Drug of Choice (8/13/14)
An Old Miracle?
Simple stuff does work.
One of the cheapest drugs in the world is perhaps the most single effective agent in helping populations stay alive. The way it works this magic is now recognized as completely different from past theories.
The drug is aspirin.
For decades people throughout the world have been taking aspirin to prevent heart attacks and strokes. The doses have been progressively reduced, from the standard 325 mg pill to ones of 75, 81, or 100mg.
The reason for smaller doses? To reduce the risk of bleeding, aspirin’s most deadly side effect. For a long time the anti-clotting effect of aspirin was thought to cause a lower risk of heart attack and infarctive (clotting based) strokes.
But aspirin did increase the risk of hemorrhagic strokes – where the blood bursts out from the artery. Its more serious risk was and remains bleeding in the gut.
Yet preventing strokes and heart attacks is not how aspirin saves the most lives.
Many analyses and meta-analyses have been performed about aspirin’s effectiveness. One of the most recent, from Queen Mary College, University of London, put together the results of two hundred research projects http://www.bbc.com/news/health-28656812.
Its conclusions, for men and women over fifty:
Colon cancer rates went down by about thirty five percent.
Esophageal and stomach cancer rates were cut by thirty percent.
Perhaps more interesting, the death rate reduction exceeded the reduction in tumor incidence. That means the people who did get these tumors – if they were taking aspirin – lived longer.
This fits studies of the past year, involving long term epidemiologic studies of cancer incidence and course. They found aspirin cut the risk of cancer metastasis – often substantially.
So aspirin cuts the risk of getting colon, esophageal, and stomach cancer. It cuts the risk of cancers becoming metastatic. It further decreases overall cancer death rates. There is also evidence that it cuts the risk of prostate and breast cancer as well – two major cancers.
Perhaps the real shocker of the Queen Mary meta-analysis was a break down of the number of deaths prevented by aspirin. The ratio of cancer/heart disease deaths prevented was 16 to 1.
This accords with delays in aspirin’s effectiveness. Taking aspirin did not cut death rates for three years. Taking aspirin daily for at least five years seemed to produce the real benefits – cutting cancer. The effects on clotting are far quicker.
So here is a drug that much of the world can afford. It has been sold everywhere first to allay pain and inflammation, and secondarily to prevent heart attack and stroke. Now it turns out it has a major impact on the some of the most common cancers.
This effect on tumors – to prevent their appearance and metastasis and to decrease death rates – looks more than ten fold bigger than its established effect on arterial related deaths.
Cancer incidence has been rising worldwide. Does that mean every middle aged person should be taking aspirin? No.
The Risk of Bleeding
Lots of things cause the gut to bleed. Stress in its near infinite permutations can promote gut bleeding. So can many drugs.
One of the most popular drugs that causes GI bleeding is alcohol.
Alcohol plus aspirin is an unfortunately effective way to make the stomach bleed. Yet many take alka seltzer – for their stomach pains – without any idea that combination is a problem.
Recently, journalists asked me to endorse a recommendation that people take drugs – the NSAIDS, developed to mimic aspirin – in order to prevent hangovers when drinking.
I told them they were crazy. Hangovers are bad. Bleeding in the gut can be much, much worse.
And if everyone takes aspirin, some populations may come close to doubling their risk of GI bleeding.
So as with most public health recommendations, you can’t give this blanket line that everybody should take something without many preconditions.
You better ask your general physician whether, given all the drugs you take, and your own health, whether aspirin is risky for you or not.
If she says your risk is low, you may experience prolonged benefits.
Drug of Choice
When in medical school I watched the proliferation of free for physician journals put out by “disinterested parties.” There seemed to be a journal for every imaginable subspecialty and clinical interest.
These publications were known as “throwaways.” The articles in them were written by “industry experts,” often well-regarded professors. These articles were usually paid for by the major drug companies.
My very brief fantasy at the time was to put out a different kind of specialty journal. It would be named “Drug of Choice.” All drugs – prescription, over the counter, and “other” – would be considered for their “best use.”
These days my first drug of general choice is aspirin. Cancer incidence is increasing around the globe. If used daily and intelligently, aspirin could prevent millions of deaths.
That’s nothing as significant as the public health effects of improved nutrition and sanitation, vaccination and education. But it’s where medical care – in the form of prescribed drugs – could make a big difference.
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