1 Department of Forensic Medicine, University of Freiburg, Albertstr. 9, 79104 Freiburg, Germany,
2 Herbal Medicines Research and Education Centre, University of Sydney, NSW 2006, Australia,
3 Department of Medical Biometry, Im Neuenheimer Feld 305, University of Heidelberg, 69120 Heidelberg, Germany and
4 Department of Anaesthesia, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, UK
SIR, In surveying the views of health care professionals on the treatment of osteoarthritis, Chard et al. [1] observed inter alia that general practitioners (GPs) were more likely to use complementary therapy. Many GPs in Germany undertake approved further education in complementary medicine (Naturheilverfahren), which includes 26 h on herbal medicine (www.bundesaerztekammer.de/30/Weiterbildung/40kurse.html#11Naturheilverfahren). The Südbaden district of Baden-Wuertemberg presently has 325 GPs registered with this educational qualification and 45 specialists in internal medicine (including rheumatologists). Our post-marketing surveillance on the potential economic impact of using a proprietary willow bark extract (Assalix®) in out-patient treatment of low back pain recruited three of those GPs to base their treatment on Assalix® and add other components (allowed by their budgets) as they thought fit. The effectiveness and cost of their management was compared with that of three orthopedists who did not use Assalix® but chose from the conventional treatments available within their budgets [2]. In the first 104 of the GPs' patients who received daily doses of Assalix® containing 120 mg of the marker salicin, the effectiveness assessed by a range of measures equalled that achieved by the orthopedists at between about a half and two-thirds of the costs. In a second cohort of 114 GPs' patients who received Assalix® containing 240 mg salicin, the effectiveness was greater, at about equal cost. The estimated effect sizes in the Assalix® groups were consistent with those found in a preceding placebo-controlled randomized double-blind study [3] and, in a subsequent pilot comparison of the higher dose of Assalix® with rofecoxib [4], there was no obvious difference in effectiveness.
The orthopedists appeared not to have pursued the use of non-steroid anti-inflammatory drugs (NSAIDs) to anything like the recommended limits, appearing instead to prefer more esoteric (and expensive) treatments such as nerve blocks, and manual and electrical therapy (Table 1). We suspect that the GPs could have based their treatment on a selective COX-2 inhibitor as effectively and safely as they did on Assalix® and that, if the orthopaedists had done similarly, the cost-effectiveness of their treatment might well have been increased. Perhaps specialists should look more closely at simple oral medications (including herbal medicines that have an evidence base for effectiveness [26]), and certainly should consider herbal medicines before using conventional NSAIDs in view of the expense associated with the adverse effects of NSAIDs [7].
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Notes
Correspondence to: S. Chrubasik. E-mail: sigrun.chrubasik{at}klinikum.uni-freiburg.de
References