Monday, July 7, 2008

A little story

I want to wish everyone in the US a happy 4th of July. The fateful day took tremendous amounts of courage to stand up against status quo. Our Founding Fathers risked life and limb of not only themselves, but also their families. They would not stand for the tyranny and taxation that was levied upon them.

Too bad our medical community isn't as courageous.

I want to tell you a story. I was a resident at the time.

JT was a 16 year old boy who had just been diagnosed with ulcerative colitis. It is an inflammatory condition of the bowel. He had been having episodes of horrible diarrhea and when he received the diagnosis he was started on a medication called 6-MP. If you must know, I was training in Internal Medicine at the time. Prior to this I trained in pediatrics......You see, in pediatrics before we start this medication, we do a genetic test.

6-MP can cause horrible suppression of your immune system and bone marrow. It actually has been used as a chemotherapy in the past. We do this genetic test as essential standard of care in pediatrics. Unfortunately, that was not the case in Adult Medicine. You see, there are adult GI doctors still starting this medication and watching to see if the toxins build up and case a drop in the white blood cells....(Sound Familiar?)
Well, JT went home on 6-MP and was doing great. In fact the week before his birthday he had no symptoms at all. He even skipped his check up and lab draw. But something terrible was going on in JT's body. On his birthday, he went to the bathroom and collapsed. He was unable to get up and was so weak he couldn't call for help. Luckily he had his cell phone on him and while he was in the upstairs bathroom he called his home phone.

His father picked up. "Help dad! I can't get up! I am in the upstairs bathroom"

His father raced up stairs and brought him into the ED. That's where I come in. I saw that JT was just started on this medication a little under a month ago. I ordered some labs and started JT on antibiotics. Based on the fact that he looked white as a ghost, I knew.....he had bone marrow and immune suppression. My lab values came back confirming the diagnosis. JT had the worst side effect from this medication.

While in the ICU/hospital (For 2 weeks and over 30,000 USD in charges) he fought of a bacterial infection in his blood. He received multiple units of blood and injections to stimulate his bone marrow. The Adult GI doctor THEN sent off the genetic test. Guess what? He was a NON-metabolizer of this horrible medication. That's why he did so poorly.

I recently asked my friend (Head of GI at a very respectable hospital) why they ONLY now are recommending genetic testing in Adults. He said, there was "very little evidence behind dosing patients according to genotype". Huh????? I asked if now there existed an algorithm to adjust dosing in poor and intermediate metabolizers. He said "NO"

Yet now, genetic testing is standard of care for dosing 6-MP.

So I ask you.

With an algorithm in place for Warfarin, FDA recs on the label, an FDA approved test and established evidence behind the basis of genetic testing, why do the adult doctors demand "MORE EVIDENCE"? When they obviously can see the aftermath of hundreds of JTs.... Or maybe they can't see the aftermath?

I guess just a few more thousand deaths from Warfarin toxicity need to happen.............

The Sherpa Says:

Sometimes, you just have to err on the side of protecting the patient. With GINA in place, adult doctors everywhere have nowhere to hide when it comes to this. Just ask my colleague, Gary Marchant JD, PhD............. He stated it explicitly in our last CliniCast(TM)

1 comment:

Anonymous said...

Good post.

Maybe you could compile a big list of real examples to put together a publication.