Dammit, Jim, I’m A Lawyer Not a Doctor

No, I’m not a doctor.  But I am a 68-year-old male with Type II diabetes who has been previously directed to take a low-dose aspirin every day.  Thus, these results reported in the most recent issue of The New England  Journal of Medicine are of some interest:

  • Aspirin use prevented serious vascular events in persons who had diabetes and no evident cardiovascular disease at trial entry, but it also caused major bleeding events. The absolute benefits were largely counterbalanced by the bleeding hazard. Here.
  • Higher all-cause mortality was observed among apparently healthy older adults who received daily aspirin than among those who received placebo and was attributed primarily to cancer-related death. In the context of previous studies, this result was unexpected and should be interpreted with caution.  Here.
  • The use of low-dose aspirin as a primary prevention strategy in older adults resulted in a significantly higher risk of major hemorrhage and did not result in a significantly lower risk of cardiovascular disease than placebo. Here.
  • Aspirin use in healthy elderly persons did not prolong disability-free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo. Here.

I’m seeing both my cardiologist and my endocrinologist this week.  I’ll wait to see what they say.

5 thoughts on “Dammit, Jim, I’m A Lawyer Not a Doctor”

  1. As someone who drew readers’ attention to earlier research suggesting a regimen of low-dose aspirin was a Good Thing, and am over 70 to boot, I am concerned too. I’ve given it up, at least until a new and even mote ginormous trial says to start again. SFIK the new findings are just for older patients.

    It’s worth remembering that for trials this large (in the last one, n=19,114), practically every result will be statistically significant even at a tiny effect size which is not practically significant. In the last trial, “the rate of the composite of death, dementia, or persistent physical disability was 21.5 events per 1000 person-years in the aspirin group and 21.2 per 1000 person-years in the placebo group”: one event in 3,000 person-years is too small to worry about. The increase in major haemorrhages was bigger, from 2.8% to 3.8%; from 1 in 44 to 1 in 26. That’s more of a worry, but the risk seems roughly balanced by other benefits to get the no-difference death rates. But overall, it does not look as if the general older person gets any benefit from aspirin, so you might as well save the $25 or whatever it costs a year.

    Noteworthy that the trial was abandoned before the planned completion date as the interim results were so clear. It is unethical to pursue certainty beyond a certain point when there are known risks to participants, even small ones.

    The last trial was limited to “community-dwelling” oldsters. That is not a random sample of the population, and those in poorish health and/or weak family ties will have been over-represented. The researchers excluded those with “cardiovascular disease, dementia, or physical disability”. But they did not catch those who cycle 50 miles a day. The proverbial Cretan male ideal of a good death is in your mistress’ bed at age 90, shot by her irate husband.

  2. James, if someone calls me a cretin (phonetically), now I have to ask how he spells that before I decide whether I’m insulted or flattered. Also, are you suggesting that if I take up serious cycling, I may find happiness with a mistress for the next fifteen years?

    No definite plans yet; just wondering.

    On a more serious note–This latest study makes me wonder about something I would have thought to be obvious. Didn’t they (whoever “they” are) do a serious evaluation of side effects before they decided an aspirin regimen was good for us old guys? In particular:

    (1) Point 2 in Stuart’s post seems exactly opposite to a point you made in your cited post from six years ago, in which you quoted a substantial improvement in cancer rates. Calling this latest result unexpected, after all the studying and all the data and all the analysis, is a masterful understatement. I would call it astonishing.

    (2) Blood flow has always been a known side-effect of aspirin. Didn’t anybody count the rate of hemorrhages in previous studies?

    1. Any male who cycles 50 miles a day in Crete lives to 100 and the irate husbands just slink away.

      The big difference with Rothwell seems to be the focus of the new studies on older people. We are falling apart anyway and best let nature take its course, perhaps.

  3. Yesterday and today I had a total of three doctor’s appointments. Two knew about the NEJM articles. One of them directed me to stay on the aspirin regimen. Another said absolutely not. (The issue did not come up with in the third interaction.)

    1. What to do, what to do???

      (With a hat tip to Ray Parker, Jr)

      If there’s something strange in your pharmacy
      Who you gonna call? (Drugbusters)
      If there’s something weird
      And it’s none too clear
      Who you gonna call? (Drugbusters)

      I ain’t afraid of no drug,
      I ain’t afraid of no pill.

      If the data’s all confused
      And you can’t tell what to do,
      Who you gonna call? (Drugbusters)
      An invisible risk, hiding
      In your medicine chest?
      Who you gonna call? (Drugbusters)

      I ain’t afraid of no drug,
      I ain’t afraid of no pill.

      Who you gonna call? (Drugbusters)
      If you’re all alone
      Pick up the phone
      And call Drugbusters.

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