Inverse Comorbidity: The Power of Paradox in the Advancement of Science

Abstract

Primary care physicians believe they are delivering evidence-based care, understanding that adherence to evidence-based clinical guidelines results in tangible benefits in the populations for which they were devel-oped. Unfortunately, most clinical guidelines are based on trial populations which are very different to primary care populations [1], and do not reflect the reality of multimorbidity in general practice [2–6]. Since patients with multimorbidity account for around eight in every 10 primary care consultations [7], it is unsurpris-ing that many primary care physicians find managing these patients challenging. Additionally, current clini-cal guidelines do not provide guidance on how best to prioritize recommendations for individuals with multi-morbidity, and may therefore result in over-treatment and polypharmacy, and a risk of overlooking patient preferences [2,8]. To illustrate the point, allow me to present Mary, an 82-year-old, socially active woman living alone. Mary has been taking alendronate and calcium/vitamin C fol-lowing a Colles fracture 5 years ago. She has difficulty walking as a result of osteoarthritis (for which she takes paracetamol and naproxen) and chronic obstructive pulmonary disease (for which she uses salbutamol for short-term symptom relief plus a salmeterol/fluticasone inhaler to prevent exacerbations). Mary is visiting her GP today to discuss her recently diagnosed stage 2 hyper-tension (ambulatory blood pressure 162/92 mmHg), her fasting total:HDL (high-density lipoprotein cholesterol) of 5.3, and her newly diagnosed chronic kidney disease (CKD) stage 3aA2. With strict adherence to all the current evidence-based guidelines for her conditions, Mary would be leaving her appointment today with a prescription con-taining all of the following: • Paracetamol 1 g four-times per day, as needed • Naproxen 250 mg twice-daily, as needed • Calcichew D3 Forte two tablets per day • Alendronate 70 mg once-weekly • Salbutamol and/or ipratropium bromide inhalers, as needed • Salmeterol/Fluticasone 50/500 mg inhaler, one puff twice-daily • Atorvastatin 20 mg, once daily • A calcium channel blocker, once daily • An angiotensin-converting enzyme (ACE) inhibitor, possibly at the maximum dose • Possibly a thiazide to achieve CKD blood pressure targets.