🎙What is MedEvidence: Devil in the Details - A Guide to Informed Health Decisions Ep 156

This episode wraps up our MedEvidence Guide to Informed Health Decisions by unlocking Dosing with the Devil in the Details. Dr. Michael Koren and Kevin Geddings journey together through the complex and often misunderstood world of medicine, revealing how the magic lies not just in the medicine itself, but the dose in which it's taken. Yes, you heard it right, dosage - a critical but often overlooked aspect that can turn a remedy into a poison. Using real-world examples like digitalis, a toxic substance used medicinally at low doses, we demonstrate this delicate balance. 

Discover how the interaction between different drugs can either amplify their effect or neutralize it – a key factor in medical safety. With Dr. Koren's expertise, we delve into the concept of dose response, highlighting the potential dangers of exceeding the drug's maximum effect. We also unravel the role of personal factors such as race, ethnicity, body size, and diet in drug metabolism, underscoring the necessity of personalized medicine. So, join us as we navigate the intricate details of medical research and illuminate their importance in making informed health decisions.

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

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Music: Storyblocks - Corporate Inspired

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Chapters

• 0:01 Navigating Medical Research
• 9:48 Understanding the Importance of Details

Transcript

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.

Dr. Michael Koren: 2:39

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.

Dr. Michael Koren: 3:36

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?

Dr. Michael Koren: 3:50

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.

Dr. Michael Koren: 4:48

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.

Dr. Michael Koren: 7:08

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.

Dr. Michael Koren: 7:41

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.

Dr. Michael Koren: 8:34

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.