All providers want to use drugs as safely as possible and therefore constantly and carefully try to balance the risks and benefits of anything they prescribe. This balancing is inherently uncertain, because risks are often unknown or subject to perception, bias, and misinformation. Furthermore, the time dimension is key, and it may take years of observation and very large post-marketing studies before the data are sufficient to truly know what the risks and benefits of any therapy are.
In rheumatology, I doubt that we have the metrics to judge the pluses and minuses of our therapies. Do we really know, for example, the benefit of a difference in a Sharp score of 2 between competing treatments in terms of the risks of immunosuppression that may be needed for its achievement?
Pending more real-world data (hopefully to come from the ACR Rheumatology Clinical Registry), advances in pharmacogenomics and pharmacogenetics, and more robust analytic techniques to assay the benefits of therapy in a more objective way, increasing the safe use of drugs will be the personal matter of each provider.
For my part, I try to follow Pisetsky’s rules, of which, trust me, there are many. For those of you who do not know these rules, here are two more:
- Don’t prescribe a drug if you don’t have to.
- If a drug doesn’t work, stop it.
For those of you who have your own rules, please write in. Hopefully, together, we can prove Peltzman wrong.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C. Contact him at [email protected].
