Mortality: Exercise vs Drug Interventions

No surprises – no advantage in taking drugs over exercise except in heart failure.  Patients deserve to be told that.

Metaepidemiological study. Published BMJ October 2013

Results We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent exercise trials, our review collectively included 305 randomised controlled trials with 339 274 participants. Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14 716 participants were randomised to physical activity interventions in 57 trials. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). Inconsistency between direct and indirect comparisons was not significant.

Conclusions Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

Our findings reflect the bias against testing exercise interventions and highlight the changing landscape of medical research, which seems to increasingly favour drug interventions over strategies to modify lifestyle.

As the disparity between exercise based and drug based treatment evidence has increased, clinical practice guidelines have followed suit.49 50 For example, although earlier versions of the United States’ national cholesterol education programme guidelines advised the use of statins only after exhausting interventions for intensive lifestyle modification for the prevention of coronary heart disease in people with high cholesterol levels,51 subsequent versions progressively lowered the threshold for drug treatment and considerably expanded both the scope and the intensity of drug treatment.52

Clinical practice implications of this study

The findings of our review suggest that exercise and many drug interventions are often potentially similar in terms of their mortality benefits; exercise interventions should therefore be considered as a viable alternative to, or alongside, drug therapy.

Previous research has shown that patients with a variety of chronic conditions can expect to improve their functional capacity as well as muscle strength by a range of exercise interventions.

Regulators should consider requiring pharmaceutical sponsors of new drugs to include exercise interventions as an active comparator arm in drug trials. In cases where drug options provide only modest benefit, patients deserve to understand the relative impact that physical activity might have on their condition.


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