Doctor do I need to take my anticoagulants for my VTE for longer than three months?

Bismillah, alhamdulillah

The normal and agreed upon duration of anti-coagulation after an unprovoked venous thromboembolism (VTE), also known as a Deep Vein Thrombosis (DVT), is normally 3 months but would patients benefit by being on anti-coagulants for longer. The BMJ Talk Evidence team discuss the findings of a paper published in the BMJ which finds the following:

white and blue health pill and tablet letter cutout on yellow surface

Doctor do I need to take my anticoagulants for my unprovoked VTE for longer than three months?

  • It was a study that looked at 18 studies involving 7515 patients
  • They looked at patients who had unprovoked VTEs
  • All the patients had completed 3 months of anticoagulant treatment
  • The risk of having the risk of having a second VTE once the treatment had stopped gradually increased over time from 10% in the first year, 16% at 2 years, 25% at 5 years and 36% at 10 years.
  • The authors estimate a risk of 1.5% per 10 years of a recurrent fatal VTE if treatment is discontinued
  • They also estimate the fatality rate of bleeding DUE to anti-coagulants to be around 1.32% over 10 years.

 

In short my take is: there is no clear benefit of continuous anti-coagulation in unprovoked VTEs.

As a quick reminder from UpToDate:

  • Extended anticoagulation
    • Duration =  6 – 12 months
    • Recommended in phlegmasia cerulea dolens or if there is a persisting but reversible risk factor (eg, surgery, cessation of hormonal therapy)
    • Phlegmasia cerulea dolens: a VTE marked by the traditional signs of a VTE pain and swelling but also accompanied by cyanosis with initially preserved arterial pulses. It can lead to arterial ischemia and ultimately gangrene. The amputation and mortality rates are potentially high.
  • Indefinite anticoagulation (lifelong)
    • Unprovoked proximal DVT (as opposed to distal)
    • Unprovoked symptomatic PE
    • Active cancer
    • Antiphospholipid antibody syndrome.
    • CI: High risk of bleeding, patient preference etc.
    • Follow Up: At least annually; assess new bleeding risk; chronic haemorrhage; patient preference to change agent
    • Aspirin: may be given if patients prefer not to have anticoagulant therapy if the no CI.

How good are the new cancer drugs?

Bismillah, alhamdulillah

LSE researchers call into question the trial standards of newly approved cancer drugs. 25% of all newly approved medications are for cancer, the single largest category of newly approved medication. This was based on 54 key trials but only 3/4 of these were RCTs and of this number almost half of these trials were identified as having a significant risk of bias.

The #BMJ provide a very nice video infographic overview of the study, worth viewing.

https://www.bmj.com/content/366/bmj.l5221

Vaping deaths

Bismillah, alhamdulillah

Podcast from the BMJ discussing the dangers of vaping. The interview was done with David Hammond, professor in the school of public health and health systems at the University of Waterloo in Canada. He has authored a recent editorial about vaping in the BMJ.

Vaping linked to deaths in the USA

Take home points

  • Vaping is potentially harmful to human lungs. The degree of harm is unquantified as of yet.
  • It has caused deaths in the USA and the cause is unclear, it may be due to a contaminant in the vaped substances.
  • Its harms may be less than smoking but it is too early to be sure as more data is needed ie another 10 years of data.
  • Vaping is a means of delivery of chemicals into the lung.
  • The fact that a substance can be ingested safely does not mean it is safe to vape.
  • There are thousands of flavours or substances that are commercially available for vaping but regulations are lax.
  • Young people are using vaping to ingest recreational substances.
  • It is likely that vaping will become associated with long term chronic disease but this will only become detectable on an epidemiological time scale ie 20-30 years.

The BMJ Podcast
Duration: 13:06
Published: Thu, 12 Sep 2019 16:58:18 +0000
Episode: http://feeds.bmj.com/~r/bmj/podcasts/~3/y07mFxNkVGA/vaping-deaths-does-this-change-what-we-think-about-public-health-messages

Media: http://feeds.bmj.com/~r/bmj/podcasts/~5/OQ92ZgW_kSE/680143994-bmjgroup-vaping-deaths-does-this-change-what-we-think-about-public-health-messages.mp3

Podcast: https://www.podcastrepublic.net/podcast/283916558

This week the Trump administration has banned the sale of flavoured vapes in the USA.

The reason for that is the sudden rash of cases of pulmonary disease, including deaths, linked to vaping. The mec…

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Drug driving – two reminders from the MHRA

Bismillah, alhamdulillah

The Medicines and Healthcare products Regulatory Agency (MHRA), in its August 2019 Drug Safety Update, reminds all doctors that patients taking Naltrexone/bupropion (Mysimba▼) for weight management are at risk of somnolence (common) and loss of consciousness (rare). A risk for driving.

automobile automotive autumn car

It can be illegal for patients on certain medication to drive

It also reminds doctors that it is illegal for patients on certain medication to drive if the blood levels of certain prescription medications are above a threshold amount unless they are doing so as directed by a medical practitioner without impairment of their driving. The law came into effect in 2nd March 2015 and is targeted at drugs which are abused and not at patients. Such patients should always carry a copy of their prescriptions with them. Examples given are as follows:

1. Extreme pain (morphine, diamorphine, ketamine)
2. Anxiety or inability to sleep (diazepam, clonazepam, lorazepam, oxazepam, temazepam)
3. Drug addiction (methadone)
4. Attention deficit hyperactivity disorder, also known as ADHD (amphetamine)
5. Multiple sclerosis (nabiximols)
Reference

 

Can herbs help hypertension? MedRefresh Hypertension Part 4

Bismillah, alhamdulillah

There is a growing interest in the use of herbs or plant based treatments for hypertension. The term herb itself refers to the leafy part of plants while spices are used in contrast referring to all the other parts i.e. fruits, bark, stem, roots etc. The WHO itself has shown an interest in what it calls Traditional Medicine (TM) Strategy (1) which aims to support Member States in developing proactive policies and implementing action plans that will strengthen the role traditional medicine plays in keeping populations healthy.

aroma chili condiments cook

Traditional plant based medicines such as saffron may help with hypertension

Research studies have started to explore the use of different plant based medicines both as an independent therapy and as an adjunct to standard medical therapies. There have been a number of Randomized Controlled Studies (RCTs) looking at the subject with most of the research being coming from China and India which have well established systems of traditional medicine which is now being married with modern scientific techniques and classifications to categorize the usefulness of such treatments. There are sporadic reports of plant based treatments from other parts of the world such as Iran, Korea, Lebanon and other countries.

The issue of standardization of treatments is problematical. Studies have tried to use modern methods such as High Performance Liquid Chromatography to examine the exact constituents of plant based therapies. What they have found is that the same preparation of traditional medicines can vary significantly in their constituent amounts. Plants tend to be grown at a particular time of year differ in the chemical constituents of their leaves, the place where they are grown also makes a difference and so on. This itself is a potential stumbling block in the analysis of such treatments and their efficacy in the treatment of hypertension.

Most studies that have looked at this tend to be small and there are very few head-to-head studies which compare the effects of a particular regime of traditional medicines versus newer pharmaceutical agents. Where these have been done the quantity of traditional medication has been at least three times daily. Most traditional plant based therapies can be prepared through a simple means in a persons kitchen such as boiling whole plant material. This process is known as “infusion”. If the plant material is crushed and then boiled this is known as a “decoction”.

Commercial preparations that can be found in health food stores are formed by a more intricate process with chemical processes to extract plant based components such as extracts formed by alcohol or water based extraction of components which are then purified or dried and then mixed in certain amounts as per ancient formulas. Sometimes these can include other non-plant based components such as coral powder and elements such as Magnesium.

The safety of such traditional based treatments varies, some are very safe such as one TM such as Saffron powder, a spice made from a ground flower, and another using Horse Mint leaves (a herb from the plant commonly used in Arabia in tea). One study on Saffron powder showed that the consumption of 100mg / day reduced blood pressure by about 7/2 mm Hg for the systolic and diastolic readings.(2) Another study on Horse Mint infusions, given once daily, showed a reduction in blood pressure of 12/6 mm Hg.(3) Both saffron powder and Horse Mint are traditionally used herbs and spices in the Middle East and South Asia and their safety has not been called into question over the many hundreds of years they have been used in cooking.

On the other hand some Chinese TMs have been implicated in liver damage and deaths. One such example is a Chinese TM called Tianma Gouteng Yin (TGY). Among the many herbs and ingredients it contains is the dried stem of the Tuber fleeceflower (Polygonum multiflorum Thunb.). This particular ingredient has been associated with 441 case reports of liver damage and also seven deaths and two cases requiring a liver transplant. (4)

Judging from the large interest in the topic, though chiefly fueled by China, there seems to be a significant role for the regular consumption of traditional medicines or plant based therapies in the treatment of hypertension especially as an adjunct to pharmaceutical based medicines in order to reduce the total dose consumed and achieve better control of hypertension through a means that is more palatable to patients.

InshaAllah in the next article I would like to look at one more new treatment for hypertension which is based on biofeedback devices.

 

  1. Qi, Zhang. “WHO Traditional Medicine Strategy. 2014-2023.” Geneva: World Health Organization (2013).
  2. Ebrahimi, Fatemeh, et al. “The effect of saffron (Crocus sativus L.) supplementation on blood pressure, and renal and liver function in patients with type 2 diabetes mellitus: A double-blinded, randomized clinical trial.” Avicenna journal of phytomedicine 9.4 (2019): 322.
  3. Samaha, Ali A., et al. “Antihypertensive Indigenous Lebanese Plants: Ethnopharmacology and a Clinical Trial.” Biomolecules 9.7 (2019): 292.
  4. Lei, Xiang, et al. “Liver damage associated with Polygonum multiflorum Thunb.: a systematic review of case reports and case series.” Evidence-Based Complementary and Alternative Medicine 2015 (2015).

Can a medical point of view help solve the Irish backstop and the Brexit conundrum?

“God has not made for a man two hearts in his interior.”
(Quran 33:4)

Bismillah, alhamdulillah

Brexit is caught in what programmers call an infinite loop. A dangerous infinite loop. The options to break out of the loop are not palatable. The key stumbling point is the question of the status of Northern Ireland post Brexit. In a poetic sense the problem revolves around whose heart controls Northern Ireland: European, British or a two-heart option. The first two options are ruled out, as either asks the other side to sacrifice too much. The compromise of a two-heart option is the only way forward, but after three years of negotiation everyone seems to have run out of ideas and the nation is close to exhaustion. The fundamental reason blocking the two-heart option is that men, analogical of sovereign states, cannot possess two-hearts. The only human who can bear such a burden is a mother who carries her child. Herein lies a possible solution to the Irish backstop and the Brexit conundrum.

blue and yellow round star print textile

Could the key to the Brexit conundrum be found in medicine?

Mother not father

It is worth reflecting for a moment on the analogy of the nation state as a human. Nation states behave in many ways like people simply because people are the basic and essential ingredient of any nation. Just like people some nations are young and vibrant others are old and pondering, some shun the limelight others bathe in it, some slow to act others light-footed, some are good at fighting others at negotiating, some greedy and others open-hearted and so on. All of these differences reflect a various mix of two basic sides of human personality: the limbic, quick, and intuitive while the other cerebral, slow and measured. The art of nation-craft is to build a national temperament that alloys these two qualities in the right measures to create a composite whose sum is greater than its parts. Sometimes it is best to be led by the zeal of a man but others when the intuitive nature of  woman is best.

 

Nature teaches us that the only two-heart human that exists is the mother when she is pregnant and nurtures her child whose hearts beats independently. On the beating of her heart depends the child, yet its heart is not coerced to beat in synchrony, Each beats to its own rhythm and need. In order to achieve this her immune system is tamed, to not reject the child. She sacrifices her food and air, her wealth, for the betterment of the child. She trades her desire to rule with her desire to nurture.

 

In this unique model lies the answer to Northern Ireland’s future, a child in many ways caught in an embrace of two nations that wish to rule it like men, but must relinquish their male desires and embrace the qualities of a mother. The key instrument that enables the child to stay inside its mother in a perfect symbiotic relationship is the placenta. The placenta regulates a microcosm for the child and interfaces with the mother allowing the two to exist and thrive.

Building on this analogy the seed of a proposal to solve the issue is to set up a Common Buffering Area (CBA) as opposed to a Common Regulatory Area. The main remit of the body that oversees the area is not to ‘regulate’ but to ‘track and buffer’ the financial impact of having such an area which will allow the free movement of goods across this unique border. Goods that criss-cross the border can be divided into two types: those that serve the needs of communities within Ireland and Northern Ireland and those are traded beyond the confines of the island. 

 

Public Health Approach

Economists and financial specialists may say that the ability to track the vast number of transactions is too great and arduous a task. It is technically not possible. Every expert’s opinion is at the end of the day limited by their education, experience and emotional draw. Men who deal with numbers and money have a natural instinct to control, down to the last penny. It is difficult for them to let go. The sense of control is exhilarating but at times like this is limiting. This is why a different approach is required. Fresh faces are needed at the decision table to think outside the box.

 

A very close parallel to the myriad of transactions that occur in a financial system is the way an infectious disease spreads. Infectious diseases and their spread arise from a composite or billions of ‘transactions’ of profit or loss between the infective agent and the host and its immune defences. This rapidly scales up to an immeasurable number of such transactions as the problem is vastly magnified as it spreads through a population even on a global scale. It is a scale where the atomistic approach of ‘financial number crunchers’ would be woefully inadequate. Yet as the recent tracking and containment of viruses such as Zika and Ebola by the USA authorities has shown that a public health approach works and works well.

 

Drawing on the expertise of public health medicine, a system based on sampling can be set up which tracks a representative sample of goods crossing at the border and turning up at both intra and extra-island sites. Their expertise if synergised  with financial analysts will allow the reliable tracking of trade that is both cross-border and intra or extra-island, whatever the volume. The imbalance in trade that occurs due to extra-island movement of goods is the real area of concern and is unlikely to represent the majority of goods. This imbalance can then be dealt with through the same mechanism that has been setup for emissions trading, borne principally by the EU and Britain but with a percentage that should be borne by corporations that most benefit from access to the CBA and its benefits i.e. the movement of goods across the CBA. 

 

The CBA does not have to be defined as a strictly contiguous geographic area but an area with mobile boundaries in the same way public health experts track the outbreak of a disease by searching for pockets of disease and index cases which link them. The key players here are most likely to be corporate structures, that have achieved a threshold volume of trade, making the task easier. They are equivalent to the ‘index cases’ in public health medicine. Once these ‘index cases’ are identified they should be ‘reported’ to the CBA and will need to abide by the CBA rules to allow the unfettered passage of movement of their goods, as is what happens with ‘index cases’ in public health medicine. 

 

Such companies would be required to open an account in a bank exclusively setup under the CBA to track and process all intra and extra-island transactions which route themselves through the CBA. This will allow the monitoring of financial transactions and give a suitable opportunity for the CBA to charge an administrative or transaction fee to help offset the trade-imbalances of extra-island movement of goods. Where there is a net ‘profit’ it could be reinvested in the CBA and the area it serves.

 

Summary

When a child forms in the mother’s womb, the skeletal structure takes shape very early on and then slowly is clothed by muscles and skin. The above suggestion represents the kernel of an idea, the skeleton upon which the final flesh can be formed in due course. The lessons contained in the development of the human body at a strategic level and the expertise of public health experts in tracking disease at a detailed level is not one usually found at the table in government circles dealing with such issues of national interest. This is a unique problem and a unique approach is required.

Public Proposal for Private Insurance Funded Diabetes Care Through a Bundled Care Model

Bismillah, alhamdulillah

This article is a public proposal for a model for the delivery of Diabetes Care Through a Bundled Care Model in the private healthcare sector with the conjunction and cooperation of healthcare insurance companies such as BUPA, Tawuniya, MedGulf etc. The aim is to start a discussion in the sector between all the parties to help provide a more sustainable healthcare model for the management of chronic disease. The idea is an extension of a Dutch national model for Diabetes bundled payments that has been run since 2010 and has resulted in better quality of care for lower cost. Though the idea has been developed with a view to implementation in the Middle East it is in theory applicable to any area of the world.

person holding black tube

A public proposal to reduce the cost Diabetes Care Through a Bundled Care Model

Any sufficiently motivated and large private healthcare entity or system can propose the delivery of care for uncomplicated diabetes through a diabetes bundle contract (DBC) which will improve the quality of care and reduce costs using an innovative and transparent approach that uses a statistical approach to defining virtual patient groups in conjunction with insurance providers. Transparency will encourage a market leader approach among other service providers. All figures mentioned herein are estimates.

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