not needed. The other thing is that if you're somebody that likes breakfast cereal in the morning, well, take a look at the zinc content of that and you'll find that most breakfast cereals are actually fortified with lots of different nutrients, including zinc. So do you really need that 50 milligram zinc pill if you're getting a bunch of zinc in your multivitamin and your breakfast cereal? Well, the answer is no. So in terms of value, there's pretty much no value to that. Then the other thing that comes up is that there's a lot of different preparations for all these products that are marketed, and sometimes very expensive depending on the marketing, and there's a ton of examples of that. So when you look at value, you might see something that says Chelated Zinc. Well, what does that mean? Well, what it really means is that the zinc is attached to something that makes it easier for your body to absorb. So the question is well, how easy is zinc for the body to absorb? And the answer is your body does a pretty good job of absorbing zinc. In fact, if you look at a run-of-the-mill zinc oxide, your body is going to absorb 50 or 60% of that. So if the key-lated product costs two or three times more and brings it up to 70%, is that really worth it? I would say probably not. So, again, the devil is in the details, which we'll get into the next section, but here's an example of we all have to make consumer choices and you pay $20 or $5 for the same basic preparation. Now the flip side is that there are certain nutrients, for example magnesium, that your body doesn't absorb very well and as a cardiologist, I'm really focused on magnesium because magnesium is extremely important for a number of cardiovascular functions, including prevention of arrhythmias extra heartbeats. So some people be on magnesium supplements and maybe we're not getting their magnesium levels to where they need to be, and that person may need to consider a different salt than magnesium oxide, which is a commonly used salt that's inexpensive but may not be absorbed, as well as some of the other magnesium salts that are available in the market.

Kevin Geddings: 7:07

And Dr. Koren, I think there are also an issue as well with when the gentleman your patient was taking 10 or 14, however many supplements, it was how those might interact with other prescription medications.

Dr. Michael Koren: 7:18

Oh, absolutely. It's a really important factor. So there's many examples of how one can impact another and that's why, with pharmaceuticals, you're gonna get information about do you take it on an empty stomach or do you take it on a full stomach? Do you take it at the same time as other things? A great example of that would be you shouldn't take Viagra and nitroglycerin preparations at the same time because of a drug-drug interaction, and those things also happen between supplements. I mentioned already that zinc affects the absorption of iron and copper and, again, depending upon the medication we're talking about, nutritional supplements can actually affect the absorption of multiple different medicines and again, you have to get into the details and talk to your doctor about it or look up those specific elements online which can be readily available for patients.

Kevin Geddings: 8:14

Value and convenience, one of the aspects that you will appreciate more when you look at the website MedEvidence. com. That's MedEvidence. com and that website, Dr. Koren, designed to be easy for layman like myself, right?

Dr. Michael Koren: 8:28

It is. It is and we will drill into different issues. So another example of value and convenience, for example, would be fish oils, and we've done programs on fish oils and there are a ton of fish oil products out there and there are also drugs that are omega-3 fatty acids. So one of them that's on the market that's been approved by the FDA and proven in clinical trials that we participated in is a drug called the sepa. The generic name for it is called a cossipent ethyl and it's a specific type of omega-3 fatty acid called an EPA and a acid, and it's been shown in studies that probably that does better than just a generic fish oil product. But then again, if you have your doctor right for that, you may find that you get a bill for $500 a month and that's no price. So the question is is it worth the $500 a month? Well, in some people it may be worth it. If you have super high coronary artery risk and you've had multiple complications and you happen to have high triglycerides, this may be something that's well worth that $500 a month. But there are alternatives, so there can be fish oils that are specifically prepared to have high levels of that EPA omega-3 fatty acid. There are also some generic versions of a eicosapentaenoic ethyl that may have not been approved by the FDA like Vascepa, but may have some value if you can't afford the $500. And of course, the part of the value and part of what we do on mid-evidence is help people understand when is it really important for you and your doctor to go after your insurance company and see if they can get that Vasceoa paid for and when maybe you just go with a generic alternative. So these are the kind of questions that we address. The other thing, in terms of convenience, we do a lot of clinical research on convenience. So, for example, in the cholesterol space, there's a drug that we helped develop called inclisiran, and incliscerin a drug that you give three times the first year and then after that you just get it every six months. It helps control your cholesterol. Well, that's pretty darn convenient. Yeah, well, but it may not replace taking a pill every night, and that's the funny thing. So we still recommend that you take statin. So, on one hand, it has this amazing property of being administered only once every six months. On the other hand, it may not stop you from taking a pill every night. So how do you balance those things? Well, that's why we have mid-evidence. So we'll have discussions about omega-3 fatty acids. We'll talk about them for cardiovascular disease, for psychiatric disease and for a number of other indications, and break down all the information with somebody who's a physician that has a really good understanding of the evidence but also understands the human elements of risk versus benefit, who you are and, ultimately, value and convenience, and we'll break those down for you on our MedEvidence platform.

Kevin Geddings: 11:37

Well, it all starts by looking at the website MedEvidence. com. That's MedEvidence. com.

Dr. Michael Koren: 11:44

And thank you very much for your interest, Kevin, and in our next session we're going to get into the devil in the details, which is the dose.

Narrator: 11:54

Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.

Dose, the Devil is in the Details

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Kevin Geddings: 0:16

We're spending time with Dr. Michael Koren. Of course he's with ENCORE Docs and specifically today we're talking about a great website that he and his team direct, MedEvidence. com. That's MedEvidence. com I'd love for you to check it out it deals with all sorts of issues, including risk versus benefit for you, the notion of who you are, because that matters when you're processing and making use of healthcare information. Now we're going to talk a little bit about well, we just talked about value and convenience as well, but we're going to talk a little bit about how the devil is in the details, Dr. K oren. Oftentimes, when we see a headline that flies across our social media feed, we don't get many details right. We get three or four sensational sentences designed to pull us in, but we don't really know the details, and those details can make all the difference in the world for us as individuals, right?

Dr. Michael Koren: 1:05

Absolutely yeah, the devil is in the details, and the detail is the dose. If you use logic, the dose is the devil, right?

Kevin Geddings: 1:15

Yeah, because I think a lot of us is non-healthcare and I certainly people that are not medical doctor, research scientist like you would believe that, hey, if a little bit of something works as a medicine, double that it's going to work twice as good.

Dr. Michael Koren: 1:28

Yeah well, that's where the devil is, in the details, and I have to deal with that detail quite a bit in my practice in cardiology. But yeah, thanks for the great introduction. And again, we're all about how to evaluate medical products, tests and claims in the MedEvidence website, and the dose detail is a great example of it, and literally every day this comes up. So yesterday, for example, I had a patient come in treating that patient's blood pressure. The patient was on the maximum dose of a drug that was approved by the FDA and he told me yeah well, on days when my blood pressure is high, I just double up on it. And so what he didn't understand is what we call the dose response, and the reason we know so much about our drugs and the reason drugs are fundamentally different than nutritional supplements is we understand exactly how they work and most drugs have an effect and they have a range during which the effect changes as you go up. But they also typically have a maximal effect and once you hit the maximal effect, you're not going to get any more benefit. Many examples of that I mentioned ACE inhibitors. A lot of blood pressure drugs are like that. So if you double the dose at a low dose, it'll have an additional impact. If you double the dose at the maximum dose, all you're going to do is put yourself at risk for side effects. Statins are like that also. If you start on the low dose, you get a decent degree of LDL lowering. So for an effective statin like a atorvastatin, lipitor or rosuvastatin, crestor, the first dose, the lowest dose, will drop you by 35% to 45% LDL lowering. But you double the dose and then you get only an additional 7% lowering and you double the dose again and you only get an additional 7% lowering. And if you double the dose again you're going to get liver problems. So just keep on doubling the dose doesn't make it better and better and better and better. So again, the devil's in the details and the dose is the devil. So many many examples of that in different realms. My other favorite example of that is talking about poisons. Poisons can be good for you. You like mysteries, don't you? Kevin, I think we've had a discussion about that. Yes, like how do we try to bump people off in an old Agatha Christie mystery?

Kevin Geddings: 3:58

He would use arsenic right.

Dr. Michael Koren: 3:59

Yeah, you can use arsenic or a digitalis.

Kevin Geddings: 4:01

Oh, okay, right yeah.

Dr. Michael Koren: 4:04

Yeah. So arsenic, by the way, has been explored as an anti-infective agent at very, very low doses, but it's a little bit tricky to use, so it never really had much of a push, although I saw it advocated maybe for HIV and some other things, but it's not something in a product that we use day to day. On the other hand, you've probably seen mysteries about digitalis toxicity from the Foxglove plant. So if you go back to the old Agatha Christie's the Sherlock Holmes murder mysteries, I'm sure there's one or two about how some evil physician even manipulated his or her knowledge of the Foxglove plant to knock somebody off. Well, it turns out that the Foxglove plant has a chemical called digitalis that has effects on the heart. They're called cardioglycosides and they actually help the contraction elements of the heart. A digitalis helps the heart beat more strongly and for many years it was both known to be a poison but also something that doctors use to treat congestive heart failure and signs of edema. Interestingly, this was sort of a nutritional supplement that doctors use for a long time, and it's only relatively recently that we studied it as a drug, and it turns out we now know how to dose it. Well, we know how it works and how it doesn't work, and we know that low doses can actually help patients with congestive heart failure, but higher doses can kill people. And we also know that digitalis has a lot of drug-drug interactions. So a good example of that is digitalis interacts with a drug that we use for H-fibrillation called amiodarone, and so amiodarone and digitalis need to be used very carefully together, and one should be careful. Now, usually the same doctors prescribing both, but every once in a while you'll have different doctors prescribing different things, not knowing what the other person prescribed. In that case, you can have an interaction that could be dangerous and you may not be at the right dose.

Kevin Geddings: 6:13

Very interesting. Well, these are the sorts of topics, of course, that are addressed in detail when you go and look at this website, which is very, you know, friendly for those of us who are not medical professionals, but it has great information that we can use in our everyday lives and it can help us in interacting with loved ones, family and friends. Go to MedEvidence. com. That's MedEvidence. com, Dr. K oren. Any closing thoughts?

Dr. Michael Koren: 6:36

Yeah, I'll give. I'll give one final discussion point on this dose and the devil in details, which gets into race and ethnicity. You know there is a lot of discussion about that and it turns out for most things that all different races and ethnicities can take similar doses. Obviously, body size is an element of who you are, and there's some products where our body size is important, and some products were, body size isn't that important. There's some products, for example on what you eat is important. So a good example that is Warfarin, or cumin. In is a blood thinner that we've used for many years. There was an old rat poison talking about things that can be poisonous but also can be helpful if you use them in the right dose. That's a great example of it, but it's also a drug that interacts with your food. So if you're somebody you're vegetarian and you like to eat green leafy vegetables, well you're gonna have a different reaction to this warfarin than somebody that doesn't eat any of those type of products, and so who you are can be important. People who are of Asian background sometimes metabolize drugs a little bit differently than other ethnicities or races or cultures, and so the Japanese authorities sometimes ask for specific information about people of Asian background. By the way, those studies are done both in Japan and in the US. There's a, there's a few sites out in California that specialize in recruiting patients to clinical trial who are of Japanese background, and those patients are put into studies where their response to certain treatments are compared against Caucasians or African Americans. So we find that more often than not, there is little differences, but when they do occur, they can be very important. So, again, the final word is that that puts everything together, that looks at the risk versus the benefit of the overall product. It looks at who you are in terms of your genetic background, in terms of what you eat and drink, in terms what you do for a living and all the other elements that help you make decisions about your life. These are health care. It's also about value and convenience. I just brought the example of the the older generic blood thinner versus the newer, more expensive blood thinner, and how that may be important based on your background. And then, finally, the dose is so incredibly important. Don't assume that just doubling up on things is gonna be twice as good or twice as bad as not. The devil is indeed in the detail.

Kevin Geddings: 9:12

It usually doesn't work with chili right, and just because you double the hot sauce doesn't make it twice as good.

Dr. Michael Koren: 9:18

Interesting note to end on. Is you talking about the devil, the details? There was a this lawsuit, I think. They came out because there was a product that advertised it was the hottest chili of all time, or the hottest pepper of all time, I think it was actually and somebody I said well, I love hot food. They took a bunch of it and they actually died of poisoning from the pepper and they're suing the manufacturer for advertising the fact that something that was that hot was potentially something that people would enjoy. So we'll see where that lawsuit goes.

Kevin Geddings: 9:51

Learn more about what Dr. Koren was just talking about, and so many other topics, by going Med Evidence. com the website . That's MedE vidence. com.

Dr. Michael Koren: 10:01

Thank you very much, Kevin. The Truth behind the Data.

Narrator: 10:04

Thanks for joining the med evidence podcast. To learn more, head over to MedE vidence. com or subscribe to our podcast on your favorite podcast platform.

Unearth the secrets to navigating the complex world of medicine and health issues with, Dr. Michael Koren, a top medical researcher and cardiologist. By tuning in, you'll gain a deep understanding of MedEvidence, a one-of-a-kind platform designed to help you evaluate medical products, services, tests, and claims objectively. We’ll illuminate the importance of evidence-based medicine, and explore the idea of risks versus benefits, a vital concept in making informed health decisions. Get a handle on how your individual factors can drastically affect these decisions, and why absolutes in healthcare often lead to inaccuracies.

In this compelling conversation, Dr. Koren breaks down the complexities of health claims, medications like statins and aspirin, and even the flood of healthcare information that inundates us daily. Learn how to view medical decisions through a risk versus benefit lens, and begin to recognize how understanding who you are can fundamentally shape these decisions. We also discuss the dangers of viewing health issues in absolutes and the resulting inaccuracies that can occur. Come along for this enlightening journey and arm yourself with the knowledge needed to confidently navigate the vast expanse of medical information.

Be a part of advancing science by participating in clinical research

Part 1: Risk Vs Benefits - Release November 1, 2023

Part 2. Who You Are - Release November 8, 2023

Part 3: Value and Convenience - Release November 15, 2023

Part 4: Dose, the Devil is in the Details - Release November 22,2023

Recording Date: October 13, 2023
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