Should the patient really get the drug?

Drug harms deprescribing drowning in drugs

I recently gave a lecture to 70 primary care physicians here in Stockholm, titled “should the patient really get the drug?”. The lecture seemed to generate quite a bit of cognitive dissonance among some in the audience, based on the somewhat aggressive discussion that followed the lecture, which suggests to me that much of what I was saying was stuff they had literally never been exposed to before – not at any point in medical school, and not at any point during their careers after medical school either. Cognitive dissonance is good. It’s the first step towards change.

I thought it would be interesting to re-write the lecture as an article, so that more people can hopefully achieve similar levels of cognitive dissonance. Please feel free to share it with any doctors you know that you think might benefit from an expanded perspective. Anyway, here we go.

Let’s imagine a common patient. Every primary care physician meets this patient, or someone much like her, on an almost daily basis. She’s 75 years old, and overweight. She experienced a wrist fracture two years ago, and was subsequently diagnosed with osteoporosis. She has high cholesterol levels, but she’s never had a heart attack or other “cardiovascular event”. On top of that, she has type 2 diabetes, chronic knee pain due to osteoarthritis, and high blood pressure. She was diagnosed with depression a few years ago, after her husband died.

Our patient takes seven drugs every day:

  1. Alendronate, because of her weak bones.
  2. Atorvastatin, because of her high cholesterol levels.
  3. Sertraline, because of her depression.
  4. Metformin, because of her type 2 diabetes.
  5. Insulin, also because of her type 2 diabetes.
  6. Paracetamol (a.k.a. acetaminophen), because of her knee pain.
  7. Enalapril, because of her high blood pressure.

So, the question is, are these drugs doing her any good?

Well, to answer that question, we need to consider NNT (Number Needed to Treat). NNT is the number of patients who need to take a drug for one patient to achieve a noticeable benefit.

For alendronate, the NNT is 20, i.e. if you treat 20 people for a couple of years, you prevent one fracture. For atorvastatin the NNT is 200, i.e. you need to treat 200 people for five years or so in order to prevent one heart attack. For sertraline, the NNT is 7, which means that you need to treat seven people in order to have a noticeable effect on depression in one patient. Note that this doesn’t mean that one out of seven gets cured of their depression, it just means that there is a noticeable difference on a rating scale for depression.

For metformin, the NNT is 14 – If you treat 14 type 2 diabetics with metformin for ten years, you prevent one death. For enalapril, the NNT is 70 – If you treat 70 people with high blood pressure with enalapril for five years or so, you prevent one stroke.

For insulin, however, there is no NNT, because insulin has not been shown to result in any benefit on any clinically relevant outcome, even though big studies have been carried out that have included thousands of patients and followed them for five or ten years. Note here that we’re talking about insulin for type 2 diabetics. When it comes to type 1 diabetes, insulin is pretty much magical – you don’t even need to do a randomised trial in order to show benefit. People with type 1 diabetes virtually return from the dead when treated with insulin. But when it comes to type 2 diabetes, there is no benefit, at least not to any hard outcomes. All insulin has been shown to do is reduce blood sugar, but it’s never been shown to result in any meaningful patient oriented benefit for type 2 diabetics.

The same is true for paracetamol/acetaminophen. When it comes to patients with knee pain due to osteoarthritis, the drug doesn’t provide any benefit whatsoever.

Ok, so we have seven drugs, and we know what their NNT’s are. If we plus the probabilities of benefit together, then we get the probability that our 75-year old woman will benefit in some way from at least one of the drugs she’s taking. So, what probability of benefit do we get?

We get 30%. Only 30%.

What that means is that there is a 70% probability that this woman doesn’t benefit at all from any of the seven drugs that she takes every day for years on end!

If you told her, I’d say there are pretty good odds she’d decide to stop taking her pills. Seven drugs a day, every day, and two to one odds of zero benefit.

And we haven’t even talked about harms yet. Because none of these pills are inert. All have widespread biological effects. And all can cause harms. So any rational treatment decision must include not just the potential benefits, but also the potential harms.

For figuring out harms, we have NNH (Number Needed to Harm), which is the counterpoint to NNT. NNH is the number of patients who need to get a drug for one to be harmed. Like I said, the drugs all have widespread biological effects, so there isn’t just one NNH – there is an NNH for each possible harm. That means that there are multiple NNH’s for each drug.

With our 75-year old woman and her seven drugs, we don’t have time to go through the NNH for every possible side effect, so we’re just going to look at a few, and put them side by side with the NNT, to get a somewhat more complete picture of benefits vs harms. I’ve tried to make sure that the NNH numbers apply to the same time period as the NNT numbers, since otherwise it’s an apples to oranges comparison.

If we do that, we get something like this:

NNT: 20 (fractures)
NNH: 200 (esophagitis), 260 (atrial fibrillation), 4,000 (osteonecrosis)

NNT: 200 (cardiac infarction)
NNH: 20 (myalgia), 20 (type 2 diabetes)

NNT: 7 (depression)
NNH: 2 (sexual disturbance), 10 (hyponatremia)

NNT: 14 (death)
NNH: 2 (stomach upset), 5 (B12 deficiency), 1,000 (lactic acidosis)

NNT: 70 (stroke), 125 (death)
NNH: hyperkalemia (10), acute kidney failure (100)

NNT: 0 (no benefit to clinically relevant outcomes)
NNH: severe hypoglycemia (5), weight gain (1)

NNT: 0 (no benefit to clinically relevant outcomes)
NNH: Hypertension (30), liver damage (?)

It’s possible to quibble here about specific NNT and NNH numbers. Different studies show different things. And many of the numbers come from studies carried out by pharmaceutical companies, which generally means that the risk of a certain side effect is massively underestimated (as we will discuss shortly). The point here isn’t to get hung up on any of the specific numbers. It’s to illustrate that we quickly end up with a very complex equation, where it in many cases isn’t clear at all whether the benefits outweigh the harms.

Take alendronate, as an example. We know that it decreases fractures in elderly osteoporotic women. But it doesn’t decrease hospitalisations. The only reasonable conclusion is that the reduction in hospitalisations that is seen due to the reduction in fractures is made up for by an increase in hospitalisations due to the many and varied side effects. So at the end of the day the only way to decide whether or not to take the drug is to have a detailed discussion with the patient and get them to decide which set of risks they’d rather be taking.

Hippocrates is supposed to have said “primum non nocere”, which is latin for “first, do no harm”. Actually he didn’t say that, and couldn’t have even if he wanted to. Hippocrates was greek, and didn’t speak latin. The quote comes from a 19th century American physician, Worthington Hooker.

Of course, as doctors, we all know that “first, do no harm” is completely unrealistic. Every intervention we do carries som measure of risk. If our primary guiding principle was to never do harm, we literally would never be able to do anything. A more reasonable principle is “only do something if the benefits clearly outweigh the risks”. If it isn’t clear to you that the benefits of a drug outweigh the harms, then don’t give it to the patient.

That’s a good general rule to stick by. However, it probably isn’t enough, for a few reasons we’re now going to discuss.

A study was published in JAMA Internal Medicine in 2021 that sought to establish how good physicians are at estimating the likelihood that a patient has a certain disease. 500 primary care physicians in the US were asked to consider various hypothetical scenarios, and then answer what they thought the probability of disease was. Here’s an example of a scenario that they were asked to consider:

Ms. Smith, a previously healthy 35-year-old woman who smokes tobacco presents with five days of fatigue, productive cough, worsening shortness of breath, fevers to 102 degrees Fahrenheit (38.9 degrees centigrade) and decreased breath sounds in the lower right field. She has a heart rate of 105 but otherwise vital signs are normal. She has no particular preference for testing and wants your advice.

How likely is it that Ms. Smith has pneumonia based on this information? ___%
Ms. Smith’s chest X-ray is consistent with pneumonia. How likely is she to have pneumonia? ___%
Ms. Smith’s chest X-ray is negative. How likely is she to have pneumonia?

Go ahead and make your own guesses in relation to each of the three questions.

Once you’ve done that, you can take a look at the table below, and the answers will be revealed.

So, for our pneumonia example above, we see that the actual initial risk of disease based on the presented information was around 35%. If we then move along and look at what the doctors answered, they thought the risk was 80-85%. In other words, they thought pneumonia was more than twice as likely as it actually was!

The same phenomenon was seen in all clinical scenarios tested. The doctors consistently overestimated the initial risk, and they continued to overestimate the risk after both a positive and a negative test result. In some cases the difference between reality and what the doctors thought was huge, with the doctors overestimating risk by a factor of ten or more.

What can we conclude from this?

Doctors consistently overestimate disease risk.

Hold that thought, as we move on to take a quick look at another study, which was published in BMJ Open in 2015. This study sought to do something about a problem inherent in statin trials (and for that matter, all trials in medicine), which is that the results they produce, in the form of percent absolute risk, percent relative risk, and NNT, are so abstract that they’re completely meaningless to patients (and for that matter, to doctors as well). We know that statins have an NNT of 200 when used for primary prevention (to prevent a heart attack in someone who has risk factors but hasn’t already has a heart attack), and 40 when used for secondary prevention (to prevent additional heart attacks in someone who has already experienced a heart attack). But what do those numbers actually mean? Are they good or bad?

What the patient really wants to know is “how much longer will I live if I take this drug?”

So, what the researchers did was gather together data from all the big randomised trials of statins, and use the survival curves provided to estimate how much longer the patients actually lived. Here’s what they came up with:

All the big statin trials are included here. What’s interesting to do is look at the NNT provided, and then compare that with the number to the right of it, which is how much longer the patients actually lived, on average. So, for the ALLHAT trial, to take the topmost example, we have an NNT (for primary prevention) of 250, which comes down to a postponement of death of 4.96… well, 4.96 what?

Is it years? No.

Is it months? No

The patients in the statin group lived 4.96 days longer than the patients in the placebo group. That is what the NNT of 250 means in real terms.

Let’s look instead at 4S, which was published in 1994 and is the statin trial that has produced the best results of any statin trial ever. It’s the trial that initiated the massive boom in statin prescribing that we still see today. In 4S, the NNT (for secondary prevention) is 27.8. So, in other words, one in 27.8 patients benefited from the treatment.

But what does that actually mean in terms of life extension?

It means 27 days.

Not as impressive as you would have thought, right?

When the researchers put all the data together, from all the trials, in order to get an overall average, what they found was that when statins are used for primary prevention they prolong life by 3 days. When they are used for secondary prevention, they prolong life by 4 days.

I can imagine quite a few patients turning down the offer of a statin if they knew that it will on average only prolong their life by days.

The purpose of bringing up this study was to illustrate the following general point:

Doctors consistently overestimate the benefit of the drugs they prescribe.

Hold that thought in your mind as we move on and look at a third study.

This one was published in The Lancet Healthy Longevity in 2021. It compared the rate of serious side effects seen in randomised trials with that seen in the real world. If randomised trials give us good information about what to expect in reality, then the rate of serious side effects in the trials should be the same as that seen in reality.

But that isn’t what the researchers found. What they found was that serious side effects were three to four times more common in reality than they are in the randomised trials! Three to four times!

How is this possible?

Well it’s important to remember that the randomised trials are funded and run by the drug companies, and the drug companies want to sell their drugs, so they will do what they can to make side effects appear as rare as possible.

Why is this a problem? Because it’s the randomised trials that doctors mostly use as a basis for determining whether a drug is safe to give to a patient or not.

So, what can we conclude from the study?

Doctors consistently underestimate side effects of drugs.

Ok, so we have three conclusions, that are all pointing us in the same direction:

  1. Doctors consistently overestimate disease risk.
  2. Doctors consistently overestimate drug benefit.
  3. Doctors consistently underestimate drug harm.

What does this lead to?

Massive overprescribing of drugs.

Peter Gotzche, a founding member of the Cochrane Collaboration and former director of the Nordic Cochrane Center, has estimated that prescription drugs are now the third biggest cause of death in the western world, after heart disease and cancer.

That on its own should lead to massive humility among all doctors about our drug prescribing. It should make us much more careful every time we think about prescribing a drug to a patient.

Ok, so we’ve identified the problem. The causes of this problem are many and complex, so I’m just going to bring up one that each of us as doctors can actually do something about – industry sponsored meals.

A study was published in JAMA Internal Medicine in August 2016 that sought to estimate the extent to which physicians are influenced by partaking in industry sponsored meals, which often take the form of a lecture about a specific drug given by an drug company salesperson, which the physician is supposed to sit and listen to in return for getting a free meal. Industry sponsored meals are very common. Most physicians probably take part in at least a couple of these per year, and many take part in far more than that.

As the saying goes, “there’s no such thing as a free lunch”. The drug companies are not charities whose goal it is to keep starving doctors alive. If they spend vast sums of money of sponsored meals, it’s because they’re pretty damn sure that it increases sales of their drugs, and thereby their profits.

So, anyway, the study sought to estimate the extent to which industry sponsored meals influence physician prescribing patterns, by comparing participation in such meals with later prescribing behaviour. Here’s what they found:

They looked at four different drugs. As I think is clear from the tables, participation in industry sponsored meals increased prescribing of the drug the meal was about, and the more such meals a doctor participated in, the more often he or she prescribed that drug.

The purpose of these meals is not to educate us, or make us better doctors. It’s the opposite – the purpose is to make us do a specific profit-driven company’s bidding. And it works.

If you’re a doctor, and you think you don’t get influenced by participating in industry sponsored meals, then you are very naive. The more industry sponsored meals we participate in, the worse doctors we become.

Doctors in general massively underestimate the extent to which their thoughts, beliefs, and opinions are influenced by the pharmaceutical industry. We like to think that we are evidence based. But the truth is that much of what we think we know is not based on sound scientific knowledge, but on pharmaceutical industry propaganda, which quickly becomes clear to anyone who starts going through the studies in detail themselves.

On that note, I strongly recommend reading these three books, all written by physicians, to help get some perspective on the scale of the problem we face in relation to the pharmaceutical industry.

  1. Bad Pharma by Dr. Ben Goldacre
  2. Doctoring data by Dr. Malcolm Kendrick
  3. Deadly medicines and organised crime by Dr. Peter Gotzsche

There is one very simple thing every doctor can do, to at least partially free themselves from the onslaught of drug company propaganda, and that is to refuse to take part in industry sponsored lunches, and all other forms of industry sponsored “education”. Just say No.

Ok, so, that’s number one: refuse to take part in industry sponsored lunches.

What else can you do as a doctor?

Well, something that was once considered standard, but has fallen by the wayside in recent decades, is to never have a patient on more than five drugs at the same time. With drugs, as with everything else, there is a state of diminishing returns – the more you add, the less benefit (and more harm) each additional drug confers. So try to keep a patient on at most five simultaneous drugs. If you want to add a sixth, then rank them all, and get rid of the one that you think is least important. Most likely, the sixth least important drug in a list of six is not going to do anything useful for the patient anyway, just increase their risk of harm.

Ok, so that’s number two: try to avoid having your patients on more than five drugs simultaneously.

Number three: go through the patient’s drug list with them once a year, and get rid of anything that isn’t clearly conferring a benefit. As any doctor will know, it’s common for patients to stay on drugs for years, even though the original reason they were put on the drug resolved itself a long time ago. The patient often doesn’t remember why they were put on the drug in the first place, but they keep taking it dutifully. Drug lists require regular pruning or they will become increasingly bloated as the years go by, which is one reason why so many elderly people are on 15 simultaneous drugs or more.

Number four: only prescribe a drug if the benefits clearly outweigh the harms. This should be obvious, but it requires a deep knowledge of the size of both potential benefit and potential harm, which unfortunately most doctors lack. And what they think they know is often incorrect because it’s based more on pharma propaganda than real science.

As a doctor, the only way to get around this is to start doing your due diligence and getting in to the weeds of the scientific studies. Do that for the ten drugs you prescribe most commonly, so that you’re an expert on those ten drugs, and you’ve already done a lot. If a patient asks you about the probability of benefit and the probability of harm, you should be able to answer that question correctly, at least for the ten drugs you use most frequently. It requires an up-front investment of time, but it will pay massive dividends to your patients over the remainder of your career.

Ok, so that was number four: only prescribe a drug if the benefit clearly outweighs the harm.

Here’s number five: prioritise lifestyle changes. Most of the diseases that doctors spend most of their time dealing with are caused by poor lifestyle choices. And most can be rectified by switching to good lifestyle choices, which invariably produce greater benefits than any drug can, with less risk of harm.

Doctors can accomplish a lot with their patients with simple lifestyle coaching. To take one example, a primary care clinic in the UK decided to try putting their type 2 diabetic patients on a ketogenic diet, since the drugs they were using clearly weren’t making the patients better. They published their six year follow up results in BMJ Nutrition, Prevention, and Health in 2020.

Over six years, the patients following the ketogenic diet decreased their median HbA1c (a measure of average blood sugar over the preceding few months) from 66 to 48. Normally, that would be unheard of. HbA1c doesn’t decrease over time in a type 2 diabetic. It increases. Yet here it was far better at the end of the six years than at the beginning. The same goes for body weight. Normally it goes up over time. But here the median decreased from 99 kg to 91 kg. And on top of that, median systolic blood pressure dropped from 152 to 141.

All this just with a simple diet intervention. Thanks to the improvements in all health markers, the patients were able to get off a lot of their drugs. This meant that after six years, the clinic was spending less than half as much money on anti-diabetic drugs as the other primary care clinics in the region.

To take another example of a simple lifestyle intervention, a randomised trial published in BMJ in 2021 that was carried out in nursing homes in Australia found that a diet high in protein has an effect on fracture risk that is equivalent to that seen with bisphosphonates.

There is a massive amount that can be accomplished with simple lifestyle interventions, and since they are much less risky than drugs, and actually treat the underlying problem rather than just putting a patch on top of it, they should be the primary intervention we use whenever possible. Drugs should be viewed as a complement to lifestyle interventions. It shouldn’t be the other way around.

Ok, so that was my fifth and final point. I’ll repeat the five points here again. These are five things that you as a doctor can do about the situation we currently find ourselves in, where prescription drugs are the third biggest killer in the western world:

  1. Refuse to participate in industry sponsored lunches and other industry sponsored “education”.
  2. Try to avoid having your patients on more than five drugs simultaneously.
  3. Go through the patient’s drug list with them once a year, and get rid of anything that isn’t clearly conferring a benefit.
  4. Only prescribe a drug if the benefits clearly outweigh the harms.
  5. Prioritise lifestyle changes.

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102 thoughts on “Should the patient really get the drug?”

  1. An excellent article. The situation is even more complex than you describe. The administration of 5 drugs will most probably lead to some drug drug interaction problems. This may impact on PK/PD with a further effect on NNT.

  2. Excellent article, thank you. I fear most people never question a doctor’s prescriptions, nor do they do enough by way of diet and exercise to improve their own health.

  3. I think that even if the MD is thorough and extremely limiting in the use of medication a high percentage of patients will demand that they be prescribed something. And I think covid further showed this by the reaction of most of the population

  4. Dear Sebastian,
    great stuff! I am forwarding to all people I know for having an interest in the matter.
    Many thanks!
    Kind regards

  5. Very interesting.

    A couple of petty details.
    When you say the ALLHAT trial had a NNT of 250 and delayed death by 4.96 days. Presumably that means 1 person in 250 gets a measurable benefit but that the 4.96 days is an average gain for all 250.
    That would be equivalent to zero gain for 149 patients and 4.96*250 = 1240 days or 3 years 5 months for the one significant gainer.
    (As opposed to the 4.96 days being the measurable gain for the one successful treatment). So at least the one gainer does actually gain 🙂

    Also cause and effect with sponsored meals and prescribing patterns.
    Presumably a physician that anecdotally finds a drug works is more likely to want to go to more lectures on the drug and more likely to prescribe more.

  6. Interesting article, but I have one small quibble. I think the “average days of life added” can and should be looked at a bit differently by the patient. If there is a 1% chance a drug will increase lifespan by 3.65 years, the average benefit is only 1 day. But (assuming the side effects are manageable), I’d be much more likely to take the 1% shot at another 3 plus years of life than “it’s only 1 day”. I realize the math works out that way, but not the individual perceived value.

  7. Brilliant expose Sebastian. I learnt a lot and from now on I have the framework for assessing the risk/ reward of drugs which my doctor would assume is his responsibility. May I be allowed to share this with Dr Mercola?? I will be sharing this far and wide.

  8. Thank you for being so brave in presenting this information to your peers. The world needs more like you who are willing to spend time looking into the facts and getting those facts out into the world in a way that others will listen. Your information is also so valuable to us who want to take charge of our own health as well as assist our family members when they want it.
    Your #5 should be number #2, don’t you think? Why not look at lifestyle change before putting a person on meds? I realize it’s more appealing for some patients to conveniently take a pill and think their problem is taken care of (but is it really as you pointed out?). There is also a growing number of people who want to be more in charge of their health and would like to know what they can do to improve it. I think what we are going to see in the future is more doctors who are sincere in wanting the best for their patients partnering up and referring their patients to health and life coaches.

  9. Hi Sebastian!

    THanks, this is just what I needed 👍👍👍 I’m trying to convince my cardiologist, general practitioner and pharmacist that taking statins, perindopril (ACE), ticagrelor (PTY12) and cardio teva (aspirin) is not the way to prevent heart attacks (fyi: I had two the previous weekend, have à stent since 1 week).

    All based on The NNT I’ve decided NOT to follow “protocol”:

    Thanks again, hope your posts helps me to convince my ‘drug dealers’ that are trying to get me on lifetime ‘medication’ to wake-up.

  10. Keep up the excellent doctoring! Forwarded this article. People pop pills like candy here in the US of A…and it’s sad. Really liked the protein increase and the keto advice at the end, plus weight loss, all important! Here old folks also love joint replacements, everyone seems to have bone on bone..that’s another subject for you.

  11. Poly pharmacy is a huge problem and is obviously doing more harm than good. I’ve been not taking the drugs my doc has prescribed me over the years. Is that a foolish decision? I’m not so sure. In fact I’m a 67 years old male and I am on NO prescription drugs.I do take a few supplements and eat nutritionally well .On return visits Doc always says the drug seems to be helping me. What? I just keep quiet and move on. Unless the drug is life saving and absolutely necessary, I don’t drink the big Pharma cool-aid. Seen too many folks on too many drugs and they are no better for it.

    1. Yuri, me 2 😬 A 67 years old male and NO prescription drugs. I do take supplements and eat nutritionally well (I think, fatsnotbad/keto/LCHF).

      1. I remain confused about nutritional advice too however. It’s all over the map. And of course the supplement industry also promises the stars and the moon in health benefits. is a good source for honest supplement choices. Still, more people have had adverse effects from man made drugs than from supplements.

    2. Tell your doctor that you aren’t taking the drug so that he knows it isn’t helping you otherwise he will keep drinking the big pharma koolaid.

    3. Hi Yuri,
      1 year), despite that not being evolutionarily correct. In that case it is a trade off because I like those cheeses. I never chemically altered foods and rarely grains (wheat, rye, barley etc). Grains are difficult to totally avoid when eating out and e.g. at birthdays, so it is a practical choice to avoid complicating life too much. And so on.
      I’ve been doing this since the early nineties and it has been really easy and requiring little thought.

  12. Excellent speech/article. I hope this reaches many in the medical community worldwide.
    It is time medical practitioners learned to think for themselves.
    Sometimes simplicity is so beneficial. Walk or take a pill, alter diet or take a pill, etc.

  13. Thank you for this information. It makes a lot of things clear. And some perspectives you take are rather new but very interesting to me.

  14. Great article Dr. Rushworth. Given your into to the article, I would really like to see the cognitive dissonance from the audience. Is there any way you can upload the video so we can see the back and forth?

  15. “The same is true for paracetamol/acetaminophen. When it comes to patients with knee pain due to osteoarthritis, the drug doesn’t provide any benefit whatsoever.” Are you saying that patients can’t tell if their knee pain is lessened or not? That doesn’t seem likely. Why would they keep taking Tylenol if their pain was the same?

  16. Thank you Sebastian. This 77yr old woman had already taken the decision to avoid pharmaceutical drugs like the plague, while continuing to smoke 30fags per day!
    By the way. The medicine men continue to try it on with me though. Two recent examples – statins and steroid inhaler (Trelegy).
    I am now confused about Metaformin for type two diabetes. Two of my male friends are on it. One tried lifestyle changes, though probably did not get the ketogenic diet advice. The other probably is/was just too addicted to sugary food, to even try.
    Now it seems to me that the biggest problem about type two diabetes symptoms is blurred vision. One can hardly drive a car with blurred vision.
    Apart from that, why does type two diabetes need ‘treatment’?
    Also it is unclear from this article what Metaformin actually does.

    1. See this article: Integrated or Independent Actions of Metformin in Target Tissues Underlying Its Current Use and New Possible Applications in the Endocrine and Metabolic Disorder Area (
      Main mode of action and usage is this: “In type 2 diabetes, the metformin action consists mostly of decreasing glycemia without increasing plasma insulin concentrations. Metformin exerts its effects on blood glucose levels through systemic actions in the liver, where it decreases the endogenous glucose production, and to a lesser extent in the skeletal muscle, where it increases the basal glucose uptake.” The article does also go on to describe the slew of beneficial side effects that follow by keeping blood sugar and insulin in check.

  17. I agree with the general gist of the article – people take too many medications in old age. But lifestyle changes also rarely work. Most people find it impossible to lose weight, even on a restricted diet. Until we have a better idea of anything that actually works consistently for people, I agree with taking fewer pills, but the advice sadly probably should be to enjoy life as much as you can with the problems that you have – you are unlikely to get rid of them.

  18. Great article. It would have been very interesting to listen to the animated conversations as a result of your lecture. It seems the art of critical thinking in medicine is not being encouraged.

  19. We should be careful here to distinguish between “lifestyle drugs” and others, such as a drug that replaces a missing enzyme that someone is genetically unable to make. The benefit in the latter case is clear, yet I think the public is turning so badly on the pharma companies (the COVID vaccine fiasco didn’t help) that I wonder how soon they will destroy them, regardless of what products they make.

  20. Pfizer and the rest should be financially punished for the horror show of the vaccines.
    Resultant fines should fund an independent assessment of NNT and NNH for the top 100(?) drugs.
    Not going to happen, but I’m fed up with pharma.

    I hesitate to criticize doctors, I think they do a terrific, difficult job, but by reading about and communicating with many fellow T2 diabetics, the lack of awareness of newer approaches to treatment of the condition, even merely lifestyle changes, is surprising. Many people I’ve come across have reversed their T2 with lifestyle changes, including low carb.
    Go to treatment in many newly diagnosed cases is statin and metformin.

  21. Get her on bio identical estrogen and progesterone. That will more than likely sort all her problems out and she won’t need to take all the expensive drugs that will not actually improve her health…

    1. Ah yes… and that is another story.

      Case in point: two doctors told me to stay on HRT and not listen to Katie Couric (stupid media hack) who says don’t take HRT because it causes cancer. Switched doctors since the other two sold their practice and retired.

      New doctor (high praise on her reviews) said don’t take HRT because it could cause cancer. She also said to take the DNA test that predicts cancer. Results came back at 13% risk of cancer. Don’t know how reliable that is. My own research showed that the benefits outweigh the cancer risk.

      Quit statins also after doing research. Less achy and feel better.

      I think doctors are often held captive by the medical management companies they work for; whom are also in the pockets of big pharma. This was proven during the Covid fraud.

      I urge people I can discuss this topic with, to ask their doctors many questions. I also provide them Dr. Rushworth’s articles.

      1. Interesting and thoughtful article.
        When talking to a nutritionist recently, she said that many people just don’t want to take the responsibility for their health – they trust their GP and so medicine can be seen as the magic pill to make them better. Once one takes responsibility for one’s health, it can be empowering, but it depends on character and the ability to go against the mainstream, plus time and effort.
        I have pretty much beaten R.A. symptoms with a no-drug regime. My general approach would be – and I have some basic knowledge of nutrition, biochemistry and anatomy – firstly, to research the drug on offer. If the side effects appear to be worse than the benefits, search for an alternative/s and research that thoroughly. I’m using digestive enzymes; serrapeptase (this is prescribed in several countries, eg Japan, India), plus a proprietary mix of enzymes and anti-inflammatories (Neprinol), also rose hip extract. Natural therapies take time to work, (for me, it took four months to start giving a result – I used over-the-counter anti-inflammatories with care to make the transition), but the effect is of healing, not suppressing symptoms. To see me go about daily life and with a very active lifestyle at that, you wouldn’t know that I’d been diagnosed with this horrid disease. The supplements are pricey, but I live a normal life now. So it can be done – plus I’ve got a pretty understanding GP. I also look after myself with regard to food, exercise and sleep.
        Regarding the HRT; I believe the increase-in-cancer theory is no longer standing – please correct me if I’m wrong Dr R. If you are getting benefits from the HRT, then it seems a good thing to be using it. There has been much more positive publicity about HRT for the menopause in the media in the last two years. The NHS seems not at all equipped to give treatment, nor do many GPs have expertise in this field. If you want results, private seems the way to go. It’s a very tricky subject…I bet if men went through the menopause, more would have happened sooner!

  22. Hello!

    All Medical doctors and all patients should read this article!! It is spot on when it comes to change the present narrative to create health.

    I loved to read it..and will share it with my friends!!


    Thomas Langborg , 79 years

  23. Hey Dr Rushworth.

    You are truly one doc in tune with reality!! Thank-you.
    The fact that doctors get no nutritional training, what on earth would doctors offer a patient if they couldn’t give them drugs?

  24. I believe the patients in the ALLHAT statin group lived 4.96 days shorter than the patients in the placebo group. The sign is negative.

    1. I agree that the minus sign should mean that the patient, on average, would live that many days FEWER. I.e life expectancy is shorter.

  25. What is your present point of view for the wide spread use of chlordioxide, the stuff that helps without any site affects against >97% of all known deseases by man and animals, clean vegetables and remove all fungi, bacteria, virusses and molds after a single spray in hospital rooms, theatres, kitchens and gears?

    According to FDA and her polips in the world its a quack article, despite there are hondreds of scientific testingresults to proof otherwise.

  26. A tour de force, doc, thank you.

    Let me give you one example of the success of “prioritise lifestyle changes”.

    I currently live in the British Isles and am diagnosed with Type 2 Diabetes. If I were to return to live in NZ that diagnosis would vanish. Just a change of hemisphere and I would be cured. It’s almost biblical!

    (The explanation is left as an exercise for the reader.)

  27. Another brilliant blog, consistent high quality, thoughtful and well researched information
    Thank you 🙏

  28. About the ” somewhat aggressive discussion that followed the lecture”, Sebastian, what were the main objections?

    1. ”Why would guidelines recommend drugs that are so ineffective?”, ”why should we believe you rather than the professor we listened to before who said we should prescribe more, not less?”, ”industry sponsored lunches are the only opportunity for further education we get, and often yield valuable discussions.”

      1. Isnt that awful ” the only education they get”… is it so for you doctors?

  29. I was debating sharing this post with colleagues and have tentatively decided to hold off: too triggering like you yourself said. Doctors need some sort of safe holding spaces to come to this without too much pain. Not sure what that looks like but we need to find ways to open hearts and minds quickly before we self destruct here.

  30. Dr. Rushworth:

    TY for an excellent commentary.

    I’m a physicist now heavily immersed in the medical field due to COVID-19. For example, see my website .

    A few comments:
    1) It would have been nice if you had posted a link to where non-MDs can get NNT for pharmaceuticals (e.g., like Paxlovid).
    2) It would have been helpful if you explained the important difference between relative benefit and absolute benefit.
    3) It would have been really excellent if you also talked about overprescribing COVID-19 vaccines.

  31. Congrats, Doc, you are beginning to restore my faith in the medical profession.

    You were the first one during the so-called “Pandemic” that opened my eyes to the tricks being played with statistics.

    I followed a lot of “doctors” who appeared to be pioneering the anti-narrative. Unfortunately, I found them out to be either completely IGNORANT of what was really going on…OR…complicit with the fraudsters.

    As a result I disconnected from ALL of them.

    I stopped going to my “doctor” about ten years ago when, at the end of my annual physical, she tried to push a “heart medication” on me. There is not, nor ever was, a heart problem history in my family. There was NOTHING in my medical history to indicate a heart problem.

    I took the prescription, threw it in the trash can outside her office, and never went back. My wife still goes to her and is on a schedule of meds that must give Bourla wet dreams. (By the way, did you realize that clown is a veterinarian? Explains a lot, no?)

    Now that I know that Pasteur and his “Germ Theory” was a fraud from the beginning, I realize that the “Terrain” is the real solution to medical problems…NOT more pills and jabs.

    I can only speak for myself, but when I was still fear-mongered by the “plague” I decided to eliminate my only “co-morbidity” — obesity. Over a period of about 10 months I lost 60# of body fat (I’ve got one of those scales that does reports everything…including the weather).

    I seriously reduced my carb intake, eliminated processed sugars, alcohol, sweets, and vegetables. I eat one meal a day and am rarely hungry (I eat a lot of fat which helps keep the hunger at bay).

    I now do 200 pushups a day, walk about 3-4 miles a day, I sleep like a baby at night, and have never felt better. Oh yeah, I’m 76 years old.

    You’re on the right track, my friend! Real doctors tend to the whole human. The pill pushers’ days are numbered. Elon Musk is working on a computer system right now that will completely eliminate them.

    Keep up the great work!

  32. Homeopathic remedies work and don’t cause harm. They are cheap and you only take a few doses. Look into it. The pharmaceutical industry has trashed homeopathy because it threatens their profit margin. I saw my elderly mother go from one low dose thyroid medication to dozens of pills. Each me pill was prescribed to counteract the side effects of other pills. It’s a racket! Good homeopathic prescribing saved my mother’s life. Go to the National center for homeopathy to find a practitioner. Homeopathy treats the whole person. It works!

  33. Wow, this is great! That’s a brave thing to do: to stand in front of your colleagues, some of them likely senior to you, and say: I know that you don’t want to hear it, but this is what’s wrong with our profession and this is how we begin to fix it.

    Can you elaborate a little on the discussion that followed? Have you gotten any positive feedback?

    1. Thanks. Basically, people found it hard to accept the notion that the guidelines and the esteemed university professors who write them are often not in tune with the actual evidence, and they found it hard to accept that industry sponsored lunches influence their thinking and behaviour. Overall, doctors find it hard to accept the extent to which pharma has infiltrated all medical institutions, and the extent to which what they think they know is shaped by pharma.

      1. The maxim:”don’t bite the hand that feeds you ” is one I have actually heard spoken in an academic teaching hospital…

  34. This is a great review – I’ve been a GP since 1980 and in the private sector for the past ten years. I haven’t taken a free lunch since 1982 – the entire process was so obviously a con and the food wasn’t even that good! In the past ten years I have been able to focus on patient life style and reducing the use of dangerous medications. In my clinic with 30 minute slots the patient and I both have time to talk and listen. In the public sector I was under the coshes of severe time constraints and the need to adhere to Big Pharma constructed guidelines to avoid criticism and litigation. I just couldn’t get through the day if I talked and listened. Over the years , through bitter experience, I have become increasingly ashamed by the venality, corruption, hypocrisy and cynicism of many members of our subjugated profession. There are, at the same time, plenty of good doctors out there, trying to get out from under the regimentation and diktat of the second most profitable industry on Earth. They risk concerted ad hominem attacks, loss of support for research, litigation and direct loss of income in some regimes.

  35. Reply to Patrick.
    Wish you were my GP!
    I live in Derbyshire High Peak, UK. Attend Evelyn Medical Centre, or used to. Since the stupid Covid lockdowns, masks etc., I refuse to go near the place.
    There was one GP there I could get on with, and another showed some promise. But the best one has either retired or gone very much part time. Maybe he was disgusted by the same things you were.
    I’ve a good mind to look into the possibility of seeking out private practice.

  36. the body does not produce regular levels of certain white blood cells,often due to genetic mutations.This can lead to a weakened immune system and more susceptibility to infection.Treatment includes drugs that stimulate the production of white blood cells,antibiotics to fight infections,and good hygiene.Aging could be a big problem.

  37. Thank you for this profoundly simple, yet cogent presentation/article.

    I am not a doctor, but I find it perfectly understandable to access the net benefit (or net harm) to a person – or to society – when deciding on medical treatment such as a particular pharmaceutical drug. What other honest and superior scientific assessment is there?

    What has really shocked me, during the Covid era especially, is how many medical professionals have abandoned this comprehensive view in lieu of achieving one perceived benefit and/or outcome – to the detriment of many others as we now know.

    For example, I have multiple first-hand experiences of doctors telling me that they are not interested in the meta analysis of Ivermectin – or reviewing any of the multiple controlled studies that exist- to consider it’s efficacy/safety in the early treatment of Covid. Each one told me it was ineffective and not safe to take – and refused to write a prescription. Why, and according to whom?

    While not a doctor I can certainly read data – and the data suggests there is an inconsistency with what many medical professionals say about Ivermectin use, versus its actual outcomes (benefits). Since when is asking for an objective look at the overall net benefit of a drug – by reviewing all reliable and available studies – such a controversial request? I would like to think there was a time when this was inherently just part of being a good doctor…

    1. Joanne you are spot on regarding Ivermectin. In the UK it can be prescriped for Scabies even though it is not the most effective remedy. It is interesting that approval for scabies was based on far less data than is currently available for its use with SARS Cov2 as analysed in the meta-analysis. World Council for Health has some interesting publication regarding this.

  38. Very interesting. I’m a 65 year old woman with osteoarthritis, osteopenia and high cholesterol (though my HDL/total ratio is quite good.) I’ve managed to avoid medication to a large extent, though I have had both knees replaced. I tried alendronic acid and had a severe reaction, so no more of that for me! At the moment I’m relying on mineral supplentation plus lots of walking and dancing, strength training, and carbohydrate restriction (I eat some but not a lot.) I will up my protein intake, based on this, and think very long and very hard about anything my doctor tries to prescribe.

  39. Thanks for this article, Dr, which makes a great case for what should be obvious: taking multiple drugs at once will confound and confuse one’s ability to determine the effects of any one drug.

    Along those lines, my understanding regarding vaccine trial study design is that as a rule, generally what is called a placebo is actually an “active control”, not an inert substance, but includes other ingredients, the adjuvants etc.
    They claim this is to isolate and test any reaction to the pathogen alone, whereas the actual result would be to mask any harm caused by the total package, obviously.
    The deceptive use of so-called “active controls” in place of true placebos, and the deliberate confounding of the two in order to confuse and muddy the waters, is transparently self-serving and criminal.
    Dr. Rushworth, as you have developed a large list of followers, an article analyzing this widespread malpractice in vaccine trials would be hugely beneficial.
    I wrote and asked you the same in response to your Jan article on Novavax, but I replied to your emailed newsletter which I now see is a donotreply address.

    In this letter to the U.S. Department of Health & Human Services, the Informed Consent Action Network makes the following points, and includes exhaustive references:

    “For each pediatric vaccine – except one* – that HHS promotes for routine injection into children, the clinical trials relied upon to assess its safety prior to licensing its use in children did not use a placebo-control group.
    *(as explained below, the one trial that claims to have used a placebo actually used a mixed “active control” group and “placebo” group – so, not a placebo either)

    After making the false claim that many vaccines on HHS’s childhood schedule were licensed based on a placebo-controlled trial, HHS then states:
    “Inert placebo controls are not required to understand the safety profile of a new vaccine, and are thus not required.”
    This claim is astonishing. For almost all new drugs, especially where no substantially similar product is already licensed, HHS’s guidance expects a placebo control group to be part of the clinical trial so that the adverse event rate in the test group receiving the new drug can be assessed against the rate in the placebo group.

    The following three tables, compiled from HHS’s own publications, list each pediatric vaccine that HHS’s vaccine schedule provides be routinely injected into American children. 14 Each table addresses a different age range and answers whether the trials relied upon to license each vaccine for use in children included just one clinical trial that assessed its safety against a placebo control group…”

    (As explained below, however, that trial was mischaracterized, since it did not use an inert placebo, but a so-called “active control”, or one with biologic effects. As defined by the CDC, a “placebo” is: “A substance or treatment that has no effect on human beings.” The end result of using an active control in this case would be to mask the true rate of effects of the drug being studied, as the “active control” being falsely mischaracterized as a “placebo”, being biologically active, would also cause effects.)

    “The critical difference between using an inert and non-inert substance as a control can be clearly seen from the trials relied upon to license Gardasil in 2006. The manufacturer’s package insert for Gardasil states that it was licensed based on a clinical trial in which: (i) 10,706 women received Gardasil; (ii) 9,092 women received 225 mcg or 450 mcg of Amorphous Aluminum Hydroxyphosphate Sulfate (AAHS) – the so-called “AAHS Control” (aluminum adjuvant, such as AAHS, is a known cytotoxic and neurotoxic substance used to induce autoimmunity in lab animals, and which numerous peer-reviewed publications implicate in various autoimmune conditions58); and (iii) 320 women received a “Saline Placebo.”59 During the six month study follow-up, 2.3% of the women receiving Gardasil (the “test group”) and 2.3% of the women receiving the AAHS Control or Saline Placebo (the “combined control group”) reported developing a systemic autoimmune disorder.60 Since the rate of systemic autoimmune disorders in the “test group” and the “combined control group” were similar, the vaccine was deemed safe and licensed by HHS.
    What the manufacturer’s package insert for Gardasil given to the public failed to disclose is that the Saline Placebo group had zero cases of systemic autoimmune disorder (when 7 cases – 2.3% of 320 subjects – would be expected if autoimmune disorders were equally distributed among the Saline Placebo and AAHS Control recipients). 61 This fact was obfuscated by combining the small Saline Placebo group with the large AAHS Control group into a single control group and reporting their combined systemic autoimmune disorder rate, even though all the cases of autoimmunity came from the AAHS Control group. 62”

    Once again, the deceptive use of so-called “active controls” in place of true placebos, and the deliberate confounding of the two in order to confuse and muddy the waters, is transparently self-serving and criminal.
    An article analyzing this widespread malpractice in “vaccine science” would be hugely helpful for people trying to sort the wheat from the chaf, or the junk science from the evidence-based science, in order to make accurate risk/reward decisions.
    Thanks again for all your great work.

  40. Great piece. We saw the adverse effects of multiple drugs on my MIL which but finally managed properly when a geriatrician became more involved, rationalised the regime and suggested a time schedule to minimise interaction. So glad I didn’t carry on with statins after after short term use of two different types both caused side effects. I am keen to do the same with Omeprazole which I know is not good for long term use and can cause worse symptoms than original symptoms when stopped. Any suggestions appreciated.

  41. What an excellent report. This should be essential reading for all doctors but also the general public who don’t feel they have been treated unless drugs are involved.

  42. Hi – I am a refugee from Malcolm Kendrick’s blog. He is temporarily blogging minimally because he is being treated for Prostate cancer. I am sure everyone here wishes him a speedy recovery.

    I wonder if there is any pressure to persuade doctors to quote those NNT numbers to patients, rather than the relative risk numbers.

    Maybe there should even be a maximum value of NNT above which a drug would be withdrawn.

  43. A couple of moths ago I was diagnosed with herpes zoster, a very painfull desease. My GP prescribed an antiviral drug and a really strong pain-killer. When I came home from the pharmacy, and had a look at the possible side effects, I simply throw both of them in the trash bin. I took the pain. Less risky.

  44. Zeljko I sympathise with you. Years ago, here in the UK a friend had shingles and was given a cream to be applied to the rash. I do not know whether he was taking any pills as well.
    If it is any consolation, I was daft enough to accept a vaccination against shingles and then had to take 5 aciclovir tablets a day for 2 years to suppress herpes simplex, cold sores.
    Even now I have to be very careful not to spread cold sores to my eyes.

  45. You repeat the well known quote, “Peter Gotzche, a founding member of the Cochrane Collaboration and former director of the Nordic Cochrane Center, has estimated that prescription drugs are now the third biggest cause of death in the western world, after heart disease and cancer.”

    I have never really known what that means. For example, if someone is being treated for cancer, the drugs used may be very dangerous, and might account for a lot of those deaths. Does it include drugs of that sort, or only more routine medicines?

  46. Hi Sebastian,

    Great article as usual. I was wondering if you can you recommend any good sources you use to learn about Evidence Based Medicine and how to appraise papers etc. ? Perhaps any good books out there on the topic?

  47. Dr. Rushworth,
    I’m wondering about a line in the Table 1 ‘Estimated Postponement of death …’ that shows a NNT of -143 for the study GISSI-HF. What could a negative NNT possibly mean?

  48. It is interesting to hear this perspective. It reminds me of how someone once described a Buddhist approach to crisis: “Don’t just act, stand there!”.

  49. Thank you, Dr. Rushworth. It’s rare to find a doctor that isn’t pushing drugs on you. I would love to see an article on how to safely get off long-term medication, specifically low dose aspirin. My husband has been taking it for years and would like to stop, but of course his doctor wants him to continue. There is no information out there on how to stop safely. We feel the risks outweigh the benefits, especially since he’s never had a heart attack. I would love some advice on how to stop.

    1. On the other hand, low dose aspirin makes a negligible amount of money for Big Pharma, and has been recommended for a long time. There are also reports from time to time that it helps prevent cancer.

      In other words, I suspect its benefits may be downplayed, just as the benefits of other, more expensive drugs get exaggerated.

      For those reasons I continue to take my daily 75 mg.

    1. I’m aware the risks outweigh the benefits. The problem is that it’s considered dangerous to just stop. It increases the chances of a heart attack and there’s nothing on the internet on how to safely wean off of it.

  50. Completely in agreement of your opinions, based on scientific facts, but you know what? No wonder, that there are no takers for this amongst doctors but , not amongst even the patients! I’ve been preaching on similar grounds for >25 years and I find patients switching to other doctors, especially Super-specialists! People find changes in life style boring and fancy taking medicines, spending lot of their money happily! How many want right advice? Blame it on anyone but, it’s hard truth that, consuming medicines make people happy and confident!

  51. I’m surprised you were given the opportunity to give a speach like this. Who organized this event?

  52. Apologies for going off topic now, but I believe it to be necessary.

    Should panic-mongering by others cause us to adopt conspiracy theories? How about if the people involved in the conspiracy publish about it openly?

    If people publish their conspiracy openly, is this a power game? Do they expect that they hold all the levers of power?

    We need to think a bit more (cough–a LOT more–cough) about power. There are different kinds of power. Here’s one kind of power….

    I am the asshole your mother warned you about. I’m the lurker in the shadows–the predator you feel but can’t see.

    I’m the escort walking you to the bus stop who chases away the rapist. I’m the boy you call to come over when you get back from seeing your fiance.

    I’m the man who won’t call you. The man who fascinates you. I’m the man who causes you to catch your breath, turn your head, and smile.

    I’m the musician, the poet, the dancer, the king. I’m the bare-knuckled brawler and the brass knuckle thug.

    I’m the white knight and the Knight of Night’s Doom. Arthur, Lancelot, Galahad, and Mordred.

    I’m the man who sees you briefly glance at me as you try to hide your glance even as you are on the edge of my vision. I’m the man who forgets our anniversary and makes you cry.

    Do you see all of the same kind of power or different kinds? What are the common threads? And how might we use this knowledge against pharma and their masters?

    1. This is thinking outside the box – just what SB’s insightful (indeed potentially life-changing) article is promoting (nb not prescribing!)
      You’re right about power; and the only workable exercise of it is on oneself. Journalists in thrall to Woke, doctors dazzled by the bribes of big pharma and afraid of being sued or struck off for ‘non-intervention’, anyone who’d rather be told by The Authorities (ref ‘The Science’) what the ‘right’ thing to do is …as opposed to educating themselves from the widest variety of sources… they’ve ceded the power elsewhere. I believe in DIY health; growing up semi-feral in Africa before moving to the UK, it was plain to see that animals survived and bred by following what they’d done since forever. No obesity in the wild. I’m now fully civilized/educated (London was a shock) but my conclusions haven’t changed. If as a species we thrived long enough to breed for millennia, sticking to a natural way of life has to be (based on the longest-running experiment in existence) our best hope.
      Amazing piece, Sebastian. First time I’ve ever felt moved to respond to an article.

  53. Coming from a parent of an immunocompromised child and who is on many medications, I thank you for this article.

  54. Thank you for your very informative article. I have been a registered nurse for over 40 years and I am still working part time. Your article has helped me in regards to my A1C that has been going up the last 5 years. My blood sugars were high when I was in the hospital in 2020 with Covid taking steroids for my pneumonia. I was put on insulin and then my internist tried me on several different po meds which I either was allergic to or had bad side effects. At this point he has told me to control my Type II diabetes with diet. My A1c is below 7 but I have been so concerned that I needed to take medication. Now I can relax and just watch my diet. Also, my mother has been on hospice for 2 years due to dementia. Over these two years we have stopped all her medications for high blood pressure, diabetes (aquired in her 90s), aspirin for TIAs and demetia. She is almost 98 and off these medications she has done fine. As the hospice nurse said “why keep putting money in the pockets of Big Pharm ?” Perhaps we shouldn’t wait until hospice to evaluate the need for all the drugs in the elderly.

  55. It’s said there’s nothing new under the sun.
    Back in ’78 one of my friends commenced studying medicine. He mentioned that a pharmaceutical company paid for a dinner for all 1st year students, and threw in a free stethoscope.

  56. Doctors that speak out against the global regime in today’s authoritarian fascist governments you’re liable to lose your license by medical boards that kowtow to BiG Pharma pushing pills (ask your doctor) & experimental jabs.
    Dr Rushworth is a rare find! Early on of the Covid Plandemic he was one of the very first to write about mRNA jabs & the benefit vs risks! That’s when I started following him on his substack for his astute observations! This article is a another perfect example.

    Personally during my working years I only was on one medication, atovarstatin. My Dr.s kept telling me statins are a wonder drug & wanted to increase my dosage as I got older in my 50’s even though my #’s we’re good (under 200 for total cholesterol & my ratio ~ 3, a pretty good ratio. As I got older & wiser started doing my own internet research on side effects of this wonder drug! So I started skipping every other day on my dosage.
    Then recently more sad news of more serious side effects! So now in my early sixties I completely stopped, watch what I eat (lots of fruits & veggies) & my #s are lower than before on medication.

    With hospital Fraudci Covid protocol treatment of remdesivir & ventilators that killed many I’ve lost all faith in doctors part of big conglomerates like Kaiser, Providence/ St Jude & Banner the 🇺🇸 west coast giants pushing jabs while seniors lined up out the door.
    Now the truth is coming & the medical establishment has lost all credibility for those of us paying attention! Need more Dr.s like Dr. Rushworth to speak the Truth!

  57. Socrates A.
    I totally agree with what you have said here.
    Don’t know what country you speak from but here in the UK we still have Vernon Coleman.
    But he is very old now, so understandably does less. And we can’t speak with him or discuss amongst ourselves as we do here.
    Vernon’s books are still available (most of them) from Amazon.
    When I ‘discovered’ Sebastian I was very relieved to find that someone had come forward to ‘carry the torch’ of TRUTH.

  58. “Doctors consistently overestimate disease risk.
    Doctors consistently overestimate drug benefit.
    Doctors consistently underestimate drug harm.”

    What does this lead to in case of the totally new vaccines against Covid19?

  59. This is a very interesting and important subject. Thank you for great work! 🙂

  60. Great article. The question is do we have a consolidated source for NNH and NNT information? I plan on working up a list of chemicals my mother consumes to see what the math looks like.

    1. This is what I printed and handed over, regarding the “Number Needed to Treat”:
      Statins Given for 5 Years for Heart Disease Prevention (With Known Heart Disease)
      Benefits in Percentage
      96% saw no benefit
      1.2% were helped by being saved from death
      2.6% were helped by preventing a repeat heart attack
      0.8% were helped by preventing a stroke
      Harms in Percentage
      2% were harmed by developing diabetes**
      10% were harmed by muscle damage
      Perindopril tert-butylamine Sandoz 4 mg
      Anti-Hypertensive Treatment for the Primary Prevention of Cardiovascular Events In Mild Hypertension
      Benefits in Percentage
      100% saw no benefit
      Harms in Percentage
      9% were harmed by medication side effects and stopped the drug
      Blood Pressure Medicines for Five Years to Prevent Death, Heart Attacks, and Strokes
      Benefits in Percentage
      97% saw no benefit
      0.8% were helped by preventing death
      1.5% were helped by preventing stroke
      1.0% were helped by preventing heart attack*
      Harms in Percentage
      10% were harmed by medication side effects, stopping the drug
      Ticagrelor Brilique 90 mg
      Prolonged Dual Antiplatelet Therapy After MI Reduces Major Adverse Cardiac Events
      Benefits in Percentage
      1.6% of patients avoided one major adverse cardiac event
      0.5% of patients avoided cardiovascular death
      Harms in Percentage
      None experienced an additional major bleeding complication
      Acetylsalicylzuur Cardio Teva 80 mg
      Clopidogrel Added to Aspirin to Prevent a Second Heart Attack Or Stroke
      Benefits in Percentage
      100% saw no benefit
      Harms in Percentage
      0.6% were harmed by developing a major bleeding event*
      Ticagrelor Compared to Clopidogrel in Acute Coronary Syndrome and Stable Coronary Artery Disease
      Benefits in Percentage
      No patients were helped
      Harms in Percentage
      0.6% patients had a major bleeding event
      7.7% patients developed dyspnea

  61. In my opinion is a good start:

    I’m amazed both my general practitioner, cardiologist and pharmacist had never heard of The NNT and had never looked at their website. Okay, they know the meaning of the abbreviation…

    “Can’t be right” was their first reaction. I’m still waiting for their response why The NNT is wrong. I’ll ask again in a few weeks.

  62. Vey well written. Clear and consise.
    What the statistical innumeracy (of doctors, too) is concerned, I’d like to hint at the very insightful work of Gerd Gigerenzer (Risiko/ Risk et. al. great Zürich TED- talk Risk Literacy).

  63. The paper on life expectancy and statins has perhaps been misunderstood. The paper concludes that “Statin treatment results in a surprisingly small average gain in overall survival *within the trials’ running time.*” and they say “We have only estimated the survival gain achieved within the trials’ running time, whereas in real life, treatment is often continued much longer.” Their result is relevant, as the authors note, when the patient only has a few years to live anyway, but for other patients it may not mean much. My own very rough calculations suggest that a 5 year NNT of 200 (statins used for primary prevention) would over a 30 year period be equivalent to an increase in life expectancy of the order of a year, and a 5 year NNT 0f 40 (statins used for secondary prevention) would be equivalent to an increase of several years. The reason for the dramatic increases over the paper’s estimates is that the probabilities compound over time, so a 5 year NNT of 200 is roughly equivalent to a 30 year NNT of 33 i.e. almost one extra year; in more detail, the 5 year probability of not benefitting from the treatment = 199/200, so annual probability of not benefitting is (199/200) ^ 0.2 and the 30 year probability is (199/200) ^ (30/0.2) = 0.97.

    The numbers needed to harm might also be expected to fall in a similar fashion, so assuming NNH = 20 for myalgia or diabetes, the equivalent NNH over a 30 year period would be around 4, that is to say a 25% risk of myalgia or diabetes.

    1. Looking back at Dr Rushworth’s hypothetical 75 year old patient, if we assume a 10 year life expectancy and a 5 year NNT for primary prevention with statins then that gives an increase in life expectancy of about a month (the 10 year NNT is roughly 100, and 10 years divided by 100 is roughly a month). Assuming a 15 year life expectancy gives an increase in life expectancy of about 3 months. Assuming 20 years life expectancy gives a 5 month increase.

      On that basis, already by age 75 statins don’t seem particulary interesting for primary prevention, given the risks and inconvenience. On the other hand, 75 happens to be the age by which some medical authorities want everybody to be taking statins!

    2. Actually those rough life expectancy calculations are too generous to the statins, because they assume that the patients who do benefit have their life extended by the full period being considered (e.g. 30 years), which is obviously wrong. If we assume that the fatalities prevented are evenly distributed throughout the period then the patients who do benefit will on average have their lives extended by half the period being considered, so you need to divide all the life expectancy increases I calculated by two.

    3. On what basis do you assume that the benefits compound? It is equally possible that the benefit rises in a linear fashion, i.e. that you get a few extra days on average per five year period, or that the benefits drop off to nothing after the first few years, so that you get a few days extra regardless of whether you take them for five years or fifty.

  64. Excellent artical, as usual.

    Regarding the fact that doctors estimate probabilities that largely differ from those found by systematic studies, you might be interested to read this:

    I am not suggesting that this contradicts or refutes your claims, but it may put things into perspective. Perhaps the way doctors estimate these probabilities is (at least partly) based on personal experience (observing patients) and not quite as irrational as the comparison suggests, given that such experience is necessarily limited to a finite number of events.

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