Aspirin has lost its luster. There was a time when many doctors would recommend aspirin to treat minor aches and pains. People with rheumatoid arthritis were “prescribed” large doses of aspirin. The “bible” for teaching medical students about medications was Goodman and Gilman’s The Pharmacological Basis of Therapeutics. In the 1985 edition the experts at that time contrasted aspirin vs. NSAIDs.
Aspirin vs. NSAIDS:
“Rheumatoid arthritis. Despite the development of the newer anti-inflammatory agents, salicylates are still regarded as the standard with which other drugs should be compared for the treatment of rheumatoid arthritis. In addition to the analgesia that allows more effective therapeutic exercises, there is improvement in appetite and a feeling of well-being. Salicylates also reduce the inflammation in joint tissues and surrounding structures. Damage to joints is the most difficult aspect of rheumatoid arthritis to manage, and any agent that reduces inflammation is important in lessening or delaying the development of crippling. Salicylates can be shown to produce objectively measurable anti-inflammatory changes when given in large doses for long periods to patients with active rheumatoid disease. Fairly large doses of salicylate are advised (4 to 6 g daily), but some patients respond well to less.”
Most rheumatologists today would be shocked to read that passage. The idea that a physician might prescribe 12 to 18 aspirin pills a day to treat rheumatoid arthritis would be heretical. That’s because of the risk for bleeding ulcers and other adverse reactions of such a high dose. And yet in the 1980s the question of aspirin vs. NSAIDs was weighted in favor of aspirin.
A Modern MD Wonders About Aspirin vs. NSAIDs:
Q. As a physician, I am intrigued that aspirin has cardiovascular protective effects, while other NSAIDs are deleterious. Is this due to their effects on platelets?
A. It all starts with hormone-like chemicals called prostaglandins. They are made by proteins called cyclooxygenases (COX-1 and COX-2). Aspirin blocks COX-1, which produces a pro-clotting compound in platelets, the sticky part of blood. This inhibition reduces the risk for blood clots.
NSAIDs inhibit both COX-1 and COX-2, which can lead to elevated blood pressure and blood clots. These drugs also interfere with the production of nitric oxide, a natural chemical that helps blood vessels relax and dilate.
The bottom line is that aspirin can reduce the risk of heart attacks and clotting strokes while NSAIDs increase the chance of both. Both aspirin and NSAIDs can be irritating to the digestive tract and aspirin may increase the risk for bleeding.
Long Term Benefits and Risks of Aspirin vs. NSAIDS:
Q. You have pointed out the dangers of NSAIDs but offer absolutely no suggestion about the effectiveness of going back to aspirin, the drug of choice for many years.
What does long-term use of aspirin do, other than possibly make you bleed more easily? I would love a conversation on this topic.
A. You have raised a fascinating question. Aspirin has been available for more than 100 years. One of the first non-aspirin NSAIDs (nonsteroidal anti-inflammatory drugs) was indomethacin (Indocin), initially marketed in the U.S. in 1965. Since then we have seen a lot of similar drugs including:
- Celecoxib (Celebrex)
- Diclofenac (Cataflam, Voltaren)
- Etodolac (Lodine)
- Flurbiprofen (Ansaid)
- Ibuprofen (Advil, Motrin, etc.)
- Ketoprofen (Orudis)
- Meloxicam (Mobic)
- Nabumetone (Relafen)
- Naproxen (Aleve, Anaprox, Naprosyn)
- Piroxicam (Feldene)
- Sulindac (Clinoril)
The name “nonsteroidal” anti-inflammatory drugs implies that such medications are safer than steroids such as cortisone and prednisone. Doctors were burned by steroids during the 1950s. Initially hailed as miracles for arthritis (and other inflammatory disorders), such corticosteroids were prescribed promiscuously for a range of conditions.
After a decade or two, though, it became apparent that there was a high price to pay for pain relief with such medications: cataracts, glaucoma, weight gain, high blood pressure, muscle weakness, ulcers, irregular heart rhythms, diabetes and osteoporosis.
The Love Affair with NSAIDs Begins:
That’s why there was such a love affair with NSAIDs. Doctors thought the drugs were relatively safe, except for the occasional case of heartburn. In the worst case, a patient might develop ulcers. The FDA thought NSAIDs were so safe they allowed both ibuprofen and naproxen to go over the counter in lower doses than doctors were prescribing. On any given day, an estimated 20 million Americans swallow one of the NSAIDs listed above to ease a headache, soothe a sore joint or relieve the inflammation of tendonitis, bursitis or back pain.
But here’s the rub. There is no evidence that any of the NSAIDs on the market have proven themselves superior to aspirin when it comes to pain relief or anti-inflammatory activity. Nevertheless, both physicians and patients perceive these drugs as stronger pain relievers than aspirin.
There is also the belief that aspirin is tougher on the tummy. People seem to think that NSAIDs are less likely to cause ulcers, but there is a paucity of data in this regard. Both NSAIDs and aspirin can be quite irritating to the digestive tract and can cause serious complications including life-threatening bleeding ulcers.
The Aspirin Advantage:
Here is where it gets interesting. Aspirin has some fascinating advantages. Not only does it appear to reduce the likelihood of blood clots that can cause heart attacks and strokes, it also seems to have anti-cancer benefits.
NSAIDs, on the other hand, have some serious cardiovascular complications. A study in The Lancet (May 30, 2013) reveals that NSAIDs such as ibuprofen or diclofenac increase the risk of heart attacks. They may be comparable to the discredited drug Vioxx (rofecoxib) when taken in relatively high doses for long periods of time.
Naproxen was once thought to be safer for the heart than other NSAIDs, but some research contradicts that belief. Naproxen appears to be just as toxic to the digestive tract as other drugs in this class. All NSAIDs can raise blood pressure and may increase the risk for congestive heart failure and atrial fibrillation. This heart rhythm disturbance can lead to blood clots that can escape the heart and cause a stroke.
Here are some other NSAID-related complications:
NSAID SIDE EFFECTS
- Heartburn, indigestion, abdominal pain, nausea, vomiting, constipation , diarrhea
- Headache, dizziness, drowsiness, disorientation
- Skin rash, sensitivity to sunlight, itching (potentially serious, so notify the MD!)
- Fluid retention, edema, high blood pressure
- Heart failure , heart attack, stroke
- Ringing in ears, hearing changes
- Visual disturbances
- Ulcers, bleeding ulcers, perforated ulcers
- Liver damage, kidney damage
- Blood disorders, anemia
- Worsening asthma symptoms
That is why if we were banished to a desert island and could only take one pain reliever, we’d probably choose aspirin. Not only is it a gold standard for pain relief, it eases inflammation, lowers a fever, reduces the risk for heart attacks and strokes and may be one of the most powerful anti-cancer drugs ever discovered. Of course no one should ever take aspirin for long periods of time without medical supervision. Like all NSAIDs aspirin can cause ulcers and it may also interact with certain prescription drugs. It deserves respect for both its benefits and its risks.
Here is what readers have to say about their experiences with NSAIDS:
C.A. comments on diclofenac:
“I hate it that I started having pounding fast heartbeat after being on diclofenac several days. My doctors (both family and cardiology) told me there was no connection between diclofenac and heart rhythm problems. The cardio did a heart monitor test, and found my heart was skipping beats and running as fast as 400 beats per minute. Both doctors assured me it was fine to continue taking the high doses of diclofenac, even though I knew better.”
Anne worries about how ibuprofen impacts her blood pressure:
“I never had a blood pressure problem or any side effects as a result of ibuprofen until last month. My pressure climbed to 220/110 with headache and dizziness during the night. I had to seek emergency care.
“My blood pressure improved until last night when I again took ibuprofen for back discomfort during the night. When I woke this morning my BP had climbed to 135/97 with headache and dizziness and has stayed somewhat elevated even though I took amlodipine (Norvasc). It seems clear that I have developed a reaction to ibuprofen. I had not taken any since the first incident until last night.”
Bruce wants to change his diet:
“I am a gardener and take ibuprofen occasionally for back pain. Mostly, though, I try to think about how I am working and avoid stupid maneuvers.
“My main question is what about the impact of an anti-inflammatory diet? I have read about ginger tea, but I have not memorized the items I might be eating that can cause inflammation, nor the ones that reduce it. I’d like to know more about foods/drinks to reduce inflammation. I know that the whole inflammation issue also impacts cardio-vascular as well as joints and many other parts of the body.”
Bruce, you are absolutely right that diet can affect inflammation. Cutting back on sugar and refined carbohydrates is the first step. Trans fats must be eliminated completely and we would encourage you to reduce omega 6 fatty acids found in corn oil, safflower oil and other popular vegetable oils.
Foods and drinks to embrace include pomegranate, green tea, pineapple, curry, garlic, almonds and broccoli in addition to ginger. You will be glad to know that cherries, walnuts and grape juice also have anti-inflammatory activity.
You can learn more about our favorite remedies (Certo and grape juice, gin-soaked raisins, gelatin, honey and vinegar, cayenne pepper and fish oil) in our book, The People’s Pharmacy Quick & Handy Home Remedies. We also include some wonderful anti-inflammatory recipes (Curcumin scramble, curried sweet potato fries, curry soup, golden milk with curcumin, cherry spritzer, Joe’s Brain Boosting Smoothie and spicy fresh tuna salad) in our book, Recipes & Remedies from The People’s Pharmacy.