So in the situation of paroxysmal atrial fib -would it be possible to take the DOAC as a pill in the pocket? This would reduce the complication of bleeding from day to day accidents.
Having experienced multiple hemorrhagic events from dual antiplatelet therapy including Xarelto after a 100% LAD arterial blockage STEMI with residual intracardiac thrombosis, it seems to me that the problem is one where patients are simply not monitored closely enough.
By the third ER visit for bleeding with the physician deferring to the Cardiologist's "do not stop the regimen," but refusing to order even so much as an echocardiogram to see if the clot had dissolved (EF of 45% on initial post-STEMI hospital discharge and clot dissolved approximately 75%,) I see this issue as being intractable.
General advice question because I don’t really know where to go for answers to this: my father is 86 and is on about 20 prescription medications. 5 of those are to try to control muscle spasms/pain in his feet, but I get the feeling that some of his other meds are just habit because he’s 86 and every 86yo needs to be on a cholesterol medication. Is there any way for a layperson to sort this out? Any resource or website to look at? Doctors seem really reluctant to stop a med once started. How do we overcome this? I don’t think he’s at the “I just want to lay down and die” point yet, but I’m very skeptical most of the meds are even doing anything.
This overload of medications seems to be typical care of the elderly. Would be a good idea for you sit down with his PCP and sort out which medications were absolutely necessary. I would question the cholesterol metrication first.
Yes, I talked to his podiatrist this week and he used the term polypharmacy and I’d never heard it before, but it describes my dad perfectly. He also recommended stopping the cholesterol med, but not officially, but we’ve got an appointment with his doctor in early June. I already sent her an email to let her know what I was thinking. Deprescribing. Another word I learned this week. 😄
Probably the first step would be to find him a doctor with good sense---usually an older and more experienced internist or GP. Obviously he doesn't have one now. I hope you were being sarcastic with the remark that every 86 y/old needs to be on a cholesterol medication. Actually no one needs to be on a cholesterol lowering drug. They provide no real benefit and have lots of side effects. In fact, many of his symptoms could be caused by the drug---especially if it is a statin. I would have him stop that right now---sight unseen. The other drugs should be reviewed by a competent physician, Based on my experience over forty years of practice I would bet that all but one or two of the remainder can be eliminated as well.
Thanks! Yes, I was being sarcastic about the cholesterol drug. He’s actually on two cholesterol drugs and 4 muscle relaxers, plus blood thinners and blood pressure drugs, and I just can’t imagine it’s a good cocktail for anyone! I went through everything this morning and have a good list of questions. I’d love to see him go off the muscle relaxers because it seems like he’s not getting any benefit from them. Maybe start with a clean slate and see how he does and if it is worse, then add in ONE. It’s just a nightmare.
Why is he on 2 cholesterol medications and four muscle relaxers??? Get rid of the cholesterol medication and he won’t need the muscle relaxers, he will feel like a new man. You also need to check with his pharmacy and make sure that they aren’t refilling discontinued medications. If the PCP decided to change medications, as in the case of cholesterol medications, the pharmacy may be refilling the old one as well. The automated pharmacies keep refilling medications until you have the pharmacist remove them from the system. I hope this is the case and not some negligent PCP just writing scripts.
Off topic, but it is interesting looking back on the pandemic with a bit more emotional distance now. The last paragraph, if applied to seemingly healthy grade school children with respect to the vaccine in, say, 2021, was an extremely controversial statement in our society. And yet it is clearly correct here, and was clearly correct then.
It is interesting to observe that where the bar for evidence is set very much depends on social, as opposed to scientific, factors. A lot of it is culturally mediated.
Not to minimize ICH, but it appears this trial enrolled pts with “relatively” small bleeds, and showed benefit only with an imaging surrogate endpoint while also showing real harm with “harder” clinical CV outcomes. This will be a pass for me and I would not be recommending it for my pts on the basis of this study. Plus the exorbitant cost would make any ICER assessment likely to be abysmal.
In recent years, I find the absence of an antidote to seldomly be an impediment to pt willingness to use DOACs.
But what about intracranial bleeds? That would be my question. Bleeds in other parts of the body are not fun but are usually manageable in an ICU setting. Intracranial bleeds, however, seem to me to be a bird of a different feather and require surgical intervention. That was supposed to be the advantage of dabigatran, apixaban, rivaroxaban, and edoxaban over warfarin is their lower risk of intracranial bleeds (and no required INR monitoring, and massive drug-drug, drug-food, and generic interactions).
We have seen one study after another show that oral anticoagulants give no benefit or a tiny bit which is usually canceled out by the complications of bleeding. Now we get another expensive drug that doesn't work to counteract the first expensive drug that doesn't work. Pharmacology in action.
I read this with great interest. My husband had emergency surgery for umbilical hernia incarceration December 2022. The surgeon explained he wanted to proceed without using the reversal agent for his Eliquis. He told us he’d had 2 patients recently stroke after being given the agent, and he had big concerns about it. Surgery was successful without it, although he did have more bleeding post-op which was a little worrisome for me when caring for him at home.
And now I am reminded of the issues that were bigger than the surgery. The hospital staff ignored giving his meds for his AFib (Dofetilide and metoprolol), despite my constant voicing of concerns, and he ended up in persistent AFib and panicked nurses calling in cardiology to consult. He also started complaining of horrible pain in his hand and wrist and it took 48 hours for that to get addressed. Turns out he had a chipped bone (triquetrum) and everyone was scrambling not to take the blame for it. Just admit it probably happened while you were rushing him into the OR. Stuff happens. You saved his life~ we are not going to sue. But the failure to give him his meds on time? That was a big problem, and you just blew it off.
Our surgeon was excellent. The hospital stay was not.
I so appreciate your posts, Dr. Mandrola. This retired Med Tech loves learning new things.
Thank you for sharing that most interesting and useful anecdote. Like your surgeon, I believe in my own first-hand experience (and that of those I find credible) more than clinical trials.
If we're talking about drugs that work but produce no benefit - how about statins? They do a great job of lowering cholesterol but have virtually no effect on all-cause mortality. Somehow though that doesn't affect most docs' religious devotion to them.
The designers of ANNEXA-I made a classic mistake in constructing the primary endpoint. They assumed that outcome severity should be measured by a change in a patient outcome scale, rather than using the final scale value to depict patient outcome state. The component scales have the property that the impact of a change in the scale depends on where the patient starts. This is partially due to floor or ceiling effects. This makes the outcome scale mean different things to different patients, and makes the scale not properly capture drug effectiveness or harm. Also, it is nearly impossible to place changes (as opposed to final states) on a scale with death. More details are at https://hbiostat.org/bbr/change . These points are related to Ravi’s excellent comments.
This is nice overview. Hematoma expansion can't be fully judged based on the data they presented, however. Hematoma volume is continuous measure at baseline and follow-up. The follow-up values were not reported in the publication or appendix. ANCOVA is likely the most appropriate statistical test. Instead they transformed a continuous measure into a percent change and dichotomized the percent change into event/non-event: https://pubpeer.com/publications/183088569CFFB49AA716CA78206C44#1
I would not agree to take the newer generation of anticoags for just this reason. Warfarin is less expensive, requires testing to balance, but that antidote is of supreme importance in that age group, which can be prone to falls.
I don’t know if H.L. Mencken ever had to be anti-coagulated, but he did give humanity this one wisecrack that should perhaps be chiseled in stone over the front door of every hospital: "For every complex problem there is a solution that is simple, straightforward, and wrong".
So in the situation of paroxysmal atrial fib -would it be possible to take the DOAC as a pill in the pocket? This would reduce the complication of bleeding from day to day accidents.
Having experienced multiple hemorrhagic events from dual antiplatelet therapy including Xarelto after a 100% LAD arterial blockage STEMI with residual intracardiac thrombosis, it seems to me that the problem is one where patients are simply not monitored closely enough.
By the third ER visit for bleeding with the physician deferring to the Cardiologist's "do not stop the regimen," but refusing to order even so much as an echocardiogram to see if the clot had dissolved (EF of 45% on initial post-STEMI hospital discharge and clot dissolved approximately 75%,) I see this issue as being intractable.
General advice question because I don’t really know where to go for answers to this: my father is 86 and is on about 20 prescription medications. 5 of those are to try to control muscle spasms/pain in his feet, but I get the feeling that some of his other meds are just habit because he’s 86 and every 86yo needs to be on a cholesterol medication. Is there any way for a layperson to sort this out? Any resource or website to look at? Doctors seem really reluctant to stop a med once started. How do we overcome this? I don’t think he’s at the “I just want to lay down and die” point yet, but I’m very skeptical most of the meds are even doing anything.
This overload of medications seems to be typical care of the elderly. Would be a good idea for you sit down with his PCP and sort out which medications were absolutely necessary. I would question the cholesterol metrication first.
Yes, I talked to his podiatrist this week and he used the term polypharmacy and I’d never heard it before, but it describes my dad perfectly. He also recommended stopping the cholesterol med, but not officially, but we’ve got an appointment with his doctor in early June. I already sent her an email to let her know what I was thinking. Deprescribing. Another word I learned this week. 😄
Probably the first step would be to find him a doctor with good sense---usually an older and more experienced internist or GP. Obviously he doesn't have one now. I hope you were being sarcastic with the remark that every 86 y/old needs to be on a cholesterol medication. Actually no one needs to be on a cholesterol lowering drug. They provide no real benefit and have lots of side effects. In fact, many of his symptoms could be caused by the drug---especially if it is a statin. I would have him stop that right now---sight unseen. The other drugs should be reviewed by a competent physician, Based on my experience over forty years of practice I would bet that all but one or two of the remainder can be eliminated as well.
Thanks! Yes, I was being sarcastic about the cholesterol drug. He’s actually on two cholesterol drugs and 4 muscle relaxers, plus blood thinners and blood pressure drugs, and I just can’t imagine it’s a good cocktail for anyone! I went through everything this morning and have a good list of questions. I’d love to see him go off the muscle relaxers because it seems like he’s not getting any benefit from them. Maybe start with a clean slate and see how he does and if it is worse, then add in ONE. It’s just a nightmare.
Why is he on 2 cholesterol medications and four muscle relaxers??? Get rid of the cholesterol medication and he won’t need the muscle relaxers, he will feel like a new man. You also need to check with his pharmacy and make sure that they aren’t refilling discontinued medications. If the PCP decided to change medications, as in the case of cholesterol medications, the pharmacy may be refilling the old one as well. The automated pharmacies keep refilling medications until you have the pharmacist remove them from the system. I hope this is the case and not some negligent PCP just writing scripts.
Off topic, but it is interesting looking back on the pandemic with a bit more emotional distance now. The last paragraph, if applied to seemingly healthy grade school children with respect to the vaccine in, say, 2021, was an extremely controversial statement in our society. And yet it is clearly correct here, and was clearly correct then.
It is interesting to observe that where the bar for evidence is set very much depends on social, as opposed to scientific, factors. A lot of it is culturally mediated.
Not to minimize ICH, but it appears this trial enrolled pts with “relatively” small bleeds, and showed benefit only with an imaging surrogate endpoint while also showing real harm with “harder” clinical CV outcomes. This will be a pass for me and I would not be recommending it for my pts on the basis of this study. Plus the exorbitant cost would make any ICER assessment likely to be abysmal.
In recent years, I find the absence of an antidote to seldomly be an impediment to pt willingness to use DOACs.
But what about intracranial bleeds? That would be my question. Bleeds in other parts of the body are not fun but are usually manageable in an ICU setting. Intracranial bleeds, however, seem to me to be a bird of a different feather and require surgical intervention. That was supposed to be the advantage of dabigatran, apixaban, rivaroxaban, and edoxaban over warfarin is their lower risk of intracranial bleeds (and no required INR monitoring, and massive drug-drug, drug-food, and generic interactions).
We have seen one study after another show that oral anticoagulants give no benefit or a tiny bit which is usually canceled out by the complications of bleeding. Now we get another expensive drug that doesn't work to counteract the first expensive drug that doesn't work. Pharmacology in action.
I read this with great interest. My husband had emergency surgery for umbilical hernia incarceration December 2022. The surgeon explained he wanted to proceed without using the reversal agent for his Eliquis. He told us he’d had 2 patients recently stroke after being given the agent, and he had big concerns about it. Surgery was successful without it, although he did have more bleeding post-op which was a little worrisome for me when caring for him at home.
And now I am reminded of the issues that were bigger than the surgery. The hospital staff ignored giving his meds for his AFib (Dofetilide and metoprolol), despite my constant voicing of concerns, and he ended up in persistent AFib and panicked nurses calling in cardiology to consult. He also started complaining of horrible pain in his hand and wrist and it took 48 hours for that to get addressed. Turns out he had a chipped bone (triquetrum) and everyone was scrambling not to take the blame for it. Just admit it probably happened while you were rushing him into the OR. Stuff happens. You saved his life~ we are not going to sue. But the failure to give him his meds on time? That was a big problem, and you just blew it off.
Our surgeon was excellent. The hospital stay was not.
I so appreciate your posts, Dr. Mandrola. This retired Med Tech loves learning new things.
Thank you for sharing that most interesting and useful anecdote. Like your surgeon, I believe in my own first-hand experience (and that of those I find credible) more than clinical trials.
Thank you. Nicely set out to a reader who is mildly confused by most doctors.
"The Cartesian thinkers who see therapeutics as being able to fix one aspect of the body—as if it were a car—fail miserably."
Cartesians are us. The next great challenge for western medicine will be to move beyond that imo
If we're talking about drugs that work but produce no benefit - how about statins? They do a great job of lowering cholesterol but have virtually no effect on all-cause mortality. Somehow though that doesn't affect most docs' religious devotion to them.
The designers of ANNEXA-I made a classic mistake in constructing the primary endpoint. They assumed that outcome severity should be measured by a change in a patient outcome scale, rather than using the final scale value to depict patient outcome state. The component scales have the property that the impact of a change in the scale depends on where the patient starts. This is partially due to floor or ceiling effects. This makes the outcome scale mean different things to different patients, and makes the scale not properly capture drug effectiveness or harm. Also, it is nearly impossible to place changes (as opposed to final states) on a scale with death. More details are at https://hbiostat.org/bbr/change . These points are related to Ravi’s excellent comments.
As I frequently say to my patients, "You are old enough to know there is no free lunch."
This is nice overview. Hematoma expansion can't be fully judged based on the data they presented, however. Hematoma volume is continuous measure at baseline and follow-up. The follow-up values were not reported in the publication or appendix. ANCOVA is likely the most appropriate statistical test. Instead they transformed a continuous measure into a percent change and dichotomized the percent change into event/non-event: https://pubpeer.com/publications/183088569CFFB49AA716CA78206C44#1
Edit to: "Terrible analogy coming."
I would not agree to take the newer generation of anticoags for just this reason. Warfarin is less expensive, requires testing to balance, but that antidote is of supreme importance in that age group, which can be prone to falls.
I don’t know if H.L. Mencken ever had to be anti-coagulated, but he did give humanity this one wisecrack that should perhaps be chiseled in stone over the front door of every hospital: "For every complex problem there is a solution that is simple, straightforward, and wrong".