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Comment by hombre_fatal | Hacker News Reader

I only knew Metformin by name from HNers using it as an anti-aging wonder drug over the years: https://hn.algolia.com/?dateRange=all&page=0&prefix=false&qu...

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It is also beginning to be prescribed by many of the subscription medication/doctor businesses that are springing up, powered by VC cash and looking to build strong forward flowing subscription businesses. Their model is:

- find areas that aren’t medically serious (speaking relatively, and in relation to life threatening - erectile dysfunction and male pattern baldness)

- run people through online questionnaires

- get an online subscription runner stamped by a doc on their payroll

- send out generic medications that they get cheap, package them nicely, and make bank on markup

- catch them on the next condition they roll along to

The last year I’ve seen a lot of them shifting into metformin (after finasteride and viagra/cialis) for weight loss

I expect those guys will start pushing SGLT2 inhibitors (gliflozins) next.

I just discovered that apparently that is exactly what they’re doing, not metformin presently. And there a planned shift to GLP1s - but the injectables present some interesting administration aspects

Do you see this as a bad thing? As someone who doesn't have any insurance, I'm extremely grateful for these. I don't want to have to go through the current medical racket where unless you pay a doc $300 you won't be allowed to purchase the medication you want. And then of course there's the follow up appointments, a "med check" where they can bill you $150 every 90 to 180 days just to hear you say, "yep, things are fine."

In responding to your example first - to start with, I live and practice in a country where it isn't a choice between healthcare and food on the table. Beyond that, I believe that it is a basic human right to have free healthcare. The next bit is a bit more complex. I don't think it is right or sensible to advertise medications to people directly. The US is almost alone amongst industrialised/western countries in having prescription medications being directly advertised to consumers. From my time in the US as a medical student, I saw directly how that changed the patient-doctor relationship, and I don't believe in a positive way. So - I don't think it's right that there's a medical racket that fleeces you to see a doctor, but I don't think it's right that you decide your prescription anyway. On the other hand, it should (speaking of an idealised utopian world) be easy to get refills of medications that have been appropriately prescribed.

So here is where it gets interesting with the VC-backed Subscription healthcare model. I did a touch of consulting for one starting in Australia (well, it would probably be a stretch to call it consulting but I sat down with the founders as they were running through their spin-up process).

My concerns are that you can't just prescribe anything to anyone, and for the vast majority of prescription medications there are often side-effects that need to be monitored (some of which can be serious), as well as inappropriate prescribing. The 2 examples the company I was talking to were Finasteride as well as Viagra. Seperating these two out, my concerns with Erectile Dysfunction are that it could be inappropriately funnelling everyone into prescription treatment, when there is in a reasonable percentage of cases other psychological issues that are impinging on erectile function, and whilst it might be all well and good to get viagra to get to the end result, it is also missing the broader holistic picture of aiming to achieve better health.

For finasteride, there are a reasonable percentage of people who experience quite unwanted side-effects, from gynaecomastia to erectile dysfunction. Since the target audience is young men, these effects are often more psychologically concerning than the cosmetic issue they were trying to solve with a serious prescription medication and I was concerned about follow-up, referral and support in these instances.

I was able to be reassured by them that they had adequate safeguards in place and good clinical governance oversight to achieve good all round care and then we split ways. I have no idea if they have or are maintaining those protections; additionally I have recently heard they have been pulled infront of the regulators here in Australia for cutting a few corners so my suspicion is that the money and growth hacking has gotten the better of their product development.

Ultimately it is going to be an interesting bounce between both the regulation and the inevitable clinical disasters that will pop up. There's no doubt there is room for innovation in the space, and I feel that there is certainly a way to do it safely - ensure that, for certain conditions, you can answer a few questions, get your medication, and still have safe follow-up, and do this in a innovative way that reduces overall demands on a healthcare professional for a full sit-down (ie wrap up a bunch of the bullshit in algorithms and decision trees and take care of a lot of the back room stuff).

But after 9 years as a doctor and a health-tech founder, I am also convinced that there are a number of elements of health that just do not scale, at least not with anything like the technology we currently have (ie well developed expert systems - I am also fairly fundamentally convinced that the use of AI for diagnosis and the black-box internals is going to cause issues due to uncertainty over where the fuzzy edge lies)

So - TLDR: do I see VC driven subscription prescription as a bad thing? No, but also potentially yes

> it should (speaking of an idealised utopian world) be easy to get refills of medications that have been appropriately prescribed.

I must be living in Utopia then, I thought it was Norway! :-)

When I run out of my blood pressure pills I can spend a couple of minutes online to send a message to my doctor. He spends a few seconds online to renew my prescription and then I can go to any pharmacy to pick up three months of pills. For the rest of the year I just go to a pharmacy to pick up a repeat when I run out.

I have a similar set up in the UK - I hit the "request repeat prescription" button in my GP's app, they nod it through and send it to my chosen pharmacy, then a nice person from the pharmacy delivers it the next day. No shady business models required! :D

The difference is that I don't have to specify which chemist, I can go to any one and just present my ID, they can then look up the prescriptions.

For finasteride I agree, as it decreases DHT, which is not exactly a useless hormone. It shouldn't be prescribed to anyone, as you have said. I don't necessarily agree for the Viagra/Cialis. Generally cialis is safer than viagra, with less side effects. But their mechanism of action is quite simple and doesn't cascade to a lot of other body functions, inhibition of PDE5. Viagra also inhibits PDE6 more, thats why you get a blue-ish tint to your vision, and PDE1, which is more dangerous and can cause tachycardia. Cialis inhibits PDE11 more, which affects skeletal muscles and the prostate. That's why Cialis is sometimes prescribed for BPH, and why bodybuilders take cialis as a supplement (drive more blood into the skeletal muscles, decrease blood pressure).

Getting to your point of "other psychological issues" that can result in ED. Cialis and Viagra are there for one specific case of ED, which isn't caused psychologically. If you can get an erection in the morning, while you're sleeping, PDE5 inhibitors won't help.

Of course, the less drugs you take, the better, easier on your kidneys and liver. No drugs are without side effects, PDE5 inhibitors have them, but they are mild and can be diagnosed easily. Of course, dose is important, and health issue history needs to be taken into consideration.

> If you can get an erection in the morning, while you're sleeping, PDE5 inhibitors won't help.

Did you mean to say can’t?

Nope. If you can get an erection in the morning, the vasodilatation mechanism works, so Cialis/Viagra won't help. If the mechanism works, but you still cannot get an erection when you're with your partner, the problem could be psychological, say you're not attracted anymore to your partner, anxiety, stress, all stopping you from getting aroused. And you need those neurons or endotheliums to fire. Another example is drugs that are vasoconstricting, stimulants like amphetamines or cocaine, which even though create a high arousal state, they are so vasocontricting that it's hard to achieve an erection (so Cialis/Viagra helps, but it's not indicated to combine drugs that combat eachother).

Interesting, and thank you for the clarification.

I think it’s probably more of a spectrum and not a binary thing, and so you can have layers of physiological and psychological impediments, and one could also feed the other.

I agree that viagra/cialis are generally safe for the majority of people. I guess the question with regard to the subscription prescription model is what are the subset of medications that fall into the right risk profile for the model to work effectively? It's a pretty small subset without adequate safeguards!

Good or bad, it's the logical conclusion given the free market, healthcare, and the Internet. The real problem is the "as someone without insurance" bit, the bigger question is what is best for society?

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