Tag: aspirin

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Low Dose Aspirin Increases the Risk of Upper Gastrointestinal Bleeding

Aspirin bottle. (iStockphoto)
Aspirin bottle. (iStockphoto)

Low-dose acetylsalicylic acid – also known as aspirin – (75 mg⁄day to 325 mg⁄day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB), according to a study published by Valkhoff and his colleagues (Can J Gastroenterol. 2013 Mar;27(3):159-67).

They analyzed several studies. All studies found low dose aspirin use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with low dose aspirin use was 1.2 per 1000 patients per year. Sounds like a small number when you think of the number of people who take aspirin all over the world. But the authors indicate use of low dose aspirin was associated with a 50 per cent increase in UGIB risk.

What about other anti-inflammatory drugs? Are they safe?

Commonly used traditional anti-inflammatory drugs like ibuprofen are also known as non-steroidal anti-inflammatory drugs (NSAID) are widely used for all kinds of pain. An editorial by Jacob Josh, Professor of Medicine, University of Ottawa, Ottawa, Ont. titled, “Anti-inflammatory drugs: What is safe?” (CMAJ August 29, 2006), says “Sixteen thousand deaths a year in the United States and 1900 a year in Canada were blamed on NSAID-induced gastric perforations, obstructions and bleeds. NSAID use was complicated also by numerous other side effects, including hypertension, heart failure and renal insufficiency.”

The risks are not limited to long-term use. Clinically significant adverse cardiovascular events are noted within the first 30 days of treatment.

Do you always have to take an NSAID if you are in pain and thus increase the risk of complications? Not really. You can try other modalities of pain relief by rest, application of ice and use of acetaminophen. Acetaminophen, up to 4 g/day, is as effective as an orally administered NSAID in about 40 per cent of patients with mild to moderate osteoarthritis.

Then there are occassions when pain cannot be relieved by what we call conservative measures. So we have to weigh our options. First, we should assess patient risk. There is an increased risk of gastric toxicity if:
-the patient is over 65,
-has had previous upper GI bleed,
-there is concurrent therapy with low-dose aspirin, corticosteroids or anticoagulants.

Under these conditions we should try prescribing a coxib (like Celebrex) or traditional NSAID with concurrent cytoprotection (to protect the stomach lining) with misoprostol or a proton pump inhibitor. If the patient has had a recent heart attack or episode of congestive heart failure, then he should not take NSAID or coxib.

Josh says, “In case of uncontrolled hypertension, we should not choose an NSAID or coxib until the blood pressure is well controlled. If the patient has controlled blood pressure that becomes elevated while taking an NSAID or coxib, even by 5 mm Hg systolic, adjust the antihypertensive medications or stop the anti-inflammatory, or both.” Monitor renal function as well.

Josh says there is nothing like a safe NSAID or coxib. In high-risk patients, we should avoid them. Concomitant use of low dose aspirin does not protect you from cardiac side-effects of NSAID or coxib. There is adequate data to suggest aspirin enhances the gastric toxicity of anti-inflammatory drugs as mentioned earlier.

If you are in pain, careful use of painkillers is very important. If you are taking aspirin as a prophylaxis against cardiac problems then weigh your risk factors and your options. If you are taking NSAID for chronic pain then you need to know your risks. Discuss risk vs. benefits of the medications you are taking with your doctor.

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Asprin and Colon Cancer

Dear Dr. B: Does aspirin prevent colon and rectal cancer?

Answer: In the past there have been numerous reports supporting the protective effect of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) on the development of cancer.

But a recent study from the Harvard Medical School, published in the Journal of the American Medical Association (JAMA), concluded that low doses of aspirin (100 mg) taken over a long period of time (10 years) do not help prevent colon cancer. In fact, the researchers found that low-dose use of aspirin had no effect on total cancer, breast cancer, colorectal cancer or cancers at any other sites, with the exception of lung cancer. Again, the findings on lung cancer were not conclusive.

In another study, the researchers found high doses of aspirin (14 tablets of 325 mg. aspirin in a week) taken over 10 years can prevent colorectal cancer by 53 per cent. This study involved 80,000 women. If you take six to 14 aspirins a week you reduce your risk by 22 per cent.

This information is important for individuals who are at a high risk for development of colon cancer because of personal or family history. But there is a risk involved when aspirin is consumed. For every one or two women who were protected from cancer, eight developed serious bleed from the stomach and intestine.

Aspirin is not the magic pill for prevention of colorectal cancer. But there are other things one can do to prevent colorectal cancer. Limit consumption of red meat and processed meat. Maintain normal body weight. Have a regular rectal examination after the age of 40. Have your stool checked for occult blood. Report any alarm symptoms to your doctor because you may be a candidate for further investigations involving barium enema and flexible sigmoidoscopy or colonoscopy.

These investigations are also used for screening. All screening tests have advantages and disadvantages and none of the screening tests have 100 per cent accuracy rate. Screening for colorectal cancer is important and should be encouraged among healthy asymptomatic Canadians who are 50 years of age or over. But the ideal method of screening remains controversial.

There is no controversy when it comes to patients who have alarm symptoms. The alarm symptoms are: rectal bleeding, change in bowel habit, anemia, change in the caliber of your stool, loss of weight and abdominal mass. These complaints should be investigated early as colorectal cancer is the second most common cancer among Canadians and affects men and women equally.

Something to think about!

Peter Mansbridge, Chief Correspondent of CBC Television News and Anchor of The National writes in his Macleans column, “The war on terror now enters its fifth year, making it as long as the First World War, almost as long as the Second, and longer than the Korean war.” He goes on to say that as in all wars, most of the dead are young, some very young.

“Each week there seems to be at least one 18-year-old listed. That means that on September 11, 2001, those youngsters were barely in their teens – just 13 or 14. Barely into high school… Now they are dead soldiers.”

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Aspirin

Recently, I saw a 36 year old man in my office with bowel problems. His first question was: Doc, should I take an aspirin a day to prevent colon cancer?

First, let us look back in history.

Hippocrates and the Indians of North America have known the pain killing properties of willow bark, which contains salicylates (aspirin is acetylsalicylic acid), for many hundred years.

Besides it being a painkiller, it also reduces inflammation and fever. Commercially, aspirin became available in 1899 as a result of a search by Felix Hoffman at Bayer Industries to help his father who suffered from rheumatoid arthritis.

By the 1960s, aspirin became the most widely used pharmaceutical product in the world. For example, in U. S. alone, the annual production of aspirin is over 15,000 tons (13,600 metric tons).

In 1985, researchers first established that aspirin can prevent heart attacks. If you have chest pain and are suffering a heart attack, then taking an aspirin will reduce your chance of dying from heart attack by 25 per cent. It also reduces the risk of a second heart attack by 50 per cent. For patients who have suffered a stroke, it offers protection from a second one.

So, what about cancer prevention?

For the last 25 years, researchers have been saying that aspirin, ibuprofen and other anti-inflammatory drugs may play a role in preventing cancer. Studies have found that it could reduce the risk of both colorectal cancer and mouth and throat cancers by two-thirds.

In one recent study, women who took a single ibuprofen tablet at least three days a week for 10years or more saw their risk of breast cancer fall by 49 per cent.

Women who regularly took aspirin saw their risk of breast cancer drop by only 28 per cent.

There is also some evidence that ibuprofen may offer more protection from Alzheimer’s disease. Canadian researchers have shown that ibuprofen may reduce the risk of getting Alzheimer’s by up to 30 per cent.

If this is all true then why physicians do not promote the use of aspirin and ibuprofen as a prophylactic for cancer prevention?

The above findings are from retrospective studies – they look back at men or women who were taking these products for other illnesses and see if they suffered from specific cancers compared to those who did not take aspirins or ibuprofens.

There are no prospective randomized double blind trials to prove that aspirin or ibuprofen is what prevents cancer. There may be other variables which may influence the outcome. Prospective randomized double blind trials eliminate those variables.

Many doctors are cautious about the idea of healthy people taking aspirin or ibuprofen in the hope of preventing disease. More studies are needed to confirm that the benefits outweigh the risks. They don’t know what dose is appropriate, or how many years the drugs must be taken before they offer protection.

These drugs are not always harmless. Internal bleeding is a serious risk. The painkillers can also interact dangerously with other drugs.

Recently, the Globe and Mail wrote, “Randall Harris, a respected professor of epidemiology at Ohio State University, didn’t follow the cautious approach when he announced the results of the breast-cancer study. Instead of recommending waiting until more studies are done, he urged women over the age of 40 to talk to their doctors about taking a standard dose of ibuprofen (200 milligrams) or aspirin (325 mg) daily.”

But there are other reports which say that taking ibuprofen may undo the protective effect of aspirin.

Are you confused? So are the doctors! But my answer to the young man is – there are many other ways of preventing cancer (remember ELMOSS?) – rather than looking for a miracle drug.

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Asprin and Heart Disease

“Approximately 25 percent of the reduction in the rate of death from coronary artery disease that has occurred during the past 30 years may be explained by the practice of primary prevention,” says Dr. Michael Lauer, of Cleveland Clinic Foundation, in an article in the New England Journal of Medicine (NEJM).

What is primary prevention?

Primary prevention involves a deliberate treatment of a person with established risk factors for heart disease although the person has no clinical symptoms or other evidence of heart disease. The purpose is to prevent cardiac events like heart attack.

What are the risk factors for heart disease which can be target of primary prevention?

There are several of them: high blood pressure, smoking, high cholesterol level, sedentary (much sitting and little exercise) life style, platelet activity (a type of blood cell which can stick together and block coronary arteries) and inflammation.

Family history of heart disease is a risk factor as well but there is not much you can do to change that!

What is the role of aspirin in primary prevention?

Aspirin has both anti-platelet and anti-inflammatory effects. In 1970s, studies suggested regular aspirin use could reduce the risk of heart attack and death from coronary artery disease, says the NEJM article. More recent studies have confirmed this although many aspects of aspirin use are uncertain.

The article’s conclusions are:

-Aspirin use probably reduces the risk of heart attack in men over the age 50 years. It is unclear whether women have the same sort of benefit as men.
-The decision to initiate aspirin therapy should be based on assessment of absolute risk of a heart attack.
-For prevention of heart attack, low doses of aspirin (100 mg per day or less) are adequate. For prevention of stroke, low-dose aspirin is just as effective as high-dose therapy.
-Observational studies have suggested that aspirin may prevent cancer of the colon, esophagus, stomach, and rectum. But this has not been confirmed.
-Aspirin use can cause bleeding. Most common site of major bleeding (bleeding leading to death, transfusion, or surgery) was the gastrointestinal tract. It can cause minor bleeding like nose bleeds and bruising as well.

Aspirin is also called Acetylsalicylic Acid, derivative of salicylic acid that is a mild, non-narcotic pain killer useful in the relief of headache and muscle and joint aches. Aspirin is also effective in reducing fever, inflammation, and swelling and thus has been used for treatment of rheumatoid arthritis, rheumatic fever, and mild infection.

German chemical and pharmaceutical company founded in 1863 by a chemical salesman, Friedrich Bayer (1825-80), and now operating plants in Germany and more than 30 other countries was the first developer and marketer of aspirin (1899), says Encyclopædia Britannica

Aspirin has been with us for over hundred years. It is cheap and universally available. It has many health benefits. But it is not completely safe. So, before you start taking aspirin, talk to your doctor. See if it is safe for you. And don’t forget other risk factors which require your attention. Help your doctor keep you healthy!

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