Author: Anna Wilde Mathews

Patients concerned about side effects associated with aspirin, particularly the risk of gastrointestinal problems such as ulcers, often try taking versions of the drug that are coated with enteric.

Though patients often believe these pills pose a lower risk of stomach upset, they actually don’t appear to

have much effect on the more serious damage that aspirin can cause. “That’s a huge misunderstanding,” says David A. Johnson, a past president of the American College of Gastroenterology and a professor at Eastern Virginia Medical School. Here’s some background from Harvard Health Publications.

Aspirin can cause ulcers, which can lead to complications such as bleeding and perforation of the intestines or stomach. Though coating the pills can reduce the risk of stomach irritation as the drug is digested, that is not the only way that aspirin causes the more serious problems. They also stem from the systemic effects of the drug. Aspirin prevents production of the hormone-like substances called prostaglandins. That helps reduce pain and inflammation.

But prostaglandins also play a key role in maintaining a protective layer in the stomach. That layer can get depleted, thus exposing the stomach to digestive acids that can eat away at its lining and raising the risk of ulcers and bleeds.

Aspirin may also raise the risk of bleeding through its other main mechanism of action, which is as an anti-clotting drug. Without coagulation, bleeding can become a higher risk.

More about what aspirin does and doesn’t do is here and here.

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Doctors are narrowing their recommendation on who should take daily aspirin for heart health, based largely on concerns about the drug’s side effects, which can include bleeding ulcers. See here for more about that.

But there’s another type of person who might someday be advised to steer clear of a daily aspirin: those for whom the pain reliever doesn’t work well as a blood clotter.

In most people, aspirin has an an anti-clotting effect on the blood, which is believed to be the most important reason for its ability to reduce the risk of heart attack and stroke. But when some people take the drug, their blood still clots, a phenomenon traditionally called “aspirin resistance.” That suggests that they may not get as much heart-protection benefit from it.

Estimates of how common the issue is vary widely. One rough measure is that perhaps 10% to 20% of patients who take aspirin because they’ve had a clot in the past suffer another one despite the drug.

New research is helping to pinpoint the cause of aspirin resistance, including that the phrase itself may be a misnomer. A study published in the journal Circulation last year suggested that the reason isn’t always that the drug fails to do what it’s supposed to do. The problem is that there are several triggers for blood clotting, and aspirin’s effect is mostly on one. In some folks, the mechanisms that aspirin doesn’t affect are very powerful, so they can get clots despite the drug.

At Duke University, a new National Institutes of Health-funded trial is looking at whether it might be possible to pinpoint genetic characteristics of people for whom aspirin doesn’t block clotting. It began in September and is set to go for two years. “We want to understand the biology and the genetics of those other pathways” to clotting, said Deepak Voora, a Duke cardiologist who is involved in the study.

For now, doctors say, it’s far from proven that administering blood tests to people who are considering taking a daily aspirin to prevent heart attacks and strokes is worthwhile.

Ned Calonge, the chair of the U.S. Preventive Services Task Force, said the group didn’t consider the issue in writing its new aspirin guidelines, because the studies that were used as evidence didn’t test participants for aspirin resistance. Still, he pointed out, it’s likely that the trials included some people with the issue, as the general population does.

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Pharmacy-benefit manager Medco Health Solutions reported earnings today, and the results didn’t seem to surprise Wall Street too much even though its shares declined. But the company took some time on its call with analysts to highlight its growing push into original research.

Medco made a bit of a splash in 2008 when company researchers co-authored a study that suggested that heartburn drugs known as proton-pump inhibitors could interfere with the effectiveness of the anti-clotting medicine Plavix, which is co-marketed by Bristol-Myers Squibb and Sanofi-Aventis,

In today’s call, CEO David B. Snow Jr. talked up Medco’s research efforts, noting that it had sponsored 12 studies published or presented last year and had pulled together its efforts in a new research institute. He argued that the company “can improve outcomes and reduce costs” with its work, according to a transcript of the call from Thomson Reuters. Among its research focuses are pharmacogenomics –- efforts to use genetics to guide drug therapy –- and comparative-effectiveness work.

The Health Blog caught up with Snow after the call, and found out he also has a personal case for backing Medco’s studies. He said he took an asthma drug, Merck’s Singulair, for two years before learning through a genetic test that he couldn’t metabolize it. “I was getting sicker, and I was laying out the money for a drug that wouldn’t work for me,” he said.

Medco is also looking at research on genetic tests beyond just those tied closely to pharmaceuticals, with a particular interest in cancer, he said. Last year, Medco bought DNA Direct, a company that focuses on guiding insurers, doctors and patients about the use of genetic tests.

Flashback: In what seems like ages ago, here’s what Snow had to say on his outlook for overhauling health care early last year just as the Obama administration was taking office.

Photo: Medco

As Washington dissects President Obama’s health-care plan and both parties prepare to grapple with health woes at Thursday’s summit, employers are saying their biggest cost problem lies at home.

Workers’ poor health habits were cited by 67% of companies as a top challenge to maintaining affordable benefit coverage in a new survey by Towers Watson and the National Business Group on Health. The next highest challenge, cited by 41%, was a tie between “high-cost catastrophic cases and end-of-life care” and “under use of preventive services.” And 58% of the companies said the biggest obstacle to changing employee behavior related to health is the lack of engagement by workers.

To deal with those problems, the employers said they were stepping up a number of wellness efforts that have been increasingly popular for several years, including prodding workers to fill out a health-risk appraisal, offering the services of health coaches and trimming certain drug co-pays for employees with chronic conditions.

Of course, the trend among employers for several years have been to boost workers’ out-of-pocket expenses to help defray the rising benefit expenses; according to the survey, health costs were up 7% in 2009 and are expected to rise 6.5% this year.

Indeed, the companies said they expected enrollment in consumer-directed plans, which typically involve high deductibles for participants, to continue to tick upward, and 23% plan to move in that direction in the next two years. Also, 17% said they expect to increase or add surcharges for coverage of employees’ spouses; 19% said they already had done so.

The survey involved 507 large U.S. employers, all with 1,000 workers or more, and was performed between Nov. 17 and Jan. 8.

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After California became the first state to allow medical use of marijuana, legislators decided in 1999 to fund research that was supposed figure out what the drug was good for therapeutically. Now we have an answer: a report issued today says it seems to ease some types of pain, and maybe muscle spasticity from multiple sclerosis.

Of course, lots of state residents have found their own, much more varied, answers, since California’s law is one of the most open-ended about who’s eligible for medical marijuana. Anyone who can get a doctor to write a recommendation, based on just about any medical condition, can buy marijuana in California. But this is the official report from the Center for Medicinal Cannabis Research, based at the University of California, San Diego.

Since its 2000 founding, the center has funded 15 clinical studies, including seven trials. The results include some fodder for medical-marijuana supporters who argue for the drug’s unique importance, particularly the finding that it worked as an add-on to more standard treatments for pain stemming from nerve damage.

The report argues marijuana may have a “novel mechanism of action not fully exploited by current therapies.” The drug may also have an effect on multiple-sclerosis patients’ spastic motions “beyond the benefit available from usual medical care,” the report says. Other research hasn’t shown this effect consistently.

The report also flags some mild side effects, including dizziness and, ahem, “changes in cognition.” Marijuana opponents will probably say that the studies weren’t long-term enough to show the potential downsides of chronic use.

The center has made these findings public before — they can be found on the center’s Web site. Still, the report is important because it pulls together the results in a document that is supposed to reach the general public.

And now that 13 other states have followed California in adopting medical marijuana laws, the research is likely to play a role as the Golden State once again tries to take the lead in marijuana policy: a California ballot measure that would attempt to legalize the drug’s use by adults 21 and older is likely to come to a vote later this year.

The WSJ took a recent look at marijuana research here.

A new study in JAMA reports that teens who got bariatric surgery lost a substantial amount of weight. But the clinical trial only looked at one type of surgery — gastric banding, which involves wrapping a silicone band around the upper stomach to restrict food intake.

There’s another bariatric procedure, gastric bypass surgery, which typically involves creating a small stomach pouch and a passage so food bypasses the rest of the stomach and parts of the small intestine. The authors argued in their paper that gastric banding is more appropriate for young patients because it is safer than gastric bypass as well as being “adjustable and reversible.”

Paul O’Brien, the lead author, said in an interview that “the band is safe, whereas the bypass is not yet safe enough.” For teenagers, the option to remove the band later in life is important, partly because new treatment options may emerge, according to O’Brien. “The band I can back away from, the bypass I can’t back away from,” he said.

But that argument is likely to spark some debate, reflecting the back-and-forth that’s already common among surgeons over which procedure is best for adults. Another prominent researcher, Thomas Inge of Cincinnati Children’s Hospital, who is leading a major NIH-funded study of bariatric surgery in young people, said “the jury is out for the teens on which is going to be more effective.” He said bypass operations are “generally more effective for weight loss,” and that the safety question is “subject to interpretation.”

Inge and others note that in the past, the Australian group that led the new study has seen better results from banding than are typical in the U.S., partly because of the fractured U.S. health system and payment policies that can limit follow-up care. Here’s more from the WSJ.

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Spending by private insurers tends to be higher when the hospital market is less competitive, a new study finds.

The study, published in the American Journal of Managed Care, compared geographic patterns of Medicare spending, using the Dartmouth Atlas data, with spending by big employers that cover their workers. The upshot was that the two didn’t correlate.

The reason didn’t seem to be that insurers (in this case, acting on behalf of big employers) are better than Medicare at saying no to paying for unneeded care since utilization pattenrs were somewhat parallel. Instead, the researchers suggest that when a small market has just one or a few big hospital systems, employers spend more than they do in large cities where there’s more competition, an issue that doesn’t generally affect government health payers like Medicare.

“We found that for commercial insurers, the higher-spending markets were those that were the least competitive on the provider side,” said Michael Chernew, the lead author and a professor at Harvard Medical School. The finding, he argues, signals that as policymakers push for integrated systems bringing together all kinds of health care under one umbrella, they should keep antitrust concerns in mind.

This idea matches up with a couple of recent reports from state officials, as noted here and here. But it seems to cut against some previous research arguing that when a market has a lot of hospitals, an “arms race” mentality can drive up costs as they vie to buy the best new technology.

The new study’s suggestion comes with a bucket of caveats. For one thing, there are other reasons why private insurers’ payments wouldn’t match up with Medicare’s. Most obviously, the under-65 population has different medical needs than older folks.

Some hospital executives have long argued that they are forced to rely on payments from private insurers to make up for the money they lose on government-covered patients, another reason why the two types of payment wouldn’t correlate. The database used in the study also had fewer than 60 large companies, a limited sample that could create distortions.

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