5 ms·

> There is a tension between empiricism and fundamentalism with much of medical science focusing on fundamentalism. This is a deeply unfair statement, and also

by deng 6mo ago

> There is a tension between empiricism and fundamentalism with much of medical science focusing on fundamentalism. This is a deeply unfair statement, and also a false dichotomy. Medical science is of course empiric. What you call "fundamentalism" is that compounds need to undergo a rigorous regiment of empiric testing before they are given to potentially millions of people. And no, it's not just because of Thalidomide. Many, many compounds fail clinical trials because of severe side effects, like liver toxicity, severe immune reactions or heart problems. Then there's of course increased risk of cancer, which can take many years to manifest itself empirically. You argue that you prefer living with these uncertainties rather than ME/CFS, and that's of course entirely understandable, but disparaging the field of medical science as focused on "fundamentalism" because we do not give large patient cohorts untested compounds is polemic. I understand where you are coming from, and I'm sorry that you suffer from this terrible condition, but likewise, you should try to understand the other side.

ndr 6mo ago
I think the grandparent meant "fundamentalism" as "mechanistic", and lots of things we can know (as you say using the scientific method) to be useful long before we have a good mechanistic explanation of how they work. Some examples: aspirin (willow bark used for thousands of years, drug synthesized in 1897 and mechanism explained almost 100y later), or general anesthesia used again since mid 1800s and the mechanism is quite still debated. This is not to downplay all the long term, or developmental, risks that using something novel can result in. But we can empirically know something about the effects without having good mechanistic models.
- deng 6mo ago
  But it is usually not necessary for approval of a compound to be able to describe how it works on a molecular or cellular level. What you need to show are three things: efficacy, safety and quality, so basically: the compound has the intended clinical benefit, has an acceptable safety profile and can be produced with a consistent manufacturing quality. Most compounds fail because of lack of efficacy (roughly half), and roughly a third because of lack of acceptable safety.
  - cjbgkagh 6mo ago
    The vast majority of drug candidates don’t make it to the trial stage. Much of the research has to be defensible prior to the trial and what makes them defensible is having a mechanism for action. Of course once a drug is being used off label there starts to be some empirical data which can be used for trials, and it seems that we’ll get lucky with GLP1-As.
    - deng 6mo ago
      You are entirely correct. New compounds for trials do not come out of thin air, you usually derive them from compounds you already know how and why they work. For instance, we know very well how Semaglutide works, same goes for many other peptides that are currently being studied. However, you are correct that we do not understand why they would help for ME/CFS, simply because we do not understand ME/CFS in the first place. As I've written above, it's a severely neglected disease. Anyway, I don't think we really disagree, I rather misunderstood your original post. It's good to hear that these new peptides are helping with your condition, and I wish you all the best!
      - cjbgkagh 6mo ago
        Thanks for the feedback, I’m noticing that ‘fundamentalism’ didn’t translate properly and I should have referred to first principles and mechanisms of action. I need better words for these and I will try to find them. As a fun aside, consider the effect of the birthday paradox on empiricism, as the pool of candidates grows larger the probability of a match increases substantially as potential matching candidates increases quadratically.
DebtDeflation 6mo ago
>compounds need to undergo a rigorous regiment of empiric testing before they are given to potentially millions of people Particularly when the mechanism behind most of these peptides comes down to "promotes more rapid cell growth". The intent may be to repair the skin, muscles, or ligaments, but biology is rarely that specific.
cjbgkagh 6mo ago
Doctors have been maligning ME/CFS as psychosamatic for decades and generally still do despite a large amount of modern evidence to the contrary. If you have it it’s clearly not, you can get good and bad days that are clearly not dependent on psychological state. In addition I have it due to hEDS which is a condition that is almost never diagnosed due to aforementioned blind spots. Most doctors still think the prevalence rate is 1/50K despite continued research raising that number to 1/15K and 1/500. It takes a long time for this information to percolate through the system. Doctors, like many professions, have institutional blind spots, I studied these in my search because I was looking for something that had not been found. Most doctors have to consider all people and all conditions, I only have to be concerned with one. Notably they only recently adopted Bayesian statistics for medical trials despite that math being around for hundreds of years.
- deng 6mo ago
  I completely understand your frustration with the lack of knowledge and research in ME/CFS. It's a scandal, given the prevalence and seriousness of the condition. Unfortunately, after Covid, ME/CFS was even more politicized as part of the long-Covid discussions and got caught up in the culture wars. I have several friends with ME/CFS and they basically say the same things you do - ignorant doctors, high cost due to medication usually being off-label and not covered by insurance, and even friends don't take the condition seriously. ME/CFS research is severely underfunded. The reasons for this are not simple, it's partly due to the complexity of the disease which, as cynical as it is, does not make it an attractive research topic for ambitious scientists. Same goes for "Big Pharma". Clinical trials for ME/CFS are extremely complicated, and hence expensive, due to the myriad of symptoms in how the condition can appear. It makes research in this area very difficult and expensive. There's very little funding for ME/CFS research, and that needs to change. Unfortunately, especially in the US, this is not going to happen for Kennedy reasons. The Bayesian statistics thing is a bit of red herring, though. While your are correct that the math is old, the needed compute resources for doing Bayesian modeling on large trials was simply not there until recently. But it is also correct that it also took a long time until there were official rules regarding this from FDA and EMA. These regulatory things move very, very slowly.

by deng 6mo ago

ndr 6mo ago

I think the grandparent meant "fundamentalism" as "mechanistic", and lots of things we can know (as you say using the scientific method) to be useful long before we have a good mechanistic explanation of how they work. Some examples: aspirin (willow bark used for thousands of years, drug synthesized in 1897 and mechanism explained almost 100y later), or general anesthesia used again since mid 1800s and the mechanism is quite still debated. This is not to downplay all the long term, or developmental, risks that using something novel can result in. But we can empirically know something about the effects without having good mechanistic models.

deng 6mo ago
But it is usually not necessary for approval of a compound to be able to describe how it works on a molecular or cellular level. What you need to show are three things: efficacy, safety and quality, so basically: the compound has the intended clinical benefit, has an acceptable safety profile and can be produced with a consistent manufacturing quality. Most compounds fail because of lack of efficacy (roughly half), and roughly a third because of lack of acceptable safety.
- cjbgkagh 6mo ago
  The vast majority of drug candidates don’t make it to the trial stage. Much of the research has to be defensible prior to the trial and what makes them defensible is having a mechanism for action. Of course once a drug is being used off label there starts to be some empirical data which can be used for trials, and it seems that we’ll get lucky with GLP1-As.
  - deng 6mo ago
    You are entirely correct. New compounds for trials do not come out of thin air, you usually derive them from compounds you already know how and why they work. For instance, we know very well how Semaglutide works, same goes for many other peptides that are currently being studied. However, you are correct that we do not understand why they would help for ME/CFS, simply because we do not understand ME/CFS in the first place. As I've written above, it's a severely neglected disease. Anyway, I don't think we really disagree, I rather misunderstood your original post. It's good to hear that these new peptides are helping with your condition, and I wish you all the best!
    - cjbgkagh 6mo ago
      Thanks for the feedback, I’m noticing that ‘fundamentalism’ didn’t translate properly and I should have referred to first principles and mechanisms of action. I need better words for these and I will try to find them. As a fun aside, consider the effect of the birthday paradox on empiricism, as the pool of candidates grows larger the probability of a match increases substantially as potential matching candidates increases quadratically.

DebtDeflation 6mo ago

>compounds need to undergo a rigorous regiment of empiric testing before they are given to potentially millions of people Particularly when the mechanism behind most of these peptides comes down to "promotes more rapid cell growth". The intent may be to repair the skin, muscles, or ligaments, but biology is rarely that specific.

cjbgkagh 6mo ago

Doctors have been maligning ME/CFS as psychosamatic for decades and generally still do despite a large amount of modern evidence to the contrary. If you have it it’s clearly not, you can get good and bad days that are clearly not dependent on psychological state. In addition I have it due to hEDS which is a condition that is almost never diagnosed due to aforementioned blind spots. Most doctors still think the prevalence rate is 1/50K despite continued research raising that number to 1/15K and 1/500. It takes a long time for this information to percolate through the system. Doctors, like many professions, have institutional blind spots, I studied these in my search because I was looking for something that had not been found. Most doctors have to consider all people and all conditions, I only have to be concerned with one. Notably they only recently adopted Bayesian statistics for medical trials despite that math being around for hundreds of years.

deng 6mo ago
I completely understand your frustration with the lack of knowledge and research in ME/CFS. It's a scandal, given the prevalence and seriousness of the condition. Unfortunately, after Covid, ME/CFS was even more politicized as part of the long-Covid discussions and got caught up in the culture wars. I have several friends with ME/CFS and they basically say the same things you do - ignorant doctors, high cost due to medication usually being off-label and not covered by insurance, and even friends don't take the condition seriously. ME/CFS research is severely underfunded. The reasons for this are not simple, it's partly due to the complexity of the disease which, as cynical as it is, does not make it an attractive research topic for ambitious scientists. Same goes for "Big Pharma". Clinical trials for ME/CFS are extremely complicated, and hence expensive, due to the myriad of symptoms in how the condition can appear. It makes research in this area very difficult and expensive. There's very little funding for ME/CFS research, and that needs to change. Unfortunately, especially in the US, this is not going to happen for Kennedy reasons. The Bayesian statistics thing is a bit of red herring, though. While your are correct that the math is old, the needed compute resources for doing Bayesian modeling on large trials was simply not there until recently. But it is also correct that it also took a long time until there were official rules regarding this from FDA and EMA. These regulatory things move very, very slowly.