Last month, media headlines claimed that aspirin had more risk than benefit for older adults, and a few media articles went so far as to suggest that people throw away their aspirin. The truth is that the recently published studies didn’t make this recommendation. It does bring up an important point since everyone should know who might still benefit from aspirin therapy, and who is likely to be harmed by it. Aspirin is derived from the bark of willow trees. It has been used for centuries for pain, fever, and inflammation. Baby aspirin has also been used for decades to reduce the risk of heart attacks and stroke. Yet, aspirin has been shown to carry both benefits and risk for people taking it. The established benefit has been reducing the risk for a heart attack or stroke by blocking clot formation in arteries. The known risk of taking aspirin has been from spontaneous bleeding, with sometimes fatal or disabling consequences. For the past 20 years, standard medical recommendations have been that people at high risk for a heart attack or stroke have had more benefit from taking a baby aspirin daily (84-100 mg per day). In contrast, people at low risk for a heart attack or stroke were more likely to be harmed by bleeding and should avoid using it. Last month, The New England Journal of Medicine (NEJM), published three research articles with findings from the ASPREE trial. These publications have achieved worldwide media attention, and due to this broadcasting sensation, several of my patients have called my office confused and seeking advice. After reading the articles in detail, here is the information that I shared with them. What was the purpose of the ASPREE trial? The Aspirin in Reducing Events in the Elderly (ASPREE) trial was a double-blind, randomized, placebo-controlled trial (RCT) that investigated whether the potential primary prevention benefits of low-dose aspirin outweighed the risks in healthy older adults. Participants were randomized to two groups; one group received daily aspirin (100 mg per day) and the other received daily matching placebo that contained no active ingredients. The study was designed to answer one primary research question: Would daily use of aspirin for 5 years prolong disability-free life in healthy older adults? The secondary research questions from this study aimed to see if daily use of aspirin for 5 years would impact death rates, heart attacks and strokes, cardiovascular procedures, cancer, dementia, memory loss, depression, physical disability, and clinically significant bleeding in healthy older adults. The main hypothesis of the study was that daily low-dose aspirin would extend disability-free and dementia-free life in these healthy elder adults. To understand the results of this trial, it is important to know who was excluded and who was included in this trial. The subjects in the ASPREE trial were healthier than the average general public of similar ages. From 2010 through 2014, they enrolled community-dwelling persons in Australia and the United States who were 70 years of age or older (or ≥65 years of age among blacks and Hispanics in the United States) and did not have cardiovascular disease, dementia, or disability. Participants were randomly assigned to receive 100 mg of enteric-coated aspirin or placebo. The following people were excluded:
- Anyone with significant chronic disease that would likely limit their survival to <5 years, excluding people with lung disease, kidney disease, or a history of cancer.
- Anyone with any history of cardiovascular disease
- Anyone with a major physical disability, including memory loss
What did the ASPREE trial find? Of the 19,114 persons who were enrolled, 9525 were assigned to receive aspirin and 9589 to receive placebo. A total of 1052 deaths occurred during a median of 4.7 years of follow-up. The risk of death from any cause was 12.7 events per 1000 person-years in the aspirin group and 11.1 events per 1000 person-years in the placebo group; this means taking aspirin in this subject population increased the risk of death by 1.6%. A surprise finding was that cancer was the major contributor to the higher mortality in the aspirin group, accounting for 1.6 excess deaths per 1000 person-years. Cancer-related deaths occurred in 3.1% of the participants in the aspirin group and 2.3% in the placebo group, a 0.8% increase. The bottom line is that for healthy adults over the age of 65-70, taking a baby aspirin did not prevent death rates. And in these healthy, older adults, they had a higher risk for a major bleeding event and death from any cause. There was a slight decrease in heart attacks and strokes, but this was offset by a greater risk for bleeding and/or cancer, in particular, colon cancer. The findings from the ASPREE trial support prior recommendations that healthy adults experience more harm than benefit from taking a baby aspirin daily. Keep in mind, the ASPREE study did not evaluate the benefits of aspirin for adults that are at high risk for a cardiovascular event (heart attack or stroke), who have already had a heart attack or stroke, or who have a history of colon polyps or colon cancer. For patients with a past history of a heart attack or stroke, or those who are high risk for a cardiovascular event and have excess arterial plaque (such as from a carotid IMT study), then I still recommend that they take a baby aspirin daily. Also, for people with a history of colon polyps and colon cancer, prior studies have shown that taking low-dose aspirin reduces the risk for recurrent colorectal adenomas compared to placebo and that they are less likely to suffer from metastatic colon cancer as well. Summary If you are healthy there is more harm than benefit from taking low-dose aspirin daily long term. If you are high risk for a heart attack or stroke, or have had prior colon polyps or colon cancer, then you might benefit from daily low-dose aspirin therapy; therefore, talk to your doctor to clarify if you would have greater benefit than risk from taking a baby aspirin daily. I wish you the best of health! Steven Masley, MD, FAHA, FACN, FAAFP, CNS References
- McNeil JJ, et al. Effect of aspirin on disability-free survival in the healthy elderly. NEJM. 2018. DOI: 10.1056/NEJMoa1800722.
- McNeil JJ, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. NEJM. 2018. DOI: 10.1056/NEJMoa1805819.
- McNeil JJ, et al. Effect of aspirin on all-cause mortality in the healthy elderly. NEJM. 2018. DOI: 10.1056/NEJMoa1803955.
Why would you risk taking someone off of aspirin that causes inflammatory conditions of the intestinal tract, when there are herbs and Omega 3’s that will help the body health thyself? The determination for taking someone off of aspirin is their non-compliance with healing themselves. Some people are “disloyal to themselves” and don’t want to heal themselves as they don’t feel worthy. Those are the people that need a “magic pill” like aspirin so they don’t have a heart attack. There are health consequences for taking “magic pills” with other body systems. I have been Functional Medicine Nutritionist since 2001.
The simple answer is because herbs and omega-3 fats don’t have the same proven benefits for high risk people that come from taking a baby aspirin daily. I think the proper point to make is that long-chain omega-3 fats and anti-inflammatory herbs (like curcumin and rosemary) have additional benefit and should also be used. The goal of Functional Medicine is to optimize physiological function with a combination of traditional and alternative therapy options, not avoid conventional therapies that are proven to work.
Steven Masley, MD
Thank you for clarifying the baby aspirin dilemma.
I am 64, female, and rarely take aspirin. I have been taking Simvastatin 20mg daily since 2014 for high cholesterol. Had a colon polyp removed a couple years ago.
Where is the mention of aspirin staying in your system for 1 1/2 – 2 days. So taking it daily is really almost doubling the dose.
A single dosage of aspirin impacts your platelets and clotting for up to one week. That is why they ask you to stop it one week in advance before having surgery. Having said that, most studies that used low dose aspirin showed benefits used either 81 mg or 100 mg taken daily, so if you take it, daily dosing is the proven regimen. I don’t recommend taking aspirin every other day. Steven Masley, MD
Thank you. That explains it very well.
Would a person with occasional afib who has a biotronik loop recorder in chest to monitor heart take a daily aspirin.
I am 77 female and take Xanax as needed and np thyroid daily.
A daily low dose aspirin is too low a dosage to stop clotting from atrial fibrillation. You would need to speak to your physician about take a full aspirin daily (325 mg) or more likely Eliquis or Warfarin instead to get enough anti-clotting protection.
Steven Masley, MD
Thanks you for this clarification. I called my cardiologist’s office three times, and she never got back to me. I am 70 hi-chol/bp and had aortic valve and root surgery 5 yrs ago, and I also have colon polyps. I stopped my low dose after news reports. I read all your books, (and actually live around the corner from your clinic by Jabil, St Pete)! Your info probably saved me.Thanks. Katie
If you have high cholesterol and high blood pressure, and have had an aortic valve surgery, plus a history of colon polyps, you might have more to gain than to lose. Talk to your doctor about the best plan for you. Steven Masley, MD
Why not buy pure aspirin with nothing added in bulk form and at most only a starch filler if it is the only kind? Not sure if you can buy from your local pharmacist? Would this kind of aspirin benefit people in need of the good side effects of aspirin without any added toxins ? Please let me know your expertise? Thank you.
That is a good question. Most of the studies with aspirin were done with common, over the counter preparations. You are correct that many drugs and supplements have fillers and starch in them. The critical point is the active ingredient, in this case aspirin, and whether you should be using it or not. Steven Masley, MD
Thank you so much doctor, you are simply amazing human being
I had heart attack around 20 years ago and now talking aspirin baby, my dentist asking me to stop aspirin for 3 days but my oral surgeon telling me it doesn’t matter,
Your previous answer says I should stop but is 3 days enough or I should do like a week ?
Thank you so much
If you are having a procedure with significant bleeding risk, depending upon the procedure and your risk factors for clotting, I typically say stop 7 days before. I’m going to guess that the oral surgeon does not think serious bleeding is an issue, hence he/she said it doesn’t matter. Always include our own physician who knows you when making this type of decision. Steven Masley, MD
Dear Dr. Masley:
My husband is on the Dale Bredesen Protocol which includes a number of supplements that thin the blood. Prior to taking the wide range of supplements recommended after many lab tests, he had been prescribed a daily 81mg baby aspirin. His arms showed that whenever he bumped himself, he would create a bruise. I also happen to take Mind, Mood and Memory, a newsletter from Massachusetts General Hospital. One of the questions submitted by a reader inquired whether taking a daily baby aspirin might be responsible for brain bleeds (minor infarcts). The doctor who responded said it was possible.
Since I discovered that a number of the supplements my husband is now on do contribute to thinning of the blood, I have not given him his daily aspirin. His arms have cleared up and the many supplements seem to be helping with his forgetfulness.
What do you think about the choice to suspend his baby aspirin as long as he is on the Bredesen Protocol? His arms have cleared up and so has a lot of his conversation and some of his brain fog.
This is excellent, USEFUL information for everone. Let’s start by eating the right foods and making sure our loved Ones in their golden years thrive with joy of love and true and wonderful health!
I was medically diagnosed as having a very low tolerance level to salicylates about ten years ago. Two things may have triggered this:1. I contracted Ross River Fever and 2. I was put on low dose aspirin. I now have to eat low salicylate containing foods. If I do so the level of inflammation in my body drops substantially. If I break my diet I really suffer.