Aching decisions

Take Mrs Blogg’s polymyalgia, for example. It arose insidiously, slowing her like a clockwork toy without its key. Her slim, prim frame seemed en route to my room for so long in the end that it was impossible to complete the consultation in regulation time. She was fortunate I let her in at all.

High dose steroids had a near-miraculous effect at the start, re-winding her motor and winning me her heart. My sense of propriety, backed up by a generous helping of desire to keep my job, led me to resist her warm embrace. And something else too: I knew there’d be side effects.

She ballooned like a retired sporting icon. She moved faster now, yes, but so too did she brush the walls on both sides of the corridor. Her voice dropped, her features coarsened, and she took to using the chair without arms.

We got to know each other well over the several years it took to wean her off the steroids. She did better than many in her quest to regain her former wardrobe but never quite attained that goal. Our relationship settled into a comfortable pattern, where new problems were always blamed on my medicines and their solutions led to more. By the time she was off steroids, she was hypertensive, diabetic, and ruled by a dosette box. In the years to come her osteoporosis would declare itself too. Her life had been transformed.

And this is why I mention her. Mrs Bloggs is not alone: complications of the illness and its treatment were not far below half in one recent study.¹

Mrs Bloggs didn’t, but one or two patients of mine have ended up seeing rheumatologists. Curiously, some end up taking azathioprine. This cuts their steroid needs dramatically, and so too their complication rates. There is some evidence for this,² although not enough to persuade the authors of the British Society for Rheumatology Guidelines³ to mention it. They, like the authors of a systematic review⁴ published almost synchronously, suggested methotrexate instead, but as a secondary consideration only: steroids still rule.

A pang of guilt crosses my mind. Need I have ruined this fine lady’s profile? Perhaps I need not have carried on with steroids so long. I did start her bone-sparing tablets somewhere along the line, but that was my only attempt to ameliorate. Would methotrexate have helped her more? Would azathioprine?

I even resort to checking the curriculum.⁵ What good is a GP who doesn’t know his stuff! It confirms what I suspected: I should be able to appraise the evidence. If only I could detect the selection biases, the inappropriate use of parametric and non-parametric tests, and check on the quoted odds ratios, I may know whether I acted in folly or not. Mrs Bloggs could at least be reassured she had the best treatment, or that she would be the last to suffer so.

But appraisal of the research is not the key to problems like this. The evidence is scant. We’re guessing.

I press the buzzer again, cursing the time Mr Jenks is taking. Impatiently, I stand up and open the door. He thinks it politeness and smiles stiffly. He is still several minutes away, coming to seek a key that can re-wind his motor.

I have one, yes, but I pity that it is not all so simple.