When specialists disagree

May 15, 2018 - 8:50am

 DEAR DR. ROACH: I am a snowbird who uses two different cardiologists for my health, and I am devoted to both of them. However, they have conflicting advice. I have coronary artery disease and had three stents placed in New York. I am an active 86-year-old woman who walks at least a mile daily and does light weights. My lab results are all normal. I take a daily baby aspirin and Plavix. I've done well with them.
       My Florida doctor wants me to discontinue the Plavix and take just the aspirin, but my New York doctor thinks I should keep the Plavix forever. I honestly don't know the right course of action. -- S.T.M.
       ANSWER: Both aspirin and Plavix (clopidogrel) work by decreasing the activity of platelets, the specialized blood cells that start to form clots. They have been shown to reduce blockages of stents, which hold open blood vessels that have been unblocked via a catheter in the heart. There are several different types of stents, and some of them have medications embedded in them, which release slowly over many months. These "drug-eluting" stents require using both aspirin and clopidogrel for a longer period of time. There is some debate about how long to continue these medications, but I have not read any recommendations to continue them for more than 30 months. A study (the DAPT trial) used exact information about the person and the type of stent to make predictions about balancing risks, and the results of the study showed that in your case, using both aspirin and clopidogrel would reduce heart attack risk slightly, but at an increased risk of bleeding. Nonetheless, some cardiologists will continue both medications in some patients if there are no problems.
       It sounds like your New York cardiologist may have more knowledge about the stent, as it was performed in New York, so I would try to get the two of them to reach a consensus. There may be something about your particular case that warrants long-term treatment with these medications.

  DEAR DR. ROACH: I recently was diagnosed with celiac disease. Why can I not get a decent slice of gluten-free bread? All the bread I have tried tastes bad, and most of the other baked products leave much to be desired. Although at a recent family get-together, the gluten-free sweet treats were delicious -- a big surprise. -- J.R.
       ANSWER: Humans have been baking with wheat for millennia, but wheat -- including varieties like spelt and bulgar -- contains gluten. Gluten contains gliadin, which people with celiac disease cannot tolerate.
       Celiac disease is an autoimmune disease triggered by gliadin. Unless people with celiac disease meticulously avoid gluten, they will have damage to the intestine, preventing absorption of nutrients and causing symptoms, which range from barely noticeable to health-threatening. Barley and rye also contain gluten. Oats do not, but may be contaminated with gluten, so only oats specifically labeled "gluten-free" are safe (and some people with celiac disease also may be sensitive to oats).
       As society has gained more awareness of celiac disease, there have been many new products that are gluten-free, though I agree with you that they vary in taste. The good news is that the choice and quality of gluten-free breads and other baked goods, as well as pastas, have been increasing. Keep trying new products.
       You can learn a lot more about gluten-free diets at the Mayo Clinic site at https://tinyurl.com/mayo-glutenfree.
       READERS: The booklet on constipation explains this common disorder and its treatments. Readers can order a copy by writing:
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