A recent article entitled “Using ChatGPT to predict the future of personalized medicine” in the prestigious journal Nature offers the following outlook:
“Personalised medicine is a novel frontier in health care that is based on each person’s unique genetic makeup. It represents an exciting opportunity to improve the future of individualised health care for all individuals.”
At the centre of the personalised medicine hype is a research field known as pharmacogenomics which aims to study the genetic makeup of individuals in order to optimise drug prescriptions. It is envisioned that future treatments will be algorithm-based instead of evidence-based that will consider a patient’s genetic, transcriptomic, proteomic, epigenetic, and lifestyle factors resulting in individualised medication.
That is a big mouthful; what does it mean? Supposedly, artificial intelligence (AI) tools will analyse the results of various genetic tests, microbiology assays and patient questionnaires and then prescribe what drugs will suit an individual best. The falling cost of genetic testing will, according to enthusiastic advocates, enable this process to become the universal healthcare of the near future.
The article finishes with the caveat: personalised medicine still has several limitations that need to be solved. That is an understatement of gigantic proportions. To understand these limitations, we need to examine how or more correctly if people in medicine are currently using genetic tools to personalise drug prescriptions. In other words, what is really going on here?
A Project to Implement Personalised Medicine
The UK MHRA (Medicines and Healthcare Products Regulatory Agency) is currently undertaking an investigation into blood thinners known as Direct Oral Anticoagulants (DOACs). According to the MHRA, these drugs, which include rivaroxaban, dabigatran, apixaban, and edoxaban, have been found to cause serious bleeding in between 2 to 5% of patients. In some cases, this leads to hospitalisation and even death. 1.5 million patients take DOACs in the UK alone.
The MHRA has started genetic testing of patients affected with DOAC bleeding to discover whether they have any special genetic characteristics which predispose them to excessive bleeding. According to Dr. Alison Cave, the MHRA chief safety officer: “The ultimate long-term goal for us is to identify patients most at risk of harm from side-effects with a particular medicine due to their underlying genetic make-up, and avoid them suffering from that harm.”
As she announced MHRA’s move to personalised medicine, Dr. June Raine, the CEO of MHRA predicted: “Almost a third of adverse reactions to medicines could be prevented with the introduction of genetic testing.”
This All Sounds Very Exciting and Hopeful. So What Could Possibly Go Wrong With Personalised Medicine?
Firstly, the scale of the problems associated with modern medical procedures is gargantuan. In 2016, a Johns Hopkins study published in the BMJ found that medical error is actually the third largest cause of death in the USA. Just reflect for a moment. It almost certainly became the leading cause of death during the pandemic.
One problem lies in under reporting of medical error and adverse effects of medicines. Even if medical error occurs, it is seldom listed as a cause of death on death certificates. A 2016 study also estimates that less than 5% of adverse drug reactions (ADRs) are reported to the relevant safety authorities.
A 2021 meta analysis entitled “Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis” investigated the extent of the problem and found that reactions to cardiovascular system drugs were most commonly implicated. These usually involve excessive bleeding following the administration of blood thinners. According to the study, 23% of all adverse drug reactions are preventable. So, is this a powerful argument for personalised medicine? No, because the data, the science, and the known risks do not square with the PR hype.
The 2-5% of people thought to be affected with serious bleeding by DOACs is an under estimate, the likely percentage is much higher due to under reporting of ADRs. Crucially another very important factor to consider is non-adherence to the prescribed drug regime. Only around two thirds of patients persist with DOAC use. Collectively, these factors mean that the real world rate of serious bleeding from DOAC blood thinners possibly exceeds 10% of patients. A very high rate of adverse effects which is no doubt driving MHRA concerns.
The problem doesn’t stop there. Excessive bleeding is not the only adverse effect associated with DOACs. For example, the prestigious Mayo Clinic lists 17 common adverse effects of Rivaroxaban. Other than multiple different types of bleeding, these include paralysis, headache, back pain, bowel or bladder dysfunction, leg weakness and numbness.
Blood thinners aim to reduce blood platelet counts and aggregation because platelets are responsible for clotting and are therefore involved in various types of thrombosis and heart disease, but that is not all platelets do. They also play a vital role in maintaining immunity, preventing tumour growth, maintaining the composition and stability or haemostasis of blood, and preventing leakage from blood vessels which can be associated with the metastasis or spread of cancers. Therefore blood thinners inevitably have a range of serious side effects irrespective of anyone’s genetic composition.
What is the Proposed Net Result of the Current Mhra Personalised Medicine Investigation of Blood Thinners?
In essence, if one type of blood thinner proves unsuitable, doctors will simply recommend another drug.
Patients having an adverse reaction to DOACs are often switched to antiplatelet medications such as Clopidogrol, Ticagrelor, Prasugrel, etc. However, these medications have a broad range of side effects very similar to DOACs. For example, the Mayo Clinic lists 25 common side effects of Ticagrelor antiplatelet medication. Aside from excessive bleeding, these include chest pain, confusion, blurred vision, loss of consciousness, irregular heart beat, paralysis, nervousness, and weakness. Hardly a picture of heart health. These serious side effects are not usually mentioned by doctors. Millions of people are prescribed this class of drug without full disclosure of the serious risks they carry.
Instead, heart patients, those at risk of cardiac events due to age, and even the general population are routinely prescribed various types of blood thinners, anticoagulants, and cholesterol reducing drugs. Their use is always presented as the gold standard with the best possible outcomes. Pressure and fear is exerted, including the threat of early mortality if you don’t comply.
The aim of personalised medicine is not to decrease drug use but rather to personalise drugs, even to increase the use of drugs. Whilst most pharmaceutical drugs entail adverse reactions and unanticipated side effects, drugs that are tailored to genetic characteristics may potentially have even more serious consequences and long term adverse outcomes. This is because genetic systems are involved in all the functions of the physiology, its organs, bio-molecular messaging, and overall immunity.
Are There Alternative Approaches to Cardiac Health That the MHRA Should Be Considering?
A meta-analysis published in the BMJ entitled “Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study” gives an affirmative answer. It concludes:
“Randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes…exercise interventions should therefore be considered as a viable alternative to, or alongside, drug therapy.”
Regrettably, the study also concluded:
“Our findings reflect the bias against testing exercise interventions and highlight the changing landscape of medical research, which seems to increasingly favour drug interventions over strategies to modify lifestyle. The current body of medical literature largely constricts clinicians to drug options.”
While little research has been undertaken comparing the relative effects of exercise and drugs on cardiac illness, even less research has been conducted assessing and quantifying the effects of herbal remedies. This is a remarkable omission. Inappropriate diet and lifestyle are arguably the most significant factors contributing to the genesis of heart disease. The corollary of this is highly significant: corrections to diet and lifestyle are the most significant measures that can be taken to avoid and mitigate heart disease.
A paper published in 2019 entitled “Review of herbal medications with the potential to cause bleeding: dental implications, and risk prediction and prevention avenues” describes 20 common herbs which are understood to have antiplatelet, anticoagulant or other relevant actions that could be beneficial for heart disease.
These are: Aloe, Cranberry, Feverfew, Garlic, Ginger, Ginkgo, Meadowsweet, Turmeric, White Willow, Chamomile, Fenugreek, Red Clover, Dong Quai, Evening Primrose, Ginseng, Flaxseed, Grapefruit, Green Tea, Oregano, and Saw Palmetto. The paper discusses their effects based on in vitro experiments, animal studies, individual case studies and theoretical grounds. Sadly the main thrust of the paper is not to investigate their worth but to suggest grounds to prevent their use in conjunction with dental treatment.
Some of the above are reviewed here. Other herbs, fruits or natural compounds understood in herbal lore or traditional systems such as Ayurveda to thin the blood or benefit cardiac conditions include Cayenne Pepper, Vitamin E, Cinnamon, Grape Seed extract, Arjuna, Pineapple, Ashwagandha, Guggul, Amla, Tulsi, Triphala, Rose, Rauwolfia and Water Hyssop.
The absence of any serious attempts on the part of the medical research fraternity to assess their worth in clinical practice speaks volumes about the real intent of the personalised medicine endeavour. This is not just a lost opportunity but a giant mistake and a step in entirely the wrong direction. Moreover the pharmaceutical industry has used its influence with regulators to restrict or ban the availability of many traditional herbs, not because they are harmful but because they may compete with proprietary drugs. This includes many on the above list.
Ayurveda and Traditional Personalised Medicine
In fact Ayurveda and other ancient traditions of natural medicine do operate real personalised systems of diagnosis and treatment. Ayurveda literally means the knowledge of long life. There is a system of pulse diagnosis in Ayurveda known as Nadi Vigyan which, used by the skilled practitioner, is able to diagnose the patient’s medical history and future prognosis based on the vibrations of three qualities in the deep pulse known as Doshas. This knowledge has been kept alive in some Indian families where specific knowledge and herbal lore is carefully passed on to successive generations.
The Materia Medica of Ayurveda lists over 5,000 medicinal herbs along with details of their preparation, action and prescription. The skilled Ayurvedic practitioner closely following traditional methods known as a Vaidya is able to draw upon this vast cornucopia of herbs to mitigate current imbalance and prevent future illness. A consultation with a properly trained and experienced Ayurvedic Vaidya, a Chinese medicine practitioner, a naturopath, herbalist or a holistic health professional can make a very valuable contribution to personal health.
Unfortunately, in recent years, Ayurveda has come under attack from giant pharmaceutical companies who are buying up Ayurvedic manufacturers and then cutting corners by shortening or altering the traditional methods of preparing herbal remedies as well as allowing the substitution of synthetic ingredients for traditional plants. Therefore caution is always advised when sourcing Ayurvedic remedies through the internet. Fortunately there are still some who are sticking to traditional methods and testing for contamination, these include Maharishi Ayurveda and Gopala Ayurveda.
The Indian Government Ministry of Health has a Department of Ayurveda which is seeking to preserve and promote authentic traditional practices. There is now a significant body of scientific research documenting and verifying traditional Ayurveda’s unique and highly effective contribution to health. You can find out more about the wide scope of traditional Ayurveda including its consciousness based approaches to health in my book Your DNA Diet.
Conclusion: Personalised genetic medicine is becoming a new form of drug promotion
Personalised genetic medicine as currently envisioned is a step away from finding safe and effective alternatives to risky modern pharmaceuticals, it is a step towards an era where drug use and experimentation on populations becomes the norm.
The MHRA, in common with most medical regulators, is not considering a future where proven safe natural and cost-effective approaches to heart health including diet and exercise are researched and promoted, rather it is forming an alliance with pharmaceutical companies to entangle a misinformed public in a profitable web of drug use and dependence.
What particularly strikes us is the essential madness of the personalised genetic medicine dream that is being pushed on the public using PR hype. So-called personalised medicine ultimately involves the replacement of personal doctors and medical professionals with impersonal AI programmed to push drugs.
The promised benefits are so unrealistic that they qualify as pure fantasy. It appears those paid to promote the concept of personalised medicine are poorly informed about the capabilities, accuracy and interpretation of genetic testing and assessment; and about the well known risks and uncertainties of genetic medicine and many pharmaceutical drugs.
