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No Brucie bonus for NICE



Jobbing Doctor brings out his inner conspiracy theorist. Why are drugs suddenly a good idea for dementia?

Bruce Forsyth is a national treasure.

For a man in his eighties, he is as sharp as a knife, and physically and mentally very fit. We all love Brucie, and he is up there with Judi Dench, Maggie Smith, Alan Bennett and Simon Rattle.

‘Nice to see you, to see you….Nice’ is one of his catchphrases.

However, it is not always nice to hear from that other NICE (the National Institute for Health and Care Excellence), which organisation has an extremely chequered history for Jobbing Doctors.

We’ve just had another pronouncement from NICE, and this time it is on dementia and the use of drugs in treating dementia. They have performed a volte-face on their advice, and have now decided that these drugs are now officially a ‘good idea’, whereas previously they were not.

When an organisation like this changes course so significantly, the conspiracy theorist in me wants to ask: Why?

The media has come out with the line that the revised recommendation is the result of looking at an extra 17 studies on the use of these drugs. If I am being charitable, I might wish to commend this organisation for having the devotion to science that means that they are empirically re-sifting the evidence and have come to a revised conclusion based on an accrual of new data.

That, of course, is nonsense. Indeed nonsense on stilts.

This is due to pressure from elsewhere. The well publicised diagnosis of another national treasure, Sir Terry Pratchett, with dementia has resulted in it being pushed up the agenda of political significance. Pressure groups and charities have, rightly, also pursued this issue with some tenacity, and they are entitled to do this.

Pressure also will come, inevitably from big pharma, the pharmaceutical companies who fund all these studies. It is well known, of course, that any positive studies showing a useful benefit will be published and publicised as well. Negative studies are rarely published and are frequently pushed to the back shelf.

Finally, we get pressure from families of patients who exhibit early symptoms of cognitive decline. When faced with an intractable problem, it is only natural for families and doctors to want to ‘do something’. The message that this condition is slow, inexorable and untreatable is not an easy one for everyday doctors to deal with, and so we deal with this problem with positive action rather than passivity.

I am not decrying the data that shows a ‘numbers needed to treat (NNT)’ figure of two: that is you need to treat two patients to get a benefit in one of them. Compared to the NNT for primary prevention of vascular disease of five, or of breast screening being >1000, then this is a reasonable response. Trouble is that the effect is weak and temporary.

The jigsaw relating to NICE is a little more nuanced. The final piece is about costs, and the costs of these anti-dementia drugs is coming down all the time, and it would be good if that driver could also be acknowledged in the publicity, but it is only rarely so.

My feeling about NICE is that probably rate themselves a great deal more highly than Jobbing Doctors rate them. These are not tablets of stone, carried aloft by Moses coming down Mount Sinai, and I will treat this pronouncement (like all the others) with empirical scepticism.

So, ‘not particularly nice to see you, to see you not particularly… nice’. I can’t see Brucie saying that, can you?

However, one thing about NICE I do like is their rather splendid biscuits.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

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