THE RISE AND FALL OF BABY ASPIRIN

WHY ONE BABY ASPIRIN-A-DAY TO PREVENT HEART DISEASE MAY BE RISKY IN SENIORS

The Amazing Story of Aspirin

Aspirin has a long history of fame dating back to its’ discovery from willow bark in the days of the ancient Egyptians. Hippocrates, the Greek physician, later considered it a miracle drug to treat pain from inflammation and fever. People didn’t need research studies or clinical trials to tell them that it worked. It worked to relieve pain and/or fever pretty much for anyone who took it.

Fast forward to the 1700s when the active ingredient, salicylic acid, was identified. A useful synthetic form called acetylsalicylic acid (ASA) was developed by a chemist at Bayer laboratory in Germany. The white powder was used by physicians to mix up and give to their patients.

I talked about the apothecary scale in earlier blogs when referring to the risks and benefits of medications. In this case, the apothecary scale was used to measure out the “right” amount of aspirin powder. It was first available over-the-counter to the public in the form of a pill during World War I. Today we have Bayer aspirin and many other similar generic versions in low and regular strength (81 mg and 325 mg tablets most common in the US).

TOO MANY MEDICATIONS? WEIGHING THE RISKS

IF YOU ARE TAKING ASPIRIN, YOUR DOCTOR WILL USE THE WIDELY USED ABBREVIATION, ASA, TO REFER TO THE ASPIRIN YOU TAKE.

Make sure your doctor knows that you are taking aspirin. Check your list of medications from your doctor’s electronic or paper health record to see if the daily aspirin you take is listed. Because it is an over-the-counter medication rather than prescription medication, your physician or pharmacist would have no way of knowing you are taking it unless you speak up!

Studies have shown that the medication lists in your medical record are often inaccurate or not up-to-date. You need to let every physician know what supplements and over-the-counter medications you take. Aspirin may be a powerful medication, yet it doesn’t require a prescription.

Without clinical research trials when aspirin was first discovered, no one knew how much aspirin to take. No surprise, people soon learned that large doses of aspirin led to nausea, vomiting and sometimes coma.

So using aspirin was long known to be a double edge sword. Small amounts worked well, much larger amounts not so well. And so it is with many medications we take.

I couldn’t find the history of when aspirin was first observed to cause bruising and bleeding, common effects from aspirin even after the smallest of doses. I bet it was discovered early on in the elderly. Dark purple bruises can appear even without trauma on the thinner skin of older people taking aspirin. You may have noticed this with a parent, grandparent or other older adult.

After World War II, a California physician fortuitously observed that aspirin helped reduce the risk of heart attacks. Aspirin suddenly began its widespread popularity more for preventing heart and other vascular (blood vessel) disease and less so for its relief of fever and inflammation pain.

A Nobel Prize in 1982 was awarded to the scientists who discovered how aspirin worked. Aspirin blocked the hormones called prostaglandins. Prostaglandin hormones are important because they cause the blood to clot and promote inflammation. Aspirin works by blocking the prostaglandins from doing their job. Aspirin prevents the blood from clotting and it blocks inflammation.

THE USE OF ASPIRIN TO TREAT HEART DISEASE AND PREVENT A SECOND HEART ATTACK OR STROKE IS NOT IN QUESTION, EVEN FOR OLDER ADULTS.

Daily aspirin (both low dose and higher dose) has been shown to reduce the risk of death, or another heart attack and stroke in patients who already have had a heart or vascular disease. Taking a medication such as aspirin to prevent another occurrence of a disease such as a heart attack is referred to as secondary prevention.

Aspirin works by interfering with the platelets, the tiny cell-like substances in our blood that contribute naturally to our blood clotting after an injury. If the platelets are interfered with by aspirin and therefore they can’t clump together, the blood won’t clot.

I will dedicate an entire future blog post to aspirin in the elderly who already have a history of heart disease or stroke including patients who had heart bypass surgery and placement of a stent. This post is about preventing heart disease or stroke in the first place, not about people who already know they have heart disease or a stroke.

1990’S

In the 1990s studies showed that regular aspirin use reduced the risk for colon cancer too. A more recent review of newer studies of older adults questioned that finding. The final word is still out on whether aspirin can reduce the risk of colon cancer.

NO OTHER MEDICATION HAS SO CHEAPLY AND EFFECTIVELY FOUND A PLACE IN MODERN DAY MEDICINE FOR SO MANY PEOPLE. BUT WHO CAN BENEFIT AND SAFELY TAKE IT IS NOW IN QUESTION.

Aspirin can irritate the lining of the stomach after just a few doses. It can lead to ulcers and massive bleeding, especially in the elderly.

I remember a GI doctor telling me about his research as a young doctor studying aspirin and the stomach lining. He looked at the stomach lining of healthy people taking small amounts of daily aspirin. He found that only a few doses can cause irritation and the beginning of an ulcer to form.

Anyone with a history of previous ulcers, beware.

Everyone is at risk to suffer the bleeding consequences of aspirin, but not everyone will benefit from taking it.

Or better said another way. Everyone is at risk for the bleeding and stomach ulcer complications of aspirin but not everyone is at the same risk for heart disease and stroke.

The older you are, the greater the risk. If you take enough aspirin, you will have problems. Aspirin increases bleeding pretty much everywhere in the body although the risk is greatest for gastrointestinal (GI) and brain (intracerebral) bleeding.

2014

By 2014 the FDA released an update to consumers about aspirin. They advised that daily aspirin as a preventive medication in people who have not had a heart attack, stroke or vascular disease problems may not be worth the risk or dangers. The FDA refused to allow Bayer to label baby aspirin as a way to prevent a first-ever heart attack or stroke. That means they didn’t agree that aspirin was useful as primary prevention.

2016

In 2016 it was estimated that about 40% of US adults over age 50 take a low dose of aspirin hoping to prevent heart disease and/or stroke. In 2016, both the American Heart Association and the American Stroke Association supported the use of daily low dose aspirin in people who are at high risk for having a stroke or heart attack. The American Diabetes Association also recommends daily aspirin for certain diabetic patients with an increased risk of heart and vascular disease.

2018

As of 2018, we now have the results of five excellent research studies looking at the benefits and risks of taking aspirin to prevent heart disease and stroke. If you are older and still taking aspirin to prevent heart disease or stroke, you may be surprised.

• ASPREE (Aspirin in Reducing Events in the Elderly): a study of over 19,000 healthy people ages 65–70 and older (African-Americans and Latino populations have higher heart and stroke risk so they were enrolled in the study at a younger age of 65). The people were not previously taking aspirin and had no history of heart disease, diabetes or stroke.

After almost 5 years, there was no benefit to aspirin but there was a major risk of hemorrhage in the brain and gastrointestinal tract. To everyone’s surprise, there was a slight increase in colon cancer risk too from aspirin. There was also a higher risk of death from any cause in people who took aspirin.

• ARRIVE (Aspirin to Reduce Risk of Initial Vascular Events): a study of 12,500 men and women without diabetes but with at least two other risk factors for heart and vascular disease treated for 5 years. Men were enrolled at age 55 and older. Women were enrolled at age 60 and older. Again to the surprise of everyone — the use of aspirin was not beneficial and yet the risk of serious bleeding and other problems was small but much greater for the people taking a baby aspirin daily.
• ASCEND (A Study of Cardiovascular Events in Diabetes): a study of 15,500 patients ages 40 and older with diabetes but no known heart disease were treated with low dose aspirin for over 7 years. There was a 12% reduction in major heart and vascular events such as heart attack and stroke but this was offset by a 29% increase in bleeding, mainly from the gastrointestinal tract. (Said another way, there was an absolute risk decrease of heart events by 1.1% and an absolute increased risk of major bleeding of 0.9%.) There was no decrease in cancer risk in the aspirin group.

Note: Most of the patients had reasonably good control or treatment of their blood pressure and blood fats at the start of the trial which means they were already doing a lot to reduce their heart risk.

• ACCEPT-D (Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes): a study of 5,000 healthy patients ages 50 and over with diabetes will be treated with low dose aspirin and simvastatin versus simvastatin alone. The results of this trial have not yet been reported.

2019

In May of 2019, JAMA Neurology (Journal of American Medical Association/Neurology) released a comprehensive review of 13 randomized clinical trials of healthy people taking low dose aspirin. They concluded that the use of low-dose aspirin in people without heart or vascular disease significantly increased the risk of bleeding within the brain, referred to as intracranial bleeding.

Bleeding in the brain is considered a major bleeding event. It is linked to higher chances of being impaired (symptoms similar to findings after a stroke) and leads to a higher risk of death.

Those patients of Asian race and those with a lower body mass index (lower BMI) were especially at higher risk of a brain bleed.

Is there any wonder everyone is confused as to the role of aspirin in preventing heart disease? Most experts today now agree that for most healthy people of all ages (especially older adults), without diabetes or heart disease, the risks of taking baby aspirin are likely greater than the benefits.

On the other hand, if you have diabetes or multiple other risk factors for heart disease such as smoking, high blood pressure, high cholesterol or a family history of heart disease at a young age, a careful look at your individual circumstances and conversation with your doctor makes the most sense. If you have multiple other risk factors for heart disease and a low risk for bleeding, your doctor may still suggest you consider low dose aspirin. In the end, the decision about whether to take low dose aspirin or not in these circumstances is yours.

My brother-in-law is 70 years old and he has type 2 diabetes. He has a great diet, exercises daily, has a good family history. He controls his blood pressure and blood cholesterol with medications. He was advised to take daily baby aspirin, “just in case” many years ago. I have asked him to talk to his doctor in light of current research to see if it still makes sense for him. If my brother-in-law would develop a serious ulcer or bleeding problem from the aspirin, I am sure he would question in retrospect whether it was worth it.

MEDICINE IS FULL OF TRADE-OFFS. WHAT MAKES SENSE FOR ONE PERSON MAY BE TROUBLING TO ANOTHER.

But for everyone, it always makes sense to regularly ask your doctor about any medicines you have taken for a long time (called legacy medications). Research findings can change and new information may come to light. Your medical condition and individual circumstances may change too.

Does the recent research change anything for you or a loved one? Is aspirin worth it now that you may be older and have a greater chance of bleeding from the baby aspirin than ever before?

I am over 60 with a family history of fairly early heart disease. I do not take aspirin, although I was tempted to years ago when the results of the Nurses Health Study found it may be a good idea to reduce cancer risk. I also get occasional heartburn too so I wouldn’t want to take the chance of worsening the heartburn from acid reflux or develop an ulcer. I do pay attention to my blood fats (lipids) and blood pressure and live as healthy a lifestyle as possible. I am doing everything I can to keep my heart healthy without adding unnecessary medication to my daily mix.

BODY WEIGHT AND GENDER MAKE A BIG DIFFERENCE WHEN CONSIDERING THE EFFECT OF ASPIRIN AND THE BEST DOSE.

No surprise, there are gender differences in aspirin’s effects. Studies have shown that in men, low dose aspirin works to prevent heart disease. In women, low dose aspirin works to prevent stroke but not a heart attack.

A review of aspirin studies and body weight found that weight really matters when considering the exact dose and benefits of aspirin. Researchers analyzed body weight in a number of research studies. They found that low-dose or baby aspirin (≤100 mg/day) prevented cardiovascular events only in people with a body weight under 154 pounds, whereas regular strength aspirin (≥300mg/day) was necessary for individuals weighing 154 pounds or more.

I worry that the larger strength of aspirin will lead to more bleeding and gastrointestinal complications without a benefit but the findings are intriguing.

Conclusion: Aspirin is a powerful medication that carries more risk than benefit for many seniors. Always talk to your physician about what makes the most sense for you. What are the pros? What are the cons? What matters most to you?

Some of you may be thinking, if aspirin is so dangerous to the stomach, can’t I just take an antacid, or histamine blocker such as Prilosec or Nexium to reduce the risk of bleeding since we know that works?

Although acid-blocking medications such as Prilosec or Nexium can help reduce the stomach irritation and bleeding risk of taking regular aspirin, taking acid-blocker medications for a long time have their own risks. This topic will be the subject of a future blog. As always, it is not that simple.