My team conducted the very first trial of aspirin and heart disease and that was one of the factors that ignited the present interest in aspirin. Aspirin now has been referred to as a miracle drug and it really is having a major effect on two of the most important diseases that cause disability and death; it really is quite remarkable. So I’ve spent about forty years with an interest in aspirin and other things.
Can you talk about the side effects of treating with aspirin?
Yes, there’s a general belief that aspirin causes bleeding which is serious and can lead to death. Well, aspirin does enhance, it does increase, the number of bleeds from the stomach but the evidence suggests that it’s minor bleeding from the stomach. Now that’s still most unfortunate and a horrible thing to happen to a patient who has been given some good advice to start taking aspirin but it’s not as serious as the things that aspirin prevents, no way is it as serious. The more serious bleeding from aspirin is a cerebral haemorrhage and that can cause death and does cause disablement. That’s very rare, fortunately, only perhaps two or three in every ten thousand, and there’s a certain amount of evidence in the published work, there’s evidence that it may be mainly, or perhaps only, in people who are on aspirin and have untreated hypertension. So it would be good advice for people, if there’s any history of gastric trouble, stomach pathology, then they should see a doctor and be very careful going on aspirin. There are drugs which will reduce the risk of any serious trouble. But if they are going on aspirin they should have their blood pressure measured and if they do have high blood pressure then they should certainly be well treated, that should be well controlled before they go on aspirin.
Can you explain the evidence in cases of gastric cancer of bacterial infection?
Yes, this infection with Helicobacter pylori is really quite a fascinating study and it has many strands to it. But in relation to aspirin it looks as if it increases the risk of bleeding by about five-fold and if the Helicobacter pylori is treated, which is fairly simple treatment and inexpensive, then it reduces that excess risk. There is a small risk of reinfection from Helicobacter pylori because it’s universal in our community - around 50% of people have got Helicobacter pylori in their stomach. Certainly to go on aspirin with that infection is likely to give trouble from bleeding.
What are some of the risks and benefits of low dose aspirin?
There’s just no question in people who have evidence of vascular disease. There’s really no question in people that are high risk of cancer, either because of family history or because of some genetic abnormality. There is still a lot of discussion about healthy older people but if you balance the risks and the benefits then more and more of us are coming to the conclusion that over about 50 people should seriously consider low dose aspirin daily.
Is there a need to better understand the mechanisms of aspirin?
Yes, that’s always helpful but medicine advances usually with a certain amount of ignorance. The mechanism of aspirin has been sorted out in very recent years, long after we knew that there were benefits from it in vascular disease and in cancer. The history of medicine is littered with ideas on mechanisms which turn out to be wrong and, after all, what we’re interested in is survival, and hopefully disease free survival, rather than exactly how it works. But that’s not to dismiss mechanisms that may usually give evidence on better methods of treatment and more effective and more efficient treatments.
Are you working on any other projects?
One of the most interesting projects that we ran was a citizens’ jury. This is a technique which is based on legal courts and a group of people who represent the general public with no vested interest in the medical or social issue are asked to come and hear a serious of talks on a particular subject and then they give their verdict. Now, we thought this was important in relation to aspirin because aspirin is not treatment. Now, having said that, there is evidence that it can be a benefit in treatment but the main interest in aspirin and the main use of aspirin is in prevention. So we brought together a group of the general public, we gave them talks about the benefits of aspirin and the risks of aspirin. That group very clearly saw that there is a profound difference between the treatment of disease and the preservation of health. They felt that the treatment of disease is, very rightly, delegated to healthcare professionals but the protection of health is my own responsibility. Therefore I, as a member of the public, should be given the evidence on risks and on benefits and allowed to make my own decision. If I want further evidence I can go to the literature, I can go to the web, I can go to a doctor but ultimately it’s my decision, it’s my health. That leads me always to say that evidence about the benefits of aspirin should be given within a context of healthy living – non-smoking, low BMI, regular exercise, moderate drinking. Aspirin and statins and orlistat and other drugs are preventive and should be talked about within that context of a healthy lifestyle.
