For patients like amma with complicated ailments, the extent of problems created by some of their medicines could at times be much higher than the degree of relief or cure they provide.
Consider the use of anticoagulants, commonly known as blood thinners. These are used by many heart patients and those with the risk of pulmonary embolisms (blood clots in lungs). Amma was also prescribed with these as she had chronic pulmonary embolism. Anticoagulants minimize the risk of blood clot formation. But the inability of the blood to clot easily could also endanger the lives of the same patients should they have internal bleeding or more likely, an external bleeding initiated by an injury – they will end up bleeding a lot more as the blood doesn’t clot quickly enough to stop the bleeding.
Amma took an oral anticoagulant. Over time, its dosage was reduced to half.
In 2014, amma fell on some sharp stones in our garden and had a slash in her calf. The tear wasn’t very large and the blood leak should have stopped on its own in perhaps half an hour. But as her blood wouldn’t clot easily, she continued bleeding and the situation turned so serious that she had to have an emergency admission for a blood transfusion.
Anticoagulants also carry risks of internal bleeding. Many of the popular oral anticoagulants have been shown to cause internal bleeding in the gastro-intestinal tract – which starts with the mouth, and then marches on to the esophagus, stomach, small intestine, and large intestine, ending finally at the anus. 179
In 2017, amma had an internal bleeding in her esophagus 180 which resulted in acute anemia and yet another emergency hospitalization. It is not clear if the anticoagulant was to blame for the bleeding, 181 but her doctor had stopped her anticoagulant post this episode, even though this meant that she was at a higher risk of blood clots and resulting complications.
So for people like amma, what does the doctor prescribe for? To prevent bleeding or to prevent clots?
A tough call for doctors too.
After a month, a lower dose of the anticoagulant was prescribed to balance the return and risk from the medicine. This worked well for over two and half years, until her internal bleeding that resulted in her anemia and death. While there is no proof that the anticoagulant resulted in the internal bleeding, there is a high likelihood that it did.
Every medication amma took had side effects or risk of adverse reactions with other medications. She took more than 10 different tablets a day, each having its own side effect and adverse reaction profile, even though only 2 or 3 of them presented side effect risks that were critical. That’s a large enough number to worry any patient.
I do not know how the medical profession plans to tackle the dilemma of side effects and conflicting effects of medicines such as anticoagulants. 182
Fig 54: Bleeding or clotting? Which risk do you wish to mitigate? Taking anticoagulants increases the risk of internal and external bleedings, but also significantly decreases the risk of formation of blood clots.
Why did she die?<= Side effects of medications => Conservative medical management
180. She had esophagitis, an inflammation of the esophagus.
181. Blood tests revealed that her INR, a measure of how quickly blood clotted, was 2.3, which was within accepted range for those taking blood thinners.
182. For anticoagulants, one of the recommendations is to have regular blood tests to ensure that the blood has not thinned beyond a certain level, though the practicality of this is a question mark.
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