Tag: health

Something’s Seedy at the CDC

This week Secretary of Health and Human Services Robert F. Kennedy Jr. fired CDC Director Susan Monarez after she refused to accept his vaccination policy, which was based on his belief, rather than on science. Every director since 1953 (not including some interim/acting directors) has been a physician until Susan Monarez, who is a microbiologist. President Trump replaced her with Jim O’Neill, who is neither a physician nor a scientist, but an investor.

Besides picking someone who is completely unqualified to lead one of the most prestigious medical institutions in the world, since his election the CDC has lost thousands of employees and half of its budget. Susan Monarez’s firing prompted four leaders to resign. In August a shooter shot and killed a policeman and fired close to 200 rounds into the CDC headquarters because of his beliefs spurred on by vaccine misinformation. Afterwards Kennedy posted a number of pictures of his fishing trip before commenting on the shooting.

The CDC establishes immunization schedules for children and adults in the United States. But Kennedy, who has been a vocal critic of vaccines for years, fired all 17 sitting members of the CDC’s Advisory Committee on Immunization Practices (ACIP). Even if the replacements were all perfectly qualified, and they’re not, they wouldn’t be able to come up to speed learning the job fast enough to approve upcoming vaccinations, including new COVID-19 vaccinations.

I think the damage done to the CDC, to say nothing about damage to science at universities around the country from withholding research funding, is a crisis for medical science and public health in this country, and indeed in this world, and will probably last at least a decade if not reversed soon.

It’s also causing problems for individual doctors. I have the CDC Vaccine Schedules app on my phone, but I stopped updating it as I don’t fully trust the information anymore. That means for updates I have to look to professional organizations and other sources, and maybe other countries. My older patients, in particular, ask me about getting a COVID booster. I now tell them the FDA just approved a new one to cover recent variants, though limited who could get it, but we need to wait for the CDC to approve it (at least possibly for Medicare/insurance approval and for some pharmacies to stock it). One of my patients cast doubt on whether the CDC would approve it. I told them I figured they would at least need to approve it for those 65-years and older, as congressmen would want to make sure they could get it for themselves. My patient quipped they might then approve it only for those 80-years and older!

Public Policy Puts Health at Risk

In my last post I expressed concerns about healthcare. The concerns have only worsened. This is only some of the issues, and almost every day I put off finishing this article something else would come along.

  • PEPFAR – On the first day of his second term President Trump cancelled funding for PEPFAR ? Between 2003, when the program was signed into law, until 2024, it’s credited with saving about 25 million lives. AIDS was fatal for almost everyone who was infected with HIV forty years ago but starting in the 1990s treatments became available that turned it into a manageable chronic disease. It’s estimated that 20 million people had their treatment cut off without warning. Such a system of care cannot just be replaced immediately, even if there was another source of funding. In just South Africa alone it was calculated that the funding cut would lead to 565,000 new infections, life expectancy would decrease by 3.71 years, and deaths would increase by 38%. Not only might we have up to a million people die per year from untreated HIV, interrupting treatment increases the risk of developing drug resistant HIV, and that can spread to the whole world. The United Nations agency that fights HIV announced they are cutting their employee count in half due to funding cuts, with the U.S. funding 40% of their activities in 2023. They estimated that if funding is not restored more than 6 million additional people could die from AIDS in the next 4 years, and an additional 2,000 people a day could become infected with HIV. Just in the US it can end up costing more than we saved by the funding cuts, not to mention the inhumanity of it.
  • Food Safety Checks – According to the U.S. Public Interest Research Group Education Fund there was a 41% increase in food recalls for possible contamination by E. coli, salmonella, and listeria in 2024 compared with 2023. Food born illness increased by 20% and related hospitalizations and death double. But as a result of staff cuts at the Department of Health and Human Services, the Food and Drug Administration (FDA) has suspended its quality control program for food testing laboratories.
  • Food Security – The government agency responsible for running Meals on Wheels, among other things, is being dismantled by Health Secretary Robert F. Kennedy Jr. It also funds programs at senior centers and independent living.
  • Withholding Research Funds – The Department of Health and Human Services announced that they were going to cut funding for the Women’s Health Initiative, a ground breaking study that has been ongoing since 1990 and that has been following tens of thousands of women. Fortunately they reversed their decision a day later after a loud outcry. The National Institute of Health (NIH) had funded research on almost every drug on the market here. They announced they would invest $500 million dollars to study a universal vaccine using old, traditional technology. This will come at the expense of research on mRNA vaccines, which created the highly successful COVID-19 vaccines. This technology allows vaccines to be made much more quickly, important for future pandemics, and has been shown to increase survival in pancreatic cancer, an may cure chronic and genetic diseases, such as Type 1 diabetes and multiple sclerosis.
  • Preventive Health Research – Despite Robert F Kennedy Jr proclaiming he would Make America Healthy Again, President Trump recently proposed cutting the budget almost in half for the Centers for Disease Control and Prevention. Last month 2400 jobs were cut from the National Center for Chronic Disease Prevention and Health Promotion. That includes programs for lead poisoning prevention, HIV, firearm injuries, smoking cessation, preventing cancer, heart disease, diabetes, Alzheimer’s, epilepsy and Alzheimer’s disease, and for states to deal with public emergencies and things like blood pressure screening. The proposed budget would also cut the Eliminating the Office on Smoking and Health. It’s hard to see how that will make use more healthy.
  • Infection Control – The Trump administration shut down the Healthcare Infection Control Advisory Committee (HICPAC) that helps set national standards on controlling infections in hospitals, including hand washing, mask use, and isolating sick patients. The current recommendations date back to 2007 and an update was being prepared.
  • World Health Organization – President Trump issued and executive order withdrawing the United States from the WHO. It takes year for it to be fully implemented, given that countries have to give notice first, and it could be reversed by congress, but this will hurt global health and can affect us in the event of another pandemic or other medical issues.
  • Measles – Thanks to low vaccination rates we are experiencing a measles outbreak. There have been over 880 cases in the US this year as of late April. Two doses of MMR vaccine is 97% effective in preventing measles, and we need at least 95% of people to be vaccinated to prevent additional outbreaks. Yet in the 2023-24 school year only 92.7% of kindergartners were vaccinated. If that rate persists it’s estimated we’d have more than 850,000 cases in the next 25 years. If it drops 10% more then we could expect more than 11 million cases in the next 25 years. But if we increased the rate by 5% then we’d only have about 5,800 cases in that same period. That should be a no brainer, yet Robert F Kennedy Jr has only given lip service to promoting vaccination and has talked about the value of vitamin A and other non-effective treatments.
  • Silicosis – This is a deadly lung disease that affects people who work with silicon, including miners and people who fabricate and install artificial-stone kitchen countertops. From closing Occupational Safety and Health Administration (OSHA) and Mine Safety and Health Administration (MSHA) offices, to firing Coal Workers Health Surveillance Program (CWHSP) and National Institute for Occupational Safety and Health (NIOSH) staff, more people will develop silicosis, and they won’t get diagnosed until their disease has progressed even more, if they get diagnosed at all.
  • Surgeon General – After withdrawing his initial nomination for surgeon general due to her providing misleading or incorrect credentials, he has nominated Dr. Casey Means, despite that she has not compleated a residency, sells supplements on her website, and has expressed vaccine skepticism. For a position that oversees the U.S. Public Health Service (USPHS) Commissioned Corps and provides “Americans with the best scientific information available on how to improve their health and reduce the risk of illness and injury,” we can do better.
  • Opioid Drug Deaths – At the same time the CDC announced significant progress is decreasing drug overdose deaths, their opioid surveillance programs may get a $30 million funding cut per preliminary budget reports.
  • PFAS – The Environmental Protection Agency (EPA) announced that they will be scaling back rules on limiting some PFAS, or per- and polyfluoroalkyl substances, virtually indestructible chemicals, in drinking water. They are associated with some cancers, decreased fertility, developmental delay in children, and metabolic disorders. It doesn’t sound like the EPA is protecting the environment.

One small positive is that the Agriculture Department is fast-tracking state requests to remove candy and soda pop from coverage under the Supplemental Nutrition Assistance Program (SNAP), otherwise know as food stamps.

RIP Health

With the new Trump administration there has been a flurry of activity that does not bode well for healthcare. Not all these things may come to pass, but I’ll comment on some of them.

Federal scientific meetings were cancelled, and federal health officials were told to refrain from all public communications, including publications and speaking engagements, until approved by a presidential appointee or designee. It includes email lists and social media posts. It prevented the C.D.C from publishing the Morbidity and Mortality Weekly Report on 1/23/25, that was to include information on the spreading bird flu affecting poultry and cows, as well has humans. It prevented meeting, such as advisory committees on health issues, and funding for research at the National Institute of Health (NIH). Scientific and medical information should be managed by scientists and medical professionals, not politicians. That didn’t work out well at the beginning of the COVID-19 pandemic, when political messaging took precedence, and advice was rendered that led some infected patients to drink bleach. That lesson doesn’t seem to have been learned.

There was a haphazardly announced (and probably illegal) federal funding freeze that at least temporarily (until parts were rescinded or blocked by a judge) affected such things as Medicaid, funding for doctors and nurses at Veteran’s Administration (VA) hospitals hired to start in February (some who had already moved their families), VA suicide prevention lines, disaster relief to places such as Los Angeles (fires) and North Carolina (floods), and medical research.

Robert F. Kennedy Jr. has been nominated to be the Secretary of Health and Human Services. Although he has some views about food that I might agree with, there are many reasons he is completely unsuitable for the job. Over the years he has repeatedly questioned the safety of vaccines, including measles and polio. These are devastating illnesses that we rarely see nowadays, thanks to vaccines. At a talk in November he said 48% of (American) teens are diabetic. It’s less than 1% at that age. He also seemed to mix up pre-diabetes, which is brought on by diet, with juvenile (Type 1) diabetes, that is not. He falsely said that the flu shot does not prevent hospitalizations and that it increases the risk of spreading it to others. He falsely said the pertussis vaccine (part of Tdap) causes brain injury.

Two days ago the administration ordered health organizations in other countries to stop distributing HIV medications purchased with U.S. aid. This was part of a freeze in PEPFAR overseen by the State Department. This program has been estimated to have saved 25 million lives worldwide. Besides the importance of being a good global citizen, it indirectly benefits U.S. citizens. The less cases in the world, the less likely Americans will get infected one way or the other. If patients go off HIV medications temporarily, it increases the risk they will develop drug resistant HIV, which could then spread worldwide. Providing such a benefit is soft diplomacy that buys good will and decreases the chances that other countries that are not friendly to us will be able to influence them. When countries do poorly, they are also more like to develop terrorists. Yesterday the administration at least temporarily allowed the distribution to resume.

There have been a number of initiatives that adversely affect transgender people, including healthcare.

Did I leave anything out? That’s just a little over the first week!

RSV(P)

Respiratory syncytial virus (RSV) is a virus you may never have heard about, but you’ve probably had. It affects the upper airways with cold like symptoms, but it can cause a severe pneumonia, particularly in infants, older adults, and those with lung disease, or who are immunocompromised. By two years old almost all children have been infected. It causes roughly 2/3 of the number of hospitalizations and deaths as that cause by influenza (the flu). It tends to peak around the same time as influenza and COVID-19, constituting a triple threat.

There is a monoclonal antibody for infants and young children, but this year for the first time adults 60 and older can get a vaccine for RSV.

There are currently two vaccines approved, Abrysvo from Pfizer,and Arexvy from Glaxo Smith Kline’s (GSK). Abrysvo is also approved for women who are 32 to 36 weeks pregnant during September through January (to cover when RSV is typically active). Full disclosure – I was a primary research investigator for one of the Pfizer’s studies, but I make no money from sales of the product.

In one study with Arexvy and influenza vaccines there were two cases of acute disseminated encephalomyelitis (ADEM), and one case of Guillain-Barré syndrome, serious neurologic side effect seen with some other vaccines, and sometimes for no apparent reason. It’s not clear if it was due to the RSV vaccine component, the influenza component, the combination, or unrelated. There were 3 reported cases of Guillain-Barré in the Abrysvo studies.

Although there were few reported cases of Guillain-Barré in the RSV studies, given the severity of the side effect one needs to consider risk versus benefit. For those at high risk, I think the benefit outweighs the risk. It’s harder to know what to do for those who are approved to get the vaccine, but are otherwise at low risk, such as those in their 60’s who are generally healthy. Currently for those patients I’m not encouraging them to get vaccinated, and if they ask, I say they may want to consider skipping it this season. By next season we should have a much better idea of the true risk. If you’re 60-years-old or older, you should discuss with your physician/provider.

It’s not yet known how long the vaccine provides adequate protection, but probably for 2 years or longer. In fact when the companies realized the vaccines would last more than one year, they raised their prices as their original profit calculations assumed people would need yearly vaccinations.

Shaky Business

Early in the pandemic I avoided seeing my patients for a while, except with virtual visits. After returning to the office I tried to maximize the distance, and minimize the duration of contact to lessen both our risks.

As the pandemic has progressed, both my patients and myself have gradually become more relaxed. I think this is from a combination of vaccinations, having effective treatments, and just habituating to the situation. Initially I had stopped shaking hands, and my patients stopped trying to shake mine. But eventually some did, with either a fist or elbow bump, or sometimes a full hand shake. Some would follow my lead but remark about how they guess we are no longer shaking hands.

A few months ago a plumber came out my house to replace a sprinkler valve system that sprung a leak after an earlier freeze. When he arrived he stuck his hand out to shake. Not wanting to be rude I shook his hand, then was careful to make sure I didn’t touch my face before washing my hands.

Not longer after, someone came out to pump our septic tank. The same thing occurred. No offense to those in the sanitation field, but if you’re a germaphobe, rationally or not, shaking hands with someone who empties tanks with human waste does not sound like a good idea! But again, I didn’t want to be rude, so I did so.

After those encounters, I pondered what I should do with my patients. Having seen plenty of guys in public bathrooms walk out without washing their hands, or with just a cursory rinse, and knowing that most people, myself included, often touch their faces unconsciously, which is how diseases often spread, I’m a little leery of shaking anyone’s hands. Pre-pandemic I overrode those concerns and did so anyway, for the social bonding benefit, but now it’s more socially acceptable to not shake hands.

In the office we wash our hands often, even pre-pandemic. We’re taught to gel in, gel out. That means you use alcohol gel to wash your hands when you walk in to see a patient, then again as you leave the room. Even with that I usually put the gel in one hand, open the door with the other (who knows who touched that door handle last), then rub my hands together as I walk into the room (which also demonstrates to the patient that I washed my hands). If I then shake their hand (and anyone else they came with), then I feel compelled to wash them again lest I touch my face during the visit, or just to avoid potentially contaminating the keyboard (though my nurse does wipe it down often). That can easily add up to washing my hands over 50 times a day. Certainly the alcohol is a lot faster than using soap and water, but is more drying on the skin.

So where does that leave things? Basically I shake hands when my patients offer it, and occasionally other times, as I continue to weigh the pros and cons. I suspect after the current wave of infections declines I’ll relax more and be able to shake off the feeling of impending doom.

Speaking Truth to Power

On 4/18/22, a federal judge in Florida struck down the CDC requirement of wearing masks on trains, planes on domestic flights, and other public transportation. This came less than a week after the Centers for Disease Control extended the mask mandate through 5/3/22. Immediately a number of airlines, including Delta and Alaska, announced that they were removing the requirement.

She made this ruling before a hearing was held, and nationalized the ruling rather than limiting it to the plaintiffs who had filed the case. In addition the mandate was probably going to go away in 2 weeks in any case.

Who was this federal judge? It was Kathryn Kimball Mizelle, appointed for a lifetime position at the age of 33 by President Trump, despite that she had never tried a case, and the American Bar Association rated her as, “Not Qualified.”

Just because she had the power to make this ruling, doesn’t mean she’s right. Of course when it comes to the law, I’m even less qualified than this judge, but from a medical point of view, we’re still in a pandemic. I, for one, will continue to wear a mask in an airplane, at least for a while, even if it’s just to avoid the common cold.

Omicron OMG!

Just when it looked like it was going to get safe to get back into the water, now we have a new COVID-19 variant with which we have to contend. Named after the Greek letter Omicron.

We don’t have enough information yet to know how serious of a threat this is, and whether it will significantly change what we do, but at best it’s tiresome news, and at worst it may cause significantly more cases.

For now, continue to wash your hands frequently and wear a mask in crowded places. If you’re fully vaccinated then there are a number of considerations about which situations it’s safe to not wear a mask. It includes the number of cases where you live, the chances of being exposed to those not wearing masks, and you personal risk.

Getting a booster is now a much simpler process. According to the CDC, if you’re 18-years or older and it has been 6 months since you last Pfizer-BioNTech or Moderna vaccine, get a booster. If it has been at least 2 months since a Johnson & Johnson vaccine, get a booster.

You may mix and match boosters. If you had a Johnson & Johnson vaccine, you will probably get a better response from having a Pfizer-BioNTech or Moderna vaccine booster compared with another Johnson & Johnson booster.

Stay tuned!

A is for Aspirin

You probably recently read in the news something about aspirin recently, and maybe you’re wondering if you should stop taking it, or you went ahead and already did. I know lots of my patients have been asking me.

The article by the U.S. Preventive Services Task Force talks about the use of aspirin to prevent heart attacks and strokes. They said for primary prevention (meaning to prevent a first heart attack) they recommended shared (between patient and their doctor/provider) decision making for starting aspirin in 40 to 59-years-olds with a 10% or greater risk of having a major heart event (such as a heart attack) in the next 10 years who do not have increased bleeding risk. They recommended not starting aspirin in those 60 and older who have less than a 20% risk.

There are a number of key points.

  • This is a draft recommendation. There is a public comment period and changes will be made before it’s finally published, probably in 6 or more months.
  • The recommendations only apply to starting aspirin.
  • The recommendations do not apply to people who have previously had a heart attack or stroke.
  • They make no recommendations about stopping aspirin other than considering stopping at 75 years old for primary prevention.

For patients who have had a heart attack, stroke, or peripheral artery disease (blocked artery to one’s arms or legs), the benefits of aspirin generally outweigh the risk of bleeding.

The decision to use any medication is always a balance of the benefits versus the risks (and sometimes the cost). Why the change in recommendations? Well in part we generally get progressively better as we accumulate more scientific information. But probably in this case it’s more due to treatment changes. When the original recommendations came out to use aspirin for primary prevention we did not have very good treatment for the conditions that cause heart disease, particularly cholesterol. With improved treatment, there is less incremental benefit from aspirin, yet the bleeding risk remains. That may shift who we should treat.

For now, I’m not recommending any changes before the final recommendations come out. Aspirin was first recommended for primary prevention over a century ago! If taking aspirin was that risky we’d have known there was a problem long ago. I don’t think there is any reason to make any rushed decisions unless someone is having a problem with aspirin.

So you if you are already on aspirin and doing fine on it, and your next appointment to see your doctor will be within 9 months or so, I suggest considering not even asking your doctor until your next appointment. That gives time for the final report to be published, and time for your doctor to consider the information. That’s better than making a decision based on a headline.

More COVID-19 Coronavirus Thoughts

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Christian IV’s crown in Rosenborg Castle in Copenhagen, Denmark.

Social distancing is strange when it hits home. The last time we had kids and grandkids over for dinner, about a month ago, we tended to hold back giving the usual hugs. Three people were in the medical profession and two lived 5 miles away from the nursing home in Kirkland that had the big outbreak. It was like an Agatha Christie whodunnit murder mystery and we were all suspects!

At work we’ve been careful to conserve supplies for quite a while, particularly to help out for the places that really need them.

When wearing a gown I couldn’t swipe my badge to log in and out of the computer as my badge was under the gown (if over then it risked touching the patient if I was examining them). I had to pull the reader to me. Face ID doesn’t work with a mask. Last month I saw a new patient, who happened to have a cold, so we both wore masks. Neither of us really saw what the other looked like. More recently most everyone wears masks.

I often check a patient’s throat when doing a routine exam, but would skip it if not really needed to avoid having to be relatively close while they may be actively exhaling in front of me. When I do a physical exam on men, I’d think twice about telling them to turn their head and cough!

We’ve quickly changed how we practice medicine. We try to screen patients to prevent potentially sick patients from coming in. It doesn’t always work. They may have already had an appointment to follow up on their diabetes, and not mentioned that they had a cough. A phone screener may have asked if they went to South Korea or Italy or had known exposure, but that doesn’t mean they didn’t have exposure to someone sick that has yet to be diagnosed, and more recently travel history no longer matters. I documented any personal protective equipment (PPE) I used (mask, mask with eye shield, gloves, gown). That way if I later find out my patient was infected, I could look at what protection I wore. Because of equipment shortages I could not wear everything for every patient I see.

I purchased scrubs for the first time a few weeks ago. When I worked in the hospital many years ago, they provided them to us. Working in the clinic it was not considered acceptable attire for doctors. Because of the pandemic, administration authorized us to wear them. When I would get home, they would go straight to the washing machine, and I would head to the shower as a decontamination routine. We never made so much use of our LG Sidekick pedestal washer!

We’re heading towards doing telemedicine in a much bigger way. That protects our patients from being exposed coming in, and it protects health care workers, and other patients, from being exposed to sick patients. Various legal restrictions and how we are reimbursed has limited this, but now the government as temporarily removed many

restrictions and the government and private insurances are starting to pay for virtual healthcare. I was 17 minutes late the first time I did a case by phone. I was waiting for my nurse to check her in before I realized that I was supposed to call her! I also quickly realized that I needed to use my speaker phone as I could not type efficiently holding the phone with one hand. I’m now set up to do video visits from work or home, but it has been a challenge for many patients. The easiest way is to use a smart phone (iPhone or Android) and download the Epic MyChart app as we use Epic as our electronic medical record
(EMR). Then we can connect on our end using the Haiku app and have a secure video conference call. But some patients don’t have smart phones, and for those that do they often don’t understand that they need to download the app, and that there are a few steps they have to do on their end to actually connect. Some try to connect through MyChart on a browser, but that often doesn’t work. A couple of people couldn’t download the app because they didn’t remember their password for the app store. Another video app we’ve used, that is preferred by our legal department, is less intuitive and I’ve only been successful with it a few times. Occasionally we run into bandwidth issues and sound or video quality is not good. I’m not sure where the problem is, but I suspect it’s on the patient end as I’m connecting to a fast internet and Wi-Fi. When it works, though, it’s generally a good experience for patients and myself. Patients can show me a rash or swollen ankle. For both sides of a video conference, it’s helpful to have a good light source from the front. If it’s from the back one’s face is in the shadows. Try just using the rearview camera to get an idea of what you’ll look like (and what’s behind you!) beforehand. Although I think visits in person tend to be best, it’s certainly safer doing it virtually. Patients appreciate that, as well as the convenience.

People generally know that this pandemic has been hard on healthcare workers. What many people probably don’t realize is that in a healthcare organization a lot of others play important supporting rolls. As I serve on an informatics committee and am a Physician Builder, I’ve had a chance to see some of what’s going on. To place an order for a brand- new test, for example, some analyst had to build the functionality into our electronic medical record. There are many new workflows that were needed, including for telemedicine, and in the beginning the analysts were told we needed them yesterday.

Once a week I work with a family medicine resident to teach them geriatric medicine. I spoke with one last month that I wasn’t sure what was going to happen with her rotation since both I and my colleague were moving towards stopping seeing patients in the clinic. After she spoke with one of the faculty, they suggested she observe me doing telemedicine as I have a reputation for being good with computers. But how could I have her watch yet keep the recommended 6 feet of social distance? I did a test where I chatted with her over one of the apps and I was able to share the screen but then she went on vacation. I’m still trying to figure out a way that I can have a resident remotely do a video chat with the patient and myself. Not all the software we are using allows group video chats. Plus, I want it to be meaningful education for the residents.

I think this experience has brought increased camaraderie among doctors and others in healthcare, like serving together during war. Fortunately we have had less cases than expected in Washington so far, and we’ve not faced dire circumstances in my clinic.

Although it’s unpleasant to consider, on the plus side, this has finally got me to stop procrastinating and pushed me to get my estate plan and medical directive done.

Aspirin – Questioning Established Wisdom

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Bayer began selling aspirin (acetylsalicylic acid) in 1899, and the similar salicylic acid, derived from willow bark and other sources, has been used medicinally for thousands of years.  Since the 1960’s it has often been used for heart attacks and strokes. Studies showed that in patients who have had heart attacks, daily aspirin prevents another one. This is know as secondary prevention.

Doctors have assumed that it would also be good to prevent the first heart attack in patients at higher risk. This is know as primary prevention. The problem is that’s much harder to prove.  Even patients at higher risk might never have one, or maybe not for many years, so a research study can take many thousands of patients followed for many years, thus costing many millions of dollars, to tell if there is a benefit. Rare side effects can take many years to figure out. There have been studies done over the years, with inconclusive and sometimes with inconsistent results.

According to a trio of recent articles (Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly, Effect of Aspirin on All-Cause Mortality in the Healthy Elderly, and Effect of Aspirin on Disability-free Survival in the Healthy Elderly), aspirin use may cause more harm than benefit for primary prevention. They looked at patients >= 70-year-old (>= 65-year-old for blacks/hispanics in the US). A low proportion of participants regularly took low-dose aspirin before entering the trial, which did not directly address whether healthy older persons who have been using aspirin for primary prevention should continue or discontinue its use. Now 2019 guidelines from the American College of Cardiology and the American Heart Association recommend low dose aspirin for primary prevention only in limited patient populations at higher risk.

When it comes to medical treatments, it’s pretty much always a question of balancing benefit versus risk and cost. For aspirin, cost is pretty much not an issue. Although studies may look at thousands of patients, people are not homogenous, and any particular study may not apply to a particular patient. The guidelines listed above state that aspirin might be considered for primary prevention in adults age 40 to 70 at higher heart risk but who do not have a higher bleeding risk. They do not recommend it for routine use for those over 70-years-old. Note that it still may be warranted in some because of higher risk, and it’s still recommended for most older patient if they have known heart disease.

I think these new recommendations will eventually lead to less patients taking aspirin to prevent a first heart attack. This will lead to less bleeding, but it may increase other problems For example, aspirin may decrease the risk of colon and other cancers. It may help prevent deep venous thrombosis (DVT) blood clots in the legs, which could lead to a more serious pulmonary embolism (PE), so long distance air travelers may be at higher risk of a clot if they stop taking their aspirin. They could just take it before a trip, but will they remember? The FDA just added a block box warning for Uloric (febuxostat), a medicine used for gout, because of recently appreciated increased risk of cardiovascular disease. Surely there will be patients on that medication on aspirin for primary prevention who will stop aspirin, as a result of reading in the media that they should, but will then go on to have a heart attack because either they didn’t discuss it with their physician, or they did but their doctor didn’t know or appreciate the increased heart attack risk with Uloric. That medicine, by the way, should also be judged on benefits versus risks and alternatives, and is still appropriate for some patients, though not as many people as the drug reps would have had doctors believe. They’ve stopped promoting it as it’s almost generic, but that’s another story.