An Aspirin a Day: The Wonder Drug That Could Save YOUR Life

About the Author

Dr Keith Souter graduated in Medicine from the University of Dundee in 1976 and worked as a family doctor in Wakefield for almost thirty years. The general practice at which he worked contributed statistics to the Royal College of General Practitioners Weekly Returns Service and was part of the Medical Research Council’s General Practice Research Framework. As such, Dr Souter was involved in several national trials, including one of the major studies on aspirin.

He has been a medical columnist for twenty-eight years and is a medical journalist, although he still practises medicine. He is a prolific author and has written over twenty books, including eleven novels and several health books, such as Doctors’ Latin, Coping with Rheumatism and Arthritis, 50 Things That You Can Do to Manage Back Pain, and Now You’re Talking.

He is a Fellow of the Royal College of General Practitioners, and a member of the Medical Journalists’ Association, the Society of Authors, the Crime Writers’ Association and International Thriller Writers. He is happily married and has three grown-up children and a granddaughter.

First published in Great Britain in 2011 by

Michael O’Mara Books Limited

9 Lion Yard

Tremadoc Road

London SW4 7NQ

This electronic edition published 2011

ISBN 978-1-84317-718-0 in EPub format

ISBN 978-1-84317-719-7 in Mobipocket format

ISBN 978-1-84317-632-9 in print format

Copyright © Michael O’Mara Books Limited 2011

You may not copy, store, distribute, transmit, reproduce or otherwise make available this publication (or any part of it) in any form, or by any means (electronic, digital, optical, mechanical, photocopying, recording or otherwise), without the prior written permission of the publisher. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

A CIP catalogue record for this book is available from the British Library.

Disclaimer: The information contained in this book is correct to the best of the author and publisher’s knowledge and contains the latest research at the time of publication. It is not an alternative to seeking personalized medical advice. Before anyone commits to taking aspirin on a daily basis, they should have a consultation with their own doctor. Aspirin is not suitable for everyone. Both the author and the publisher disclaim any responsibility from any medical consequences that may occur. Please also note: neither the author nor the publisher has any relationship whatsoever with any pharmaceutical company.

Designed and typeset by E-Type

Illustrations by David Woodroffe

Cover design: Burville-Riley Partnership

Cover image: istockphoto.com

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Contents

Author’s Acknowledgements

Foreword by Professor Tom Meade FRS

A Note on How to Use This Book

Introduction

1 Aspirin: The Highlights

2 Aspirin: The Wonder Drug?

3 The History of Aspirin

4 How Aspirin Works

5 Pain, Fever and Inflammation

6 The Heart and Circulation

7 Strokes

8 Arteries, Veins and Aspirin in Pregnancy

9 Aspirin and Dementia

10 Cancer: A Short Overview

11 Colorectal Cancer

12 Cancer of the Lung

13 Breast Cancer

14 Cancer of the Prostate

15 Aspirin in Diabetes

16 Depression

17 The Skin

18 Unusual Uses of Aspirin

19 Aspirin: Side Effects and Precautions

Conclusion: Aspirin Reflections

Glossary of Terms

References

Index

Footnotes

Author’s

Acknowledgements

I would like to thank Professor Tom Meade FRS for taking the time to write the Foreword to this book, which highlights the need for continuing research into this simple yet very important drug.

I would also like to thank Kate Moore, commissioning editor at Michael O’Mara, both for commissioning the book and for her deft touch with the editorial pen. Thank you too to David Woodroffe for his illustrations.

As always, thanks to Isabel Atherton, my agent at Creative Authors, who started my journey through the history and research on aspirin that has become this book.

And finally, thanks to my wife Rachel for her support during the many long hours when I was working away in my study.

Foreword

by Professor Tom Meade FRS

Only forty years ago – quite a short time as these things go – aspirin was really only used for pain relief and for lowering the temperature during fever. True, laboratory studies in the late 1960s had shown that aspirin inhibits platelet clumping or aggregability. However, it was not until 1974 that the first trial of aspirin in secondary prevention, i.e. in men who had already had a heart attack (myocardial infarction), was published in the British Medical Journal from the MRC (Medical Research Council) Epidemiology Unit in South Wales.¹ It was a small, underpowered trial and not much notice was paid to it at the time. But the same group published another trial soon after, and gradually other investigators carried out their own secondary prevention trials. It was the large international ISIS-2 trial² published in The Lancet in 1988 that made the greatest impact. The trial was a factorial evaluation of two drugs, aspirin 160mg (enteric coated) and streptokinase 1.5 MU infusion, soon after the onset of myocardial infarction. Each agent on its own lowered vascular mortality within the next 35 days by about 25 per cent, while the rate was reduced by just over 40 per cent in those allocated to both agents. A survey soon after the trial showed that the trial had had an unusually swift and quite remarkable effect on clinical practice, so that the combination of aspirin and streptokinase became virtually routine treatment in those with recent onset myocardial infarction.

By 2002 the Antithrombotic Trialists’ Collaboration³, having gathered the individual patient data from all the secondary prevention trials that had been carried out, left no doubt that aspirin reduced serious vascular events by a quarter, vascular mortality by a sixth, non-fatal myocardial infarction by a third and non-fatal stroke by a quarter. It was clear that the benefit of aspirin greatly outweighed the risk of serious bleeding, so that aspirin in those who had had cardiac or vascular episodes at other sites became standard treatment for both short- and long-term secondary prevention.

The value of aspirin in secondary prevention raised the obvious question – would it be useful in primary prevention as well, that is, preventing first episodes in those who had not previously experienced any? So far, six primary prevention trials have reported and their combined experience was written up in The Lancet in 2009.⁴ As with secondary prevention, aspirin resulted in a large reduction, by about 20 per cent, in non-fatal heart attacks. But, unlike the secondary prevention results, there was no clear benefit in terms of either stroke or death from fatal heart attacks. Vascular mortality was not reduced. Compared with secondary prevention, these results are puzzling. On the one hand, it is reasonably argued that there is a continuum of severity of pathological changes in coronary arteries, so that it is hard to imagine a point at which aspirin confers no benefit but then becomes beneficial. On the other hand, it shouldn’t be assumed that the pathological background and the responsiveness to aspirin are necessarily the same in those previously affected or unaffected by clinical events.

Whatever the explanation, one clear contrast with secondary prevention has emerged. While the benefit attributable to aspirin in those who have previously had vascular events clearly outweighs the risk of serious bleeding, the same can’t be said in the context of primary prevention, where benefit only begins to outweigh hazard in those at high risk of events. This should make doctors recommend aspirin only cautiously to patients who haven’t had heart or stroke problems. Furthermore, it may be that those who self-medicate with aspirin through over-the-counter purchases are potentially doing themselves more harm than good.

Very recently, aspirin has sprung another surprise – the likelihood that after it has been taken for about five years, it reduces mortality rates from several cancers by substantial amounts, particularly those of the gastrointestinal tract.⁵

Aspirin therefore benefits the two major causes of death – cardiovascular disease and cancer. The findings on cancer need to be taken into account along with those on vascular disease, tipping the previous balance more towards benefit than harm. In primary and secondary prevention of vascular disease and taking account of its effect on cancer mortality as well, it seems that an aspirin dose of 75mg daily is as effective as higher doses, with almost certainly less risk of serious bleeding.

Aspirin is cheap and, provided it is used with care, it is relatively free of serious hazards, though the possibility of serious gastrointestinal or cerebral bleeding should not to be overlooked. Whoever you are – medical professional or lay reader – what single medication would you choose if you could only have one from now on? Might it be aspirin?

Drawing on his years in general practice and on his writing skills, Dr Keith Souter is ideally placed to answer these and other questions about aspirin.

Professor Tom Meade FRS

A NOTE ON HOW TO

USE THIS BOOK

It is not the intention of the author or of the publisher that readers should regard this book as a substitute for a medical opinion from their own doctor. Indeed, its aim is to lay before the interested reader information about the history, science and research that has been done on aspirin over the years, presenting the results so that readers can learn more for themselves about this extraordinary drug.

Low dose aspirin has undoubted potential benefits for many people, provided that there are clear indications as to why it could help them reduce their risk of various conditions. On the other hand, aspirin does have a number of potential side effects, some of which are very serious.

No one should just start taking regular aspirin. Before anyone commits to taking this drug on a daily basis, they should have a consultation with their own doctor in order to assess their level of risk for the various conditions discussed in this book. This should be balanced against the risk of any of the side effects that are possible. If you have risk factors for several conditions, e.g. both cardiovascular disease and some types of cancer, then your decision may be fairly simple.

The question of whether or not someone who is currently well, with a seemingly low risk of cardiovascular disease or cancer, should take aspirin as a primary preventive is more difficult. If you are simply considering it as a preventive against one group of diseases, then you may be swayed against taking it because of the risk of side effects. If you are considering its potential against both groups, then you may consider that the benefits far outweigh the risks. A look at the research that has been done on aspirin in these different areas may help you to make that decision.

In order to compile this book, I have read a vast number of research papers on aspirin. At this point I feel I should add that the interpretation of those trials and papers is mine alone. I have aimed to be accurate and present findings in as clear a manner as possible, in order to give a balanced view about the drug.

Essentially, the whole reason for this book is to help both the reader and his or her doctor come to an informed decision about whether they should consider using aspirin as a preventive agent against cardiovascular disease, cancer, Alzheimer’s disease, or other conditions – an aspirin a day.

Dr Keith Souter

A note on the glossary

I have at all times aimed to make this book accessible to everybody who has an interest in learning more about aspirin and its potential for health, regardless of medical knowledge and training.

To that end, I explain any medical terms used in the book when they are first introduced, and I have also compiled a glossary of terms as a one-stop reference point, in case you encounter an unfamiliar phrase later in the book.

I suspect some readers may consult only those chapters relevant to their own health concerns, and would therefore like to point readers in the direction of the glossary of terms located at the back of this book here, which I hope will be of use.

INTRODUCTION

Ihave always had a healthy respect for aspirin. This predates my entrance to medical school by a dozen years and my qualification as a doctor by eighteen years. Quite simply, aspirin transformed my father’s life.

According to my mother, our family doctor told her that aspirin actually saved his life. In retrospect, I do not think that his life was actually at risk at that time, although he undoubtedly had a case of rheumatic fever, some of the complications of which can be extremely serious.

I vividly remember the treatment he was given with large doses of aspirin, the daily visits by the silver-haired doctor, and the sense of relief in the family when the sick room, from which I was excluded, became instead a visiting room, where I could see my father recover and convalesce.

In a sense, aspirin was one of the reasons that I decided to become a doctor myself.

When I was at medical school, aspirin was going through one of its periodic falls from favour. New drugs had been developed that had bypassed it in popularity, so that it had become regarded as little more than a household remedy.

Then some spectacular research revealed that aspirin was anything but a remedy to be despised and disparaged. It had beneficial effects that no one had realized before when it was taken in low dose, just an aspirin a day.

Over the last thirty-five years, I have been fascinated to see the continued rehabilitation of aspirin. In low dose, it proved to be effective in reducing the risk of having heart attacks and strokes, and also seemed to reduce the risk of some types of cancer. Gradually, the number of conditions that it reduces the risk of having has increased. Most recently, a huge study covering 25,000 patients (from Oxford University and several other centres) has shown that a small daily dose of aspirin could substantially reduce the overall cancer death rate when it has been taken regularly for a period of five years or more.

Before I became a medical journalist, I was the partner responsible for research and for coordinating data collection within my general practice, which was one of the contributing practices on the Medical Research Council’s GP Research Framework. I was delighted when one of the trials we worked on showed a positive result in terms of aspirin’s ability to reduce the risk of having a first heart attack. I am proud to have contributed, albeit in a very minor way as a mere data collector, to a trial that has had an impact upon clinical practice.

Since then, more and more research has been published about aspirin, the way