Drug of Choice

Simple stuff does work.

One of the cheapest drugs in the world is perhaps the most single effective agent in preventing death. The way it works this magic is not how people think.

That drug is aspirin.

Cardiovascular Risk

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? To reduce the risk of bleeding, aspirin’s major deadly side effect. For a long time the anti-clotting effect of aspirin was thought to cause the lower risk of heart attack and infarctive (clot produced) strokes.

But it did increase the risk of hemorrhagic strokes – where the blood bursts out from the artery. It’s real risk was and remains increased bleeding in the gut.

Yet preventing strokes and heart attacks is not how aspirin saves the most lives.

Stopping Cancer

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.)

The analysis, 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 for those tumors exceeded the reduction in incidence. That means the people who got these tumors – if they were taking aspirin – lived longer.

This fit studies of 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, or killing you. There may be evidence that it also cuts the risk of prostate and breast cancer as well – two more of the most common cancers.

One of the real shockers of this meta-analysis was a break down of the number of deaths prevented from cancer versus heart disease. The ratio was 16 to 1 – in cancer prevention's favor.

This also fit with the delay in effect. In the Queen Mary study, taking aspirin did not cut death rates for three years. Taking it for at least five years seemed to produce the most important benefits.

Staying Alive

So here is a drug that much of the world can afford. It has been sold to middle aged people 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.

That effect on tumors – to prevent their appearance, metastasis, and causation of death – looks more than ten fold bigger than its established effect on arteries.

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 – alcohol.

Alcohol plus aspirin is a great way to get the stomach to bleed. Yet many take alka seltzer – for their stomach – without any idea that might happen.

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 a blanket line that everybody should take something without 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 it’s not, you may experience a considerable, long standing benefit.

Drug of Choice

When in medical school I watched the proliferation of journals put out by “disinterested parties” providing medical information to doctors. There seemed something for everyone – for every specialty and clinical interest.

The journals were known as “throwaways.” The articles in them were written by “industry experts,” often famous professors. They were usually paid for by the major drug companies.

My very brief fantasy at the time was to put out a similar throwaway. It would be named “Drug of Choice.” It would look at all drugs, prescription, over the counter, and “other.” What result could they best provide?

These days my first drug of choice would be aspirin. Cancer incidence is increasing around the globe. If used daily and intelligently, aspirin could prevent millions of deaths.

That’s not as much as prevention as supplied through better nutrition and sanitation, vaccination and education. But it’s a lot of people. And it’s where medical care – in the form of prescribed drugs – could make a huge difference.


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