Mailbag – Shot in the Dark Side Edition

With Eliquis you don’t need to give up green tea with your blood thinners.

Vaccines, alongside guns, appears to be a topic our readers like to write in regarding.

Operative BG writes:

Did you ever see this video of Penn and Teller totally destroying the anti-vaccination argument? The complete, unrebuttable argument in a minute and a half. — BG

Dear BG,

Dr. J.’s always had a soft spot in his heart for Penn and Teller. They’re hilarious but fair minded. They nail it with this must watch video. The only thing that they don’t show effecively is that vaccines aren’t perfect, just far better than if we didn’t have them.

The Royal Exchequer also writes in:

While I applaud your support for vaccinations, the difficulty you and others face is that, as Stalin observed, large numbers of deaths are just statistics. We are bombarded with statistics every day. Stalin also observed that a single death is a tragedy. 

So, in your support, I want to present the family of just one man, George Goodrich, in north central Utah in 1885. 

In four months he lost five of his children: 

Eliza Goodrich – died 5 June, age 12, diphtheria. 

Esther Goodrich – died 18 July, age 10, diphtheria. 

Fanny Goodrich – died 22 August, age 20, diphtheria. 

Julia Goodrich – died 6 September, age 13, diphtheria. 

Hyram Goodrich – died 6 September, age 10, diphtheria. 

Spend a bit of time researching your genealogy and the cost of no vaccinations becomes very, very real. 

- SW, Royal Exchequer

SW, your point is very well taken. I was discussing this issue while lecturing to folks regarding the new oral anticoagulants Pradaxa (dabigatran), Xarelto (rivaroxaban), and Eliquis (apixiban). In the treatment of atrial fibrillation Effient has a 2%/year bleeding rate compared to 3%/year in the clinical trial. That being said, time and supportive measures (holding pressure, transfusions, surgical hemostasis) are the only treatment for bleeding because it inhibits clotting factors. There is theoretical benefit of giving concentrated clotting factor (4 factor PCC or FEIBA). With warfarin, the drug causes the clotting factors to made incorrectly. Giving plasma is the (temporary) antidote if you need to take a patient to surgery while waiting for the patient’s liver to start making the correct clotting factors.

Nevertheless these new drugs after being dreamed about for so long because you don’t need to titrate the drug, there are no dietary or medication interactions, weekly/monthly blood draws, etc, now folks are scared to use them because they don’t have an antidote similar to warfarin, even though the bleeding risk is clearly less for Eliquis, and probably less for Pradaxa. You never see the stroke you’ve prevented, but you see the bleed your treatment causes, and many doctors will then ask, what if…if the bleed happens on the new drug versus the older one even though the numbers say they’re in the right.

Indeed, Dr. Garret FitzGerald, Chairman of Pharmacology at the University of Pennsylvania said it best in an NYT article soundbite discussing the approval of Eliquis:

“What matters to a patient is the individual effect in them.”

And unfortunately we don’t always have a measuring stick or a crystal ball to help us, which is why medicine is an art and a science.

Best,
Dr. J.

About Dr. J.

Dr. J. was born the son of a New Atlantean sharecropper who cornered the market on notoriously delicious seaweed Himanthalia elongata (popularly known as Thongweed). With his newly minted seaweed fortune, Mr. J. the Elder sent his son to attend the Academy of Sorcery, Alchemy and Surgery where the good doctor apprenticed with the finest sorcerer surgeons in New Atlantis.Dr. J.'s areas of expertise grew to include bleeding, cutting for stone, trephination, medical divination with outstanding spatial and temporal resolution, cybernetic sorcery and medicinal alchemy. When King Orin of Atlantis fell ill with the Ick, Dr. J. stepped in with an elixir he devised from a combination of minerals, herbs and saps. Curing the king, Dr. J. gained significant notoriety which afforded him the luxury of time to devote himself to his side hobbies which include porpoise racing, the study of supply-side economics, cooking and raising his lovely merchildren alongside his lovely bride the archconservative Mrs. Dr. J.

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