**EP56: Interview With Senior Gastroenterologist Gautam Ramnath**
**Dr. Warwick Bishop:** Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
Hi, my name's Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today, I'm absolutely delighted to have the opportunity to interview a senior gastroenterologist from Queensland. I'm going to be interviewing Dr. Gautam Ramnath, and some of his details will be available on my website so that you can find out more about him as you need.
I can let you know that Gautam qualified from the University of Queensland in 1994. He did his intern year in the far north in the Northern Territory, Darwin. He made his way back south to Adelaide, where he did a lot of his specialty training at Flinders Medical Centre. He trained in geriatrics, pharmacology, and finally gastroenterology, which is what he's really been predominantly practicing in for the last 10 years or so in Brisbane. I really am delighted to have him here joining us today. Welcome, Dr. Gautam Ramnath.
**Dr. Gautam Ramnath:** Delighted, Warwick. Thank you, that's a very flattering portrayal. A little rather senior though; I'd like to have been a little bit younger.
**Dr. Warwick Bishop:** I would all like to wind the clock back a little bit, Gautam. Today, what I'd like to speak about is really something that crosses both of our specialty disciplines, and that's aspirin. Now, aspirin to a cardiologist, I'm guessing, is different to aspirin to a gastroenterologist. So I'm going to give you the opportunity to give the other side of the discussion. What does aspirin mean to you, and how do you see it as a gastroenterologist, Gautam?
**Dr. Gautam Ramnath:** Look, aspirin is one of the original agents that's been in our armamentarium for years. It comes from a derivative of willow bark until a brilliant German figured out how to synthesize it. It's been known as a fever-curing agent. It's widely now known as having some anti-cancer properties in the right setting. You and I see it most often in its ability to alter the way blood clots. So blood clotting has chemical processes and also cell-based processes. Aspirin interferes mainly with the cell-based process and some of the chemicals.
**Dr. Warwick Bishop:** I'm sorry, Gautam, I was going to say just for the listeners, from a cardiologist's point of view, we're very interested in stopping that blood clotting because it's clots in the arteries of the heart that give rise to heart attacks. So that's why us cardiologists love to give aspirin out. Sorry to break your flow there, but I just wanted to make sure people understood that it's a particular action of aspirin that we're interested in as cardiologists.
**Dr. Gautam Ramnath:** Indeed, and it's quite a central action. It's still the most widely used agent, one that actually has still good evidence. I'm sure we can touch later on some of the emerging controversies about whether there are limitations on the benefits of aspirin. For all the good that it does, especially in small arteries, not so much for veins and more for the arterial blockages, it's always been plagued by a potential problem to create ulcers. The gastric ulcers, the stomach ulcers it creates, can sometimes result in bleeding. The gastric ulcer can eat its way through and create a hole in the stomach called perforation, which is a surgical emergency. And in a person who has heart disease, that's always been a concern. How do you balance those risks?
**Dr. Warwick Bishop:** Happily, 97 to 99% of people with aspirin will do quite well. We know that population-wide, 1% to 3% of people with aspirin use will come in with ulcers or complications of ulcers. So, Gautam, can I ask for the sake of the listeners and for my own education, when we think about aspirin and gut ulcers or bleeding from the upper gastrointestinal tract, are we dealing with an agent, aspirin, that actually causes ulcers, and then once it causes ulcers, also makes you bleed more from them? So has it got a double whammy effect in terms of complications of bleeding from ulcers? Could you explain that for me and the listeners?
**Dr. Gautam Ramnath:** Sure. That's absolutely true, Warwick. It interferes with some of the stomach's protective mechanisms. It removes a lovely inner mucus coating that protects the stomach from its own acid production. So the stomach is actually a chemical battery. It makes industrial-grade acid day in and day out. And it has a brilliant biological way of protecting itself to stop itself from being digested. Aspirin removes a protective coating. It allows the surface to be worn away. And then over time, this stomach's own acid production will erode these little red areas away further and further to create a larger hole, which we call an ulcer. If it gets deep enough to hit a blood vessel, you have a big bleed. The problem with the bleeding, then, is we now have an agent that does interfere with the ability to clot. Happily, we have, with all things medicine, the body has multiple ways of stopping it from clotting, not just the aspirin pathway. But you can have some very profound, life-threatening bleeding events. Some we can control with endoscopy, and some we can't. So this is important to understand. It means that aspirin really is a sort of negative double whammy for the risk of bleeding in the upper gastrointestinal tract.
**Dr. Warwick Bishop:** So what you're saying is it reduces the mucus protection that the gut produces, and it increases the flow of bleeding should that occur?
**Dr. Gautam Ramnath:** It does. There's some controversy over whether aspirin in its own right is acidic enough to contribute to some of the gastric damage. And perhaps if you get a tablet of aspirin stuck in your gullet for... some people, even in their mouth, have their difficulty swallowing. Over time, it can cause an ulcer in its own right. But whether it is relevant enough in the face of the industrial hydrochloric acid the stomach makes, that's still controversial. My own feeling is it's a very small factor in that regard. So, yes, it takes away the protection, creates the defect, opens the blood vessel, digested by acid, and then you have a problem with clotting.
**Dr. Warwick Bishop:** So one of the things that many of the heart patients who are listening to this would be thinking is, well, what about the aspirin that they take that supposedly has an enteric coating? And an enteric coating, as you and I both know, means a gut coating. And that's been produced by drug companies to try and reduce the likelihood of aspirin causing ulcers and leading to problems like this. Do you think these enteric-coated preparations really work, Gautam?
**Dr. Gautam Ramnath:** Personally, Warwick, I don't think they work. It certainly adds to the cost of the agent. The enteric-coated aspirin, the theory behind it is if aspirin is acidic in its own right, surely stopping the stomach from being exposed to aspirin will prevent some damage. But as we've already discussed, the effects of aspirin on the stomach actually happen after aspirin is absorbed into the body, goes into the bloodstream, comes back to the stomach, and then, by chemical means, causes the damage.
**Dr. Warwick Bishop:** Could I hold you there for a second, Gautam? Because I just didn't understand this, and I'm sure our listeners would be interested in this. What you're saying, as far as I understand, is that the mechanism that leads to aspirin causing ulcers in the stomach occurs not by aspirin actually being in the stomach but by the aspirin being in the bloodstream after it's been absorbed. So you could almost suck on a tablet of aspirin and still get an ulcer in your stomach. Is that what you're saying?
**Dr. Gautam Ramnath:** That is absolutely correct. And we have many other agents that work like aspirin in a similar way that create exactly the same problem. So that then creates the issue: what does the enteric coating actually achieve? Well, probably a psychological benefit from what you've just described. I think there is a theoretical advantage that on paper you could say surely it's one less insult to the stomach. Keep in mind, though, that our body is amazing. It produces acid. We would refer to it as a pH of 2. If we could wrap the stomach around an iron bar and keep it working, it would eat its way through the iron bar. It is profound and amazing in how much strong acid can be used. The effect of a little tablet of aspirin in that aspect is trivial, and I don't think the entire coating does anything, but it does provide reassurance. It does also, though, limit the dose of aspirin, doesn't it? Because it comes in one particular spread.
**Dr. Warwick Bishop:** Yeah, that's exactly right. The dose of enteric-coated aspirin that we're most familiar with here in Australia is 100 milligrams. So what's your comment on that, Gautam? And before you answer that, just a very quick one, which I don't expect you to know off the top of your head, but do you know if there are any studies that have shown that enteric-coated aspirin leads to any less problems or not?
**Dr. Gautam Ramnath:** No. There is, as with many studies where there is no clear-cut answer or where the answer that people are looking for does not arrive, there are numerous what we call sub-study analyses. It's a rifling fluid being to look for a random statistic that suits you. Yeah. And there is utterly no evidence that going on this low-dose aspirin alters the risk of severe bleeding. It is all much the same. And certainly from a cost perspective, you'd wonder why you don't then just have soluble aspirin from Woolworths, which does pretty much the same job.
**Dr. Warwick Bishop:** Well, I did interrupt a bit there, so what I would like to do is give you the chance to answer the last question I asked before I interrupted you, which is, what are your thoughts about the dosing that we're using?
**Dr. Gautam Ramnath:** Yeah, because the enteric-coated preparation that we've been talking about comes in a standard 100 milligram dose. That's what we're most familiar with in Australia. So what's your comment on that, Gautam?
I'd like to phrase my comment on if I had a heart problem and I have a terrible family history of heart disease, how much aspirin would I take on a daily basis as a gastroenterologist, knowing its potential downside? And the answer is I would take 300 milligrams. It is still an area where there is no clear-cut definitive trial, but I'd like to just describe to you how we ended up with these low doses of aspirin. I'm sure you may remember from your training days, Warwick, there was a time when we didn't have any data to prove that aspirin was a benefit in heart disease. We were using it. We were using it in doses of 300 to 600 milligrams. It took one of the largest multinationals to actually speed it up. I'll speed it up a bit. It was difficult to prove that aspirin worked. And the original trials used very large doses. And we found a benefit. Having found a benefit, we then thought, well, maybe a smaller dose gives us the same benefit and less bleeding risk. And it's true. There is a very small decrease in the risk of bleeding risk as if the dose comes down from 300 down to 150 to 100. But no one's actually shown that the absolute benefit of 100 milligrams of aspirin has the same impact as the original trials. And there's a lot of other evidence to suggest it is so difficult to block these blood vessels, clotting off, stop them from clotting off, that you may need much larger doses of aspirin to be effective. There's a concept called platelet resistance, which is that the little clotting cells can actually not respond to aspirin. The impression is you simply need more in most people. So I think there is a lot of controversy still that when you look at the original trials, the assumption that 100 of aspirin is the same as 300 is not fully substantiated. We use it a lot, it's true.
**Dr. Warwick Bishop:** Well, this is sort of pretty interesting because we often try and set our treatment recommendations on the evidence available, and that evidence available sets our guidelines. So it is interesting to hear that historical perspective of that, Gautam, and I wonder if we were to re-look at that evidence in greater detail, whether that would influence prescribing habits across the nation.
**Dr. Gautam Ramnath:** Look, I think it would. And the problem, though, is how do you convince anyone to put the money forward for what would have to be a very large trial? Enormous numbers would be needed to show that whether or not 100 milligrams of aspirin is identical to 300 or superior or less effective. And that's my concern, that we can only go on the data we have. The original study that showed its efficacy was 300 to 600. Everything else from then has been an assumption.
**Dr. Warwick Bishop:** So I think this is a fascinating conversation. Because of the interest of time, I'm going to wrap up and I'm going to ask two last questions to finish up on, if that's OK. The first is, if you were going to take your 300 milligrams of aspirin a day, Gautam, would you take it as soluble or would you just swallow a pill?
And that's an easy first question. The second question is, just in terms of practical clinical application, for anyone listening who is taking aspirin at the moment, are there any tablets or foods or beverages in particular that may interact with aspirin and increase their risk of having problems with their gastrointestinal system? So two questions for you to finish up on for me, if you wouldn't mind.
**Dr. Gautam Ramnath:** Sure. The first one, I don't think there's a problem or difference significantly between a solid tablet and soluble. If I look around my house, I have more soluble aspirin. For people who have swallowing disorders where food doesn't go down properly or food gets stuck, I would prefer that you take the soluble version.
Interactions. I often get people asking me, "But I take my aspirin with food. Does that protect my stomach?" The answer is no. It is a lot like asking the enteric-coated aspirin. You're coating the stomach. Will it make a difference? No. Aspirin exerts its effect after it's absorbed. We have the same risks. We know that people who are on high-dose steroids for asthma or inflammatory conditions are at increased risk of ulceration. We know that people who have critical illnesses share the same increased risk. And again, naturally, if you're on other blood thinners, then the risk is multiplied. So overall, then, there is no evidence to say that taking your aspirin with or without food makes any difference, much like the enteric-coated aspirin. And if you have other diseases or other medication, we'd always look at what the overall risk is to the individual.
**Dr. Warwick Bishop:** Well, I reckon that's a lovely insight into aspirin and where a gastroenterologist sees it in the cardiological world. Gautham, I'd genuinely like to thank you for the time you've given today to share some thoughts. I think you've covered some really interesting stuff. I hope the people listening have appreciated it. I'm sure they will. And if I could be so bold, I would love to tease you out in another podcast at another time if you'd be open to that.
**Dr. Gautam Ramnath:** Thank you so much for joining me today on the Healthy Heart Network podcast.
**Dr. Warwick Bishop:** My pleasure, Warwick. Thank you for having me on the podcast. Thank you. Goodbye.
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