There is no risks right, doctor?

Recently I was asked to see an adolescent for abdominal pain. After taking a full medical history and examining the patient, I diagnosed acute appendicitis and recommended surgery to the patient and mother. The mother’s first response was “There is no risks right?”. I often hear this response from patients or parents but I don’t hear this response when I prescribed a pill.

Aspirin tablet is freely available and we commonly take it for headaches or toothaches. Low dose aspirin is also used in an attempt to prevent cardiovascular event in at-risk patients. Even without the doctor’s recommendation, some are self medicating with daily aspirin because they have read or heard that it prevents cardiovascular events. However, is taking a pill without risk? The answer is a definite ‘NO’. Low dose aspirin use can cause gastro-intestinal mucosa haemorrhage. The key consideration for the doctor and patient should be - Is it necessary to take the medicine and if so, can the risk be minimized?

A recent study from the University of Glasgow investigated the efficacy of famotidine, a histamine 2 receptor antagonist, in preventing peptic ulcers and erosive oesophagitis in patients receiving low-dose aspirin (75 – 325 mg) for cardiovascular protection (Lancet 2009; 374: 119 – 125). A total of 404 patients were randomized to receive famotidine twice daily or placebo twice daily together with low dose aspirin. At the end of 12 weeks, patients were re-endoscoped to determine how many had developed stomach or duodenal ulcers or erosive oesophagitis. The study showed that mucosal protection with famotidine led to significantly fewer ulcers or oesophagitis. The incidence of gastric ulcers, duodenal ulcers and erosive oesophagitis in famotidine treated patients were 3.4%, 0.5% and 4.4% respectively versus 15%, 8.5% and 19% respectively in the placebo group.

The study is not advocating that all patients on low dose aspirin must take famotidine at the same time. If future large studies confirm the findings of the above study, then patients should be informed of the risks involved and the possible options in mitigating the risks. It is then up to the patient to decide what options suits him best.

Whenever I am asked ‘There is no risks right, doctor?’, I prefer to use the analogy of crossing a road. In crossing the road, we run the risk of being knocked down and possibly killed by a vehicle. The risk is always there but is it a big risk or a small risk. Can the risk be minimized?

In my line of work, everything I prescribed is associated with a finite risk. I can only suggest the best course of action but in the end it is the patient’s choice to take the risk or not.