Treating inflammatory diseases

Posted on : 21-07-2011 | By : Fabio Sanchez | In : Articles

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Being diagnosed with a chronic inflammatory disease brings about the prospect of a long, painful and debilitating experience. Thus, the desire to regain health at all cost becomes a dominant part of the patient’s life. While reasonable, this attitude might under some circumstances blur patient’s judgment, making them vulnerable to abuse. In this article I present my views about certain cognitive biases that might prove costly when taking decisions about treating inflammatory diseases. My motivation is to empower sufferers of inflammatory diseases to take decisions related to their health. Expert opinion is very important, but the patient’s proactive role is also necessary to improve the chances of a proper treatment.

What are cognitive biases? They are faults in the reasoning process brought about by defects in perception or by faulty logic. In other words it is bad thinking that brings us to wrong conclusions because we do not have the necessary and sufficient information or because we interpret information in a prejudiced and faulty way (List of cognitive biases).

For example, if one is upset about being diagnosed with a difficult disease one might be inclined to believe unscrupulous advertising. This contributes to giving certain substances the panacea status or   cure-all. This tendency to focus on stimuli with high emotional content is called attentional bias.

Another common mistake results from the bandwagon effect or the belief that we should do certain things because others are doing it. For example we might believe that if other patients are taking a certain “super” treatment we should do it also, without assessing other relevant information.

We might be presented with a false dichotomy so that one might believe that there are only two ways to treat something but in reality there might be many more options.

Information overload is another phenomenon that can lead us to mistaken thinking. The availability of medical information is a great asset for professionals and patients as well. But too much information can blur our decision making if we focus on the wrong sources. Physicians are realizing that patients come to their practice with a wealth of information about their condition, which can be both useful and dangerous. The danger resides in the fact that there are bits of specialized information that require proper training in order to be interpreted. Patients might develop false expectations or false representations of their disease due to lack of professional training. This situation can even turn patients hostile. Patients might perceive that they are not being taken seriously and turn away from healthcare personnel in search of unorthodox and potentially dangerous alternatives. Knowledge should be interpreted in a contextual manner, every patient lives under particular circumstances that deserve being studied in detail in order to take decisions concerning therapy. A very dangerous way to look for and interpret information is called confirmation bias. In this error of thinking one is inclined to look for information that confirms our own prejudices, disregarding many other sources of information that might oppose our prejudiced views. As dangerous is the framing effect or the tendency we might have to interpret the same information in ways that adapt to different situations. A final bias I want to refer to regarding the search and interpretation of medical information is the neglect of probabilities. Reading a lot of information does not guarantee certainty about how to make a decision. Medical studies are performed so that medical professionals can assess the probability of certain treatment outcomes. If one disregards these studies or lacks the training to interpret them one might reduce the chances to manage the disease in a proper way. Such studies are what differentiate the so called official medicine from unscientific or prescientific medical opinions.

A greater danger however, resides in the fact that the driving force behind production of new therapeutic agents is economic profit. This means that patients and health personnel must hold pharmaceutical industries to high standards. Even though different social systems have organization that surveil drug development and production, there exist also lobbyists that intend to affect political decisions in order to favor the industry. Therefore, it is essential that health professionals as well as patients demand high quality information in order to make decisions. Companies that proactively show accurate and thorough information regarding their products deserve our support. Anyone trying to misrepresent the potential of their products should be met with suspicion. That includes omitting valuable information. A good example of a misinformation campaign aimed at profiteering is what the tobacco industry did to support their economic status. As a patient you deserve to be informed in a responsible manner.

We are entering a promising era in the treatment of inflammatory diseases; scores of molecules are being treated as potential targets for developing new therapeutic agents. But this brings some problems that need to be tackled at the outset. First the desire of material gain is causing that scientists and entrepreneurs alike  race to patent anything that shows some promise. In this feeding frenzy scientific values are often disregarded and exaggerated claims are used as currency to get more funding or claim higher status. This is something that patient organizations and health professionals ought to influence so that scientific rigor will not be compromised. But the greatest challenge, in my opinion,  is that our thinking about treating inflammatory diseases is deeply flawed by our expectations about how a treatment should work vis a vis how it can work in reality under natural constrains. We expect to be cured of our diseases just as many infectious diseases can be cured with antibiotics or as trauma can be repaired with surgery. But regarding inflammatory diseases, the major problem seems to be regulation of complex networks of genes, metabolites, cells and tissues. Thus for example, anti-TNF biologicals cannot be considered a cure. Biologicals that reduce the bioavailable levels of TNF in the body are a great promise for treating inflammatory diseases but we are far from understanding all their potential and limitations because research seldom focuses on how anti-TNF affects can be called the “TNF network”. TNF is but a node in that network, the other connectors in the network might be crucial for controlling other functions in the body thus making it possible that, if one blocks TNF without understanding the entire network, undesired effects will emerge. There are already many articles that describe problems that arise from treating patients with the accepted anti-TNF biologicals (infliximab, etanercept & adalimumab), you can visit the National Center for Biotechnology Information of the US if you want a list of such articles.

Next generation biologicals will probably be developed in such a way that we will know how much anti-TNF or how much antagonist for other cytokines must be given. We will also know which and how other parts of the cytokine network will be affected  after giving different amounts of the biologicals.  Because every individual has a particular combination of genetic variations that might influence how different metabolic networks work, it will be possible also to determine how different combinations of genetic variants should be treated. Until then we can only strive to communicate with politicians and researchers as well, demanding that the scientific integrity of this type of research is guaranteed. Also, through patient organizations, patients can support the companies and researchers that best represent their interests.