Pharmacist William Garst: To take or not to take (aspirin), that is the question

OPINION

BY WILLIAM GARST, PHARM.D.

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.

A history of aspirin

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 1800s, 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), 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 were not known. It has been postulated that the large frequent doses of aspirin may have contributed to the many deaths of the Great Influenza.

Conditions for which aspirin is recommended

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 low-dose aspirin, 81mg. But aspirin is also available as a suppository.

Who should avoid aspirin?

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 (AFIB) guidelines from the American Academy of Family Physicians, chronic anticoagulation is recommended for those diagnosed with AFIB unless the patient has a low risk of a stroke. The options for anticoagulation do 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 because they may want you on aspirin for other indications. 

The FDA also recommends avoidance of aspirin for patients who are pregnant or have uncontrolled high blood pressure, bleeding disorders, asthma, peptic (stomach) ulcers, or liver or 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.

William Garst is a consultant pharmacist who resides in Alachua, Florida. He received his B.S. in Pharmacy from Auburn University in 1975. He earned a master’s degree in public health in 1988 from the University of South Florida and a master’s in pharmacy from UF in 2001. In 2007 he received his Doctor of Pharmacy from the University of Colorado. William Garst is a member of many national, state, and local professional associations. He serves as Chair of the Alachua County Health Care Advisory Board and is a part-time pharmacist at Lake Butler Hospital. In 2016 he retired from the VA. He writes a blog called The Pharmacy Newsletter (https://thepharmacynewsletter.com/). William Garst can be contacted at garstcph@gmail.com.