The Pharmaceutical Journal Vol 264 No 7079 p94
January 15, Letters

Homoeopathy

Misleading

From Dr S. B. Kayne, FRPharmS, and Dr L. R. Kayne, MRPharmS

SIR,—Professor Ernst makes a number of statements in his paper entitled "The demise of homoeopathy" (PJ, January 8, p56) on which we make the following comments.
It is misleading to imply that homoeopathy is based on the notion of highly diluted remedies. We agree that some homoeopathic remedies have been diluted to such an extent that it is not possible to identify any molecules of drug present. However, many commonly used remedies, especially those sold in pharmacies as part of commercially available ranges, are offered in dilutions below Avogadro (eg, 6c) and thus contain material amounts of medicine. The dilution factor of some of these remedies is similar to some widely used orthodox medicines. It would be interesting to investigate how these material doses achieve a therapeutic result.
The meta-analysis referred to by Professor Ernst¹ did not seek to identify whether a particular remedy was active in treating any
given disease, but whether homoeopathy as a therapy was effective or not. On balance, the study concluded that its apparent successes probably did represent more that a placebo effect. Pooling data from all orthodox treatments (or more reasonably from different methods of treating a single condition) as suggested by Professor Ernst would produce evidence that administering drugs as a therapy worked, and it would indeed be analogous to the homoeopathic meta-analysis. It is, of course, well acknowledged that orthodox successes may be due to placebo effects in some cases.
We share Professor Ernst's concern that much of the information published about homoeopathy is of poor quality and open to reinterpretation. This problem is not confined to homoeopathy, for it has been estimated that only 1 per cent of the millions of scientific papers published annually may be considered sound.² It depends to some extent on the bias of those making the critique and the importance placed on individual elements of the research. A detailed assessment of the approach adopted by Professor Ernst in his reviews is beyond the scope of this letter.
Professor Ernst frequently uses derivatives of the word "efficacy" in his paper when talking of positive outcomes. Measures of efficacy are typically derived from randomised clinical trials (RCTs) using standardised scientific criteria. The holistic nature of homoeopathic practice involving individualisation of the treatment for every patient and condition means that the controls imposed by some RCT protocols may be inappropriate. The concept of effectiveness is likely to be more applicable, since it takes account of the patient's perception of the outcome under "field" conditions. A system of patient oriented outcome measures, such as those being developed at Glasgow Homoeopathic hospital, could provide the answer.³ The use of some orthodox drugs is based on trials employing non-significant numbers of subjects. In other well publicised instances drugs licensed on the basis of satisfactory trials have been withdrawn subsequently because of unacceptable side effects. Finally, homoeopathy is used widely in paediatrics where RCTs have been largely ignored. Thus, clinical trials may not be the gold standard at all.
A reference is made to in vitro testing. There is little guarantee that in vitro results in homoeopathic research can be directly related to in vivo situations.⁴ A similar difficulty exists in orthodox investigations, eg, gene therapy studies. There is likely to be a much closer relevance in administering a medicine to a patient when its use is based on extended clinical observation, rather than on the results of in vitro testing, a fact recognised by the requirements of Phase 3 clinical trials.
We take issue with Professor Ernst over the necessity of discovering a mechanism of action. Certainly it would be academically satisfying to know how homoeopathy worked. Such data may well impress sceptics among our professional colleagues. One of us (SBK) has often stated that in his experience over the past 25 years, the average patient cares little about how homoeopathic remedies work. They are far more interested in whether they get better, using their own individual markers of what constitutes improvement. There are numerous examples of orthodox drugs whose mechanism of action is not understood, yet they are still used widely in medical practice.
We are surprised that Professor Ernst found it necessary to repeat his previously stated views on the problems of homoeopathy.⁵ His suggestion for solving the problems - carrying out a series of rigorous trials agreed by proponents and opponents in advance - adds nothing new to the debate. It would be interesting to hear his ideas on the exact form that these trials should take. Than
kfully, we do not disagree with absolutely everything our friend Edzard Ernst has written. We agree wholeheartedly with his conclusion that the demise of homoeopathy does not seem to be in sight.

Steven Kayne, Lee Kayne
Glasgow

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