HAILED as a panacea or a pill for all ills, aspirin, or acetylsalicylic acid as it is generically known, is one of the oldest medicines on the market.
The name “Aspirin” was trademarked by the German pharmaceutical company Bayer over 100 years ago, yet acetylsalicylic acid, extracted from plants including willow and myrtle, has been used as far back as 4,000 years.
It is easy to see why it has garnered such enthusiasm. As the first discovered non-steroidal anti-inflammatory drug (NSAID) it is an effective painkiller for ailments as diverse as cold and flu symptoms, joint and muscle aches as well as menstrual disorders and migraines.
As an anti-clotting agent, it prevents platelets clumping together, one of the pathways that results in complete blockage of a blood vessel during heart or stroke.
Easily available over the counter, it and paracetamol are the go-to drugs if you need analgesia, but don’t want the numerous unpleasant side effects associated with stronger painkillers.
The role of aspirin in acute cardiovascular events, such as suspected heart attack and ischaemic stroke, as well as in secondary prevention, to reduce the chance of a further incident are established and agreed.
It is also approved in the treatment and prevention of repeat deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as atrial fibrillation (AF), although other medications are often preferentially offered.
However, advice is changing as to the role of aspirin in preventing a first heart attack or stroke, known as primary prevention, even in those with risk factors.
The American Preventative Services Task Force has issued draft guidance advising older adults, classified as those over 60, shouldn’t take low dose daily aspirin to prevent a heart attack, as the risks of bleeding outweigh any potential benefit.
The evidence is that low dose aspirin may benefit those in their forties with risk factors for heart attack and stroke, but without risk factors for bleeding, yet by the time individuals reach their fifties, risks may outweigh benefits.
Although this contradicts the same body’s guidance from 2016, it must be remembered that scientific developments will often make obsolete previous recommendations.
Thankfully the UK Guidelines on aspirin are pleasingly clear, reminding us aspirin is not licensed for the primary prevention of cardiovascular disease (CVD), with other medications such as statins for raised cholesterol, as well as lifestyle modifications first line.
Aspirin is no longer recommended for primary prevention in those with type 1 or 2 diabetes. For pregnant women who are at high risk of pre-eclampsia, it may be prescribed by an obstetrician, but it is not routinely promoted for all pregnancies.
Previously it was suggested that it reduced the risk of colorectal cancer, yet again this is no longer clear, apart from for individuals with Lynch Syndrome, a condition which predisposes to the development of certain malignancies.
It should not be used routinely in those under 16 as it may cause the life-threatening condition Reye’s Syndrome, which results in swelling of the brain and liver.
The biggest issue with aspirin is its availability over the counter, hence patients may take low dose aspirin without full appreciation of the risks, with doctors in the dark as to the fact that a patient is taking it in the first place.
Long-term low dose aspirin may cause stomach inflammation, an ulcer and in the worst-case scenario, a life-threatening gastrointestinal bleed. A frail elderly person on aspirin who falls will be at higher chance of a bleed in the brain, again potentially fatal.
Aspirin interacts with several commonly prescribed medications to increase risk of bleeding, namely antidepressants.
Some may unwittingly take aspirin and another medication from the same class of drugs (ibuprofen, naproxen or diclofenac), also elevating the potential for harm.
To hopefully simplify the situation, I would advise the following:
l There is no need to routinely take an aspirin to prevent heart attack, stroke or the development of a clot in the leg or lung.
l If you have been prescribed aspirin by either your GP or a hospital specialist, please continue to take this and if you are concerned about any potential side effects, please discuss this with your routine GP.
– If you are considering going on aspirin as you are worried about your risk of heart attack or stroke, talk to your GP beforehand to be fully aware of the risks and benefits.
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