Aspirin Resistance?

Aspirin is back in the news.  Recently the science of “aspirin resistance” has taken a big knock.  And once again calls for “aspirin for everyone” – at least everyone middle aged – are being pushed as “the” heart disease and cancer preventive.

What we really learn from these debates is what runs the economics of health in America, and the nature of drug discovery and use.

Coated or Clear?

In the old days aspirin was just over the counter 325 mg tablets. But “regular” aspirin can cause ulcers and bleeding. Soon data appeared that coated aspirin was “superior” for preventing GI bleeding. Bayer used this evidence to mount a campaign trumpeting the advantages of their “pure” product.

It was known for decades that aspirin could decrease the risk of heart attacks and infarctive strokes.  However, the risk of GI bleeding –and increased hemorrhagic strokes – often kept people from using aspirin.  This in turn led to the rise of NSAIDS – non-steroidal drugs that mimicked aspirin’s biological effects.  It was hoped they would cause fewer problems with bleeding.  Many were developed, including ibuprofen (advil)  and naproxen (aleve).

They were and are very useful drugs.  But they still cause bleeding, ulcers, and kidney damage. And their profile in preventing heart attacks was nowhere near as effective as aspirin.

So Big Pharma went on to research and manufacture the  the “new” NSAIDs – the Cox 2 inhibitors, like vioxx and celebrex.  Not only were these drugs felt to be superior in terms of gastric bleeding to aspirin, but they possessed useful properties against different kinds of arthritis.

It tooks years.  Eventually it became clear the drug companies had lied about their data.  Not only were vioxx and celebrex not particularly superior for pain and GI bleeding – they actively increased the risk of heart attacks.

CEO heads rolled.  Billions were paid in fines.  Major  drug companies almost went under.

Next new drugs like clopidogrel were developed to prevent strokes and clotting.  As the NY Times reported on 12/11/12, that was the same time when studies of “aspirin resistance” began to appear.

Somehow a sizable percentage of people on aspirin were thought to not develop desired decreased clotting.  These folks would need expensive drugs like clopidogrel.

Yet the most recent, comprehensive can’t find any evidence of aspirin resistance – unless people are taking coated versions.  And over time, even these appear to work.

So a new “syndrome or resistance” may now be explained – or perhaps, never existed in the first place.

And aspirin still has plenty of uses.

Aspirin for Everybody?

Aspirin is cheap.  It works – in low dose and higher dose – to prevent the two main killers within cardiovascular disease, stroke and heart attack – in people with risk factors for those diseases.

And as I’ve explained before, old and new data has shown aspirin cuts some tumor incidence – particularly of colon cancer.  More recent evidence finds that aspirin can decrease the risk of metastasis when people are diagnosed with certain solid tumors.

Now David Agus, oncologist and  writer of “The End of Illness”, where he advocated putting every adult on a statin, is now advocating aspirin for all of us middle aged folk.  He quotes “studies” that aspirin will cut the risk of adenocarcinomas like colon and pancreas 46%.

Were that it were so.

The numbers are significant, but not as positive as he claims.  And the idea that prostate cancer is dramatically decreased by aspirin use is at best misleading.

But his point that aspirin is underused remains valid.

Orphan Drugs and Orphan Treatments

So called orphan drugs are those, like medications  for Gaucher’s disease, that are supported by government subsidy.  Without those subsidies, the populations afflicted would be too small to merit drug company research and development.

But the real orphaned drugs are those like aspirin and lithium that are so cheap and ubiquitous  drug companies don’t tend to make that much money on them (Bayer aspirin is an exception.)

Aspirin has many uses.  But these uses are not for everyone.

More recent epidemiologic papers have not been so enthralled by the cardiovascular disease preventive capacity of aspirin. People who lack major risk factors don’t do particularly well.  The data on tumors is new, and requires long term prospective evaluation in large populations.  If those findings are confirmed, many adults may want to take daily aspirin, especially at between 75-81 mg, to prevent tumors – even before we consider their ability to prevent strokes and heart attacks.

But the other orphan in this story is health – health obtained by regenerating people through life sustaining lifestyle.

Data show American subpopulations vary more than three decades in lifespan –  based on lifestyle alone.  Eating whole foods, walking, socializing and properly resting might add several to more than 10 years to Americans’ overall survival.  More recent data also argues that clean air appreciably improves lifespan.

But the focus of the country – and especially the health care industry – remains on pills and treatments.  There are pills for everything – youthfulness, beauty, weight loss, “happiness”.  And the public is taught that much of what they want can be obtained ingesting a pill.

Yet the evidence is that lifestyle modification is vastly more effective than even “preventive” health care. To really turn the clock back on aging, you don’t use botox or statins – you move your body.  You converse.  You congregate.  You take a walk in the sun (wearing a hat of course.)

Health gets little shrift in the “health care” debate. Even though health is not primarily about health care.  It is much more governed by how you live – and the environment you live in.

But it’s harder to make hundreds of billions in profit advocating walking and bike trails, whole foods and mass transit.  The drug companies know this.  Advertisers know this.

So today the real orphan is health.  And that’s a situation where almost all of us lose.