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.

Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href='https://www.123rf.com/profile_andreykuzmin'>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to healthcare.gov.

Remote Globe Puppy

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The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.

I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.

I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.

If Doctors Ran Their Practice Like The Airlines

Copyright: <a href='http://www.123rf.com/profile_itrace'>itrace / 123RF Stock Photo</a>Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for two hours of wi-fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

A New Target for Food Companies

Image credit: <a href='http://www.123rf.com/photo_14942511_mature-satisfied-chef-smell-the-aroma-of-his-food-while-cooking-at-restaurant.html'>rido / 123RF Stock Photo</a>

Food companies use sophisticated science and psychology to get people to buy their food. Using combinations of salt, sugar, and fat, among other things, they entice us and cause actual addiction. Although many people are rightfully concerned given the levels of obesity, diabetes, and other health problems, I think they’re missing out on a segment of the population that might actually benefit from their craft.

Not infrequently do I see patients, often elderly, who have a problem many of us could only wish for. They have a poor appetite. This may be due to many factors, including diminished smell and taste, poor vision, and dry mouth. What they need is food meant to appeal to them.

One of the tricks used to sell us more food is vanishing caloric density. Foods like Cheetos, that quickly melt in the mouth, fool the brain  to think there are less calories than there really are, so people eat more of them. If you’re malnourished, that might be a good thing. The food engineers should create foods that people with a poor appetite will actually want to eat. Throw in some vitamins and fiber, and just maybe they would get physicians to recommend them.

Spam Flattery

You’re familiar with email spam, but what you may not know is that people also try and spam blogs by posting comments that in effect are actually advertisements. Some of these spammers are cleaver and don’t come right out making a pitch for their product. What they hope for is that you will read their comment then be curious to click on a link to another website associated with their name. Spelling and grammatical mistakes may be accidental, or intentional to make them appear more like an every day person, but most misspelled words are probably attempts to confuse computer spam filters. Viagra can be spelled wrong so many ways it’s difficult to catch them all.

To prevent spam, many blogs are moderated and must be approved before posting. Spammers must believe in the adage that you catch more flies with honey than vinegar, and often post flattering remarks. Those doing the reviewing are human, and may be more likely to accept a comment praising their site. If you use Google or other search engine and look for the comments below, you will see that most, if not all, of them have appeared on other sites.

Most of the spam on this site is identified by WordPress, however I manually review them before deleting. Here are some of the spam comments I’ve received since starting this blog:

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FDA and Generic OxyContin

As recently reported in the Wall Street Journal, the pain killer OxyContin is set to go generic next year, and Purdue Pharma is trying to postpone it.

A funny thing often happens before a drug goes generic. Close to that time the manufacturer comes up with a new indication, formulation or dose. They claim it’s an improvement in the product, but it often has the appearance of coincidentally coming out close to when they would lose exclusive rights to sell the product. And wonder of wonders, they often get the market to themselves for a longer period of time because of it.

As someone who treats a lot of patients with pain, from my perspective OxyContin is a fairly good drug. Because it’s timed release oxycodone, it often gives better pain control, has a lot of dosing flexibility, and probably has less potential of causing addiction than immediate release oxycodone. Less is not none, however, and it’s still a frequently abused drug, whether swallowing the pills, or more illicitly, snorting or injecting it.

OxyContin has a new formulation containing polyethylene oxide that makes it harder to crush or inject. Although it’s not yet clear how effective it will be, the street price has decreased, suggesting it is a less desirable drug for someone wanting to get high. So Purdue Pharma is arguing that no one should be allowed to sell timed release oxycodone that does not have the protection they have, which of course is itself patented until 2025. Purdue Pharma is being sued for allegedly previoulsy making false claims to doctors, minimizing the risk of addiction. That has bearing on their new claim that it’s the new and improved version that has the low risk.

Besides that the improved safety is still not certain, their logic is false. From the perspective of controlling drug abuse, supply will meet demand. People will find better ways to process the new OxyContin pills to make them easier to abuse, or they will use substitutes.

From the perspective of a clinician treating pain patients, the cost of the pills and insurance formularies often dictate what doctors can prescribe. I often don’t prescribe OxyContin now, even when I want to, because of this, and have to prescribe controlled release morphine (which used to be sold as the brand MS Contin), methadone, which is a tricky drug to prescribe with a higher risk of accidental overdose, or use other alternatives.

I hope the FDA does not accept Purdue Pharma’s argument. They should either allow generic OxyContin, with or without the polyethylene oxide contained in the new pills, or allow generic manufacturers to use other similar methods of deterrence.