8.4 Problems: OverTreatment: Heart Caths, Alzheimer's Drugs, Ozempic

[00:00:00] This segment contains multiple snippets from Taylor in my conversations about over-treatment.

[00:00:07] First, Dr. Beckman, who will start his cardiology fellowship in July, talks about how heart

[00:00:16] catheterizations for unstable plaques can oftentimes do more harm than good. Then Taylor and I are both passionate in talking about

[00:00:27] how the new drugs for Alzheimer's,

[00:00:30] lecanumab and adicanumab, monoclonal antibodies,

[00:00:34] meant to remove beta amyloid plaques

[00:00:37] are ineffective and likely causing more harm than good.

[00:00:41] What I didn't know is that the leading theory

[00:00:44] of what causes Alzheimer's, the deposition

[00:00:46] of these beta amyloid plaques and tau proteins

[00:00:50] into our brains, which is what the canamabs

[00:00:54] effectively remove.

[00:00:55] Well, that entire theory has been called into question

[00:00:59] based on the primary researchers manipulating

[00:01:03] close to 100 images in their data

[00:01:06] dating back to the early 2000s that further supported and funded the amyloid deposition theory taking away funding from

[00:01:16] instiming the progress of

[00:01:18] other potential theories or causes and treatments for Alzheimer's for almost 20 years.

[00:01:25] And we finish up with a discussion about one of the hottest new drugs or class of drugs,

[00:01:30] the GLP1 agonists used for weight loss, the most famous of which is Semiclutide or Ozenbeck.

[00:01:40] Somebody get this guy some help!

[00:01:55] We talk about cardiologists, we break it down into, there's plumbers and there's electricians. Plumbers are concerned with the arteries of your heart and they unclog the plumbing.

[00:02:00] Electricians, we have an electrical system that runs their heart, keeps it beating.

[00:02:04] They deal with the electrical issues.

[00:02:05] I don't like the plumbing as much as I do the electricity.

[00:02:08] Plumbing seems pretty straightforward, right?

[00:02:11] Yeah.

[00:02:11] Find the blockage, clear the blockage in enough time before it shuts down and dies, right?

[00:02:17] Yeah.

[00:02:17] There is a lot of nuance and also I don't want to use the word conspiracy,

[00:02:22] but it's actually an interesting topic.

[00:02:24] Yeah. All the heart cats. but it's actually an interesting topic. Yeah.

[00:02:25] All the heart cats.

[00:02:26] Another example of overtreatment in America.

[00:02:29] Yeah.

[00:02:30] We actually have a very old attending here in his 80s, Dr. Sohi, who was around before

[00:02:36] the advent of the heart cat, watched the advent of the heart cat, and then the advent of angioplasty,

[00:02:40] which is ballooning to open up blockages and then stenting, which is putting a little metal tube in there to keep the blockages open.

[00:02:47] And he was around and saw it firsthand and said,

[00:02:50] we killed a lot of people doing this.

[00:02:52] At the beginning, when this was new, they just said,

[00:02:54] let's do it to everyone, all the blockages.

[00:02:56] More is better. Keep those things open.

[00:02:58] Yeah.

[00:02:59] We didn't know that there are stable plaques and there's unstable plaques,

[00:03:02] and doing stinting and ballooning every plaque kills a lot of people. How does it kill

[00:03:08] them? The thought is that if you have a stable plaque the outside of that plaque

[00:03:13] is covered in calcium which keeps pieces of it from breaking off. Usually when

[00:03:20] someone's dying from a clog on their arteries, the inside of that artery, the lumen,

[00:03:27] is narrowed by cholesterol plaques that have these calcium caps on them. But it's not the

[00:03:33] narrowing per se that kills you. Something breaks off upstream of that artery and then

[00:03:38] clogs it completely. So essentially you bust open a big blockage and then you're releasing all of these smaller

[00:03:45] clots to go plug elsewhere.

[00:03:48] Yes.

[00:03:49] A person that has a lot of plaque in general, you're going to have narrowing in that artery

[00:03:53] at some point.

[00:03:54] And if you are taking a stable plaque and putting a balloon and crushing it up against

[00:03:59] the wall, you're releasing a lot of these parts that are unstable, especially these

[00:04:03] lipid-rich cores.

[00:04:04] When they come in contact with blood, you get a lot of platelet activation too that can cause

[00:04:09] even platelet thrombi that can go downstream and clog those narrowed arteries. So it is a very

[00:04:15] straightforward thing in terms of concepts, but the actual doing has a lot of nuance. And

[00:04:28] doing has a lot of nuance and the trend right now is to kind of do the minimal amount of stenting. Last year there was a big study that came out showing that

[00:04:33] stenting in the workup for heart failure. Anytime someone is discovered they have

[00:04:39] heart failure, their ejection fraction though how hard their left physical

[00:04:43] squeezes, they get what we call an ischemic workup to make sure that they don't have heart failure

[00:04:47] due to a previous heart attack and if they have blockages that they go ahead

[00:04:52] and stent them this new trial said that there is no difference in mortality and

[00:04:58] stenting those people or just managing them medically because they're not

[00:05:02] coming in for a heart attack they're coming in for the aftermath of, per se, a heart attack.

[00:05:07] And if they're stable at that time,

[00:05:09] you just treat them with medicines for heart failure.

[00:05:12] And they do just as well as people that go in and get stents.

[00:05:16] And that's dangerous because people that go in and get stents,

[00:05:21] there is a lot of risk involved with doing that procedure too.

[00:05:24] The risk is definitely not zero.

[00:05:25] People die from this procedure sometimes.

[00:05:26] Yeah.

[00:05:27] And correct me if I'm wrong, but you can think about it like if you're out on the golf course

[00:05:31] and you see a guy gets his first hole in one and then he suddenly collapses, he probably

[00:05:36] has an unstable plaque.

[00:05:38] And if you can get him to the hospital and cat fast enough, then you can take out that

[00:05:43] blockage and he'll likely do pretty well.

[00:05:46] Whereas if you have somebody who's been building up that gunk in their plumbing and the more that

[00:05:52] builds up in the human body, the person finds ways to compensate for it. They develop what's

[00:05:59] called collateral circulation or you actually grow new arteries that are not nearly as efficient,

[00:06:06] but they go around the blockage.

[00:06:08] And so this is a great example of over treatment.

[00:06:11] I see something on the angiogram and then you jump in and want to rush to fix it and

[00:06:16] then you end up causing more harm than good.

[00:06:19] Same with somebody who comes in and has had a stroke and their blood pressure sky high

[00:06:24] and somebody who doesn't understand the complexities of what they're doing.

[00:06:28] They may want to rush in there and say, we got to lower the blood pressure. We got to lower the

[00:06:31] blood pressure. That person is relying on that elevated pressure to get their blood flowing

[00:06:37] everywhere that they need it. Definitely. In their brain. Yeah. Interesting stuff.

[00:06:44] Since you had an interest in the past in neuroscience, how you feel about Lacanumab

[00:06:49] and Atticanumab for Alzheimer's.

[00:06:52] Oh, the whole years and years of research and money that's imported into this and these

[00:06:58] drugs that really have showed no efficacy, got approved by the FDA. I don't know, it just kind of shows us that the FDA can be bought,

[00:07:09] that if they were truly practicing evidence-based medicine

[00:07:13] and trying to put out medications that are really going to help people,

[00:07:17] they would have said no to this.

[00:07:18] The fact that these medications got approved and for such high cost too,

[00:07:24] these are very expensive medications. It's

[00:07:26] just showing that the people that run the FDA probably were previously working for the

[00:07:32] pharmaceutical industry and have gotten government roles.

[00:07:35] Yeah. Medicare agreed to pay for Lacanumab. I don't know the specifics of that. And then

[00:07:41] I saw an article on CNN that really pissed me off that said,

[00:07:45] oh, we had this new treatment

[00:07:46] that prevents the progression of Alzheimer's.

[00:07:50] And I'm just like, no, it doesn't.

[00:07:52] And compared to the standard of care, don't episode,

[00:07:56] even in those studies,

[00:07:57] which I don't trust the studies on it,

[00:08:00] and limiting the reduction in cognitive function,

[00:08:04] it barely outperforms the standard

[00:08:06] of care now. And don't episode is very well tolerated. Diarrhea is probably the most common side effect.

[00:08:12] Lachanomab is a little bit better side effect profile than atocanomab. It's the next generation

[00:08:17] of this monoclonal antibody that removes beta amyloid, which is something we thought was

[00:08:24] very heavily implicated is causing.

[00:08:26] Exactly, I think this tells us that we obviously

[00:08:29] don't know the whole story.

[00:08:30] Or once beta amyloid is depositing in the brain tissue,

[00:08:35] it causes some irreversible changes.

[00:08:38] I think personally, I don't have any major evidence,

[00:08:41] but knowing a little bit about how the brain works,

[00:08:43] I think it disrupts the

[00:08:45] glial network, that network of glial cells, which again, we all think about neurons, but 90% of

[00:08:51] the brain is glial cells. And these cells also communicate with each other and dictate what the

[00:08:57] neurons do. I wonder if when those proteins deposit, if they disrupt that matrix and therefore there's not a good

[00:09:06] way to regenerate it. That seems definitely plausible. There's obviously

[00:09:11] still a lot we don't know because if we've been in the last 30 years focusing

[00:09:15] all our research on beta amyloid and coming up with these drugs that are

[00:09:20] targeting beta amyloid and they obviously aren't working. There's

[00:09:23] something we don't know. But there's a lot of money that's been poured into it.

[00:09:26] So that money's got to be recouped to some degree.

[00:09:28] Lecanamat, I was saying earlier,

[00:09:29] it's a little bit safer than adicanamat,

[00:09:31] it only causes brain bleeds in 15% of people.

[00:09:36] Which is crazy, right?

[00:09:37] Hey, it's brain bleed, but I don't know,

[00:09:39] they probably use some other term

[00:09:41] that makes it seem more innocuous to the American public. Focusing on prevention, that's never going to work right?

[00:09:47] Nobody's making money off of prevention, right?

[00:09:49] They've tied type 2 diabetes as an increasing risk factor for developing dementia at the

[00:09:54] end of life. Metabolic dysfunction, diabetes, heart disease, neurodegenerative disease,

[00:10:00] all of these things are linked together. Preventing one is going to help prevent the others.

[00:10:04] We have pretty good evidence that's showing this.

[00:10:06] You hear about these billion-dollar drugs.

[00:10:09] You don't really hear the news talking about increasing prevention at all.

[00:10:12] Lecanamab in the clinical trials, they recruited people who were very early stage Alzheimer's.

[00:10:20] And they, I think, extrapolated and thought this is definitely going to happen with the second

[00:10:24] generation of this the more comorbidities that you have

[00:10:27] The more likely you are to have a brain bleed so they purposely recruited people who were in a less severe stage of Alzheimer's

[00:10:35] and that does a couple of things it

[00:10:38] Make sure your population a little healthier less likely to have adverse side effects and

[00:10:44] This population is already less likely to have this huge progression in

[00:10:50] their Alzheimer's, which is a disease that takes, at its most rapid,

[00:10:55] I would say five years, but really a lot of people live with Alzheimer's for

[00:10:59] 15 or 20 years. So you've already got a population who is not going to have a

[00:11:04] whole lot of cognitive

[00:11:05] decline over the six or eight or 12 months of however long the study was.

[00:11:10] But even with those factors, three people died in the clinical trials with Lekana map.

[00:11:18] Three relatively healthy people who died in the clinical trial.

[00:11:23] I need to go look over those trials. I haven't had the time

[00:11:26] to look over that day yet. Don't do it. It's depressing, man. It's so depressing. Yeah.

[00:11:33] All of the towel, like the whole pyramid built in the last 20 years of Alzheimer's research might

[00:11:40] all be built on like photoshopped images that have been gone around in Mayo. Are they really trying to push the

[00:11:46] beta amyloid deposition hypothesis?

[00:11:49] Based on what I've read recently is

[00:11:52] the millions of dollars have gone into that.

[00:11:53] And we have recently discovered that that may actually

[00:11:55] not be the case that the beta amyloid and tau proteins

[00:11:59] might just be a manifest state, like a side product,

[00:12:01] but definitely not the root cause

[00:12:03] in defecting them is not gonna change anything.

[00:12:05] And then it came out, the researchers that,

[00:12:08] their whole career is based on this,

[00:12:11] photoshopped images of the beta-towel proteins

[00:12:14] in some of these microscope slides.

[00:12:15] They concurred with the overall conclusions of this paper

[00:12:17] that cast doubt on hundreds of images,

[00:12:19] including more than 70 in LaSanne's papers.

[00:12:22] Some look like shockingly blatant examples

[00:12:24] of image tampering, says Donald Wilcox and also I'm an expert at UK

[00:12:29] If you have composed figures by piecing together parts of photos from different experiments

[00:12:34] It's a better fit hypothesis

[00:12:38] If your whole career is based on something you're like okay

[00:12:40] Because a year-long experiment is like to answer one little question

[00:12:44] We don't get the results you want or the results are inconclusive. You're like, because a year-long experiment is like to answer one little question and we don't get the results you want or the

[00:12:46] Results are inconclusive. You're like, oh got to repeat it. I know so fucking tedious

[00:12:50] Yeah, it's defeating you don't want to publish anything negative you should want to like something work. Yeah, negative shit affects your funding

[00:12:59] I saw today of Zimbeck Simic lutide one of the

[00:13:03] Diabetes medications that recently has been

[00:13:06] used a lot for weight loss, the hot new craze in the general American public.

[00:13:11] Take this injection every week and you'll lose weight and it works really well.

[00:13:15] You lose a lot of weight, but now what they're finding is that it's causing gastroparesis

[00:13:21] in some people to a very severe degree. Gastroparesis being your stomach is not moving the contents

[00:13:28] through your GI tract like it's supposed to.

[00:13:31] Well, that's actually how the drug works

[00:13:33] or was designed to work.

[00:13:34] It's slowing the mortality or something.

[00:13:35] Is it a GLP1 agonist?

[00:13:38] There's many of them, ozimpic, wagovii, Montegeo,

[00:13:42] more and more potent ones are coming out the market.

[00:13:44] And they do work.

[00:13:46] For most people, they tolerant pretty well.

[00:13:48] The whole gashro purses thing is they're designed

[00:13:50] to work like that though.

[00:13:51] So maybe it's more about-

[00:13:52] These are the most basic motility.

[00:13:53] People taking them for too long.

[00:13:55] Maybe, because losing weight is definitely important

[00:13:58] and obviously not everybody is going to diet or exercise.

[00:14:01] There is a risk benefit ratio there where I could say,

[00:14:04] yeah, that this works but

[00:14:06] then the problem is that the makers of the drug ideally want the patient to take it forever.

[00:14:14] Going on a Zenpica GOP one you're eating less food because you're hitting that point of satiety

[00:14:19] early because the food that you are eating is moving out of your stomach more slowly. You get more full, you eat less food, less calories in, equals less weight gained.

[00:14:29] The issue is if you stop taking it as an epic, your hunger, your satiety is going to naturally

[00:14:35] increase back to the way it is, or the way it was before and you'll probably gain all

[00:14:39] that weight back.

[00:14:40] The same way if you were on a diet, like going keto or something, you lost a lot of

[00:14:43] weight, you went back to eating the way before you were going to gain that way back again.

[00:14:48] There are a lot of good things about ozimpic as anything though, it's a tool and it has

[00:14:53] its cons as well.

[00:14:55] People that are just using ozimpic and they're losing weight because they're eating less,

[00:15:01] but they're not increasing their amount of exercise.

[00:15:04] There's peruminated data showing that they are becoming sarcopenic as in they're eating less but they're not increasing their amount of exercise. There's periminated data showing that they are becoming sarcopenic as in they're losing

[00:15:10] muscle too.

[00:15:11] Yeah.

[00:15:12] So they're not getting enough protein in and they end up, especially if you're not strength

[00:15:15] training while you're doing this, you're going to start seeing muscle wasting.

[00:15:19] The other thing is once you become obese, man, I wish there was like general health classes

[00:15:24] that people would

[00:15:25] take in elementary school through high school that would tell you about this because the

[00:15:29] more you find out, the crazier it is that once you become obese, your hormonal access

[00:15:36] is permanently out of whack.

[00:15:38] You have a set weight point that is driven by your metabolism.

[00:15:43] Once you become obese, your set weight point is moved so far up that even when you do all the right things, diet

[00:15:49] exercise, you lose all that weight. Sometimes you can't get that set weight

[00:15:53] point of your metabolism down and you'll go right back to the way you were.

[00:15:57] There's a lot of yo-yoing that goes on which become obese and trying to lose

[00:16:01] that weight. Whether it be from getting gastric sleeve surgery,

[00:16:06] bariatric surgery, or even just doing it the natural way,

[00:16:09] people yo-yo a lot.

[00:16:11] And they think it's because of the damage

[00:16:14] that happens to that hormonal axis.

[00:16:16] I would guess that you could reverse that,

[00:16:19] but it's going to take the same amount of time

[00:16:22] that it took for you to get there,

[00:16:24] changing your habits for your body to wake up and say,

[00:16:28] oh, okay, we're doing this now.

[00:16:29] We're not yo-yoing anymore.

[00:16:31] We've committed to this change.

[00:16:34] It'd be great if we could use things like Ozembik as a tool,

[00:16:37] pair them with a lot of counseling and pair them with,

[00:16:40] hey, this is going to instigate a change

[00:16:43] that is going to grow on its own independent of the drug

[00:16:47] After an amount of time and that is the expectation is there's got to be the drug with this behavioral change

[00:16:54] Yeah, that needs to be long-standing ideally

[00:16:58] That's what we want to do the how often have I seen that work?

[00:17:03] It's kind of like a Xanax in panic attacks, right?

[00:17:07] I'll give you a little bit of Xanax,

[00:17:08] not to the degree to totally knock you out,

[00:17:11] but to take the edge off so that you can process

[00:17:14] your trauma or process whatever is causing you

[00:17:18] to have these panic attacks, do the psychological work

[00:17:21] to overcome them, to actually cure your panic and then come off

[00:17:26] of the Xanax, but same thing. How often does that actually work or how often do we just create

[00:17:32] somebody who's now dependent on Xanax to control their anxiety? I've found in my brief medical career

[00:17:39] that being a good life coach is almost as important as being a good doctor just as much as knowing about

[00:17:46] all the physiology and knowing the JOPI one. Being able to convince people to do things is

[00:17:53] maybe the most important.

[00:17:57] Somebody get this guy some help!

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[00:18:59] Or put more simply.

[00:19:00] You need help like this guy.

[00:19:01] Call your own doctor.