To Take or Not to Take, that is the Question?

In Shakespeare’s Hamlet there is a famous quote, “To Be or Not to Be, that is the Question?”. In healthcare there is a similar idea, “To Take , or Not to Take, that is the Question?”. In addition, in healthcare, as in all science, ideas are constantly changing, as we learn new knowledge. It can be said that the only thing that does not change is change itself. This short article is about the conditions that are indicated currently for aspirin use.

First, a little history. Salicylates, which aspirin is an example of, were first derived from the bark of the willow tree, genus Salix, thus the name salicylates. The Sumerians, some 4000 years ago, used remedies from the willow bark to treat pain.  Apparently, Hippocrates (460-370 B.C.) used the willow bark to treat pain and fever. He also made tea using willow bark for pain management during childbirth. In 1763, Reverend Edward Stone, studied the effects of willow bark powder in the first of its kind clinical trial for treating fever. Professor Johann Buchner, in 1828,  first used the word salicin, the Latin for willow. It was used to treat rheumatism by Henri Leroux after isolating it in crystalline form in 1829. During the 1800’s the Heyden Chemical Company was the first to mass produce salicylic acid for commercial use. In 1899 the Bayer Company in Germany modified the salicylic acid to acetylsalicylic acid, which it registered and trademarked under the name we now know as aspirin. Aspirin was used for decades without knowing how it actually produced effects. It was not until the 1970s that its mechanism of action was finally deduced. Aspirin was widely used during the Great Influenza (Spanish Flu 1918-1920). It was prescribed as much as one gram every 3 hours to combat the fever of influenza; normal adult routine doses currently are at 650 mg every 6 hours. However, at that time it was a very new drug and the bleeding risk and pulmonary edema associated with high doses of aspirin use was not widely known. It has been postulated that the large frequent doses of aspirin may have contributed to the many deaths of the Great Influenza.

Currently, aspirin is indicated in the treatment of the following conditions:

• Angina pectoris
• Angina pectoris prophylaxis
• Ankylosing spondylitis
• Cardiovascular risk reduction
• Colorectal cancer prevention
• Fever
• Ischemic stroke
• Ischemic stroke prophylaxis
• Myocardial infarction
• Myocardial infarction prophylaxis
• Osteoarthritis
• Pain
• Rheumatoid arthritis
• Systemic lupus erythematosus

Most of us are familiar with regular aspirin tabs, 325mg, and the low-dose aspirin, 81mg. But it is also available as a suppository.

Now the question is Who should avoid aspirin? There is a condition called Reye’s Syndrome that is linked to aspirin use in children recovering from a viral disease. The symptoms include:

• Persistent or recurring vomiting
• Listlessness
• Personality changes such as irritability or combativeness
• Disorientation or confusion
• Delirium
• Convulsions
• Loss of consciousness

There is no cure for Reye’s Syndrome. Treatment involves the reduction of any damage from the swelling of the brain. Some individuals recover completely, while others sustain brain damage. With other agents available for fever and pain, it is highly recommended to avoid aspirin use in children.

According to the latest atrial fibrillation guidelines from the American Academy of Family Physicians, chronic anticoagulation is recommended unless the patient has a low risk of a stroke. The options for anticoagulation does not include aspirin. The recommended options are warfarin, apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Lixiana/Savaysa), or rivaroxaban (Xarelto). The reason that aspirin is not recommended is that the risk of harm from bleeding is greater than the benefit from the antiplatelet effects (blood thinning). However, if you have been diagnosed with atrial fibrillation and are currently on a daily aspirin, please do not stop taking the aspirin until you have consulted your medical provider. They may want you on the aspirin for other indications. Other conditions that avoidance of aspirin is recommended by the FDA are pregnancy, uncontrolled high blood pressure, bleeding disorders, asthma, peptic (stomach) ulcers, liver, and kidney disease.

Aspirin turns out to be a very useful and effective medication, but it should not be taken without consideration and medical advice if a person has a chronic health condition.

Prosper and be in health.