Tax dollars doing good work: An opinionated take on NEJM highlights for December 2019


The loneliness of the patent-less drug

Colchicine is a very old drug commonly used in gout with an anti-inflammatory mechanism of action that is not well defined. It is a generic (although in the US, the story is somewhat peculiar) and therefore incentives are lacking for further development in new indications by private companies. Given a well-established (but not well-understood) connection between inflammation and cardiovascular events, some researchers have hypothesized and explored potential utility in patients with high cardiovascular risk – but this would have to be validated by a robust, large, expensive, randomized-controlled trial. Thanks to the Canadian taxpayer, we now have such a study in which 4745 patients with a previous myocardial infarction were recruited across 12 countries (but not the US) and followed for about 2 years. The treated arm had a reduction in cardiovascular events of about 23% (which is to be compared to a reduction of about 15% with PCSK9 inhibitors although the studies did not quite cover the same populations). If colchicine were a new-fangled drug in some biopharma pipeline, there would have been fanfare and celebration, and likely billion dollar deals. Instead we get a lukewarm editorial (the trial was kind of small and they lost some patients and we don’t really understand the mechanism of action, etc.). I can’t help think that the tone would have been very different for a product with millions of dollars of marketing behind it.  And just to say, if I had a heart attack, I’d likely take colchicine before a PCSK9 drug – seems like better value for money. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction; Inflammation as a Treatment Target after Acute Myocardial Infarction


Figuring out vaping-associated lung injury

A couple papers on the epidemic of lung injury from vaping. One establishes a very strong correlation between a vitamin E additive found in bootleg vaping fluid and the occurrence of injury by analyzing actual pulmonary fluid collected from victims and from unaffected controls.  The second shows a trend analysis for incidence that clearly indicates an abrupt increase over the summer of 2019 and a decline into the last months of the year – which I would surmise is due to a change of behavior by users brought about by awareness of the risks related with using vaping fluid of uncertain provenance.  This trend analysis was built on the National Syndromic Surveillance Program, a tool that I had never heard of but that collects near real-time data from about 70% of ED visits in the US – and considering its richness, seems to me generally under-utilized.  Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI; Syndromic Surveillance for E-Cigarette, or Vaping, Product Use–Associated Lung Injury (free access)


Evolution did not optimize Homo sapiens for three meals a day

A fascinating review of the emerging evidence around the health benefits of fasting. The main message is that it is beneficial to periodically mobilize fat stores for energy metabolism, something that won’t happen in a perpetually fed state. My key takeaway: breakfast is indeed the most important meal of the day – to skip. Effects of Intermittent Fasting on Health, Aging, and Disease


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.