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#6 SGLT-2 Inhibitors: One Med to Rule Them All? - Austin Bush, MD
64 Plays2 years ago
How can one class of medication be beneficial in treating type 2 diabetes, heart failure, and chronic kidney disease? It may seem too good to be true, but your hosts welcome guest Austin Bush, MD to discuss the evidence and why family physicians should be regularly prescribing these medications.
We then introduce a new segment, "This Week in Placebo Effect," where we discuss the mysterious effects of placebo, even when study participants know they are taking a placebo! We look at a trial where open-label placebo is used for treatment of pediatric functional abdominal pain and irritable bowel syndrome.
Episode Outline:
- Intro and welcoming Dr. Bush 00:36
- SGLT-2 inhibitors: Background and early CV outcome trials 02:56
- Use of SGLT-2 inhibitors in heart failure 05:57
- Use of SGLT-2 inhibitors in chronic kidney disease 08:26
- Potential harms of SGLT-2 inhibitors 10:32
- Which patients should be prescribed these medications? 14:02
- "This Week in Placebo Effect" 21:05
Links from this episode:
- Dapagliflozin in HF with reduced EF (DAPA-HF) https://pubmed.ncbi.nlm.nih.gov/31535829/
- Dapagliflozin in HF with preserved EF (DELIVER) https://pubmed.ncbi.nlm.nih.gov/36027570/
- Empagliflozin in HF with reduced EF (EMPEROR-Reduced) https://pubmed.ncbi.nlm.nih.gov/32865377/
- Empagliflozin in HF with preserved EF (EMPEROR-Preserved) https://pubmed.ncbi.nlm.nih.gov/34449189/
- Dapagliflozin in chronic kidney disease (DAPA-CKD) https://pubmed.ncbi.nlm.nih.gov/32970396/
- Empagliflozin in chronic kidney disease (EMPA-Kidney) https://pubmed.ncbi.nlm.nih.gov/36331190/
- Effects of open-label placebo in children with functional abdominal pain or IBS https://pubmed.ncbi.nlm.nih.gov/35099543/
- Effects of open-label placebo in adults with chronic back pain https://pubmed.ncbi.nlm.nih.gov/31479068/
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Comments/Questions/Suggestions? Email us at whatstheproofpodcast@gmail.com or find us on Twitter @theproofpodcast!
Credits:
- Hosts: Bobby Scott, MD, FAAFP; Sandy Robertson, PharmD; Dawn Caviness, MD, BSN
- Production & Cover Art: Bobby Scott, MD, FAAFP
- Music: Twisterium, MondayHopes, Muzaproduction, and SergeQuadrado from Pixabay
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Transcript
Podcast Introduction
00:00:00
Speaker
You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
00:00:36
Speaker
Welcome back to the What's The Proof podcast.
Meet the Hosts & Guest
00:00:39
Speaker
My name is Bobby Scott and here with Dawn Kavanis and Sandy Robertson. Decided to bring you another interesting and exciting episode today.
00:00:47
Speaker
I'm very excited about this episode where we have Dr. Bush, who is one of our own, and he is sharing about SGLT2's inhibitors. Very excited that he's here to talk with us. It's also good to be back because I wasn't here last podcast. Yeah, it's glad to have you back, Dawn. It's been a while in general. We've been really busy over the holidays.
00:01:08
Speaker
It's interview season at our residency program, so we apologize for being, I guess, almost three months now since we put out an episode, but hopefully the value of this one will make up for it, because like you said, we have Dr. Austin Bush here today, who is not only a graduate of our program, but is one of our excellent faculty. He is already acclaimed by our residents as being just an excellent teacher.
00:01:36
Speaker
And I know you would agree that he has such a passion for evidence-based medicine and it's contagious, really. I think it rubs off on a lot of people. I agree. I agree. And I think he's an example of, um, you know, the fact that as an intern, he came and was teaching us from day one and how really some of the suggestions and data that's been brought up from our residents, including Dr. Bush, really does impact the care we give as attendings and as a program. So yes, very exciting day.
00:02:05
Speaker
Totally agree. Let's go right to it. Let's go to the interview. Austin, thanks so much for being on the show. We're just really excited to have you here. We know that you have been passionate about evidence-based medicine and even seeing you as an intern in our program. You were teaching even faculty a lot of stuff when you've been reading latest studies and just had a real understanding of
00:02:31
Speaker
looking at the evidence to help manage your patients. And so I'm really excited to have you come on in because I think you have a lot to offer for our listeners as well. Yeah, great to be here. Of course, I didn't do this on my own. I had the great faculty at CFM to kind of guide me through that process and, you know, drive my desire for evidence-based medicine.
00:02:48
Speaker
Well, we did not pay you to say that, so I just want to make sure that that's clear, but that is appreciated. Sure. Well, it comes from the heart. Yes. Well, thank you.
SGLT2 Inhibitors: Beyond Diabetes
00:02:55
Speaker
So today we're talking about SGLT2 inhibitors, and these are really amazing medicines. I've just been amazed at how this has evolved over the last couple of years.
00:03:08
Speaker
Um, you know, you have, and they came out originally just to treat diabetes, but now we're seeing them used in heart failure, in chronic kidney disease. And I was wondering if you could give us a little bit of background on how did we get to this point where these diabetes meds are being used for other clinical indications. Uh, and not only that have a robust evidence base to support that use.
00:03:31
Speaker
Yeah, definitely. I mean, it didn't start off like this, you know, having a medicine class that was, you know, presumed to have all these different beneficial effects on common severe conditions. But it all started back when, you know, the TZDs were in wide use and Rosaglitazone, one of those was being widely used for control of diabetes. And, you know, there were some concerning findings with, you know, post marketing outcomes, and there was, you know,
00:03:57
Speaker
cardiac effects that were being noticed, patients were developing heart failure and being hospitalized more frequently. And because of this, it was actually withdrawn from the market for a period of time. And there was a requirement that any further medicines that were for the management of diabetes were required to go through a CVOT or a cardiovascular outcome trial that would make sure that they were non-inferior to existing medicines as far as cardiac effects.
00:04:19
Speaker
So, early on, the trials started as, you know, MPA Reg, Canvas program, Declare Timmy. These were mainly focused on cardiac safety, non-inferiority, and then follow-up trials, Credence, DAP-HF. We'll talk about these a little bit later, but these were all to kind of take the next step after that initial safety data was confirmed. Yeah, it's really kind of cool how you started out just proving that they didn't hurt people, but now finding out that these medicines can actually be beneficial in these other outcomes.
00:04:45
Speaker
It's really amazing to see how it's helping to shift some of the focus and diabetes management away from disease-oriented outcomes, just like A1C, how low can we get that, and now thinking about the whole patient, thinking about patient-oriented outcomes that are important to them as well.
Mechanism of SGLT2 Inhibitors
00:05:02
Speaker
Well, Austin, can you tell us a little bit more about how do SGLT2 inhibitors actually work and what SGLT2 inhibitors are currently in use? Sure. And of course, I don't have a deep, deep understanding of every, you know, pathophysiological mechanism by which these are operating, but in a basic sense, you know, they are blocking glucose absorption, you know, in the tubules as it goes through the kidney.
00:05:29
Speaker
And this is having a variety of different effects, lowering the glucose because it's taking that serum glucose, putting it into the urine. And also it's having effects on a mild diuretic effect and things like that that we think is responsible for some degree of its benefit. Medicines currently in use are dipagoflozin, empagoflozin, and kinagoflozin, going by different brand names. All of them having a fairly similar effect based on all the follow-up trials that have been done.
00:05:58
Speaker
Okay, Austin, it's time to go over the evidence for me. You ready for that? I'm ready.
Cardiovascular Impact of SGLT2 Inhibitors
00:06:02
Speaker
Okay, so what are the key studies that demonstrate the key clinical benefit with regards to both heart failure and chronic kidney disease? I mean, that's not a hard question, right? No. I mean, the benefit now is that we have ample evidence to show that this class of medicines is helpful for a variety of conditions.
00:06:18
Speaker
if we kind of take it back and break it down by a disease state, so we first have our heart failure with reduced ejection fraction, and the initial study that kind of kicked off this was the DAPA-HF study in 2019, and that took patients who were already on, at that time, optimal medical therapy for their heart failure with reduced EF, and then they put them on to DAPA-GO flows and in addition to it.
00:06:42
Speaker
And there was a great 20% reduction in death from cardiovascular causes in patients without diabetes who were placed on this medicine. And so that was a game changer, really. We needed new medicines because this is a really high-risk population that gets readmitted frequently. They have terrible cardiac mortality. And so this was really helpful. Moving on from that, we then had the emperor reduced trial, which looked at empirical flows and showed very similar benefits.
00:07:10
Speaker
If we kind of branch out from the reduced EF and moved over to the preserved EF, then we started off with Emperor Preserved, which was looking at Empagliflozin, and that was, you know, I would say in addition to optimal therapy, but there really was no really good therapy that was being used for the preserved ejection fraction in heart failure patients. And so this medicine was very helpful for reduction in heart failure hospitalization and had some mortality benefit as well.
00:07:35
Speaker
And then the deliver trial is the most recent one, which looked at the DAPA Gliflozin in patients with preserved ejection fraction heart failure and showed similar benefits. Right, right. So it is interesting to me how similar the reductions are, the benefit is, with using both either DAPA or Impicable Gliflozin, it just doesn't matter. So just to make sure that I'm understanding this and that the audience is,
00:08:00
Speaker
So with both reduced ejection fraction and preserved ejection fraction, we have multiple studies that show benefit, correct? Yeah, we have an initial study and a follow-up study for both commonly prescribed medicines, dapagliflozin and empagliflozin, that show a very good benefit in disease states for heart failure with reduced ejection fraction and preserved ejection fraction. Correct, very good. Okay, so we have heart failure down.
SGLT2 Inhibitors in CKD
00:08:25
Speaker
Now, teach me about chronic kidney disease.
00:08:29
Speaker
Well, I love chronic kidney disease, so I'm always happy to talk more about it. But this started off with the Canvas studies that were done as part of these cardiovascular outcome trials, and then kind of branched into this DAPA CKD trial that was done in 2020. And the results of this, honestly, to me, are even more incredible in some ways than the heart failure studies. There was, in this 2020 trial, a 40% decrease in a lot of these composite kidney outcomes
00:08:56
Speaker
EGFR reduction of more than 50%, NSAID kidney disease, death from renal or cardiovascular causes. So this is impressive data. And this was 4,000 patients enrolled in this study, regardless of whether or not they had diabetes. So it really gives a lot of weight behind those results. And the most recent trial would be Impa Kidney. This was just released in November of 2022. This trial was actually stopped earlier because of a really good benefit found in this study.
00:09:22
Speaker
And so I really like this one because it liberalized the inclusion criteria for these patients with CKD. So this went all the way down to a GFR of 20 and really went all the way up to higher limits of minimally reduced GFR in patients without significant albuminuria. And it showed a very similar benefit with a number needed to treat of just 27 for improvement in the composite outcome of CKD progression and cardiovascular death.
00:09:49
Speaker
Um, so I think that that's a really helpful result because it incorporates more of a general family medicine population and also helps us feel confident prescribing this medicine in patients with significantly reduced EGFR and maybe those with a heart failure who previously weren't candidates for it because of their reduced GFR. Right. Yeah. This is definitely family medicine friendly right here. This is before they're going to Nefro, right? Definitely. Yeah. This is something you can feel comfortable prescribing in the office.
00:10:13
Speaker
Yeah, and I'm really impressed that, you know, again, this is not the first time that we've seen a study of this caliber having to stop early because of benefit. But to see this kind of benefit within two years is, it's impressive, right? Yeah, and it shows that you don't necessarily need five, ten years in all these patients to show benefit. Right.
00:10:33
Speaker
Okay Austin, so always with benefit comes risk and we really need to educate our patients
Safety Profile of SGLT2 Inhibitors
00:10:40
Speaker
on that. So let's review the harms of this class of medication and you can be very forthcoming with us and you're not going to frighten us, just tell us what the harms are.
00:10:48
Speaker
Sure. And that's the first job of a physician is to do no harm. So if you're really harming patients with these, we'd have to really take these findings into consideration with the previous benefits. But fortunately, time after time in these studies, they've shown an excellent safety profile.
00:11:04
Speaker
with generally mild things like UTIs or hypotension being most common. Some of the most compelling safety findings were in those in patients with significant heart failure, who I know you were concerned about their possible risk for hypotension.
00:11:21
Speaker
Right. Right. Yeah. We have hundreds and hundreds of thousands of patients that have now been studied with, when you combine all of these studies together, and that's really, really great. I really go into the adverse effect column and say, okay, I want to see exactly how many, you know, genital infections, how many UTIs, how much hypotension, how much orthostatic hypotension, how much, and it's impressive. It's hardly ever different than placebo, correct? Am I over simplifying this?
00:11:48
Speaker
No, I mean, I think in general, for the vast majority of patients, the benefits of this metastation class are going to far outweigh the risks. If you have a patient who's got really recurrent UTIs that are landing them in the hospital or recurrent candida infections that are very bothersome or things like that, you'd have to really weigh the benefits, make sure it's going to go out in their favor. But for the vast majority of patients, this is going to be a very positive offering that offers minimal side effects and is typically a weight negative medication. So you're not talking about a medicine that's going to cause them to put on extra weight.
00:12:18
Speaker
Right. Right. And then we have to bring up euglycemic decay. Sure. I know it's very rare. I can't remember the exact number, but I think some of these trials that have, you know, 50 or 60,000 patients, there might be one. Zero to one, right? Yeah. Tell me about that. I mean, and that's, of course, the feared complication, along with the other feared complication being the possible
00:12:38
Speaker
lower limb amputation risk in some of the earlier studies. So fortunately that did not pan out to be very relevant later down the road. It's generally considered to be just as safe as the other SGLT2s at this time. And as far as the UX and the DKA,
00:12:54
Speaker
Really, I have not seen this been identified specifically in a study, but this has all been, in my experience, younger patients who might have had this kind of type 1, type 2 overlap syndrome. And so I think just the takeaway is just be mindful if this is a really young patient who might have some type 1 characteristics.
00:13:13
Speaker
Right, the other characteristic that I've noticed are patients that are type two, or they're labeled type two, they're on insulin, they've been on very high doses of insulin, with the goal of reducing the insulin, which is appropriate, you're trying to get on other oral therapies and newer therapies, and maybe we're too aggressive with going down on the insulin, and they become insulin deficient, and that kind of helps to kind of put them in that DKA setting. That is another theory, these are all kind of just running theories,
00:13:41
Speaker
And that makes sense to me. So it's not something that I fear, but
Identifying Beneficiaries of SGLT2 Inhibitors
00:13:45
Speaker
I have a healthy respect for it. It's something we should all know about and to watch for. And with any medication change, you want to make sure if this patient has characteristics that might put them at risk for a side effect, just ensuring they have more frequent follow-up and have access to your office is really important. I agree. All right, Dr. Bush. So this is the question I care the most about. When I look at my patient panel, when we're all looking at our patient panels, which of our patients should be on these medications?
00:14:12
Speaker
Fortunately, that question is getting easier and easier to answer because of how many trials now we have showing positive effects in a variety of conditions. So in patients with type 2 diabetes, this is still a great option for diabetes because you know that it has a positive cardiovascular outcome trials. You know it's not gonna cause them to gain weight. You know that you're gonna have a modest A1C benefit. You know, you're talking about more in the 0.5 to 1 if you're generous range of A1C reduction with these.
00:14:41
Speaker
But, you know, if they have other risk factors or if they just need a mild reduction in their A1C to get them to go, that'd be a great option. So, you know, you can always reach for that over something like a sulfonyl rear or something else that might not have as favorable a cardiac profile. And then, of course, you got your patients with a heart failure. You know, hopefully this is being co-managed if it's a reduced ejection fraction or preserved ejection fraction with a cardiologist who has, you know, a lot of experience treating these conditions and has hopefully already put them on an SDS2 inhibitor. But for a lot of these patients, I find that we're the more accessible option as their family physician.
00:15:11
Speaker
And we're seeing them again more often than their cardiologist is. And so if you have somebody who has heart failure with reduced ejection infraction, they're already on optimal medical therapy with an evidence-based beta blocker, an ACE or an ARB, maybe they're on spironolactone or something like that. This is a great add-on that has way better data than spironolactone and some of the other medicines
00:15:36
Speaker
to be honest, for heart failure. And you can feel really confident adding this because we know that it has a good safety profile, you're not gonna increase the risk of hypotension dramatically, and it could have some benefits on other things like weight, especially if the patient has comorbid diabetes. That's just a slam dunk right there. You're two birds with one stone.
00:15:54
Speaker
And then, of course, you got your patients with HEPF or heart failure preserved ejection fraction, which one of the number one risk factors for developing that is diabetes. And so now you got, you know, usually your patient has diabetes who then has maybe some diastolic dysfunction. They have some signs of volume overload, some lower extremity edema, something like that to fit the clinical picture of HEPF. And those are patients who they now have an FDA indication for an SDSU inhibitor because these studies have been done showing benefit in a heart failure preserved ejection fraction.
00:16:22
Speaker
Insurance companies shouldn't give you as much of a hard time about trying to get this medicine, because it's now not just thought to be beneficial. It's known to be beneficial, and it can have significant benefit for reduction in heart failure and other outcomes that we really care about. And then, of course, you got your CQD patients. These patients are often under-recognized in the clinic. These are your patients with diabetes, longstanding hypertension. And they might have had this creatinine that's creeping up over the years.
00:16:48
Speaker
And, you know, I think if this is a patient you want to see are they on evidence-based strategies that we already have for CKD, which would be your ACE inhibitors and your intrusense and receptor blockers. And if a patient is on those medicines and you want to add additional benefit, you want to further reduce their risk for progressive CKD, development of end-stage kidney disease, hospitalization or death from cardiac or renal causes, it's a great option. And lots of times those other comorbidities tend to flock together. The diabetes
00:17:17
Speaker
Hey, you're also treating their hyperglycemia and you're maybe helping with a little bit of weight as well as at least not causing them to gain weight in the process with the new medicine. That's incredibly helpful.
Cost Management Strategies for SGLT2 Inhibitors
00:17:29
Speaker
And also, you know, I know I can already hear different ones asking us about cost. So I know that there's some coupons and some insurances are starting to cover it. And is there any advice you would give to us about making sure or pointers on making sure it's covered?
00:17:46
Speaker
Definitely. And this is a huge concern. I mean, and you want to make sure that when you're giving a new medication to a patient, that you're not putting them in, you know, financial jeopardy by recommending this medicine. And so, fortunately, with a lot of these studies, they're now all FDA approved, you know, for a variety of indications, CKD, HEPF, HEPF-REF. And so, as far as getting it approved shouldn't be a huge deal.
00:18:10
Speaker
But it doesn't mean it's going to be cheap. And so if the patient has private insurance, reaching for a coupon card online is always a good option. There's a bit of this loophole here where the whole cost of the card plus their payment goes towards their deductible. And so you could be helping them meet their deductible faster.
00:18:27
Speaker
so that when they can't use the card anymore, they have less of a copay in the future. That's a good tip there. And then, so that's a patient with private insurance who their existing copay on the medicine is not affordable. You can use your coupon card. Then you're talking about Medicare patients. This gets a little trickier because you can't use manufacturer coupon cards and patients with Medicare.
00:18:47
Speaker
because it's a government funded insurance. In that case, if the patient's not able to afford it, you're going to want to ask about their financial situation in more detail and get them plugged in with someone who can help them file for manufacturer assistance. These forms are not hard to find and it doesn't take a pharmacist to fill them out or a physician for that matter.
00:19:08
Speaker
You could simply go to the manufacturer's website, download the forms, and give them to the patient to fill out and return to the office. And some of these are very generous. I know a lot of them will use the 400% of the federal poverty line to say whether or not the patient qualifies.
00:19:22
Speaker
And if they have one person in their family, that's about $54,000 a year. And if there's two people, it goes up to in the 70K range. And so you can imagine how many of your patients who are on Medicare have a fixed income, you know, and they're not bringing in more money than that each year. And so a lot of our patients will qualify for these medicines. And that's a great option.
00:19:44
Speaker
And then, yeah, so besides the paying it through standard, through deductible, you know, paying it through a coupon card or using manufacturer assistance, those would be the main ways to make these medications affordable for patients. Dr. Bush, I just want to thank you so much for being here. I think this is really helpful for, it's going to be helpful for a lot of people. I think, you know, you presented the evidence in such a clear and organized way and just really appreciate it and hope to have you back again someday.
00:20:14
Speaker
Yeah, really happy to be able to share that information. I have a real passion for patients with heart failure, CKD, and STC2 inhibitors. I love talking about them. So I'm glad that we have some growing amount of data for all these conditions. And I think that really, family physicians should feel very confident prescribing these medicines in clinic because of their great safety profile and their outstanding benefit for a number of common conditions. And now,
00:20:40
Speaker
hopefully increasing affordability or at least have some resources to find them ways to make them more affordable. So happy to be here. Hope to see more SO2 inhibitors prescribed in the future. Absolutely. Thank you.
00:20:54
Speaker
Okay, what an awesome interview that was. Yes, that was great. And I think it's fun to have guests on to hear other people's perspectives, and Dr. Bish is awesome. Yes, he's amazing. But let's move forward. We have a brand new segment to bring you this episode, and it's one we like to call This Week in Placebo
Exploring the Placebo Effect
00:21:15
Speaker
Effect.
00:21:21
Speaker
Okay, Dawn, I gotta tell you, I am so excited about this. I'm intrigued. This is just before we recorded looking at this for the first time, so I'm excited for you to teach me about this. Yeah, I just find this interesting. This is just my little niche of evidence-based medicine that I just find interesting and fun. Placebo effect is one, virtually every study, the placebo group has a benefit, right?
00:21:50
Speaker
Yeah. And it's been mysterious. People don't understand why does this happen. It has long been thought that it is mainly just due to deception, that it was a, you know, deception was a necessary component for a placebo effect. Like if patients are almost being tricked into thinking that they're getting better and their brain plays tricks on them to produce real physiologic
00:22:15
Speaker
change or an improvement in symptoms. But what's really interesting is that there have been a number of studies in the last few years that have been looking at open label placebo, meaning when patients are randomized to an intervention and the intervention is the placebo, they know and are told beforehand that what a placebo is and that it's not actually an active medication.
00:22:44
Speaker
which, and they still have the same benefit, which is amazing to me. So incredibly interesting. Yeah. So, uh, there was one study that just came out, um, uh, in, uh, JAMA pediatrics, uh, earlier this year, and it was looking at, uh, children eight to 18 years of age and they have either functional abdominal pain or irritable bowel syndrome.
00:23:08
Speaker
And it's a little bit of a complex study because it's a crossover trial. So what they did is they randomized the patients into two groups. One was
00:23:21
Speaker
basically getting the intervention, which was a placebo and it was a liquid, that they were told it was an inert liquid, had no active medication, but they were given some information about how some research has shown potential benefits with placebo and the gut-brain response, which may
00:23:41
Speaker
which the hypothesis of the study was that this would help these patients that are dealing with this. So they usually had either moderate to severe symptoms at baseline. And they randomized them to the placebo group. And then the control group, which is basically they had a symptom diary. And then both groups were allowed to use dicyclamine as a rescue analgesic if they had pain.
00:24:09
Speaker
And so after three weeks, this is why it's a crossover trial, is that the group's actually switched over to the other side. So it's supposed to increase power, I guess by having both groups also be their own control group. So that's why it's a little bit complicated.
00:24:27
Speaker
But when they, when all is said and done, the patients that were taking placebo at the end of the trial had, um, lower pain scores than the other group, which is really cool. And the scores probably aren't the difference in scores probably aren't clinically significant because it was small. But one of the interesting things is, is that the secondary outcome was how frequently they would.
00:24:52
Speaker
use the rescue analgesic. And there was a significant difference between the placebo group and the control group.
00:25:01
Speaker
what's kind of weird calling the control group, not the placebo group. And it turned out a number, it came out with a number needed to treat of only three. So to get a significant reduction in analgesic use. So who knows, we'll see how things go in the future, whether placebo may actually be something we
00:25:24
Speaker
recommend to patients. I really got interested in this when I came across a study that came out a couple years ago with patients with chronic back pain. These are people that have had it for years and were randomized basically to placebo, which they were told was placebo, and then also just standard care for the other group. They had better pain control with the placebo, even when they knew it was placebo.
00:25:52
Speaker
I find it incredibly fascinating. So maybe not enough daddy yet to prescribe placebo, but it is intriguing. I mean, would this change your practice, though?
00:26:03
Speaker
Not yet. I mean, I would love to be able to prescribe placebo. I think there's still just a little bit of ethical concerns with, you know, you're not really recommending a real medicine, but it definitely feels a lot more comfortable if the patient knows that it's a placebo. I certainly wouldn't advocate, you know, giving a patient a placebo. That would be incredibly unethical to do that and not, you know, not tell them what you are doing.
00:26:30
Speaker
So no, I wouldn't go out and start recommending a bunch of placebos yet, but I just find it really interesting to, I hope, you know, years down the road, we have a much better understanding of placebo effect and maybe can tap into it as a therapeutic use. It's really cool.
Podcast Conclusion & Feedback Invitation
00:26:44
Speaker
That's all we have for today. Don, thank you very much. Sandy, thank you for being here. Hopefully we can be a little bit
00:26:53
Speaker
more prompt in delivering our next episode. We got some great topics planned ahead and looking forward to bringing those to you. If you like the show, please give us a like on your podcast app of choice and feel free. We'd love to hear from you. Email us at whatstheproof.gmail.com or follow us on Twitter at theproofpodcast and we'll see you next time.