To Aspirin or Not To Aspirin; That Is the Question

Warning:  Daily use of aspirin can lead to side effects which may include total loss of impulse control, man boobs, toe hair, and third nipples.  Please consult your doctor before taking this and other over the counter medicine.

Well, not really. But your really should know the risks and benefits of anything you take, even if it’s over the counter, even if it’s aspirin. I have an early memory, and I cannot have been beyond high school or early college, for I was still going to Friday night services with my Parents-of-Blessed-Memory.  My father would not let me in the choir with the other retired senior types with weak voices; but, it seemed to amuse him to no end when I out sang them and the cantor from the congregation.  The cantor had some kind of a congenital dislocation of the hip and some kind of back pain and I don’t know what else.  My parents had discouraged my still premature medical curiosity and told me not to ask him.

I remember distinctly the Friday when he told the three of us that his doctor told him to take an aspirin a day so he did not get a stroke, as he was a big stroke risk.  We were in the Oneg Shabba, which meant a little wine for many and a lot of sweet cakes for my brother and me. My mother told him to his face to mind his doctor, but the minute he left she told everyone this was the stupidest recommendation she had ever heard.  The doctor was probably playing a joke on him and just told him something harmless to get him the hell out of the way.  This was long before the internet, but during the time when I was doing a lot of research at the Countway Library of Medicine at Harvard. It was not long after that night at synagogue that I read something about aspirin stopping platelets from aggregating.  I once tried to tell my Mother-of-Blessed-Memory, who always wanted to hear what I was reading and learning – although she’d always ask me to “dumb it down” for her.  This is obviously how I became pretty damned good at explaining things.  She never bought the stuff about aspirin.  It made no sense to her, and I only tried to explain it once, before her wincing was plenty enough to make me stop trying.

I should, I suppose, have located and congratulated the cantor’s doctor for trying to put something like that into practice.  I didn’t.  I have now lived to see the recommendations for aspirin use go from 80mg to 325 mg for stroke prevention – from a baby aspirin to an average grown up aspirin.

There’s been a study done in Australia, ultimately picked up by ABC News, showing that aspirin use in older folks may be associated with macular degeneration of the “wet” sort, a major cause of blindness in older folks.  Well, folks over 49 anyway. Egads, I’m ten years past this and still in active denial of aging and trying to pirouette through the living room. This is why medicine is an art, not a science.  Flashback to one of my wonderful medical school professors in France, Dr. Jeanne Orfila.  She taught me many things, one of which was that the hardest thing to do in the practice of medicine was to read research and decide if and how it should change the way you practice.  Flash forward to one of my preceptors in residency, who passed out to a room full of psychiatrists in training, copies of a pharmacology research paper which I thought was particularly useless.  When he asked if anyone had anything to say about it, I criticized profusely and said I would not use that data to alter my practice.  He looked at me, and asked me where the hell I had learned to do that.  Why, in medical school, in France, from a wonderful bacteriology professor.  I never even tried to explain she was a female and was twice as smart and worked twice as hard as everyone else.  I had stolen the preceptor’s thunder.

I found something curious about the ABC News article and chased it back to the original article in the JAMA, Journal of the American Medical Association.  There’s also editorial criticism, which rightfully brings the findings into question.

Aspirin is an amazing drug, with so many effects on so many organ systems.  It affects so many things that it would likely have some trouble getting past the FDA today.  It is still primarily regarded clinically as an antiplatelet aggregant; read anticoagulant that works in the really early stages of clot formation – this is a good thing which other prescription drugs seem to do either poorly or with more side effects.  Our government has listed a lot of other things it can do.  Like inhibiting prostaglandins, which means a lot of good stuff like maybe even helping with the Curse of Eve — menstrual cramps, you heathens — or lowering fevers, etc.  How like our western medicine to go on blithely recommending a drug perceived as harmless, because it has been over the counter for so long, with professional organizations recommending higher and higher doses. The Aussies did a good study for JAMA.  No matter what kind of study they could have done, it is virtually impossible to prove that anything causes anything.  This one is a cohort study that compared folks who took aspirin with folks who did not.  They are, clearly, not the same folks.  They did something statistically nice with nicely structured questionnaires.  Unfortunately, nobody thought of asking why these folks were taking aspirin in the first place.  Maybe they had really good reasons for taking aspirin, like having had heart attacks and trying to stay alive.  Maybe, then, the risk of macular blindness is less important than a life and death risk.  So, not only can we not tell if the aspirin really increased the risk let alone incidence of blindness, but we surely cannot tell whether or not the aspirin is justified. Of course, the individual physician must practice this art the way Dr. Jeanne Orfila said.  The answer is, as for everything else, that the liability is on the physician, who should be thinking about how to get a valid informed consent for aspirin from a patient.  The physician should be determining a risk-benefit analysis for every patient who is told to use aspirin regularly, and should be communicating this to the patient.  There is no time, in general.  It just does not happen. Pharmacists may be more available for talking, but they have less liability. More than ever, physicians must be descended from their pedestals and patients must become smarter advocates.  Ask for risks and benefits for everything you take.  Pharmacy printouts can be a start, but the responsibility is, as always, with the doctors.  Case by case decision is needed, even on something as seemingly small and common as aspirin.