Black, White and Many Shades of Grey

Medicine can be messy business – that’s because medical knowledge keeps evolving and practice guidelines will change with time based on new evidence.  But before we can definitely change practice, there is often a period with no black or white answer but many shades of grey.  In addition, medical decisions aren’t so simple when patient factors, risks of treatment and benefits of treatment all need to be considered simultaneously.

We call it controversy.  It is not uncommon that different clinicians will have different approaches to managing different diseases or medical conditions.

Here are some common controversies or grey areas in medicine that you may hear people continue to discuss and debate. Each decision is unique to each patient’s scenario, risk factors and latest evidence around when the decision is to be made or evaluated.

  • Use of oral anticoagulants in atrial fibrillation.  It is well established that individuals with atrial fibrillation will have a higher risk of developing stroke and therefore, the use of oral anticoagulatants such as warfarin or dabigatran, rivaroxaban and apixaban is indicated. However, these oral anticoagulants – also known as blood thinners – can also increase the risk of bleeds. Many clinicians may need to balance the risk of stroke vs. the risk of bleed. There are tools to help guide the decision such as the CHAD2 score (for estimating the risk of stroke) and HASBLED score (to estimate bleeding risks).  In terms of bleeding risks, minor bleeds or bruises are not uncommon but they do not necessarily lead to worse outcomes. It’s the serious bleeds including intracranial bleeds or severe GI bleeds that we should be concerned about.
  • Role of calcium supplement in Osteoporosis. Treatment of osteoporosis often aims to build stronger bone and the basic ingredient to healthy bone is calcium. There are concerns that calcium intake may be inadequate; however, we also know that excessive calcium intake in the form of supplement may lead to calcification of blood vessels and internal organs. The latest thinking around calcium supplement is to encourage intake from dietary sources as much as possible. In individuals with high risk for fall, supplementing with maximum of 500 mg per day of calcium seems to be safe and reasonable if intake from dietary source is not enough to make up for the total daily requirement.
  • Anything related to steroids. We often have this love-hate relationship with steroids. We know they work like wonders to reverse many autoimmune conditions such as rheumatoid arthritis, inflammatory bowel disease, asthma. In individuals who are critically ill, a little bit of steroids may help to manage any underlying adrenal insufficiency.  However, we also know it can be bad for the body. We may become dependent on steroids, develop long term side effects and in general, just like to sometime keep our distance unless we absolutely need to use it in more desperate situations.
  • Use of anti-psychotics for behaviour and psychological symptoms in dementia. It is not uncommon for individuals with dementia to develop behaviour and psychological symptoms such as wondering, verbal aggression or delusions. The use of anti-psychotic is not effective for all types of symptoms but may be helpful with symptoms of hallucination, delusions or severely aggressive behaviours.  There are real safety concerns too including increasing the risk of fall, the risk of stroke and death. There are many non-drug measures to try such as distraction, avoiding triggers and music therapy. The general rule is to reserve the use of anti-psychotics when these non-drug measures have failed and only in symptoms that have been deemed to be effective.
  • Aspirin use for Primary Prevention in Cardiovascular Diseases. Aspirin is an anti-platelet that has been around for a very long time. We have strong evidence to indicate its effectiveness in secondary prevention of stroke or heart attack. However its use as a primary prevention is not well supported. Yet we see individuals buying Baby Aspirin all the time at the advice of their next door neighbours or from reading various sources on the internet.  In United States, aspirin is recommended for primary prevention of cardiovascular disease in diabetes but in Canada, we have not advocated this position for all diabetes.  One of the challenges is that clinician may be presented with an individual with no previous history of cardiovascular disease but has been taking Aspirin for years and now has developed some risk factors such as obesity and hypertension.  Should this individual keep taking the aspirin?
  • Medical marijuana. Lately there has been many discussion around the use of medical marijuana in conditions such as pain, post-traumatic stress disorder, multiple sclerosis and other conditions where conventional treatments have not been successful or adequate. There seems to be an excitement among many advocacy groups but its long term safety effect is not well established. We know it can affect the developing brain. We know it can impair cognition. We also know mixing marijuana and alcohol / psychotropic medications may potentiate sedation and other effects of the central nervous system. While we may be seeing some promising benefits with preliminary studies, it is important to keep an objective view as we move forward with the legalization of marijuana in Canada.

These are just few of the topics I can think of today. Do you have other thoughts or controversies you see in your practice that you want to share?

Thank you for reading my post and have a wonderful Friday!



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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permissions. I hope you will enjoy reading my posts!

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