The Doctor’s Surgery

Aspirin makes me sick

I hate the taste – and the magical elixir has mixed results theodore dalrymple

As readers will no doubt by now have noticed, life is a complicated business, and even supposedly straightforward questions often do not give themselves to easy answers. Take, for example, the question of aspirin: should one take it as a matter of course?

For long time, it seemed this humble medicament was almost the elixir of life. It prolonged the survival of – or prevented heart attacks and strokes for – those with angina or transient ischaemic attacks. Taken by the symptomless in daily, small doses, it reduced the risk of developing many cancers. It also reduced the death rate after heart attack by half – as measured by survival at five weeks – if a person suffering the crushing central chest pain took 600 milligrams of the soluble form nearly at once.

And, of course, it was cheap, though worth much more than the guinea a box that Beecham’s Pills (which consisted of aloe, ginger and soap) were claimed to be worth.

Sometimes I even feel guiltily irresponsible for not taking it, as if, by failing to do so, I were a treason against myself, punishable by early death. My problem is that I detest it: I shudder at the very thought of its taste, and it always upsets my stomach as cholera and dysentery never did. I can induce nausea in myself just by thinking of the taste of aspirin, though I know people who like the taste. I wonder whether there is a genetic basis to their perversion, as there is a genetic basis to the ability to taste phenylthiourea.

It was not without a certain sense of relief, then, that I read the results of a double-blind trial of 19,114 people over the age of 70. Free of cardiac disease, dementia or disability, they were randomly allocated to a regime of daily, low-dose aspirin or a placebo.

At just over 4½ years of follow-up, those in the aspirin-treated group had a higher death rate than those who took the placebo. The difference was not great but it was statistically significant – that is to say, it was unlikely to have arisen by chance. And one must always remember that the onus is on a prescription drug to do the patient good, not just to do him or her no harm. Why bother to take a pill every day that does you no good?

The result was unexpected. The excess deaths were caused not by the wellknown gastrointestinal side effects of aspirin, but by cancer. A subsequent analysis showed that the deaths were caused not by an increased number of cancers, but by an increase in their virulence.

As is always the case, however, and as life’s complexity might lead one to expect, the results were not definitive. In earlier trials of daily low-dose aspirin given to younger people, there was a marked reduction in the incidence of many cancers, and of colon cancer in particular. This beneficial effect was not observed until patients had been taking the aspirin for more than five years.

It might be, then, that some benefit of giving it to older people ‘kicks in’ only after the 4½ years of follow-up in this study, and that would more than offset the deleterious initial effect.

Probably, though, I have missed the boat as far as aspirin prophylaxis of cancer is concerned – thank God! The idea of taking aspirin daily for years to reduce by 40 per cent my chances of getting various cancers – ugh!

There was one very revealing sentence in the report of the trial. ‘We enrolled community-dwelling persons in Australia and the United States who were 70 years of age or older (or more than 65 years of age among blacks and Hispanics in the United States).’

This reminded me that when I started out, geriatricians treated patients of 65 and over. Now they treat those of 80 or even 85 and older, provided they have multiple pathologies. So, 85 is the new 65.