Is precision medicine mostly nonsense?
The holy grail of personalized medicine is a single pill that’s customized for each individual’s own specific risk factors that prevents disease before it starts.
It sounds so wonderful in theory - a precision approach to medicine so that we each get bespoke care that’s perfect for us.
As you might have gathered from your interactions with the medical system, we’re not quite there with healthcare, especially in the realm of prevention.
The ongoing joke about precision medicine is that it’s the future of health care and it always will be.
But what if precision medicine for preventive care is the wrong approach?
What are we even trying to prevent?
After the age of 40, the majority of people die from heart disease, cancer, and neurodegenerative disease (meaning dementia, the most common example being Alzheimer’s).
Any medications that prevent these diseases are going to make us live longer.
It’s interesting to note that if you look at people who live to be 100, the commonality is that they avoid chronic disease for a longer time than people who die younger and then they die of the same diseases that everyone else does.
In other words, it’s not that the folks who live to 100 have better survival when they get sick, they’re just able to stay healthy for longer.
Avoiding the big 3 - cancer, heart disease, and Alzheimer’s - is an important part of focusing any personalized prevention.
So how do we prevent the big 3?
Cancer prevention is a recipe for another day - I’ll start and end here by saying don’t smoke, get your screening tests, and avoid heavy drinking and bad sunburns.
We’ll get to cardiovascular disease in just a minute.
Alzheimer’s prevention, well, may seen like nonsense at first. After all, isn’t Alzheimer’s just something that happens to you?
Not really!
I suspect that the reason that concept of Alzheimer’s prevention is a foreign one for many people is that the public messaging about Alzheimer’s never discusses this!
One of the major risk factors for Alzheimer’s disease is vascular disease and improving cardiovasculr health helps to prevent Alzheimer’s.
It’s worth noting that the nation’s only Alzheimer’s prevention clinic at Cornell, run by Richard Isaacson, probably focuses more on vascular health than most cardiologists do.
Of course, cardiovascular disease is only part of the Alzheimer’s puzzle. But it’s a big part!
The commonalities in prevention of Alzheimer’s and cardiovascular disease mean that a lot of truly personalized prevention has a focus on your own individual heart disease risk.
Maybe personalizing cardiovascular prevention is the wrong approach
Since heart disease is so common and so much of heart disease risk is related to the same common things - cholesterol, blood pressure, blood clots, blood sugar - there’s been a lot of research interest into the idea of a generalized preventive approach for everyone in the population.
The public health case here is straightforward - just treat everyone rather than screening for specific risk factors and targeting them for each individual patient.
A polypill is a single pill with a handful of different medications in it. It’s an intriguing population-based strategy for overall prevention advocated by some in the public health sphere.
The research into polypills has been influential in the way that I think about preventive medicine.
Prescribing a polypill with a low dose of a few different medications used in cardiovascular disease - aspirin, a statin, two different blood pressure medicines - to the general population seems to lower risk of cardiovascular disease by about a third.
What’s interesting is that everyone seems to benefit, regardless of underlying medical issues. Benefit can be seen even in groups without traditional risk factors:
People without high blood pressure
People without high blood sugar
People without high cholesterol
People who didn’t smoke
The important outcomes that were reduced is similarly impressive:
Fewer heart attacks
Fewer strokes
Fewer cardiac deaths
What’s the bottom line? Should we all be taking a polypill?
Maybe we should.
Risk factors like high blood pressure and cholesterol are not just about what our levels are at any given time, they’re about cumulative exposure, where total risk is a function of Exposure x Time.
Think area under the curve rather than a snapshot.
Reducing cumulative risk exposure reduces risk. So lowering your levels even if they aren’t high reduces your exposure and thus reduces risk.
It’s an intriguing approach to personalized care - scrap the personalized part and just do a little bit of a bunch of different things.
Perhaps someday we will think of a polypill as the modern equivalent of an apple a day.
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Disclaimer: nothing in this newsletter should be considered a medical recommendation. My newsletter is not a substitute for medical advice and reading this newsletter does not constitute forming of a doctor-patient relationship.