Posted on 09/25/2018 10:43:57 AM PDT by nikos1121
We shall not look upon his like again.
Only a touch of hyperbole here, as the results of the ASPREE trial flip everything we thought we knew about aspirin on its head and draw to a close a rough month for the willow bark–derived compound.
Some quick background: We've had data for decades that aspirin can prevent recurrent heart attacks and strokes—secondary prevention. And up until recently, mixed data leaned toward a benefit for primary prevention as well. The meta-analyses on this topic even suggested that there might be a benefit in terms of all-cause mortality and, tantalizingly, a reduction in the risk for colon cancer if you take aspirin.
Then everything changed.
Two weeks ago, we were treated to the results of the ASCEND trial, which looked at aspirin for primary prevention in 15,000 patients with diabetes.
While there was a modest benefit in terms of reduction in cardiovascular events, a fairly significant increase in the risk for major hemorrhage took the wind out of the sails of those results. Strike one.
Strike two was the ARRIVE study, a randomized trial of 13,000 patients with moderate cardiovascular risk. Aspirin had no effect on all-cause death or the cardiovascular outcome.
And now, strike three comes in the form of a trio of papers published in the New England Journal of Medicine, examining the results of the ASPREE trial. These studies paint an even bleaker picture for aspirin.
The ASPREE trial was a huge study, enrolling almost 20,000 individuals in the United States and Australia. It was targeted to older adults—over age 70—a group expected to be at higher risk for cardiovascular disease or death. The primary outcome was a composite of death, dementia, and disability, an effort to capture the fact that in an older population, simply living longer is not always the only goal.
Aspirin had no effect on the primary outcome. But the results get weirder. Looking just at all-cause mortality, the rate was higher in the aspirin than the placebo group.
Fortunately, absolute mortality rates were really low. It would suggest that for every 100 patients you treat with aspirin, you'll see one extra death over a 5-year period. This is tiny, but still, this is aspirin. What happened to the wonder drug?
Spurred on by these strange findings, the authors published their second paper in the journal, examining the causes of death. And the findings were driven by—wait for it—cancer.
The rate of new cancer diagnoses and death from cancer was higher among those taking aspirin compared with those on placebo. This runs counter to much of what we've been told about aspirin in the past.
What's going on? I suspect... nothing. And here's why.
Death was not the primary outcome in the ASPREE trial. We specify a primary outcome because we know that the more outcomes we test, the higher the chance we'll see a false positive. In fact, if you account for multiple comparisons in the ASPREE study, the "death signal" would not have achieved statistical significance. We would chalk it up to simple noise in the data.
Nevertheless, now we go down this rabbit hole and try to explain why death is higher. And what you have to realize here is that if we got a skew in death rates by chance alone, something would have to explain it; everyone dies of something. So the finding that it was "cancer" is not necessarily that weird either.
My number-one rule in medical research goes like this: One study doesn't prove anything. One study can suggest. One study can raise doubts, but one study never proves. So let's not jump on the aspirin-causes-cancer train. Too many prior studies conflict with that finding.
What we do have here, though, are multiple studies, in multiple moderate-risk populations, that all reach the same conclusion. Aspirin has no role in the primary prevention of heart disease.
Has something changed? Actually, yes. We are way, way better at preventing heart disease than we ever were in the past. We treat cholesterol and blood pressure more aggressively, and we manage diabetes much better.
In fact, all three of these trials share one other point in common (aside from the fact that they found that aspirin did essentially bupkis). They all dramatically overestimated the cardiovascular event rates they would see.
Our old risk equations aren't that good anymore, because we are doing a better job at reducing risk. And in this brave new world, aspirin appears to have lost its mojo.
So, aspirin, my old friend: Good night, sweet prince, and flights of platelets sing thee to thy rest.
“But...you’re a long time dead so...bottoms up”!
That’s right. Good for you.
Cheers!
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More likely it will be the Canola oil in the Bleu cheese salad dressing.
Canola is simply a re-named industrial lubricant that is not fit for human consumption.
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I’ll keep taking aspirin. I have had no side effects and most importantly I have had no heart attacks. I have a long family history of premature heart deaths. I’m still alive. Thank you Dr. Bayer.
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My family also has a history of heart disease and premature deaths. I’ll continue with my 81 mg.
How mg aspirin do you take?
Quacktors probably take aspirin.
If aspirin were invented today, it would probably be prescription only.
Good. As I mentioned, both parents lived to around 90 and died within 6 months of each other. Mother had hypertension but died of congestive heart failure, peacefully in her morning nap. Father had heart disease / blockage and low blood pressure — he had a hemorrhagic stroke which he lived past to over 90. My point being, the best strategy is unknown but damaging behavior is best avoided.
I take one 325 every morning. Baby aspirin is for sissies.
Good points. You’ll probably make it to 100.
I had bleeding problems when I took 325. I had a terrible experience with a major nose bleed.
Looks like the pill salesman from big pharma paid him a visit.
Hey... It’s aspirin. Any chance these studies were paid for by the makers of Tylenol? Just asking.
I’ve been popping an aspirin once or twice a week for decades... So far, so good.
Possibly. These studies were a huge surprise to all of us. We give aspirin during at the onset of an MI. The whole system from ambulance to the ED are trained.
It’s going to shake up a lot of people.
I have that sort of longevity in the family but you have to be careful what you wish for... ;-P
My dad, prior to his stroke, had some mobility issues with his back which cut into his overall health. He told me, “I’ve just lived too long.” It was a calm analysis, not bitterness.
Right now, I am working on weight loss and cardio fitness with long walks and low carbs. Lost over 10% of my body weight this year.
I here magnesium is better if you pile it up, light it on fire, and then gobble it up quickly - followed by aspirin.
Yeah, but you old guitar players have a lot of other problems that aspirin has to treat. LOL
“Possibly. These studies were a huge surprise to all of us. We give aspirin during at the onset of an MI. The whole system from ambulance to the ED are trained.
It’s going to shake up a lot of people.”
My understanding of the latest research results is that a daily aspirin is no longer indicated for people who have not had a heart attack or who are not at high risk for one. However, for heart attack survivors and those at high risk, a daily 81 mg aspirin is still recommended. And for someone experiencing a MI, I would think that multiple aspirin, along with the usual accompanying treatments, will still be used.
I would probably not bleed at all if I didn’t take 325. :-)
The passage from the Globe and Mail nicely summarizes the relevant findings:
“People who have had a heart attack (a clot that stops blood flow to the heart) or an ischemic stroke (a clot that stops blood flow to the brain) – as well as those who have had a stent installed – are at significantly greater risk of having another.
Those who don’t take a daily Aspirin have two to three times the risk of another cardiac event. So it’s a well-established treatment.
This is known as secondary prevention, and the recommendations haven’t changed. But most people who take low doses (or ‘baby’ Aspirin) daily have never had a heart attack or stroke.
They do so based on the intuitive notion that, if blood clots can cause heart attacks and strokes, and Aspirin lessens clotting, then the drug will provide protection.
This theory was first floated in the 1960s, and by the early 1980s, large studies showed that that those who took a daily dose of ASA did indeed have fewer fatal heart problems.
That research has become less valid because, over the years, smoking rates have declined and we’ve become better at treating high blood pressure, so the number of fatal heart attacks and strokes have fallen sharply. In other words, Aspirin works as it always has, but its relative importance for prevention is not as high.”
You’re right. I have arthritis in both my thumbs. I just play through the pain. I’ve taken up the ukulele. Four strings and no need to crush your thumb trying to bar a chord. If I need any low notes I can always hire a bass player. They will work for beer.
Take care.
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