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CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
9/6/2001

The Wonders of Aspirin

 Of all the many drugs stocked in our pharmacies, aspirin is still one of the most commonly used. The therapeutic value of willow bark which contains the active ingredient of aspirin was known to the ancients. The modern use of aspirin began in 1899 when the German chemical firm known as Bayer introduced the chemical acetylsalicylic acid more commonly known as aspirin. It was touted then as treatment for pain, arthritis and to lower fevers. Through the years, its wonderful therapeutic value has not diminished in spite of the introduction of many similar products such as ibuprofen (Motrin), Naprosyn (Aleve), and Ketoprofen (Orudis). Each of these four products are variably effective in certain individuals and a different product more effective in another individual yet they still remain the mainstay of treatment for chronic wear and tear arthritis so common in our elderly population.

In 1969, Dr. John Vane working in England made a most extraordinary discovery. He was aware that some people who took aspirin seemed to develop bleeding tendencies. Tests had been done on such people and it was noted that even in individuals who were normal, using only one or two aspirin per day could prolong the length of time the small test cut on a person's arm would take to clot and stop bleeding. Dr. Vane was working with something called platelets which are one of the main clotting factors in blood. Platelets are very tiny pieces of tissue that are pivotal in forming the blood clot. Normally, when an injury occurs, such as a cut or a scratch, platelets come along and stick to the injured surface. Somehow, once a platelet is stuck to an injured surface, that platelet itself becomes very sticky and more platelets stick to that.

Pretty soon, a blood clot grows and the bleeding stops. This function was obviously very important to our ancestors in evolution because injures in the bad old days were a common cause of death. Today, the ability to form a blood clot is still useful but not as pivotal to survival as it was thousands of years ago.

Today, platelets sticking to each other is the leading cause of death in our society. Normally, inside of our blood vessels, platelets run over a magic smooth surface and clots do not form inside the blood vessels in the body. But, if an injury occurs, such as a nick or a scratch in a blood vessel due to an injury, then platelets stick to that surface. A clot can grow and stop that blood vessel up. If that blood vessel happens to be in the heart, the result is called a heart attack. If the injured blood vessel happens to be in the brain, it is called a stroke. Thus, platelets stopping up blood vessels at injury sites inside our body are a leading cause of death today.

What John Vane discovered was that if a person took an aspirin per day, their platelets would not stick to each other and a clot would not grow. Most remarkably, the platelets would still stick to an injured surface. The difference was that aspirin prevented all of their buddies from piling on, growing a big clot and stopping the blood vessel up. Now that was amazing. That showed that what starts a blood clot and what makes a blood clot are two different things. At that time, the pivotal role of the growth of a blood clot in causing strokes and heart attacks to stop up blood vessels was not appreciated. But as our understanding of how heart attacks and strokes occur developed over the last 20 years, it became apparent that aspirin was probably the single most important drug a person could take to prevent strokes and heart attacks because it prevented a clot from growing at injury sites to blood vessels in our body.  The real importance of this comes from the fact that high blood pressure, cigarettes, diabetes mellitus and high cholesterol are the four major risk factors for heart attacks and strokes.  These four risk factors cause nicks and scratches and bumps on the insides of the blood vessels of the body. For some reason, the most common sites for these nicks and scratches are on the blood vessels in the heart and the brain. Without aspirin, clots can form and grow and results can be mortal.

Studies done in the 1970s and 1980s demonstrated that individuals who took an aspirin per day had a significantly lower heart attack and stroke rate than those people who never took aspirin. More recently, it has been recommended that individuals who are having chest pain that might represent a heart attack can actually stop a heart attack in process by taking an aspirin at the time that the chest pain is occurring. That aspirin should be chewed and swallowed and it works remarkably well in the early stages of a heart attack when the clot is still growing but has not completely obstructed the blood vessel. Thus, by a strange twist of fate, a pill that started off to stop fevers and arthritis aches turns out to be our best public weapon to both prevent and reverse heart attacks in process.

An additional and little known observation is that aspirin prevents cataracts. The mechanism of this effect is unknown but it has been observed in individuals with rheumatoid arthritis who took large doses of aspirin. It was noted that they had a significantly less risk of cataracts.

No discussion of any drug is complete without mentioning the potential for side effects. Anyone who has used a large amount of aspirin in a short period of time has learned that it can cause severe gastritis and in some people bleeding ulcers. This is because the same chemical process that causes arthritis is used to generate chemical compounds that protect the stomach from itself. It has always been a wonder to me why it is our stomach can dissolve meat and potatoes and peas and carrots and corn and yet does not digest itself. This is because the stomach generates a protective chemical layer that prevents its digestive juices from attacking itself. Aspirin turns these protective juices off and the stomach can indeed digest itself if a person takes large amounts of aspirin.

Recently there were notices in the newspaper and on television that the two new arthritis drugs called Celebrex and Vioxx can cause heart problems. Vioxx is somewhat more of a risk than Celebrex but then it is the more potent medication for preventing pain. Celebrex perhaps is somewhat better for preventing arthritis. Be that as it may, neither of these products are any more or less dangerous than aspirin, Motrin, Aleve or Orudis. They can cause some degree of salt retention and raise blood pressure. Thus, if a heart is struggling with high blood pressure problems to begin with, any one of these six products will tend to raise the blood pressure a little further and can get a person marginally balanced into trouble. It would be my opinion that Celebrex is the safest of the lot, although it is not a good primary pain medication.

The other side effects that can come from aspirin and be a major problem are allergic reactions. There are some people who are exquisitely sensitive to aspirin and can develop sudden asthma attacks or episodes of hives with just a single aspirin. Obviously, these people have to be very careful to avoid any product that has aspirin in it.

The last question to consider is the right dose of aspirin. Some people talk about baby aspirin at 81 mg per day or "low-dose" aspirin twice a day or should a person take a standard 5 grain aspirin tablet? Should a person use Bufferin or aspirin or Ecotrin? The best information we have at this time is that a standard 5 grain aspirin tablet protects most people if they can tolerate it. If side effects occur with a standard 5 grain aspirin tablet, it is recommended that the "low-dose" or 2 grain aspirin tablet be used instead. The baby aspirin at 81 mg or 1 grain size is probably not enough to protect the general public from heart problems. It may sound extreme but there are some people with rheumatoid arthritis who take 20 adult aspirin pills per day and need that much in order to avoid the pain and suffering that comes with rheumatoid arthritis. As a general rule, anyone taking more than seven aspirin tablets per day is probably having some gastric irritation and a small amount of bleeding. The amount of bleeding may not be enough to cause problems but it can be detected in the person's stools. The right dose is the lowest dose that works for the individual person.