Now that health concerns have been raised about newer anti-inflammatory drugs like Vioxx, Celebrex and Bextra, some Americans may be taking another look at one of the few medicines that have been around since the Victorian era.
That would, of course, be aspirin. According to some estimates, a trillion tablets have been taken in its long history.
Aspirin is effective, relatively safe and costs as little as a penny a tablet. So what's not to like?
"We medically know it's as good an anti-inflammatory as any other," says Dr. Alan Kimmel, a Towson internist. "But it's not sexy, it has no cachet, and it's too inexpensive."
In other words, the wonder drug of modern medicine, first synthesized in the 19th century, gets very little respect in spite of its many uses. Newer drugs cost 10 to 15 times as much for the equivalent pain relief. But as Kimmel points out, Americans tend to believe if something costs more, it must be better.
With the news that popular prescription anti-inflammatories may pose serious risks to the heart, Kimmel says he's had "a hundred conversations" with patients in recent weeks. Only a couple of them have been interested in considering aspirin as an alternative.
Aspirin "lost its luster largely due to age," believes pharmacologist Steven Weisman, a consultant to Bayer, the world's largest manufacturer of the drug. "People like newer things. Consumers move away from the tried and true to experiment."
But there were good reasons people turned to newer medicines. Aspirin can have serious side effects, including internal bleeding and stomach ulcers, especially when taken long term to treat arthritis or chronic pain. Some people are more susceptible than others.
At low doses, this isn't a huge concern. A safety review published in 2002 in the Archives of Internal Medicine reported that less than 1 percent of patients on a low dose for heart health were diagnosed with bleeding. (An adult aspirin is 325 milligrams. A low-dose, or cardiac-dose, aspirin is 81 milligrams.)
Aspirin inhibits the production of prostaglandins, hormone-like substances that, among other things, cause pain and inflammation; and it prevents blood platelets from sticking together, decreasing the chance of a blood clot.
Drugs like Vioxx, Celebrex and Bextra, known as Cox-2 inhibitors, were developed to reduce or eliminate internal bleeding associated with aspirin, but that also meant they didn't affect blood in a positive way to help prevent heart attacks and some strokes.
Aspirin is a reasonable choice to take short term for a headache or a sprained ankle. You could even try it long term for minor arthritis pain if you're not in the high-risk group (the elderly, steroid users and those with a history of stomach problems or ulcers).
But it's unlikely Americans will return in numbers to aspirin as the pain reliever and anti-inflammatory of choice, not only because of the risk of internal bleeding but also because the newer drugs only have to be taken once a day, helping what doctors call "compliance." That is, people are more likely to keep taking newer drugs once a day, while aspirin has to be taken around the clock.
"Time will tell whether people will be able to tolerate aspirin as they did 20 years ago," says Dr. William Henrich, chairman of the department of medicine at the University of Maryland School of Medicine. "Twenty years ago, people had to tolerate it. I'm not sure they will with the newer drugs available."
Tolerance and compliance aren't the only issues. Many people don't think aspirin works as well as newer anti-inflammatory drugs. At age 47, John Murphy, a lawyer who lives in Cub Hill, doesn't fall into any of the high-risk categories, but when he has aches and pains, he never considers aspirin.
"I take Advil," he says. "It works 10,000 times better."
For him, it may. Pain relief is a very individual thing, explains Dr. Howard Hauptman, division head of rheumatology at Greater Baltimore Medical Center. "There's an incredible variety of response [to anti-inflammatories]. Even when they are in the same family of drugs, they are all slightly different chemically."
To get the same anti-inflammatory effect as one 200-milligram Celebrex, he estimates, you would have to take 12 or 14 aspirin. (For simple pain relief, the dose would be more like four to six tablets a day.)
On the other hand, William Camp, a 45-year-old personal trainer, swears by aspirin. He rarely needs medication, but when he does he takes one or two tablets. They don't bother his stomach.
"It's a medicine I've grown up with since childhood," the Timonium resident says, explaining why he doesn't reach for one of the newer over-the-counter painkillers. "Its safety has been proven. I'm familiar with it."
That childhood familiarity is how aspirin manufacturers built a base of loyal adult users. From the beginning, aspirin was marketed as a non-habit-forming, family-friendly pain reliever, unlike the opiates that preceded it.