Can aspirin rebound?

With concerns growing over the health risks associated with painkillers such as Bextra, Vioxx and Celebrex, some Americans may be taking another look at one of the few medicines that have been around since the Victorian era.

That would, of course, be aspirin. According to some estimates, a trillion tablets have been taken in its long history.

Aspirin is effective, relatively safe and costs as little as a penny a tablet. So what’s not to like?

“We medically know it’s as good an anti-inflammatory as any other,” says Dr. Alan Kimmel, a Towson, Md., internist. “But it’s not sexy, it has no cachet and it’s too inexpensive.”

In other words, the wonder drug of modern medicine, first synthesized in the 19th century, gets very little respect in spite of its many uses. Newer drugs cost 10 to 15 times as much for the equivalent pain relief. But as Kimmel points out, Americans tend to think that if something costs more, it must be better.

Last week, Pfizer agreed to suspend sales of its painkiller, Bextra, at the request of the Food and Drug Administration. The FDA also required that a tougher “black box” warning be placed on other Cox-2 inhibitors, such as Celebrex, which is also made by Pfizer. Bextra, Vioxx and Celebrex belong to a class of drugs that has been linked to a higher risk of cardiovascular disease.

Kimmel says news about possible health risks with painkillers has prompted “a hundred conversations” with his patients in recent weeks. Only a couple of them have been interested in considering aspirin.

Aspirin “lost its luster largely due to age,” says pharmacologist Steven Weisman, a consultant to Bayer, the world’s largest manufacturer of the drug. “People like newer things. Consumers move away from the tried and true to experiment.”

But there were good reasons people turned to newer medicines. Aspirin can have serious side effects, including internal bleeding and stomach ulcers, especially when taken long term to treat arthritis or chronic pain. Some people are more susceptible than others.

At low doses, this isn’t a huge concern. A safety review published in 2002 in the Archives of Internal Medicine reported that less than 1% of patients on a low dose for heart health were diagnosed with bleeding. (An adult aspirin is 325 milligrams; a low-dose, or cardiac-dose, aspirin is 81 milligrams.)

Aspirin inhibits the production of prostaglandins, hormone-like substances that, among other things, cause pain and inflammation; and it prevents blood platelets from sticking together, decreasing the chance of a blood clot.

Drugs such as Vioxx, Celebrex and Bextra, known as Cox-2 inhibitors, were developed to reduce or eliminate internal bleeding associated with aspirin, but that also meant they didn’t affect blood in a positive way to help prevent heart attacks and strokes.

Aspirin is a reasonable choice to take short term for a headache or a sprained ankle. You could even try it long term for minor arthritis pain if you’re not in the high-risk group (the elderly, steroid users and those with a history of stomach problems or ulcers).

But it’s unlikely Americans will return in numbers to aspirin as the pain reliever and anti-inflammatory of choice, not only because of the risk of internal bleeding but also because the newer drugs only have to be taken once a day, helping what doctors call compliance. “Time will tell whether people will be able to tolerate aspirin as they did 20 years ago,” says Dr. William Henrich, chairman of the department of medicine at the University of Maryland School of Medicine. Tolerance and compliance aren’t the only issues. Many people don’t think aspirin works as well as newer anti-inflammatory drugs. Pain relief is a very individual thing, says Dr. Howard Hauptman, division head of rheumatology at Greater Baltimore Medical Center. “There’s an incredible variety of response [to anti-inflammatories]. Even when they are in the same family of drugs, they are all slightly different chemically.”

To get the same anti-inflammatory effect as one 200-milligram Celebrex, he estimates, you would have to take 12 or 14 aspirin. (For simple pain relief, the dose would be more like four to six tablets a day.)

Childhood familiarity is how aspirin manufacturers have built a base of loyal adult users. From the beginning, aspirin was marketed as a non-habit-forming, family-friendly pain reliever, unlike the opiates that preceded it.

Salicylic acid, aspirin’s active ingredient, was first synthesized in France by Charles Gerhardt in 1853; but its commercial possibilities weren’t realized for several decades. The German corporation Bayer launched aspirin as a pain reliever in Germany in 1899, and within 15 years it was one of the most successful medicines in the world.

In the early 1980s, studies linked the pain reliever to Reye’s syndrome, a rare but serious childhood disease. Aspirin is now not recommended for anyone under 16 years old. Baby aspirin disappeared from Americans’ medicine cabinets until the low-dose tablet re-emerged in the last decade as a heart attack preventive. When baby aspirin disappeared, so did the drug’s early customer base.

But Reye’s syndrome wasn’t the greatest blow to aspirin’s prestige and profits. Aspirin had dominated the market for more than 50 years when acetaminophen, sold as Tylenol, arrived in the 1950s. Acetaminophen was a pain reliever but not an anti-inflammatory. Most important, it wasn’t irritating to the stomach.

With an aggressive marketing campaign, including giving free samples to hospitals, Tylenol quickly became the bestselling pain reliever in the United States. In the 1970s, ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), gained acceptance, dealing aspirin another blow.

Aspirin would probably have ended up languishing on drugstore shelves as a cheap painkiller for those who couldn’t afford anything newer, if scientists hadn’t figured out how it works. In 1982, John R. Vane, a British pharmacologist, won the Nobel Prize for his research clarifying the process.

That research led to new uses, and aspirin has now become the most common drug used for heart health worldwide. Many doctors now recommend that men and women over 50 take the equivalent of a low-dose aspirin daily, even though the Food and Drug Administration advises aspirin for use only during or after a first heart attack.

“Aspirin will always be there,” says Dr. Thomas E. Bryant, president of the Aspirin Foundation of America, “largely because it’s so cheap. But the increasing market is in new usage.”

*

(BEGIN TEXT OF INFOBOX)

More than a painkiller

Aspirin has a variety of uses and potential uses being investigated by continuing research. The positives should always be weighed against the risk of internal bleeding.

* Aspirin relieves mild to moderate pain.

* It treats inflammation and reduces fever.

* It can reduce the risk of a second heart attack.

* It can help prevent an ischemic stroke, which is a stroke caused by a blood clot.

* Taking aspirin during a heart attack may reduce the risk of death or complications from the attack.

* Aspirin may cut the risk of colorectal cancer by as much as 50%.

* It may help survival rates of prostate cancer patients.

* It may be a treatment for preeclampsia, a complication of pregnancy.

* Taking aspirin for two or more years may decrease the risk of Alzheimer’s.

* Scientists are looking into whether aspirin has a beneficial effect on the immune system.

From Baltimore Sun