Aspirin after a broken bone: health equity in a $5 bottle

There are few things that are more exciting for researchers than conducting and completing a clinical trial that could change medicine and save lives. That’s what we had when The New England Journal of Medicine published our findings in January 2023 that aspirin was as effective in preventing life-threatening wounds after surgery as it was much more expensive and painful than injectable blood thinners.

We and our colleagues thought that doctors and hospitals would immediately change their approach and switch to aspirin. This would improve health equity by providing affordable treatment to people who cannot afford expensive treatment, and would improve quality of life by swapping painful injections for two pills. aspirin a day. Unfortunately, the transition is taking longer than we thought.

When given a choice between two drugs that produce similar results in clinical trials, many doctors do not follow the latest evidence but turn to hospital policy, practice and preference as the basis for decision making. . But they should use a lifestyle lens in choosing care as often as possible.

The research involved colleagues at the University of Maryland School of Medicine, the University of Maryland Medical Center, and several other institutions that are part of the Major Extremity Trauma Research Consortium. It compared the use of two treatments – aspirin and low molecular weight heparin (LMWH) – to prevent bleeding after major bone fractures. Preventing clots, which can occur after a fracture, is important because they can cause life-threatening blockages that block blood flow when they enter an artery in the lungs (pulmonary embolism), which can be fatal.

The study included more than 12,000 people with fractures who were treated with surgery or non-surgery. They were assigned to take low-dose aspirin or LMWH twice a day while in the hospital, and continued to take their prescribed medication after discharge as prescribed. Aspirin has been empirically proven to be as effective as LMWH in preventing death from any cause within 90 days after a fracture. (People whose wounds are not very good treated in the emergency department are usually not given aspirin or LMWH because they are at a much lower risk of bleeding.)

This result may seem to apply only to orthopedic surgeons, as most people do not read medical journals and tend to follow doctor’s orders after serious injuries. But people find LMWH very uncomfortable to take. It is a shot inserted into the abdominal wall, usually twice a day, usually three to four weeks after the injury. A dozen doses of LMWH can cost anywhere between $70 and $300, depending on various factors, while a bottle of 81 milligram aspirin containing 200 tablets can be found for about that much. for $5, and maybe $12 for a brand name. People with medical insurance are protected from the cost of LMWH, but those who are uninsured or underinsured must pay out of pocket.

Although we don’t have a lot of data on how faithfully people took their medication after they were released from the hospital, and it wasn’t part of the study, we found in our previous research that at least 20% of people are prescribed LMWH after being discharged from the hospital. to break a bone do not take it, which can increase the risk of blood clots four times. We also know that being uninsured or having high payers reduces the likelihood of not filling a prescription for LMWH. About 10 percent of Americans with osteoporosis don’t have health insurance, and those who have to come forward — people without the help of a family member to help them recover — are they have four chances to recover. skip the prescription.

From a health equity perspective, people with low-income commercial insurance who have a strong support network can afford the cost and burden of a LMWH prescription. Those who lack social support networks and/or financial resources, and those who do not have access to reliable transportation, are more likely to skip an injection drug and will be at greater risk. the growth of having a fatal blood clot in their body. Those people come from ethnic and racial minorities as well as disproportionately poor people. It is a point that should be taken into account by doctors, hospitals, and everyone in the care chain.

About 15% of providers now give aspirin to prevent bleeding after a fracture in the hospital, and 50% give aspirin at discharge. But many hospital policies and guidelines have not changed since the trial results were published, and although some providers may choose to prescribe aspirin, they are unable to do so because of hospital policies. theirs. Some providers also remain skeptical that these effects may not apply to people at high risk of developing a blood clot, but the benefits of aspirin for blood clotting are also applies to high-risk patients.

Not every change in medicine has to be a good gesture. Small changes in practice, such as substituting aspirin for LMWH, can provide significant improvements in health equity.

Many health systems, including our own – the University of Maryland Medical System – have made major changes in care standards that used outdated or inaccurate genetic algorithms, including some highlighted in an influential paper from the New England Journal of Medicine that explained how inadequate. is deeply embedded in clinical practice. There are also many everyday possibilities to think about, including the simple case of aspirin, the so-called miracle drug patented in 1899.

The story of “aspirin after a broken bone” is just one example of recovery. We have seen some examples of this, such as using the high blood pressure drug minoxidil to treat male pattern baldness or the use of the teratogenic drug thalidomide to treat leprosy. Replacing aspirin with LMWH after a fracture may be a baby step on the road to health, but it could prevent hundreds or thousands of unnecessary hospitalizations and deaths. year, as well as providing easy healing for anyone who is broken. bone.

Deborah M. Stein, MD, is the R Adams Cowley, MD, Professor of Shock and Trauma at the University of Maryland School of Medicine. Robert V. O’Toole, MD, is the Hansjörg Wyss Medical Foundation Endowed Professor of Orthopedic Trauma at the University of Maryland School of Medicine.