7/28/2019 Prophylactic aspirin and public health.pdf

1/2

Guest Editorial

Prophylactic aspirin and public health

Low-dose aspirin prophylaxis is widely promoted for

patients who have evidence of vascular disease, together

with subjects who have a raised vascular risk score. The use

of prophylactic aspirin by healthy subjects is however con-

troversial on the grounds that the number of vascular events

likely to be prevented can be close to the number of haem-

orrhagic episodes likely to be precipitated by the drug.1

A number of large-scale prospective studies have now

given evidence that aspirin also reduces cancer incidence. Its

use for this purpose is however controversial, again on the

basis of the risk of haemorrhage.2

These risk/benefit evaluations appear to be based on the

assumption that a bleed can be equated with a heart attack,

a stroke or a cancer. With regard to both severity and seque-

lae this can clearly be challenged, and a comment in one of

the major overviews of aspirin trials is apposite: . . . the al-

ternative to primary prevention is deferral. . . .. [but] the

first manifestation[s] of disease might be a disabling or fatal

event.3

Evidence from an overview of primary vascular rando-

mized trials

4

shows that the risk of death from gastrointes-tinal bleeding in subjects randomized to aspirin (4 per 100

000 subjects per year) is almost identical to that in subjects

who had been randomized to placebo (5 per 100 000 per

year).5 The report of one of the largest meta-analysis con-

firms this: . . . there were actually fewer fatal bleeds in parti-

cipants allocated to aspirin than in the controls (nine vs

twenty).6 This absence of a difference in mortality suggests

that bleeds caused by aspirin are not the most serious.

Furthermore, the long-term follow-up by Rothwell et al.,7

based on 51 randomized trials, shows a marked and signifi-

cant decrease over the first few years in bleeding attributable

to aspirin.On the basis of vascular risk alone, recommendations

have been made,810 and challenged,11 that prophylactic

aspirin be considered by subjects over the age of50 years.

For cancer prevention, Rothwell et al.12 recommend aspirin

from the age of45 years. In fact, population surveys show

that many older people have made their decision and about

one-third in people in Wales,13,14 and rather more in the

USA15 state that they take aspirin regularly.

McKee and Raine16 have pointed out, with reference to

choices about health, first choose your philosophy. We

believe that the appropriate philosophy in relation to health

care is that while the treatment of disease has been delegated

to health-care professionals, low-dose aspirin is prophylactic

and whether or not to take it is ultimately the responsibility

of subjects themselvesjust as non-smoking, dietary choice

and regular physical activity are a subjects own choice. The

responsibility of health-care practitioners is therefore to

ensure that adequate information on risks and benefits of all

prophylactic measures is made widely available to enable

people to make informed decisions about the protection oftheir own health. As a recent editorial commented: a deci-

sion on whether or not a patient should take an aspirin

requires a robust discussion of its benefits and harms . . . .

[and] the elicitation of patient preferences.17

Lenaghan et al.18 has urged that decision-makers at a local

and national level should take time and make an effort to

obtain informed comment from groups representative of

the general public, and should not only listen to but should

act on the voice of the public. A Citizens Jury conducted a

few years ago under the title: My Health whose responsi-

bility? used low-dose aspirin as an example of a prophylac-

tic medicine.19

The verdicts of 16 jurors, chosen to berepresentative of the general public, stated that public money

should be spent on informing people about the risks and

benefits of low-dose aspirin, and although at the time of

that jury (2006) the available evidence on the reduction of

cancer by aspirin was only suggestive, the jurors stated that

the evidence on the risks and possible benefits of prophylac-

tic drugs should be made available to the public . . . . even

before there is agreement amongst doctors (our italics).

The Wanless report on Securing good health for the

whole population20 stated that health services in the UK

are unsustainable in their current form unless members of

the public are fully engaged and take responsibility for theirown health. The role of prophylactic aspirin, and how it

might be handled within health care is being intensely

debated in clinical circles and amongst epidemiologists. For

Peter Elwood, Honorary Professor

Marcus Longley, Professor of Applied Health Policy

320 # The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

Journal of Publi c Health | Vol. 34, No. 3, pp. 320 32 1 | doi:10.1093/pubmed/fds051 | Advance Access Publication 21 June 2012

7/28/2019 Prophylactic aspirin and public health.pdf

2/2

people generally, the distinction between a medicine such as

aspirin and other preventive approaches is arbitraryall are

readily available consumer choices, and all carry potential,

but uncertain risks and benefits.

It is time that public health specialists engage with this

issue to help people understand the evidence and ensure

that members of the general public are equipped to makeinformed choices on issues of enormous potential to health.

Peter Elwood1, Marcus Longley2

1Department of Primary Care and Public Health, Cardiff

University, Cardiff, UK

E-mail: elwoodpc@cf.ac.uk2Welsh Institute for Health and Social Care, University of

Glamorgan, Pontypridd, UK

References1 Drugs and Therapeutic Bulletin. Aspirin for primary prevention of

cardiovascular disease? 2009;47:1225.

2 Kurth T. Aspirin and cancer prevention. BMJ 2012;344:e2480.

3 Antithrombotic Trialists Collaboration. Aspirin in the primary and

secondary prevention of vascular disease: collaborative meta-analysis

of individual participant data from randomised trials. Lancet

2009;373:184960.

4 Guise J-M, Mahon SM, Aicken M et al. Aspirin for the prevention

of cardiovascular events: a summary of the evidence. Ann Intern

Med 2002;136:16172.

5 Morgan G. Aspirin for the prevention of vascular events. Public

Health2009;123:787818.6 Antithrombotic Trialists Collaboration. Collective meta-analysis of

randomised trial of antiplatelet therapy for prevention of death,

myocardial infarction and stroke in high risk patients. BMJ

2002;324:7186.

7 Rothwell PM, Price JF, Fowkes FGR et al. Short-term effects of

daily aspirin on cancer incidence, mortality and non-vascular death:

analysis of the time course of risks and benefits in 51 randomised

trials. Lancet2012; doi:10.1016/s0140-6736(11)61720-0.

8 Elwood P, Morgan G, Brown G et al. Aspirin for all over 50? For.

BMJ 2005;330:14402.

9 Vandvic PO, Lincoff AM, Gore JM et al. Primary and secondary

prevention of cardiovascular disease: antithrombotic therapy and

prevention of thrombosis: Amer College of Chest Physicians

evidence-based clinical practice guidelines. Chest

2012;141:637S68S.

10 US Preventive Services Task Force. Aspirin for the prevention of

cardiovascular disease: US preventive services task force recommen-

dation statement. Ann Intern Med 2009;150:396404.

11 Baigent C. Aspirin for all over 50? Against. BMJ 2005;330:14423.

12 Rothwell PM, Fowkes FGR, Belch JFF et al. Effect of daily aspirin

on long-term risk of death due to cancer: analysis of individual

patient data from randomised trials. Lancet 2011;377:3141.

13 Elwood P, White J, Fone D et al. Aspirin taking in Caerphilly: a

pilot survey. Br J Cardiol 2011;18:23840.

14 Elwood P, Morgan G, White J et al. Aspirin taking in a South Wales

County. Br J Cardiol 2011;18:23840.

15 Ajani UA, Ford ES, Greenland KJ. Aspirin use among US adults:

Behavioural Risk Factor Surveillance System. Am J Prev Med

2006;30:747.

16 McKee M, Raine R. Choosing health? First choose your philosophy.

Lancet 2005;365:36971.

17 Kent DM, Shah ND. Personalising evidence-based primary preven-

tion with aspirin. Individualised risks and patient preference. Circ

Cardiovasc Qual Outcomes 2011;4:2602.

18 Lenaghan J, New B, Mitchell E. Setting priorities: is there a role for

Citizens juries? BMJ 1996;312:15913.

19 Elwood PC, Longley M. My healthwhose responsibility: a jury

decides. J Epidem Comm Health 2010;64:7614.

20 Wanless D, Treasury HM. Securing good health for the whole

population. HM 7 Treasury, 2004 ISBN: 0-947819-98-3.

GU EST EDI T O R I AL 321