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THE

PEOPLE'S PHARMACY

Graedons' Guide to

Key Aspirin Information

A

Americans down 29,200,000,000 doses of aspirin each year. That equals 117 pills for every man, woman and child.

spirin is truly a miracle. No other medicine does so much for so many at so low a price. Every single day in the U.S. 80 million aspirin tablets are swallowed. At a time when many medicines now cost a dollar or more per pill, aspirin is still the best bargain in town at less than one cent a tablet.

PROPER STORAGE

The medicine chest is the worst place in your house to store aspirin. Heat and humidity are enemies of all drugs, especially acetylsalicylic acid. Child-proof caps may not be airtight. Always remove the cotton from your aspirin bottle since it serves absolutely no purpose once you've bought it. The only reason this filler is there in the first place is to stabilize the pills during shipping so they don't crumble. Cotton can absorb moisture and make aspirin deteriorate more quickly. You may be able to tell if aspirin is going bad by smelling the open bottle. A vinegar-like odor signals acetic acid, a breakdown product of aspirin. This is not dangerous, but it could signal that your aspirin is beginning to lose its punch. Even if you are within the expiration date, you may want to replace aspirin that smells.

V ERSATILITY

People take aspirin for everything from aches and pains to strains and sprains. It is still considered the gold standard when it comes to arthritis. Most garden-variety headaches respond well to aspirin and new data suggests that one tablet taken every other day may even help prevent some migraine attacks. Researchers have been impressed with this drug's ability to reduce the risk of heart attacks and strokes. Now preliminary data suggest it may also help lower the chances of colorectal cancer.

s

POPULAR ASPIRIN MYTHS

1) Aspirin applied directly to a toothache can relieve the pain. Don`t use aspirin directly on a toothache; it's far too irritating to the gum tissue and can do damage to the tooth. Of course you can swallow two aspirins to ease minor pain. 2) Aspirin gum can ease pain from a sore throat. Aspirin does not provide a local soothing effect. The only benefit from aspirin gum depends on how much aspirin you swallow, how much gets into your stomach and ultimately circulates through your blood stream. That is a roundabout way to get aspirin to ease a sore throat. Swallow two pills and gargle with salt water instead. 3) An aspirin in a vase of cut flowers will make them last longer. Aspirin does not appear to prevent flowers from deteriorating or stimulate plant growth. Save the aspirin for aches and pains, strains and sprains. 4) Combine aspirin with Coca Cola and you can get high. We don't know how this story got started, but there is no way you can get high on aspirin and Coke. Once upon a time there was a small amount of cocaine in Coca Cola, but not enough to get "high." Caffeine in Coke might boost the pain relieving power of aspirin.

© 1993 Graedon Enterprises

D OSAGE

Have you ever wondered why aspirin is often labeled "5 gr."? Although it is rare to find old-fashioned apothecary measurements like grains, drams and minims on most medicines these days, aspirin is still measured in an outmoded dose. When this drug was developed almost 100 years ago, the usual recommendation was 10 grains, which translates into our modern measurement of 648 milligrams. That means each tablet should be 324 mg--a rather unusual dose, to say the least. Most manufacturers actually put 325 mg in their regular-strength aspirin tablets so the label won't look too peculiar, but there is nothing sacred about the standard 5 grain dose. Garden-variety pain How much aspirin should people take? The standard recommendation, "take two tablets every four hours," probably dates back to the time of aspirin's 5 gr. dose, but for regular headaches, minor pains or fever, it still holds for most people. Now, a 95-pound grandmother may find that one and a half tablets works fine, whereas a lumberjack who weighs in at 285 pounds may need three. Manufacturers have long fiddled with the dose so that they could make marketing claims. For example, the makers of Anacin advertised for years that their product contained more pain reliever than any of the other leading brands. Big deal! They have 400 mg of aspirin in each tablet instead of 325 mg. If you truly need this "extra strength" you could accomplish virtually the same thing by taking two and a half regular-strength generic tablets. Other manufacturers have come up with their own dosing strategy. For example, Maximum Bayer Aspirin Tablets each contain 500 mg. Boots Pharmaceuticals markets a prescription controlled-release aspirin product called ZORprin which has 800 mg, while Parke-Davis makes Easprin, a prescription-only coated aspirin with 975 mg per tablet.

I nflammation

If you are using aspirin for something other than pain relief, the "right" dose may be quite different from the standard two-every-fourhours. The anti-inflammatory action of aspirin only kicks in at higher levels. For people with arthritis, the recommended dose ranges from 3,600 mg to 5,400 mg a day. That translates to anywhere from about a dozen to 16 or so standard tablets daily. Heart attacks/Strokes When it comes to the anti-clotting aspects of aspirin, a much lower dose is appropriate. We're talking about preventing heart attacks, strokes and perhaps even migraine headaches. Researchers wonder how low you can go and still measure a therapeutic benefit. The results are truly astounding. Over 22,000 doctors were recruited to serve as guinea pigs in the largest aspirin study to date. Half received one regular-strength aspirin tablet every other day. The other group took an inactive placebo. This Physicians' Health Study showed that healthy men taking low-dose aspirin therapy had 44 percent fewer heart attacks. A follow-up analysis demonstrated even more impressive results for those physicians at high risk of heart attack. The same aspirin dose reduced the risk of heart attack by 87 percent for those men with chronic chest pain (stable angina). Not only did aspirin lower the chance of heart attack, it also appeared to reduce the frequency of migraine headaches. Doctors on aspirin in the Physicians' Health Study had 20 percent fewer migraines than those on placebo. British research supports this finding. Dr. Richard Peto has reported that in a similar study, British doctors experienced almost 30 percent fewer migraines. He suggests, "A migraine patient should consider taking a baby aspirin a day." It is hard for most people to believe that such a low dose (one-fourth of a regular tablet) could do much of anything. Certainly no one would

Children's aspirin for adults?

ST. JOSEPH CHEWABLE ASPIRIN Low Strengh Caplets (81 mg each) It may be hard to find baby aspirin these days because of a fear of Reye's syndrome, but the maker of St. Joseph brands now has a "baby strength" specifically for adults.

2

PROTECTING YOUR STOMACH FROM ASPIRIN DAMAGE

Stomach irritation from aspirin is both direct and indirect. Counteracting the immediate effect of aspirin in the stomach with food, antacids, buffered brands or coated products such as Ecotrin, Easprin, or Therapy Bayer Caplets may help a little with indigestion and heartburn. But aspirin also lowers body-wide levels of hormone-like chemicals (prostaglandins). Prostaglandins protect the stomach lining from ulcers and bleeding, so when aspirin reduces their action, irritation and blood loss is common. Salsalate (Disalcid, Salflex) and choline magnesium trisalicylate (Trilisate) are aspirin-like drugs that may be a little easier on the digestive tract. They work well against inflammation but may not relieve pain as well as aspirin. Carafate (sucralfate) or Cytotec (misoprostol) are sometimes prescribed to counteract stomach irritation. Carafate is well tolerated, but Cytotec can cause severe diarrhea, stomach pain, nausea, gas and headache. expect it to relieve a normal headache, let alone a migraine. But low doses of aspirin apparently prevent blood platelets from sticking to each other and forming a clot. Scientists now think that such spontaneous clots may play a role in triggering heart attacks and one type of stroke. Clumps of platelets also seem to give off serotonin, a brain chemical that is important in the initial stage of migraines. This may explain how it helps cut migraine attacks. Doctors are still trying to determine the optimum aspirin dose for heart attack and stroke prevention. Swedish and Dutch data suggest that mini doses are as effective as larger doses and reduce side effects. They found that as little as 30 to 75 mg (one twentieth to one eighth of a standard dose) worked against blood clots. No one should ever start a life-long aspirin regimen without first consulting with a physician about the appropriate dose and possible risks. develop nasal growths (polyps) and such people are more likely to suffer from aspirin-induced asthma. Another serious complication from regular aspirin use is bleeding. Because the platelets become less "sticky," people may bruise easily or even hemorrhage. If this were to occur in the brain, it could lead to a bleeding stroke. Although this complication is relatively rare, people with a bleeding tendency or uncontrolled high blood pressure should not be taking aspirin except under a physician's supervision. For all these reasons aspirin should never be taken for granted, especially if you are on other medications. Aspirin can interact with dozens of other over-the-counter and prescription drugs. Some of these combinations can be life-threatening.

Reye's

Syndrome

This is a rare but very dangerous condition that may occur in children, from babies to teenagers, following a viral infection such as influenza or chicken pox. Since it is often hard to know if your child has the flu, be extremely cautious when it comes to administering aspirin in any form. That includes Pepto-Bismol, which contains bismuth subsalicylate, an aspirinlike ingredient. Symptoms of Reye's syndrome include nausea, vomiting, irritability, lethargy, disorientation, and in severe cases, coma.

DRUG INTERACTIONS

Because aspirin doesn't require a prescription and may be taken on a daily basis, there may be a temptation to take this drug for granted. That could be tragic. Aspirin can interact with a number of other medications. Coumadin (warfarin), for example, is a blood thinner that could cause lifethreatening hemorrhage in combination with aspirin. New research shows that aspirin can reduce the effectiveness of Vasotec (enalapril) for controlling heart failure. Always check with your physician and pharmacist before taking aspirin together with other medications. 3

SIDE EFFECTS

Despite such impressive benefits, aspirin poses a number of risks. Stomach irritation is very common, even at relatively low doses. Stomach bleeding and ulcers can be a real hazard, especially for older people who must take larger amounts for arthritis. Ringing in the ears (tinnitis), dizziness or hearing loss can also occur at high doses and require prompt medical attention. People who are allergic to aspirin-like drugs can

DRUG Activated AcDRUG Charcoal

INTERACTS WITH ASPIRIN:

Activated charcoal, sometimes taken for flatulence, can attach to many other drugs, aspirin among them. It may reduce aspirin's effectiveness.

Alcohol

Taking aspirin together with an alcoholic drink could easily aggravate stomach irritation. There is also a possibility that blood alcohol levels might end up higher than expected after just one and a half drinks if aspirin were taken an hour beforehand. There is disagreement about the clinical and legal implications of this interaction, but why not avoid it?

Antacids

Advanced Formula Di-Gel Gelusil Maalox Milk of Magnesia Tums, etc. Using antacids regularly can reduce the amount of aspirin circulating in the body. People using anti-inflammatory doses of aspirin should be monitored if they start or stop taking antacids daily.

Anticoagulants

Coumadin (warfarin) Dicumarol Heparin Miradon (anisindione)

Because aspirin also has anticlotting action, any of these prescription blood thinners (including heparin) might work too well in combination with aspirin. The potential exists for dangerous excessive bleeding. Careful monitoring is crucial.

Arthritis

Drugs

Although this interaction is not well established, some people find that these drugs for arthritis, bursitis, tendinitis, and other problems are less effective in combination with aspirin. In addition, stomach irritation may become worse.

Advil (ibuprofen) Clinoril (sulindac) Feldene (piroxicam) Motrin (ibuprofen) Naprosyn (naproxen) Voltaren (diclofenac), etc.

Ascorbic Acid

Vitamin C

People who take aspirin on a regular basis may have lower levels of this vitamin inside certain cells. It's not clear, though, whether there are any medically significant consequences. The interaction between aspirin and vitamin C is complicated and seems to differ with dietary levels of the vitamin. In one study, aspirin reduced urinary excretion of ascorbic acid when the vitamin was in ample supply; paradoxically, when dietary levels were low, aspirin led to greater excretion of vitamin C.

Baking

Soda

This home remedy for indigestion could make urine alkaline. The result would be more rapid elimination of aspirin from the system.

Beta Blockers

Blocadren (timolol) Corgard (nadolol) Cartrol (carteolol) Inderal (propranolol) Lopressor (metoprolol) Sectral (acebutolol) Tenormin (atenolol) Visken (pindolol), etc. 4 These medicines used to treat high blood pressure and heart disease may not work as effectively in the presence of aspirin. Research on this issue is not solid, but if you must take aspirin as well as one of the beta-blockers, you and your doctor should monitor your blood pressure response carefully.

DRUG Capoten (captopril)

INTERACTS WITH ASPIRIN:

In theory, aspirin might interfere with the effectiveness of this blood pressure medicine, but a small study did not turn up any problem. Monitor your blood pressure if you must take both drugs. See Vasotec for a similar interaction.

Cortisone-like drugs

Cortef (hydrocortisone) Decadron (dexamethasone) Deltasone (prednisolone) Medrol (methylprednisolone) Aspirin is eliminated more rapidly in the presence of these strong prescription steroids. Physicians should monitor dosing carefully.

Diabetes Drugs

DiaBeta (glyburide) Diabinese (chlorpropamide) Glucotrol (glipizide) Micronase (glyburide), etc. Insulin Type-II diabetics should take aspirin only under a doctor's supervision, with careful blood sugar monitoring. Otherwise, blood glucose might drop too low unexpectedly.

Diuretics

Bumex (bumetanide) Edecrin (ethacrynic acid) Lasix (furosemide)

Aspirin can counteract the effectiveness of these strong "loop" diuretics in people with kidney or liver problems, especially if there is fluid build-up in the abdomen (ascites). This could have serious consequences; consult the physician.

Epilepsy Drugs

Depakene (valproic acid) Dilantin (phenytoin)

These important anticonvulsant drugs could become more toxic in the presence of aspirin. A person who must take aspirin should be monitored closely for adverse reactions and blood levels of these medicines.

Glaucoma

Drugs

Aspirin might increase blood levels of these glaucoma medicines to potentially toxic amounts. Elderly patients and people with kidney trouble are at particular risk. Check with your ophthalmologist before adding aspirin.

Daranide (dichlorphenamide) Diamox (acetazolamide) Neptazane (methazolamide)

Gout Medicine

Anturane (sulfinpyrazone) Benemid (probenecid)

Taking aspirin with either of these gout medicines may keep them from controlling the uric acid build-up. In addition, aspirin won't be able to work against gout either. It takes no more than 700 mg of aspirin to block Anturane almost totally.

Methotrexate

Folex Mexate Rheumatrex, etc.

This medication, used to treat psoriasis, rheumatoid arthritis and cancer, could reach surprisingly high levels in the body when combined with aspirin. This is a double-edged action, potentially increasing the power of the drug, but also its toxicity. Don't take any chances. Check with your doctor before taking any aspirin while you are also taking methotrexate.

Vasotec

(For more details on this interaction see: Hall, D., et al. "Counteraction of the Vasodilator Effects of Enalapril by Aspirin in Severe Heart Failure." J. Am. Coll. Cardiol. 1992; 20:15491555.)

(enalapril)

A small controlled trial (18 patients) showed that aspirin taken with or before Vasotec blunts its beneficial effect in heart failure. There are also a few case reports of Vasotec failing to control blood pressure as effectively when taken together with aspirin. Talk to your doctor. 5

ARE BRAND NAMES BETTER?

People often tell us that they can only get adequate pain relief from one particular kind of aspirin. Some folks swear by the Bayer brand while others love Empirin or Ascriptin. Many insist that the only effective headache remedy for them is AlkaSeltzer. All we can say is that aspirin is aspirin is acetylsalicylic acid. There is no chemical or biological reason for one brand to be stronger or more effective as long as the dose is roughly equivalent. Experts for Consumers Union tested a number of different brands ranging from cheap house brands to expensive, highly promoted products. They found no significant differences. But people continue to pay five to ten times more for their favorite brand. Why? British researchers may have come up with an answer. In their study an inactive placebo pill was made to resemble a familiar brand name aspirin product. It relieved many people's headache pain better than a chemically identical but plainlooking placebo. In other words, two totally inactive products produced different results purely on the power of suggestion. In fact the scientists concluded that as much as one-third of the pain-relieving effect of brand name aspirin is due to psychological expectation of the patient. If you are convinced that only one brand of aspirin will do, then that is the brand you should use. You might very well notice the difference between it and an inexpensive generic. If, on the other hand, you get relief from any house-brand USP aspirin product, you are fortunate. You can get your analgesic action at substantial savings by shopping comparatively.

A panel of experts looked at the safety of such over-the-counter pain relievers. In 1984 these scientists found "the weight of evidence supports the view that combinations of antipyretic [fever reducing] analgesics [pain killers] taken in large doses over long periods can cause kidney disease and chronic renal failure." The experts recommended that the Food and Drug Administration seriously consider limiting over-thecounter products to those with only one pain-fighting ingredient. For unknown reasons the FDA chose to ignore this suggestion. We'll leave it to you to decide whether the risk is worth the benefit.

Buffered

Aspirin

THE CAFFEINE CONTROVERSY

One of the more controversial questions among pain specialists is whether caffeine can boost the painkilling power of aspirin. A recent study published in the Archives of Internal Medicine suggests that the answer may actually be yes. Patients with sore throats were given either plain aspirin or aspirin with caffeine (64 mg). According to the investigators the patients who received the extra caffeine noted greater pain relief. The study was conducted in a scientific manner, but paid for by the makers of Anacin. Not surprisingly, they were pleased with the results since Anacin contains aspirin and caffeine. Whether these results hold any meaning for people with headaches or other kinds of pain remains to be determined. If you want this "magic" formula you could take your aspirin with a glass of iced tea or a cup of coffee and probably achieve much the same benefit.

Drug companies have tried to counteract the direct irritating effects of aspirin by adding antacids such as aluminum and magnesium hydroxide. Some people do benefit, but regular, high-dose aspirin consumption can still lead to stomach upset through an indirect action of aspirin on the stomach lining. Even if aspirin could be injected intravenously it might still cause stomach problems for some people. Don't assume that buffered aspirin guarantees safety.

The Aspirin Handbook :

A User's Guide to the Breakthrough Drug of the 90s (Bantam Books, 1993) by Joe Graedon, Teresa Graedon, Ph.D. & Tom Ferguson, M.D. Everything you ever wanted to know about aspirin and then some. We also cover acetaminophen (Tylenol) and ibuprofen (Advil, Motrin IB, Nuprin, etc). You will learn lots more about proper dosing, usage and precautions. This indispenable guide is 244 pages and costs just $4.99. Add $1.00 for postage and handling. The People's Pharmacy P.O. Box 52027 Durham, NC 27717-2027 You may also wish to order one of our many publications or audio cassette tapes.

FUTURE MIRACLES?

New discoveries of aspirin's incredible powers never seem to stop. In one recent study people who routinely used aspirin were reported to have roughly 50 percent less stomach, throat, colon and rectal cancer. No one knows what the next aspirin breakthrough might be, but stay tuned. It's bound to be breathtaking!

COMBINED PAIN RELIEVERS

There are lots of pain relievers on the market that combine analgesic ingredients. Excedrin, Goody's Headache Powers, Trigesic, Tri-Pain and Vanquish are just a few of the products that contain more than one kind of pain medicine. 6

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