The placebo effect and randomized trials: analysis of alternative medicine

What Do We Know About the Do-It-Yourself Diets of Patients in Our Care?

This pilot study aimed to investigate dietary changes introduced after being diagnosed with cancer in a sample of 60 consecutive children and adolescents on the basis of a self-report questionnaire. The study showed that 53% of patients changed their diet, usually "to combat the tumor" (in 47% of cases). In 1 in 2 of these cases, the health care staff were not informed about any changes. This study underscores the fact that many patients and families chose to impose dietary changes that are not always discussed with their health care staff and that may risk interfering with the continuity of a patient's treatment. It is essential to have more opportunities to speak with patients and families about this issue.

Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo

BACKGROUND

Clinical study and practice data have shown sildenafil improves sexual function in men with erectile dysfunction (ED). However, some men treated with placebo in double-blind, placebo-controlled sildenafil studies also report improved erectile function as measured by International Index of Erectile Function (IIEF)-Erectile Function Domain (EFD) scores.

AIM

This analysis estimated the relationship between post-baseline IIEF-EFD scores and demographic variables, including co-morbidities, in men with ED receiving placebo in flexible-dose sildenafil studies.

METHODS

Placebo-treated participants in the intent-to-treat population of 42 double-blind, placebo-controlled, flexible-dose, sildenafil studies were included. A participant was classified as a placebo responder if the IIEF-EFD score was ≥26 at the last visit.

OUTCOMES

Variables assessed were age (<45, 45-64, ≥65 years), race, body mass index, co-morbidities (cardiovascular disease/hypertension, diabetes mellitus, depression), date the last study dose was taken, study completion date, ED etiology (psychogenic, organic, mixed), history of cigarette smoking, ED duration, baseline IIEF-EFD score (≤10, 11-16, ≥17), and treatment duration. Stepwise multivariate logistic regression models assessed the odds of being a responder vs a non-responder for each variable.

RESULTS

A total of 4,360 men were included; 13.5% were responders. Odds estimates indicated the largest likelihood of placebo response occurred in men who were black (odds = 20.2, P < .0001), were younger than 45 years (odds = 7.3, P < .0001), had mild ED (baseline IIEF-EFD ≥17; odds >100, P < .0001), and did not have diabetes (odds = 4.5, P < .0001). The likelihood of a placebo response decreased as ED duration increased (odds = 0.74, P < .0001). The frequency of common adverse events was similar between placebo responders and non-responders.

CLINICAL TRANSLATION

These findings contribute to the improved understanding of predictors of placebo response in sildenafil clinical studies. Elucidation of these factors may contribute to the development of further interventions and treatment strategies and best practices for clinical trials.

STRENGTHS AND CONCLUSIONS

Strengths of this analysis include the large and diverse population and the duration of follow-up. Limitations include those associated with retrospective analyses and the inability to ascertain to what extent other demographic factors might have contributed to the placebo responses or how these placebo responses might be related to the natural course of ED.

CONCLUSIONS

Certain demographics, co-morbidities, and condition characteristics predicted the odds of a placebo response in sildenafil clinical studies of ED. Underlying reasons behind a placebo response warrant further evaluation. Mulhall JP, Carlsson M, Stecher V, et al. Predictors of Erectile Function Normalization in Men With Erectile Dysfunction Treated With Placebo. J Sex Med 2018;15:866-872.

Randomised controlled trials in the evaluation of non-biomedical therapeutic interventions for pain: The gold standard?

This paper offers a critical review of important issues in the implementation and interpretation of randomised controlled trials (RCTs) used to evaluate non-biomedical therapeutic interventions for pain. The analysis of methodological issues focuses on the validity, relevance and clinical importance of outcome measures; sampling and randomization bias; blinding procedures used to control for the placebo response and therapist influences, and treatment standardisation. A key issue is that pain management is inextricably linked to the establishment of a therapeutic relationship. In such circumstances, it is argued that the 'gold standard' double-blind RCT is impracticable. Those relying on RCTs as sources of evidence need to be aware that an 'unblinded' RCT can enhance placebo responses to the intervention and introduce important sources of bias. The challenge faced by healthcare researchers is to identify alternative research designs able to provide valid and reliable evidence that the proposed therapeutic intervention is capable of achieving cost-effective, clinically important and personally relevant outcomes in naturalistic settings.

Dietary supplements and nutraceuticals in the management of andrologic disorders

Dietary supplements and nutraceuticals are commonly used by men with erectile dysfunction, decreased libido, BPH, and concerns about developing prostate cancer. Many preparations do not contain the advertised dosages of the active ingredient or are contaminated. Dietary supplements and nutraceuticals, particularly those addressing erectile dysfunction and libido, need to undergo rigorous testing before they can be wholeheartedly recommended.

Botanical medicine and cancer: a review of the safety and efficacy

It is currently estimated that > 50% of all patients diagnosed with cancer explore complementary and alternative medicine - especially herbal medicine. We conducted a comprehensive review to assess the safety and efficacy of herbal medicines commonly used by patients in an attempt to: prevent cancer; treat cancer; and treat adverse effects associated with conventional cancer treatments. Current evidence suggests that Asian ginseng, garlic, green tea, tomatoes and soy intake as part of the diet may be useful in preventing various cancers; additional research is needed in order to determine the efficacy of essiac, evening primrose oil, mistletoe, reishi, shiitake and turmeric as cancer treatments; and ginger may be effective in treating chemotherapy-induced nausea and vomiting.

Prevention and treatment of erectile dysfunction using lifestyle changes and dietary supplements: what works and what is worthless, part I

Clinicians working in urology should adhere to the same guidelines that are observed in cardiovascular medicine when dealing with a patient with ED. A golden opportunity exists to discuss lifestyle changes with any man with or concerned about ED. Providing heart-healthy recommendations to men with minimal to extensive ED may produce a twofold impact: (1) patients may be able to affect the future extent of their disease, and (2) patients may become healthier overall. Patients following a heart-healthy lifestyle after a diagnosis of ED or to prevent ED should enjoy increased quality or quantity of life. The time is more than ripe for patients to understand that heart health is tantamount to erectile health.