Aspirin and macular degeneration

[Frank Merton]

I noted several reports today in the popular press of an association between self-reported regular aspirin use and neovascular macular degeneration.

The report seems to contradict other work that has not found any association, and appears to be flawed in several other ways.

However, it enters my head that I may be engaging in wishful thinking here, as aspirin is an important part of my eternal life plan . If anyone, specially informed or not, has a slant on this, please comment.

 

[Skeptic Ginger]

PubMed is your friend:

Massive subretinal hemorrhage and anticoagulants. An unfortunate combination?

Just recently, several authors reported a strong association of anticoagulants and antiplatelet agents with the development of large subretinal hemorrhages in ARMD patients. Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

It doesn't sound like aspirin causes macular degeneration but if one is prone to it or has it, aspirin may not be a good drug for that patient.

This study, OTOH, that looked at 4691 participants 65 years of age and older did show a worrisome association: Associations between aspirin use and aging macula disorder: the European Eye Study.

RESULTS:
Early AMD was present in 36.4% of the participants and late AMD was present in 3.3% of participants. Monthly aspirin use was reported by 1931 (41.2%), at least once weekly by 7%, and daily use by 17.3%. For daily aspirin users, the ORs, adjusted for potential confounders, showed a steady increase with increasing severity of AMD grades. These were: grade 1, 1.26 (95% confidence interval [CI], 1.08-1.46; P<0.001); grade 2, 1.42 (95% CI, 1.18-1.70), and wet late AMD, 2.22 (95% CI, 1.61-3.05).

CONCLUSIONS:
Frequent aspirin use was associated with early AMD and wet late AMD, and the ORs rose with increasing frequency of consumption. This interesting observation warrants further evaluation of the associations between aspirin use and AMD.

From both of those links you can search for related studies. Remember, medical research results depend on cumulative results. Single studies rarely give definitive results.

 

[Frank Merton]

Quoting from your source,

"_{Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.}"

I read this as saying that aspirin should be avoided in patients with high blood pressure, something that I had figured anyway since aspirin is also associated with the vessel-bursting form of stroke.

My wishful thinking, then, goes to the effect that one might gain the obvious huge benefits of regular aspirin use (against the other form of stroke, heart disease, and several forms of cancer) if one has low blood pressure, and, if one does not, to get blood pressure down before beginning aspirin.

Does this strike you as a sensible middle course, given that it may in fact turn out to be a false alarm -- as was, it seems, the alarm over reports of "aspirin resistance?"

 

[Skeptic Ginger]

Quoting from your source,

"_{Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.}"

I read this as saying that aspirin should be avoided in patients with high blood pressure, something that I had figured anyway since aspirin is also associated with the vessel-bursting form of stroke.

My wishful thinking, then, goes to the effect that one might gain the obvious huge benefits of regular aspirin use (against the other form of stroke, heart disease, and several forms of cancer) if one has low blood pressure, and, if one does not, to get blood pressure down before beginning aspirin.

Does this strike you as a sensible middle course, given that it may in fact turn out to be a false alarm -- as was, it seems, the alarm over reports of "aspirin resistance?"

Did you skip the second link?

I'd say you are trying to oversimplify the issues. It's all about risk vs benefit. A medical provider would look at your overall risks when deciding to recommend aspirin or not. Everyone doesn't have the same risk profile. I suggest you get an educated opinion.

 

[Frank Merton]

I'd say you are trying to oversimplify the issues. It's all about risk vs benefit. A medical provider would look at your overall risks when deciding to recommend aspirin or not. Everyone doesn't have the same risk profile. I suggest you get an educated opinion.

That's why I started the thread -- to see if I could get educated opinions. The people out there tend to include many of that sort.

It goes without saying that one consults one's doctor, and that no two people are the same. I don't know about my oversimplifying it; I feel that maybe the sources make it too complex and obscure, probably out of training and habit.

My experience with doctors is, perhaps, a little unfortunate. They are well-meaning reasonably well-informed people with a superiority complex when it comes to medical questions, and prone to be overly cautious. I suppose in the States they have to be, with all the lawyers making their living off any mistake.

I also know that all drugs have side effects, but tend to the view that if one knows the side effects and one knows the benefits outweigh them, then the better course may be to accept the side effects, trying to use other means to mitigate them as much as possible.

 

[Andy_Ross]

do you have to post such small text?

 

[Frank Merton]

I prefer a serif font as they are easier to read -- they provide clues to the eye.

As far as I can determine, I can choose only the style, but I will try to make it appear bigger.

 

[Frank Merton]

I'm a bit frustrated; the options give me no way of testing the various offered fonts except by adopting one and posting with it, which I doubt the powers that be would like, so I don't know what to do.

 

[Daylightstar]

I'm a bit frustrated; the options give me no way of testing the various offered fonts except by adopting one and posting with it, which I doubt the powers that be would like, so I don't know what to do.

There's a nice little section for just that .... test away :
http://www.internationalskeptics.com/forums/forumdisplay.php?f=65

E.T.A.: You can find that link on this page, where it's described as:

"Test
A section for testing out features of the forum software. We will regularly empty this forum."

 

[casebro]

Let's test the trade offs: I'm diabetic, with hypertension and arterial disease. Taking aspirin should postpone clot related diseases, which will probably kill me before I go blind anyhow.

Or: 3% of us will lose some vision from AMD. 40% of us die from cardio vascular disease, of which aspirin lowers the rate by about 20%. 20% of 40% is 8%, nearly a 3:1 trade off of blindness for live extension.

Seems like a no brainer to me. Do YOU need a doctor visit to make that decision?

 

[Frank Merton]

The only problem with what you say (and thank you for it) is that if I don't die I go blind. My plan is to not die, but then I guess I can't have everything.

Thanks again: it was brilliant.

 

[Skeptic Ginger]

do you have to post such small text?

He needs to learn how to use the quote function. He used _{[/] on quotes.}

 

[Skeptic Ginger]

... I feel that maybe the sources make it too complex and obscure, probably out of training and habit.

Ever think maybe it's because such decisions are complex and obscure? I'm guessing you find the medical research just as complex and obscure?

...I also know that all drugs have side effects, but tend to the view that if one knows the side effects and one knows the benefits outweigh them, then the better course may be to accept the side effects, trying to use other means to mitigate them as much as possible.

It's impossible to give this kind of advice without knowing a whole lot more about you, the individual. For starters, what are you trying to accomplish? Hopefully you aren't falling for the aspirin TV ad claiming people should be on aspirin regimens?

What those ads are not pointing clearly out is all those people are post heart attack, not pre heart attack. The drug seller cannot make the claim people should take aspirin to prevent heart attacks because that has not been clearly established.

In some very specific cases a doctor might recommend daily aspirin. But in general the blanket, every person in middle age should be on low dose aspirin, has gone somewhat out of favor and now only applies to some people with known cardiovascular risks.

 

[Skeptic Ginger]

The only problem with what you say (and thank you for it) is that if I don't die I go blind. My plan is to not die, but then I guess I can't have everything.

Thanks again: it was brilliant.

Great, take Casebro's anecdotal advice, that's going to be reliable.

 

[Skeptic Ginger]

I prefer a serif font as they are easier to read -- they provide clues to the eye.

As far as I can determine, I can choose only the style, but I will try to make it appear bigger.

You can make your fonts bigger using the size code.

[size=2 ][/size ]

But people will probably be even more annoyed.

For quotes: [ quote][ /quote]

Leave the spaces out, of course.

 

[Frank Merton]

He needs to learn how to use the quote function. He used _{[/] on quotes.}

_{Actually that was an attempt to quote a quote. The quote function is for when we quote posts. It did have unfortunate consequences and I won't repeat it. I wish it were easier to change one's default font (both the size and the style) and that the place where one makes the choice provided examples. However, it seems (although I didn't check absolutely all of them) that the only serif font available is Times Roman, and for it I have to make it either too large or too small, so I will desist and accept the defaults. I promise not to talk about this any more.}

 

[Frank Merton]

Ever think maybe it's because such decisions are complex and obscure? I'm guessing you find the medical research just as complex and obscure?

I'm not ignorant and am able to read and understand pretty much the most technical stuff. The thing is I don't have the arrogance to make important decisions without getting other views -- which is what I was trying to do here.

It's impossible to give this kind of advice without knowing a whole lot more about you, the individual. For starters, what are you trying to accomplish? Hopefully you aren't falling for the aspirin TV ad claiming people should be on aspirin regimens?

I live in Vietnam -- where there are no such ads that I've ever heard of -- and don't watch TV anyway. As I said (only half tongue-in-cheek) my objective is to live forever. Of course death will come when it comes, but I'm not a fatalist. I think I want to stay around as long as I can. Does that help with understanding my objectives? At the moment I am a healthy 69-year old, overweight but physically fit. My only serious health problem is chronic Hepatitis B, something endemic around here.

What those ads are not pointing clearly out is all those people are post heart attack, not pre heart attack. The drug seller cannot make the claim people should take aspirin to prevent heart attacks because that has not been clearly established.

Aspirin was not even available here in Vietnam until about a year ago. The government here makes bulk purchases of pharmaceuticals and then distributes them to pharmacies, and some bureaucrat no doubt decides which drugs the people need, and that is all that is available. This has loosened up a great deal recently, but it is still not possible here to get the various "herbal" and "health food" supplements that are sold in the States. (Oddly, though, Chinese traditional medicines are separately sold without much regulation).

In some very specific cases a doctor might recommend daily aspirin. But in general the blanket, every person in middle age should be on low dose aspirin, has gone somewhat out of favor and now only applies to some people with known cardiovascular risks.

I'm not sure you are right on this. Aspirin is dangerous, but the dangers seem to be associated with dose, blood pressure, and whether the aspirin is taken with food or not. By not abusing it, by watching one's blood pressure, and by always taking the aspirin with food, it seems to me the benefits far exceed the risks. However, I am certainly open to other views.

 

[Skeptic Ginger]

I'm trying to help you but your tone suggests you don't want help unless it simply confirms what you already believe.

I'm not ignorant and am able to read and understand pretty much the most technical stuff. The thing is I don't have the arrogance to make important decisions without getting other views -- which is what I was trying to do here.

My professional opinion is, you are trying to oversimplify the issues. It's all about risk vs benefit. A medical provider would look at your overall risks when deciding to recommend aspirin or not. Everyone doesn't have the same risk profile. I suggest you get an educated opinion.

I live in Vietnam -- where there are no such ads that I've ever heard of -- and don't watch TV anyway. As I said (only half tongue-in-cheek) my objective is to live forever. Of course death will come when it comes, but I'm not a fatalist. I think I want to stay around as long as I can. Does that help with understanding my objectives? At the moment I am a healthy 69-year old, overweight but physically fit. My only serious health problem is chronic Hepatitis B, something endemic around here.

All the more reason to get a good doctor to help you sort this out.

On the one hand, the liver plays a big role in the formation of clotting factors. If/when your hepB becomes active (sometimes hepB viremia has long asymptomatic periods as opposed to chronic hepC which typically causes continual low grade hepatitis) the typical school of thought is you will not want to be adding an anti-platelet drug like aspirin to the problem.

On the other hand, very very preliminary research found: Antiplatelet therapy prevents hepatocellular carcinoma and improves survival in a mouse model of chronic hepatitis B.. Trouble is, that is not a large scale clinical human trial.

Statins are probably safer: Statins and the risk of hepatocellular carcinoma in patients with hepatitis B virus infection.

I'm not sure you are right on this. Aspirin is dangerous, but the dangers seem to be associated with dose, blood pressure, and whether the aspirin is taken with food or not.

It depends, it depends and yes, in that order. For cardiovascular benefit low dose aspirin (80mg) has the same effect as regular strength (325 mg).

As for it not being correct that aspirin is not recommended for everyone, yes, I am correct. But believe what you want, it would seem you are arguing with things that contradict your opinion. If that's the case, why bother asking?

By not abusing it, by watching one's blood pressure, and by always taking the aspirin with food, it seems to me the benefits far exceed the risks. However, I am certainly open to other views.

I don't know what you mean by "abusing it" in the context you've been asking.

People with atherosclerotic blood vessels (the very people who benefit from low dose aspirin) are typically going to have high blood pressure.

Enteric coated aspirin solves the gastric irritation better than taking it with food if that option is available.

 

[Frank Merton]

I'm trying to help you but your tone suggests you don't want help unless it simply confirms what you already believe.

Well of course that's what I'm doing -- isn't it what we all do? I'm sorry about my tone -- often we type in a different tone of voice than we are read. Let me qualify my first sentence; I want confirmation because I have my doubts, and I am open to having my mind changed.

My professional opinion is, you are trying to oversimplify the issues. It's all about risk vs benefit. A medical provider would look at your overall risks when deciding to recommend aspirin or not. Everyone doesn't have the same risk profile. I suggest you get an educated opinion.

By educated opinion I assume you mean a doctor. In my view, doctors exist mainly to deal with specific complaints. They are not much use in daily life, including preventive medicine -- they haven't the time. To be sure they offer opinions, but I fear they suffer from a professional bias. This derives from the fact that they tend to see the situations where things have gone wrong but not the perhaps majority of cases where things have gone well.

In the case of aspirin, this means that they see the cases of aspirin-associated bleeding, and so are very aware of the danger, but don't see other patients who never have this problem. So they develop a natural bias.

Now don't misunderstand: I have talked at length with several doctors about this; the sense I get is that they are as ambivalent as I am. The fact is we never have enough information, and must always make decisions in that environment.

On the one hand, the liver plays a big role in the formation of clotting factors. If/when your hepB becomes active (sometimes hepB viremia has long asymptomatic periods as opposed to chronic hepC which typically causes continual low grade hepatitis) the typical school of thought is you will not want to be adding an anti-platelet drug like aspirin to the problem.

Thanks for that. The first thing the doctor did here was put me on anti-virals. The American doctors (later) were disturbed by this but accepted it as fait-accompli but something I may seriously regret in future. Still, at present and for the past couple of years there has been no detectable virus, although antibodies remain (I am not sure what all that means but it doesn't sound too bad). I completely avoid alcohol and acetaminophen.

Statins are probably safer: Statins and the risk of hepatocellular carcinoma in patients with hepatitis B virus infection.

Yes, absolutely. I've been taking Lovastatin for several years now. Because I exercise quite a bit, and eat a good Vietnamese diet except brown rather than white rice, I've never had high cholesterol. The doctors seemed to think that I should take the statin regardless, and I do.

I don't know what you mean by "abusing it" in the context you've been asking.

Well I'm not sure what I mean either; I would say my arthritic grandmother abused aspirin -- she would take several at a time several times a day -- she died in her seventies of a series of strokes, but I don't know which kind.

People with atherosclerotic blood vessels (the very people who benefit from low dose aspirin) are typically going to have high blood pressure.

Let me elaborate on my thinking here. One of the concerns is the kind of stroke where the blood vessel in the brain bursts. This is seen as associated with both aspirin and with high blood pressure. Therefor the danger is less if one's blood pressure is low. Maybe that's my misinformed thinking.

 

[Skeptic Ginger]

Well of course that's what I'm doing -- isn't it what we all do? I'm sorry about my tone -- often we type in a different tone of voice than we are read. Let me qualify my first sentence; I want confirmation because I have my doubts, and I am open to having my mind changed.

Fair enough.

By educated opinion I assume you mean a doctor. In my view, doctors exist mainly to deal with specific complaints. They are not much use in daily life, including preventive medicine -- they haven't the time. To be sure they offer opinions, but I fear they suffer from a professional bias. This derives from the fact that they tend to see the situations where things have gone wrong but not the perhaps majority of cases where things have gone well.

More overgeneralizing and in this case with a whole lot of crap.

First, I'm a nurse practitioner not a doctor.

Second, how many physicians are there in the world? And you think they are all the same, practicing in some narrow fields, none interested in the least in prevention? That is a naive belief.

In the case of aspirin, this means that they see the cases of aspirin-associated bleeding, and so are very aware of the danger, but don't see other patients who never have this problem. So they develop a natural bias.

And you have developed this naive belief because you talked to several of them?

Thanks for that. The first thing the doctor did here was put me on anti-virals. The American doctors (later) were disturbed by this but accepted it as fait-accompli but something I may seriously regret in future. Still, at present and for the past couple of years there has been no detectable virus, although antibodies remain (I am not sure what all that means but it doesn't sound too bad). I completely avoid alcohol and acetaminophen.

American doctors disturbed? Puhleese. We've been treating hep B in the US with antivirals for well over a decade.

...Let me elaborate on my thinking here. One of the concerns is the kind of stroke where the blood vessel in the brain bursts. This is seen as associated with both aspirin and with high blood pressure. Therefor the danger is less if one's blood pressure is low. Maybe that's my misinformed thinking.

Aspirin does not cause your blood vessels to burst. Aspirin affects platelet function. If you experience trauma (accident, surgical, or spontaneous) then normal clotting is affected by aspirin.