Aspirin About-Face(davidepstein.bulletin.com)
davidepstein.bulletin.com
Aspirin About-Face
https://davidepstein.bulletin.com/563262208234593/
30 comments
Here is the actual draft of the recommendation as well as supporting evidence: https://www.uspreventiveservicestaskforce.org/uspstf/recomme...
Edit: Here's the document that actually outlines "what changed" from 2016 to the current draft: file:///Users/nkrumm/Downloads/aspirin-use-cvd-prevention-draft-modeling-report.pdf
Edit: Here's the document that actually outlines "what changed" from 2016 to the current draft: file:///Users/nkrumm/Downloads/aspirin-use-cvd-prevention-draft-modeling-report.pdf
You may wish to edit your edit.
I don't see how what the article says and what you say are in conflict.
The recommendation used to be "just take aspirin, you won't have a heart attack" and now it's "wait, this could be bad, let's qualify that".
He uses this as a lead-in to discuss the concepts of NNT and NNH. It makes sense.
The recommendation used to be "just take aspirin, you won't have a heart attack" and now it's "wait, this could be bad, let's qualify that".
He uses this as a lead-in to discuss the concepts of NNT and NNH. It makes sense.
I saw a cardiologist for a routine checkup (no medical events had occurred). She said my EKG looked great and I would probably live to 102 (that's a while from now, in case you're wondering), but still recommended that I take a low-dose aspirin.
So I am planning to stop now. It seems like I'm a poster child for "stop taking daily aspirin."
So I am planning to stop now. It seems like I'm a poster child for "stop taking daily aspirin."
I would love to see this analysis for statins.
On a slightly related note, it seems many people don't know (aren't being told) the risks associated with not taking a drug and taking it. It seems like is just "the FDA ruled the benefits out weight the risks" and that gets applied to everyone. Just like generally safe is often misinterpreted as completely safe.
On a slightly related note, it seems many people don't know (aren't being told) the risks associated with not taking a drug and taking it. It seems like is just "the FDA ruled the benefits out weight the risks" and that gets applied to everyone. Just like generally safe is often misinterpreted as completely safe.
It also feels like with statins, that the standard of when to take the drug is some kind of Overton window. If the FDA rules that that it's worthwhile for people with diabetes, then it gets prescribed for people at risk of diabetes, then for people at risk of pre-diabetes, then it gets prescribed for people who may be at risk of pre-diabetes, then it gets prescribed for people wanting to be precautious of potentially being at risk for pre-diabetes, and so forth.
Linked from the primary source of the article - https://www.thennt.com/nnt/statins-persons-low-risk-cardiova...
Awesome. I can't believe I missed that.
This. Even this recommendation change referenced blood thinners and statins of which researchers beg doctors to weigh use against accelerated muscle degeneration.
"That means if 1,000 elderly women take aspirin daily for a decade, 11 of them will avoid a heart attack; meanwhile, twice that many will suffer a major gastrointestinal bleeding event that would not have occurred if they hadn’t been taking aspirin."
"The U.S. task force wants to strongly discourage anyone 60 and older from starting a low-dose aspirin regimen, citing concerns about the age-related heightened risk for life-threatening bleeding."
I understand that the bleeding is a serious concern, but does that have an immediate, potentially fatal or life changing impact - or does it happen with enough warning that you could stop taking aspirin and/or get medical assistance?
If so, then I think most people would feel that is worth the risk to take aspirin even though it has a more numerically higher likelihood of a bad outcome.
"The U.S. task force wants to strongly discourage anyone 60 and older from starting a low-dose aspirin regimen, citing concerns about the age-related heightened risk for life-threatening bleeding."
I understand that the bleeding is a serious concern, but does that have an immediate, potentially fatal or life changing impact - or does it happen with enough warning that you could stop taking aspirin and/or get medical assistance?
If so, then I think most people would feel that is worth the risk to take aspirin even though it has a more numerically higher likelihood of a bad outcome.
I understand that the bleeding is a serious concern, but does that have an immediate, potentially fatal or life changing impact - or does it happen with enough warning that you could stop taking aspirin and/or get medical assistance?
Anecdote time!
My dad was on a bit too many blood thinners—a prescription, and aspirin.
He’d been feeling weak and a little down for a week. On a Friday night…bam, passed out, in the bathroom, and hit his head.
Went to the ER. When…I’ll elide details…using the restroom, he had a huge GI bleed. They had to put 2 units of blood into him in the ICU.
So, yeah, bleeds can be bad. As bad as a heart attack? No, but they really can sneak up on you.
Anecdote time!
My dad was on a bit too many blood thinners—a prescription, and aspirin.
He’d been feeling weak and a little down for a week. On a Friday night…bam, passed out, in the bathroom, and hit his head.
Went to the ER. When…I’ll elide details…using the restroom, he had a huge GI bleed. They had to put 2 units of blood into him in the ICU.
So, yeah, bleeds can be bad. As bad as a heart attack? No, but they really can sneak up on you.
I doubt extra blood thinners on top of aspirin's thinning effects were part of the study.
Generally, people aren't aware of the symptoms of gastrointestinal bleeding. I'd assume without a pretty good education outreach, it'd be unlikely to be caught except in the really bad cases.
And while you're right, that GI bleeding on it's own might not be a huge issue, I suspect a gastroenterologist would want to do a colonoscopy if it does happen, something that patients probably wont to avoid if they can.
And while you're right, that GI bleeding on it's own might not be a huge issue, I suspect a gastroenterologist would want to do a colonoscopy if it does happen, something that patients probably wont to avoid if they can.
As others here have hinted at, while NNT and NNH are both extremely useful concepts, they (deliberately) leave the consideration of whether a treatment's level of effectiveness, or the magnitude of a harmful side effect, subjective. When, after all, should a negative side effect be counted as "harm"? This is especially true for NNH; there are usually far more possible (helpful or harmful) side effects than the one intended remedy for the ailment, for a given drug.
As an example, in one study, for elderly patients the NNT of a number of (admittedly different) sedative hypnotics was 13, while the NNH was 6 [1]. From that alone, you'd probably rightfully avoid using them! But for certain populations who have chronic insomnia, the benefits may still outweigh the risks.
Of course, there are ways to (less subjectively albeit still subjectively) quantify harm, and these get used to keep "harm" comparable to "treatment". But it can definitely be more of an art than an exact science.
[1] https://www.ncbi.nlm.nih.gov/books/NBK71441/
As an example, in one study, for elderly patients the NNT of a number of (admittedly different) sedative hypnotics was 13, while the NNH was 6 [1]. From that alone, you'd probably rightfully avoid using them! But for certain populations who have chronic insomnia, the benefits may still outweigh the risks.
Of course, there are ways to (less subjectively albeit still subjectively) quantify harm, and these get used to keep "harm" comparable to "treatment". But it can definitely be more of an art than an exact science.
[1] https://www.ncbi.nlm.nih.gov/books/NBK71441/
> relative risk reduction [...] “is just another way of lying.”
> You read that a new drug reduces your chance of dying from Ryantastic syndrome by 40 percent. Here’s what that means in practice: if 10 in 100,000 people normally die from Ryantastic syndrome, and everyone takes the new drug, only 6 in 100,000 people will die from Ryantastic syndrome. Now let’s think about it from an NNT perspective.
> For 100,000 patients who took the new drug, four deaths by Ryantastic syndrome were avoided, or one per 25,000 patients who took the drug. So the NNT is 25,000; that is, 25,000 patients must take the drug in order for one death-by-Ryantastic to be avoided. Ideally, you also want to know the NNH, or “number needed to harm.”
> Let’s say that 1 in 1,000 patients who take the new drug suffer a particular grievous side effect. In that case, the NNH is 1,000, while the NNT is 25,000. Suddenly, the decision seems a lot more complicated than if you’re just told the drug will lower your chance of dying from Ryantastic syndrome by 40 percent.
> You read that a new drug reduces your chance of dying from Ryantastic syndrome by 40 percent. Here’s what that means in practice: if 10 in 100,000 people normally die from Ryantastic syndrome, and everyone takes the new drug, only 6 in 100,000 people will die from Ryantastic syndrome. Now let’s think about it from an NNT perspective.
> For 100,000 patients who took the new drug, four deaths by Ryantastic syndrome were avoided, or one per 25,000 patients who took the drug. So the NNT is 25,000; that is, 25,000 patients must take the drug in order for one death-by-Ryantastic to be avoided. Ideally, you also want to know the NNH, or “number needed to harm.”
> Let’s say that 1 in 1,000 patients who take the new drug suffer a particular grievous side effect. In that case, the NNH is 1,000, while the NNT is 25,000. Suddenly, the decision seems a lot more complicated than if you’re just told the drug will lower your chance of dying from Ryantastic syndrome by 40 percent.
This is surprising for 2 reasons
1) that there was this significant bleeding from baby aspirin
2) that a miracle drug from 300bc is being found to have downsides.
I'm still an aspirin proponent for treating sunburns and minor ailments. And salycilic acid for my face routine.
Fish oil's recent science on hormone regulation and inflammation reduction should make it a first stop.
Then there is AKG.
1) that there was this significant bleeding from baby aspirin
2) that a miracle drug from 300bc is being found to have downsides.
I'm still an aspirin proponent for treating sunburns and minor ailments. And salycilic acid for my face routine.
Fish oil's recent science on hormone regulation and inflammation reduction should make it a first stop.
Then there is AKG.
Asprin for sunburn?
thats a new one on me.
What’s your face routine?
https://en.wikipedia.org/wiki/Salicylic_acid
is a precursor to and a metabolite of aspirin (acetylsalicylic acid). It is a plant hormone. The name is from Latin salix for willow tree
is a precursor to and a metabolite of aspirin (acetylsalicylic acid). It is a plant hormone. The name is from Latin salix for willow tree
Is this an American thing? I've never heard of people (without any preconditions, or feaver, pain or illness) taking Aspirin on daily basis. But apparently 30 million US citizens do. How did that happen? (Was this only caused by the pre-reversal recommendation?)
Studies several decades ago indicated that daily low-dose aspirin (80mg or less per day I think) led to fewer heart attacks and strokes and this led to a lot of people taking a low-dose aspirin with their daily vitamins. When statins and other daily blood thinners started to be prescribed there was a group of people who learned that you should not mix aspirin and statins but in general the trend continued. Now it seems that the advice is that there are downsides in addition to the benefits and that they probably cancel out.
Me, I will continue to take my daily aspirin given a family history that indicates this might be wise.
Me, I will continue to take my daily aspirin given a family history that indicates this might be wise.
It would be interesting to learn whether some other forms of treatment or drugs have appeared in the years people have been taking daily aspirin. The article makes it sound like "whoops we've been wrong all these years, sorry for all the bleeding" but in reality the risk balance constantly shifts so what made sense for great-grandma may not make sense for grandma.
Brilliant short article about decision making in general, and in medical uses as an example.
The aspirin example is great for everyone to read, because it is so ubiquitous.
Anybody got the NNT vs NNH for the Pfizer covid vaccine?
Please no FB content here.
Use the archive.org link posted above and you avoid the FB loaded content.
The new recommendation is that aspirin should not be used to prevent heart attack in those without a history of heart disease (ie avoid routine aspirin for "primary prevention"). Aspirin for primary prevention has always been a grey area. The reversal came after a large trial in the New England Journal of Medicine looking at this. The trial showed the decrease in cardiovascular events was balanced by a similar increase of bleeds. So it's still grey because some people would prefer to bleed because blood is easily replaceable, your heart is not.
What remains clear is that people who have had heart attacks, strokes, or peripheral arterial disease should in most cases continue their anti-platelet agent.