Aspirin, in one form or another, has been part of the pharmacopoeia (GREAT word! and I love using it) for relieving suffering for literally thousands of years. Detractors quip that if aspirin came up for FDA approval today, it would never make it out of the gate since it can produce a host of side effects. Yet some of those self-same side effects also prove beneficial, and Rick and I discuss in PodMed this week and as seen on our YouTube, based on a study in NEJM.
Warfarin and Aspirin in Patients With Heart Failure and Sinus Rhythm followed over 2000 patients with heart failure for up to six years. Use of these medications in people with heart failure is thought to reduce the risk that they'll form blood clots, an observed phenomenon in those with the condition. People eligible for the study had a left ventricular ejection fraction, the putative test for heart failure, of 35% or less, but they did have a normal heart rhythm and were able to take the study medications. Outcome measures included strokes due to clot formation (ischemic stroke), bleeding inside the brain, or death from any cause. The good news is that there was no real difference between the two medications, with a few minor caveats: warfarin appeared to be better with regard to preventing ischemic stroke but worse with regard to major bleeding episodes. So why is this good news?
It's good news for the millions of people worldwide who currently have congestive heart failure, a number that is expected to rise dramatically, according to the World Health Organization. That in itself is partially a success story as people are living long enough to develop the condition and we're much better at managing it once they do. I would be remiss in not mentioning, however, that better management of cardiac risk factors in general and high blood pressure specifically would go a long way toward reducing this disease burden.
Managing congestive heart failure can require a number of medications, and when we examine aspirin versus warfarin we find a big disparity in price, with aspirin therapy costing very little. There's also the need to monitor blood levels when warfarin is used, most often requiring people to travel to a clinic and have their level measured. Warfarin is a really great example of Goldilocks medicine, where the level of the drug needs to be just right. That's not the case with aspirin. So aspirin works, it's much less expensive and doesn't require close monitoring. That's a win domestically and internationally, where the healthcare infrastructure often isn't as robust.
Other topics this week include two studies on mammography from Annals, addressing who is most likely to benefit from earlier screening, management of type 2 diabetes in adolescents in NEJM, and neonatal abstinence syndrome in newborns, in JAMA. Until next week, y'all live well.
Mom Was Right!
May 11th, 2012 | Medical News Commentary | By Elizabeth Tracey
So let's start with some background. Turns out that about 30% of people who must take antibiotics for a variety of infections develop diarrhea, sometimes severe diarrhea, and this is also an important determinant for non-compliance with therapy. For some time, of course, so-called probiotics have been touted as the method for coping with this problem, and a host of other problems, btw. Yet what has clearly emerged as probiotics have been studied rigorously is that a) gut flora is incredibly complicated b)modifying gut flora via oral administration of single bacterial cultures or mixtures may or may not significantly impact on changing the gut flora c) normal gut flora is challenging to study because recreating gut conditions in a laboratory environment is technically difficult, and d) one's gut flora changes secondary to a number of factors, including diet, where and with whom one is living, and health conditions. So no wonder that establishing a clear benefit from probiotics has been difficult, and add to that the fact that makers of probiotics have had a clear profit motive , thus rendering their claims suspicious.
So where does this study take us? This is a meta-analysis of 63 randomized, controlled trials of the use of probiotics when antibiotics were also taken. The usual bacterium was Lactobacillus, the self-same organism used to produce the majority of yogurt. While each of the specific studies included were small and the reporting methods sometimes suboptimal, the final analysis included data from almost 12,000 participants. The study concluded that use of probiotics was able to reduce the risk of developing diarrhea secondary to antibiotic use by 42%.
Here's what we like about this study: it suggests that a self-administered, low-risk, and low-cost strategy for avoiding one common side effect of antibiotic use works. And there's no need to consume specialized concoctions, it's most likely that the store-brand, lowly yogurt will do the trick. As Rick points out in the podcast, there are a number of questions this analysis doesn't have the power to answer, including dosing data, but it seems reasonable to conclude that patients can try this safely at home.
Other topics this week include two from the Lancet: Millennium villages and their very positive impact on child mortality in Africa, and the worldwide burden of infection-related cancers, and substituting fruit for fruit juice in the diet of young people in Archives of Pediatrics and Adolescent Medicine. Until next week, y'all live well.