The Uselessness of Phenylephrine • Hacker News Board

Re: The Uselessness of Phenylephrine

#381

Post by paulmd » Wed, Mar 30, 2022, 10:19 PM UTC

rscho wrote: post #297

paulmd wrote: post #250

Earlier quoted context omitted.

(to be clear: not a doctor) the "daily" recommended doses are for a single day. If you are taking it daily you need to at least halve the recommended dose. I wouldn't have said a week was a problem but... yeah. Tylenol is dangerous. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913076/ Specifically this study referenced: https://jamanetwork.com/journals/jama/fullarticle/211014 > One study reported that ingestion of t…

> the "daily" recommended doses are for a single day. No. We've got thousands of people living more or less permanently on the maximum daily dose, including some children and vulnerable populations. Yes, some of those people have elevated liver enzymes. Yes, Tylenol is dangerous, but certainly not more than the alternatives. NSAIDs are certainly not any less dangerous, especially in populations with high prevalence o…

The intervention-based study (giving patients a controlled dose and measuring the enzyme response) found that over half of study participants will have clinically-significant elevation of ALT at the recommended dose, and 20-30% will have numbers as bad as 5x sustained. Short study aside, that's not what I would personally choose.

Remember, there were never Phase trials showing 4g is the right maximum either. It’s just grandfathered in Uber the “well I guess if it were dangerous we’d have noticed by now” standard. But did a statistically large enough segment take exactly 4g over a course of years such that we can definitively say that’s safe? Most people are taking lower doses and shorter doses. At least on paper.

It's "there's no double-blind study that shows masks can prevent the spread of covid!" redux. And actually it's worse because there already is a standard for what clinically-significant elevated levels of that enzyme are, and healthy study participants are blasting right by it. That's not relevant .... because?

It's not just a random number going up from some un-related mechanism, it's liver stress, they even think they know what the mechanism is. It’s a reaction that is well-known for this drug, as a warning sign for this problem. Claiming that it suddenly doesn’t mean the same thing it’d mean if you took 0.001mg more is just pedantic. It was never formally studied and approved, it would be completely unsurprising if they got the number a little wrong.

And again - that's study participants who are chosen to be healthy. If you're fat, or aren't getting your macronutrients, your risk is much higher.

Using a lower dose or using something else is always a valid option. "The dose makes the poison" and using the lowest effective dose is absolutely standard practice and any doctor is going to tell you that's a baseline they always operate under.

Anyway, do whatever you want personally, but I would personally think strongly about staying at half the recommended dose or less for chronic usage, or looking for an alternative option. 20% of the healthy population, plus the unhealthy population, is a decent chunk of people.

Re: The Uselessness of Phenylephrine

#382

Post by asmithmd1 » Wed, Mar 30, 2022, 10:20 PM UTC

rscho wrote: post #361

asmithmd1 wrote: post #356

Earlier quoted context omitted.

There are some things that are helpful that they will answer that have steered me away from a surgeon: How many of these surgeries do you do per year? An answer of 50 or above is good. What is YOUR rate of ? Keep pushing until they tell you their rate, not the overall rate.

They almost universally don't know their own rate. I don't know my own rates of complications. But, if I want you to go away because you seem to be the kind of guy that will come back to bite me, I'll gladly tell you I have a huge rate of complication.

For a colonoscopy I asked about the risk of a perforated bowel. Their first response was, “that is meaningless, if it happens to you the rate is 100%.” I said if the chances are 50:50, then I am not doing it. They said it has happened twice in their career and based on my lack of risk factors, it would not happen to me.

For my daughters tonsillectomy, the doctor was very happy to share how her stats for post surgery bleeding compared to both other doctors in her group, and the national average. But I live in a Boston suburb and every doctor is a lecturer at either Harvard or Mass General.

Another question to ask is will an intern take part in the surgery. At teaching hospitals the answer is almost always yes. You can ask if they operate at any other hospitals, and again the answer is almost always yes, they operate at a suburban, non-teaching hospital where they will be the only one operating.

I got a little bit humbled at Boston Childrens Hospital. I was doing some Googling about the risks of a CAT scan and asked if they did low-dose ones. They informed me that they in fact invented that procedure. Sure enough, the paper I was looking at was authored by a doctor on their staff.

Re: The Uselessness of Phenylephrine

#383

Post by CamperBob2 » Wed, Mar 30, 2022, 10:20 PM UTC

drdeca wrote: post #342

CamperBob2 wrote: post #303

Earlier quoted context omitted.

What makes you say the FDA is actively adding poison to other drugs, are there first hand sources from them? "Not everyone thought it was a good idea to make alcohol deadly, when making it illegal hadn’t stopped drinkers, and New Jersey Senator Edward I. Edwards called it “legalized murder.” However, the Anti-Saloon League persisted, arguing that legal alcohol had killed many more in its day than denatured alcohol wo…

This makes me wonder if it would have been possible to, instead of using something that causes significant harms to health, instead something which just causes a rather unpleasant experience. But, I guess one important thing is whether such an additive is compatible with the altered substance still being usable for the purpose for which it is being made available. Now, presumably something as simple as “dissolve larg…

I think that's what they ended up doing, post-Prohibition. A bottle of rubbing alcohol from the drugstore is either isopropyl alcohol, which is toxic by itself but not intentionally so, or ethanol mixed with a denaturing agent that's more benign than methanol or whatever they were using back in the day.

Re: The Uselessness of Phenylephrine

#384

Post by grog454 » Wed, Mar 30, 2022, 10:21 PM UTC

lcuff wrote: post #375

grog454 wrote: post #347

Earlier quoted context omitted.

Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.

In my mind it is not a good system, because if the surgeon is looking at a much-more-difficult than average circumstance, than he could reasonably expect a lower-than-average result, but a result that might be much better than average for a case so difficult. As a separate observation, any time data is kept, turned into metrics that then become the basis for goals ("I want to have a better-than-average success rate,…

I think you are right that there is a natural and understandable psychological resistance to a data-based evaluation system. I understand that the doctor may realize something about the patient that will lower his/her chances of success.

I'm arguing that a sufficiently comprehensive system would take in to account whatever that doctor realized (and perhaps much more) and compensate for it when determining expected outcomes.

Re: The Uselessness of Phenylephrine

#385

Post by insickness » Wed, Mar 30, 2022, 10:25 PM UTC

HL33tibCe7 wrote: post #373

Reminds me of docusate, a very commonly prescribed “Laxative”. The problem? There’s seemingly barely any evidence that it actually works. And plenty to suggest it has no effect over that of a placebo. Yet there’s a culture of prescribing it, so on prescribed it goes.

Wow. I've purchased more than a few bottles of ducosate. But it looks like you're right:

Reevaluating the Use of Docusate in the Management of Constipation https://www.drugtopics.com/view/reevaluating-the-use-of-docu...

Re: The Uselessness of Phenylephrine

#386

Post by tastysandwich » Wed, Mar 30, 2022, 10:26 PM UTC

dataangel wrote: post #146

I've recently had to deal with the medical profession a lot more than in the past and I'm finding this sort of thing everywhere. OTC medicines that by current standards would not be made OTC, surgeries that are extremely common but have never had quality randomized trials, official sounding diagnoses that on inspection are actually defined as "we have no idea", lack of consensus about how to treat some of the most co…

Nowhere is this more evident than in the treatment of endometriosis.

It seems like even gynaecologists are woefully ignorant & untrained in this disease, leading to so much unnecessary suffering by women (my wife included).

Guys & gals, if you or your partner suffer from endometriosis, listen up!

* Find the best gynaecologist you can that specialises in endo & can perform excision surgery.

* Burning off the lesions (ablation) is not an effective treatment. Excision surgery is by far the most effective current treatment. Unfortunately, it seems like many gynaecologists do not have the training to perform this surgery, and therefore don't even mention it (lest they lose your valuable business).

* There is absolutely zero evidence that pregnancy "cures" endometriosis, despite doctors continually repeating this myth. My wife's awesome gyno told us - and you can research yourself - that this is absolute rubbish.

https://theconversation.com/pregnancy-doesnt-cure-endometrio...

It causes me to wonder when I go see a doctor, what else are they ignorant about? I like to think I can defer to their expertise, and set my mind to other things. Maybe not.

Re: The Uselessness of Phenylephrine

#387

Post by lr4444lr » Wed, Mar 30, 2022, 10:26 PM UTC

salawat wrote: post #316

edmundsauto wrote: post #236

Earlier quoted context omitted.

What makes you say the FDA is actively adding poison to other drugs, are there first hand sources from them? This sounds like it could also be a case where they want to lower opiate consumption, and so adding some Tylenol increases pain relief without increasing opiate intake. I am not sure that’s wise policy, but if you don’t think Tylenol is all that bad (again, I’m not sufficiently informed to say this, but the FD…

Look up DXM. You will never find it without either Gualfenisin or acetaminophen. Does DXM need either of those to do what it does? No. Would it simplify dosing to be sold alone so that laymen didn't have to worry about potentially overdosing on three drugs at once instead of just one? Yes. However, from the war on drugs perspective, that makes it "easier to abuse" to achieve it's hallucinogenic side effect. Bundled w…

Dextromethorphan HBr? It's definitely sold on its own in the US.

Re: The Uselessness of Phenylephrine

#388

Post by rscho » Wed, Mar 30, 2022, 10:26 PM UTC

paulmd wrote: post #381

rscho wrote: post #297

Earlier quoted context omitted.

> the "daily" recommended doses are for a single day. No. We've got thousands of people living more or less permanently on the maximum daily dose, including some children and vulnerable populations. Yes, some of those people have elevated liver enzymes. Yes, Tylenol is dangerous, but certainly not more than the alternatives. NSAIDs are certainly not any less dangerous, especially in populations with high prevalence o…

The intervention-based study (giving patients a controlled dose and measuring the enzyme response) found that over half of study participants will have clinically-significant elevation of ALT at the recommended dose, and 20-30% will have numbers as bad as 5x sustained. Short study aside, that's not what I would personally choose. Remember, there were never Phase trials showing 4g is the right maximum either. It’s jus…

I personally prescribe loads of painkillers, including the whole range of the WHO ladder, and many of those patients have liver tests. It rarely happens that we have to discontinue Tylenol due to hepatitis. I see people on NSAIDs with kidney failure every week. So again yes, Tylenol is toxic. But from personal experience, it's rarely a clinically relevant problem.

Re: The Uselessness of Phenylephrine

#389

Post by opportune » Wed, Mar 30, 2022, 10:31 PM UTC

travisathougies wrote: post #159

dataangel wrote: post #146

I've recently had to deal with the medical profession a lot more than in the past and I'm finding this sort of thing everywhere. OTC medicines that by current standards would not be made OTC, surgeries that are extremely common but have never had quality randomized trials, official sounding diagnoses that on inspection are actually defined as "we have no idea", lack of consensus about how to treat some of the most co…

You seem to be under the impression that there is some 'advanced technology' out there that will magically solve your problems that the US fails to have. In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever. In reality, there are a plethora of conditions, some…

The problem with empowering people medically is that 10% of people will benefit from it but 90% of people will get info from Facebook and infomercials and fall victim to quacks. Hence everything being gated behind credentials and prescriptions (along with some good old regulatory capture).

I disagree with the characterization of medicine not being able to treat so many things. Many things are incurable but a lot of medicine/public health is so effective we barely think about it. Of course we are going to notice and pay more attention to the things medicine sucks at treating, because they’re real problems that inflict a lot of pain due to the lack of treatment.

But medicine is very good at treating plenty of things like infections (of many different kinds), traumatic/acute injuries, and many disabilities. Most of the chronic issues that medicine fails to address are simply lifestyle issues that medicine tries to alleviate the symptoms for. Yes there are certain conditions medicine doesn’t begin to fully understand like Alzheimer’s or various chronic pain conditions, or where treatment is still pretty middling like Cancer, but a lot of the biggest things are treatable very well - we just don’t notice them much because they are treated so well.

Re: The Uselessness of Phenylephrine

#390

Post by s0rce » Wed, Mar 30, 2022, 10:31 PM UTC

travisathougies wrote: post #159

dataangel wrote: post #146

I've recently had to deal with the medical profession a lot more than in the past and I'm finding this sort of thing everywhere. OTC medicines that by current standards would not be made OTC, surgeries that are extremely common but have never had quality randomized trials, official sounding diagnoses that on inspection are actually defined as "we have no idea", lack of consensus about how to treat some of the most co…

You seem to be under the impression that there is some 'advanced technology' out there that will magically solve your problems that the US fails to have. In my experience, many people have a quasi-religious belief in the capability of modern medicine to perform what would otherwise be called a miracle. This belief is typically held without any evidence whatsoever. In reality, there are a plethora of conditions, some…

Since when is "evidence based medicine" defined as ignoring patients with currently untreatable conditions. There are enormous amounts of funding and effort constantly devoted to developing new treatments. I'm not sure how else you want to practice medicine other than "evidence based".