AstraZeneca’s drug Crestor lowers the risk of heart attacks in apparently healthy adults with no prior history of cardiac disease and normal cholesterol levels, according to the results of a trial known as Jupiter.

Participants in Jupiter did have elevated levels of C-reactive protein (CRP), a non-specific marker for inflammation that identifies people at risk for cardiac events regardless of their cholesterol levels. CRP levels are measured using a $20 dollar blood test that is covered by most insurance policies.

Jupiter was a multicenter, prospective trial involving 17,802 participants in 26 countries that had entered an age where cardiac risk is highest—men over 50 and women over 60. Participants had no signs or symptoms of cardiac disease, and their cholesterol levels were not high enough to prompt treatment using current guidelines. But their CRP levels were high—at least 2.0 milligrams/liter.

Participants were randomized to receive 20 milligrams of Crestor or a placebo. Those who took Crestor experienced a 54% reduction in the risk of heart attack and a 48% reduction in the risk of stroke. They were 46% less likely to require angioplasty or coronary bypass surgery and had 20% lower mortality from all causes. LDL (bad) cholesterol dropped 50% and CRP levels dropped 37% in the Crestor group. Serious adverse events were rare and occurred at the same rate in both groups.

Paul Ridker, a cardiologist at Brigham and Women’s Hospital, was the principal investigator of the Jupiter trial. He presented the results in New Orleans yesterday during a meeting of the American Heart Association. Ridker is listed as an inventor on several CRP assays whose patents are held by the Brigham. He and several co-authors receive grants and other income from AstraZeneca.

“The potential public health benefits are huge,” Ridker told the Washington Post. “It really changes the way we have to think about prevention of heart attack and stroke.” Ridker’s point seems well taken since nearly half of all heart attacks occur in people that have normal cholesterol levels.  JUPITER suggests a broader screening role for CRP, especially in those with normal cholesterol.

However, Stanford cardiologist Mark Hlatky expressed caution to the Wall Street Journal. “Before we expand treatment indications in any drastic way, we need to do due diligence,” he said. “The idea that everybody should get CRP measured is premature and not backed up by good data.”

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US spending on diabetes drugs nearly doubled to $12.5 billion over the last 6 years, according to a study published in this week’s Archives of Internal Medicine.

The cost escalations were driven by a 40% increase in the number of drugs prescribed per patient and a tendency to prescribe newer, costly drugs in lieu of tried-and-true generics despite safety concerns swirling around some of the newer ones.

The study investigators noted that the newer drugs Januvia (Merck, FDA approved in 2006), Avandia (GlaxoSmithKline, FDA approved 2006), and the wildly popular Actos (Takeda, FDA approved 1999) were prescribed in 28% of all doctor visits by the end of the study period.

“We need to pay attention to this,” Dr. David Nathan wrote in an accompanying editorial. Nathan, who is Chief of the Diabetes Unit at Massachusetts General Hospital, added “if you can achieve the same glucose control at lower cost and lower side effects, that’s what you want to do.”

Current guidelines for Type 2 (adult onset) Diabetes recommend metformin, a generic drug that costs about $30 per month along with dietary modifications and exercise as first-line therapy. The guidelines suggest adding other drugs for patients who fail to respond adequately, but the recommendations specifically do not include Avandia which costs nearly $225 per month.

Last year, the FDA released a safety alert for Avandia after a meta-analysis revealed an increased risk of heart attacks in patients taking the drug. There are no safety concerns of this sort for Actos or Januvia.

About 24 million Americans have Type 2 diabetes.

In a stunning policy turnabout made possible by its swollen coffers, China announced that it will cover health care costs for 90% of its population by 2010 and implement universal coverage by 2020.

The plan has global implications given China’s enormous population, its questionable capacity to address epidemics of communicable diseases such as avian influenza and SARS, and its troubled pharmaceutical and food processing industries.

For 35 years after Mao Zedong assumed control of China, the government employed physicians and owned, funded and operated China’s health care system. During this time, China achieved dramatic improvements (albeit from a very low baseline) in life expectancy, infant mortality and other measures of population health.

Then in the early 1980s, in what appears to have been collateral damage from a larger effort to privatize its economy, China essentially dismantled its health care system overnight, replacing it with nothing. Central government spending on health evaporated, leaving overwhelmed provincial and local authorities to coordinate care, physicians to fend for themselves and normal citizens with no choice but to pay for health services out of pocket.

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In July, the American Academy of Pediatrics (AAP) updated its guidelines for managing high cholesterol in children. The revisions generated a blizzard of media attention that surprised many in the pediatrics community.

After all, the revisions were for the most part incremental compared with previous iterations: slightly more comprehensive screening, an emphasis on the quality of fat intake rather than total fat intake, and a reduction in the recommended age for initiating drug therapy from 10 to 8 years.

There was one thing though, that was not incremental. The AAP now recommends statins as potential first-line cholesterol-lowering drugs for kids in whom efforts to lose weight and exercise fail to sufficiently reduce high cholesterol level. The older version made no mention of statins and recommended bile acid-binding drugs instead.

The bile acid binders don’t work well and are poorly tolerated. Statins work exceedingly well and are well tolerated in adults. The problem is that there is only limited, short-term data showing statins are safe in kids. In selecting a drug to recommend, the AAP had to trade-off unknown long-term risks of statins vs. their clear superiority as cholesterol lowering agents.

Sales of statins are already in the billions and how exactly can we subject our kids to unknown risks like that? The reasons for the firestorm are clear.

Now, two Harvard clinicians have posited that the epidemic of childhood obesity is the larger contextual issue at work here. That is what drives unprecedented numbers of kids to the point where they need cholesterol-lowering drugs in the first place. And that is what forces pediatricians to use other powerful “adult” drugs like diuretics and beta blockers for high blood pressure, insulin sensitizers for metabolic syndrome, and even aspirin for coagulopathies that these kids end up with in addition to high cholesterol. We don’t know much about how these drugs work in kids, either.

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A randomized controlled trial has revealed that for patients with osteoarthritis (OA) of the knee, arthroscopic surgery offers no benefit versus conservative therapy.

The arthroscopic intervention tested in this study is lavage and debridement. Conservative therapy included anti-inflammatory medications and physical therapy.

The investigators randomized 178 patients with moderate to severe OA. They assessed patient outcomes using two symptom-based questionnaires-the Western Ontario and McMaster Universities Osteoarthritis Index and the Short Form-36 Physical Component summary score. When investigators compared scores on these tests for the treatment and control groups at the end of two years, they found no significant difference. In particular, there was no difference in pain or activity level. Score comparisons at earlier time intervals also showed no difference.

The authors concluded that “the resources currently allocated towards arthroscopic surgery for osteoarthritis would be better directed elsewhere.”

Interestingly, Medicare stopped paying for the procedure in 2003 after an earlier study had come to the same conclusion, despite protests from many surgeons who felt the trial design was flawed. It is not clear how many arthroscopic surgeries for OA had been done between then and now (and presumably billed for using a reimbursable procedure code), but the number is probably in the hundreds of thousands per year.

Last year, US doctors ordered 68 million CT scans. That’s three times more than in 1995. There are 24,000 CT scanners in the US, or 81 scanners per million citizens. That ratio is three times higher than other western countries.

In 2000, when half as many CT scans were done, Highmark Blue Cross Blue Shield of Pennsylvania concluded that 30% of all scans and imaging procedures were inappropriate or contributed no useful information.

CT scan manufacturers such as GE and Siemens have plug-and-play business plans for physicians. The plans point out that break-even throughput is 2 scans per day for 5 years, and that it’s possible to do 20 scans per day with proper staffing and organization. In case you wondered, physicians owning CT scans are 2-7 times more likely to order them than those who refer patients to outside facilities.

Then there’s the cancer risk due to radiation exposure from CT scans. A recent article in the New England Journal of Medicine estimated that such exposure could cause 2% of all cancer deaths 20-30 years from now.