Monday, 1 February 2016

Prednisolone drug of choice for Addison's?

Amin BMJ 2014;349:g4843 suggested prednisolone be the drug of first choice for people with primary Addison's disease.
There were a lot of illogical criticisms of this article by doctors in the BMJ, which will be the subject of a more detailed post later. A lot of these revolve around the so-called lack of evidence (because doctors refuse to collect any evidence that could disagree with their pre-conceived notions) and because many doctors still think in terms of plasma drug levels rather than effect site concentrations, because that is all they were taught.

Here are some very sensible comments from Fiona Godlee, editor of the BMJ.

1.Yes, patient preferences are important. N-of-1 trials not that difficult to conduct. If only more doctors understood the concept.
2. Doctors are acting contrary to the principles of Evidence Based Medicine if they insist on randomised trials before any treatment changes are made. They should stop denying "lesser" evidence. EBM is about using the best evidence available. Maintaining the status quo until an RCT is done is not EBM.
3. As stated, thrice daily hydrocortisone is better than the twice daily dose frequently prescribed in Australia.
4. IMHO the licensing of modified-release HC should not be revoked. There should be adequate post-marketing surveillance.

FWIW the only Addisonian olympic athlete I know of got better results with pred than HC.