Aspirin is just an ordinary little white pill that you have seen hundreds of times before and no doubt you'll see hundreds of them again. It's nothing special. Look again and consider this. What you're holding is one of the  most amazing creations in medical history, a drug so astonishingly versatile that it can relieve your headache, ease your aching limbs, lower your temperature and treat some of the deadliest human diseases. There's now evidence to show that aspirin might prevent heart attacks, strokes, deep vein thrombosis, bowel, lung and breast cancer, cataracts, migraine, infertility, herpes, Alzheimer's disease, and much else. The list is growing every year — which might go some way towards explaining why over 25,000 scientific papers have been written about aspirin and why an estimated one trillion little white pills, just like yours, have been consumed since it first came into being. In short, what you have there is a wonder drug, something with few equivalents in the annals of medical science, and one of the most endurably successful commercial products of all time. Today, however, there are concerns about the most appropriate long term daily use for treating cardiovascular disease.

History

One of the first drugs we studied in pharmacy school was aspirin and rightly so because of its long term use and multiple indications.  Acetylsalicylic acid, the chemical name for aspirin, is a derivative of salicin, found in myrtle or willow leaves.  These salicylate- containing plants were used by the Assyrians and Egyptians for more than 3500 years as a treatment for joint pain.  The use of willow bark for pain relief continued through ancient Greece, where it was recommended by Hippocrates to relieve the pain of childbirth. In 1763, the Royal Academy in England published a report detailing five years of experiments using dried, powdered willow bark in curing fevers (an antipyretic).  In 1828, a German chemist, Joseph Bruchner, extracted the active ingredient in willow, producing bitter tasting yellow crystals, he named salicin.   A French chemist, Charles Gerhardt, in 1853, was the first person to synthesize aspirin in a crude form, but his findings were ignored. (He modified salicylic acid with the introduction of an acetyl group in place of a hydroxyl group.)  The first clinical trial of salicin was published by Thomas Maclagan in 1876.  He investigated the use of salicylate in relieving the symptoms of rheumatic fever.  The drug was later studied by Felix Hoffmann and Arthur Eichengrum, both chemists,and Heinrich Dreser, a pharmacologist,  in Germany in 1897.  Hoffmann tested the drug on himself and his father, who suffered from chronic arthritis.  It was first branded in 1899 by Bayer Laboratories as aspirin. (“ A” stands for acetyl, ”spir” is derived from the plant known as Spiraea ulmaria, a source similar to willow species and “in” was a common suffix used for drugs as the time of the first synthesis of acetylsalicylic acid.) Aspirin soon became a profitable over the counter treatment for rheumatism, and sales were bolstered by the Spanish flu epidemic of 1918.  The drug was patented in the U.S. until 1917, and competition by other manufacturers heightened from then on.  Aspirin is now the most commonly used drug in the world.  Its role in preventing cardiovascular and cerebrovascular diseases has been revolutionary and one of the biggest pharmaceutical success stories in the last century.  A good resource about the history of aspirin discovery was published in a paper written by Michael Desborough and David Keeling in the British Journal of Hematology in 2017.

Today

Currently, approximately 36 percent of the adult U.S. population—more than 50 million people—is estimated to take aspirin regularly for cardiovascular disease (CVD) prevention. Among individuals known to have CVD, this percentage increases to more than 80 percent.  This translates into roughly 10 billion to 20 billion aspirin tablets consumed annually in the U.S. alone, solely for CVD prevention.

In a recent publication from the Journal of the American Medical Association, the author note that available clinical data do not support the routine, long term use of aspirin dosages greater than 75 to 81 mg per day in the setting of cardiovascular disease prevention. (75 to 81 mg is the dose designated a baby aspirin.) An adult aspirin contains 325 mg or 5 grains. Higher dosages, which may be commonly prescribed, do not better prevent events but are associated with increased risks of gastrointestinal bleeding.  Although aspirin is generally a very well tolerated drug, like most medications it carries a risk of significant adverse effects, many of which are dose related. With long term aspirin therapy so widely used to treat and prevent CVD, maximizing benefits and minimizing risks by providing optimal dosing is of great importance.  In the U.S., the FDA recommends dosages ranging from 50 mg per day to 1300 mg per day for the treatment of the clinical manifestations of atherosclerotic disease.   In the U.S. 81 mg per day is prescribed most commonly (60 percent). Your doctor should be the judge.

Max Sherman is a medical writer and pharmacist retired from the medical device industry.  His new book “Science Snippets” is available from Amazon and other book sellers. It contains a number of previously published columns.  He can be reached by email at  [email protected].