Blood thinners and NSAIDs...The Increased Risk of Bleading

The risk of major bleeding is well documented while taking blood thinners such as: Warfarin; novel anti-coagulants such as  Pradaxa, Xarelto and Eliquis; aspirin; and other NSAIDs such as advil and Motrin. One of the easiest ways to picture this is to think of you blood like this. If you spill a creamier salad dressing verses an Italian salad dressing, obviously, the bottle of Italian dressing will be empty before the bottle of the creamier dressing such as ranch is empty. When a person is on blood thinners, the person's blood is less viscous (less thick) compared to a person not on blood thinners. 

There was a study conducted which was recently published in JAMA in June of 2014 which set out
"[t]o estimate the bleeding risk of combined anticoagulant (rivaroxaban or enoxaparin–vitamin K antagonist [VKA]) and NSAID or aspirin therapy in patients with venous thromboembolism."  In plain english, that means to determine the risk of a major bleed like a stroke or stomach bleed while on these medicines or a combination of these medicines.

In a blog post linked to here, the lead author, Bruce L. Davidson, M.D., discusses the findings. Some of the major findings were that if people are taking anticoagulant medications such as Xarelto, Lovenox, or Warfarin, and are additionally taking an NSAID, they are 2.5 times as likely to suffer a major bleed than if they are just taking the anti-coagulant medication alone. The risk of taking aspirin together with an anticoagulant raised the risk of a major bleed by 1.5 times compared to taking the anticoagulant alone.  Also, almost a quarter of the bleeds happened within 8 days of starting the NSAID.

Dr. Davidson is also quoted there saying that many people could take Tylenol instead of an NSAID for everyday aches and pains while on anticoagulant medications. 

Major Public Health Implication: If people taking anticoagulant medications  would be encouraged to take tylenol instead of NSAIDs for minor problems like colds and sore throats, many major bleeds could be prevented, lives saved, and many healthcare dollars saved.

Economic Burden of Blood Clots...Number$

         Why are anticoagulant medicines so economically significant? Why are drug companies coming up with new so called novel anti-coagulants?
          Because many people get treated every year in the U.S. for blood clots. And although the medicine to prevent blood clots them can be expensive, it is also very expensive to treat blood clots that already exist. And obviously, this is not even measuring the grievous human toll from sickness, disability and death caused by blood clots....and the heart attacks and strokes caused by them. Read a previous post here which discusses that toll. And read another website post  here which discusses some of the risk factors and statistics related to blood clots.
        In an April 2009  article published by the American Journal for Preventive Medicine linked to here, it is estimated that annually there are 300,000-600,000 new incidences of Venous thromboembolism (VTE) (colloquially referred to as blood clots). It is also estimated that the cost to the U.S. medical system at that time was ranges from $7594 to $16,644 per patient per incident. That translates to an annual cost at that time in the range of 2-10 billion USD.
         Obviously, the more blood clots prevented results in savings in medical expenditures....oh, yeah...and it results in more people remaining healthier and alive.

Strokes, and Blood Thinners: Some numbers, treatments, risks, and costs

           About 795,000  suffer a stroke in the U.S. every year. That is one person suffering a stroke every 40 seconds. Someone dies every 4 minutes from the U.S. See this link here from the American Heart association and the American Heart Association.

           Blood clots can cause heart attacks and strokes. Strokes and heart attacks, specifically in the elderly population, can cause severe debilitating long term effects including paralysis and even death. Blood thinners have lowered the risk of strokes and heart attacks and all of their debilitating side effects  by reducing the formation of  blood clots in the body.  In order to reduce the risk of blood clots for vulnerable patients (e.g. older people or people with a history of blood clots), doctors prescribe anti-coagulant drugs.    Anti-coagulant drugs reduce the risk of blood clots that can lead to heart attacks and strokes by decreasing the clotting ability of blood. However, as a necessary consequence of reducing the clotting ability of blood, anti-coagulant drugs increase the risk of excessive bleeding.  

         The leading anti-coagulant drug for decades was Warfarin, also known as Coumadin.  It works by inhibiting the production of vitamin K. The known antidote to stop bleeding while on Warfarin is the injection of vitamin k.

          Recently, the pharmaceutical industry has developed novel anti-coagulant drugs. Their scientific names are dabigatran, rivaraxaban, and apixaba  Their trade names are Pradaxa, Xarelto and Eliquis. 

One advantage of the novel anti-coagulants, as compared to Warfarin, is that there is a less severe risk of intracranial bleeding (AKA a brain hemorrhage).  A serious disadvantage, however, is that there is (or was) no known specific antidote for bleeding caused by the novel anti-coagulants.    The vitamin K method used to stop bleeding caused by Warfarin does not work for Pradaxa, Xarelto and Eliquis because those drugs do not work by inhibiting the production of vitamin K. Rather, they work by directly targeting an enzyme in the blood called Factor Xa, which stimulates the production of thrombin, another enzyme which promotes blood clot formation.  

Economically, Warfarin is estimated to cost about $200 annually compared to Xarelto which can cost close to $3,000 anually.

           In 2013, Pradaxa’s globals sales were about $1.63 billion USD.  Xarelto’s sales were $271 million USD. Eliquis’es sales were only $71 million USD but it only became available in the middle of the year.

           Many strokes are preventable. It is important to know your risk and weigh the cost and benefit of treatment. But it is also important to keep in mind the risk from the treatment. 

         I am short on time so I will continue this post later on....

Low-t Controversy

Many people are inundated with ads asking them if they can benefit from testosterone therapy while many of those same people are also inundated with ads asking them if they have been harmed by androgel (or similar medications), a medicine commonly used therapeutically to raise the testosterone levels in people with low testosterone levels who meet certain criteria. So is low-t treatment beneficial or harmful?

Dr. Todd B. Nippoldt, M.D., A Mayo Clinic physician, wrote in an expert answers segment earlier this year which is  linked to here responding to the question of what are the risks associated with testosterone therapy that some studies suggest that testosterone therapy may:
1.increase the risk of heart attack in men older than 65
2. increase the risk of heart attack in men younger than 65 with a history of heart disease
3.increase the frequency of death and heart problems in men who had coronary artery disease
Dr. Nippoldt also wrote, however, that other studies suggest a lower risk of death in men on testosterone therapy compared to men not being treated.
Dr. Nippoldt also pointed out that, "[c]urrently, the Food and Drug Administration (FDA) is investigating the risk of stroke, heart attack and death in men taking FDA-approved testosterone products.'"

Just yesterday, Fox News published an article which is linked to here where physician Dr. David B. Samadi generally outlines main points about testosterone therapy and its risks and benefits. A very important idea he wrote was that "[s]tricter regulations and warnings by government agencies such as the FDA could prove extremely beneficial for men seeking this type of therapy. Often, testosterone is prescribed to men without proper blood testing, with no regulation or review of side effects or risks. This push towards regulation forces both patients and physicians to question whether the benefits of Low-T products outweigh potential risks of treatment." 

Testosterone replacement therapy is also a big business. According to a November 11, 2013 article in the New York Times, linked to here, that physician recommendations and "and the marketing of low T as a common medical condition helped propel sales of testosterone gels, patches, injections and tablets to about $2 billion in the United States last year, according to IMS".

Bottom line: While Low-t treatment may be beneficial for a certain population, it may be dangerous for other populations. People should be careful that the benefit they can receive from low-t therapy outweighs the risks of the treatment.