The question here is, does taking an aspirin a day or a baby aspirin a day, which is really just a low dose of aspirin, make sense for preventing cardiovascular disease and blood clots? In particular, Betty’s question was about polycythemia vera and essential thrombocythemia, and we’re going to call that ET. That’s what it goes by in the medical world, and it’s going to save me from saying “essential thrombocythemia” every time! In these conditions, the main concern that happens is blood clot that can lead to an occlusion of the artery and a heart attack or a stroke, and of course, I’m sure many of you out there have been advised by your doctor to take a baby aspirin a day to prevent cardiovascular disease or you know somebody who has, so even as these particular conditions that Betty’s mom is suffering from are fairly rare, the general principle that we’re going to discuss applies to a lot of people.
In this episode, we cover:
6:15 Is low-dose aspirin safe?
12:20 Drugs vs. natural alternatives
16:42 Natural alternatives to aspirin
Links we discuss
Full Text Transcript:
Steve Wright: Hey, everyone. Welcome to another episode of the Revolution Health Radio Show. This show is brought to you by ChrisKresser.com. I’m your host, Steve Wright from SCDlifestyle.com, and with me is integrative medical practitioner and New York Times bestseller, Chris Kresser! Chris, good morning!
Chris Kresser: Good morning, Steve. How are you?
Steve Wright: Drinking my first cup of coffee, man, just getting rolling. It’s going to be a good day.
Chris Kresser: Bright and early, yeah. Let’s just dive right in today. We have a great question from Betty. Let’s give it a listen.
Question from Betty: Hi, Chris. My mom was diagnosed five years ago with polycythemia vera and essential thrombocythemia, the hardest things to pronounce ever. Although she has a hematologist who’s great who has her on baby aspirin every day, I wanted to know, one, if that’s a treatment that can last a long time or are there any disadvantages or any kind of health issues that result in being on aspirin for that many years, and also what kind of dietary things would you recommend? I have her taking some fermented cod liver oil. She eats really healthy, kind of whole foods. We did, for a period of time, try ketosis, and it went quite well, but then she also tried a kind of raw food diet prior to that, and her blood was good again. I was just wondering. It’s really hard to get a clear message about what the mechanism is and why it’s happened and all that kind of stuff, so I look forward to hearing from you.
Steve Wright: Chris, before we let you jump in on this question from Betty, I just want to remind everybody that the way that we’re doing this new podcast format is listener-submitted voice questions. I just want to remind all the listeners of RHR to go to ChrisKresser.com/PodcastQuestion. There you can call in or you can just voice in your question that you’d like Chris and I to chat about. Chris, take it away!
Chris Kresser: Yeah, thanks for doing that, Steve. I always forget to mention it. It’s great. I love this new format. We’ve had a lot of great feedback about it, so do make sure to leave us a question. We’ve had some great questions so far, and I’d love to keep them coming.
OK, so this may sound like it’s kind of a complex question and doesn’t apply to a lot of people, but really the question here is, does taking an aspirin a day or a baby aspirin a day, which is really just a low dose of aspirin, make sense for preventing cardiovascular disease and blood clots? In particular, Betty’s question was about polycythemia vera and essential thrombocythemia, and we’re going to call that ET. That’s what it goes by in the medical world, and it’s going to save me from saying “essential thrombocythemia” every time! In these conditions, the main concern that happens is blood clot that can lead to an occlusion of the artery and a heart attack or a stroke, and of course, I’m sure many of you out there have been advised by your doctor to take a baby aspirin a day to prevent cardiovascular disease or you know somebody who has, so even as these particular conditions that Betty’s mom is suffering from are fairly rare, the general principle that we’re going to discuss applies to a lot of people.
Polycythemia vera, in case you don’t know, is a disorder of the bone marrow that causes too many red blood cells to be produced, and essential thrombocythemia, or ET, is a blood cancer that involves overproduction of one or more blood cell lines. And unlike many other cancers, ET does not typically shorten life expectancy, so people who have it tend to live normal lives, the same lifespan as people who don’t have it. But there is kind of a spectrum of how serious ET is or how significantly people are affected, and so patients need to be supervised in order to prevent or treat complications. As I said, those complications are usually related to increased risk of thromboembolism, which is a formation of a blood clot that breaks loose and then can occlude the artery and cause a heart attack or a stroke.
Now, the standard treatment for ET is low-dose aspirin, which is often referred to as baby aspirin, because aspirin has a blood-thinning effect and can reduce the risk of clots for that reason. The typical adult dose of aspirin is around 300 mg, 325 mg. That’s the adult dose. And the baby aspirin dose or the low dose is around 80 mg. Really there are two important questions here, and the first one is more specific as it relates to Betty’s mom, which is, does research support the use of low-dose aspirin continuously over time as a treatment for ET? And then the second question, which is much more general and applies to anyone who’s been told to take low-dose aspirin for cardiovascular prevention is, is low-dose aspirin safe? And I suppose a third question would be, if low-dose aspirin is not safe, what are the natural alternatives that can accomplish the same effect?
Steve Wright: Is this foreshadowing here?
Is low-dose aspirin safe?
Chris Kresser: A little bit of foreshadowing. Yeah, exactly. Because if I tell you that low-dose aspirin might not be a good idea and I don’t give you any alternatives, you’re not going to be happy. Fortunately there are plenty, so we’re going to talk about all of those in a moment. Let’s take the aspirin safety question first.
Aspirin is quite simply not as safe as many have been led to believe, and if you understand how it works, it’s easier to get why that is. Aspirin can alter the natural structure and function of red blood cells as well as how blood flows through our veins and our arteries. This is called hemodynamics, and these really foundational changes that aspirin causes in hemodynamics and the structure and function of red blood cells explains why aspirin has such a wide range of adverse effects even at relatively low doses like baby aspirin. It’s been associated with increased risk of ulcer, hearing loss and tinnitus, bleeding in the brain, an increase in influenza mortality, so a greater risk of death if you get a serious case of influenza and you’re in a vulnerable population, Reye’s syndrome, Crohn’s disease, increased risk of H. pylori infection probably because of the effect of aspirin on the gastric mucosa, and although taking a lower dose, like 80 mg, of baby aspirin is considered certainly to be safer than the full adult dose of 325 mg, it’s still known to cause GI damage. For example, in a 2009 study in the journal Current Medical Research and Opinion, researchers found that low-dose aspirin caused “significant gastroduodenal damage even at the low doses used for cardiovascular protection.” Another 2009 study found that 80%, 8 in 10 people who used short-term low-dose aspirin experienced small intestinal toxicity, including small bowel mucosal breaks, which can lead to leaky gut, and mucosal inflammation.
Steve Wright: Wow. Do you know what “short-term” was in that study?
Chris Kresser: I think it was a couple of weeks. I’d have to go back and look again, but I think it was a couple of weeks, and here we’re talking about people who are being advised to take low-dose aspirin for the rest of their lives essentially and sometimes starting as early as 30 or 40 years old in the case of polycythemia vera and ET, which are often diagnosed at that time, so you’re talking potentially about 30 to 40 or even 50 years of taking low-dose aspirin. It used to be within the conventional guidelines that aspirin was recommended for CVD, cardiovascular disease, prevention, but because of some of this research on adverse effects that I just shared with you, new guidelines that I think were published in either 2011 or maybe 2012 by the US Preventive Services Task Force actually don’t recommend aspirin for cardiovascular disease prevention anymore except in really high-risk categories, like men who are aged 45 to 79 years old, so middle-aged men, with pre-existing heart disease or really elevated risk factors, like extremely high cholesterol, smoking, hypertension, etc., although even that is debatable, in my opinion.
In summary, it’s pretty clear that low-dose aspirin is not safe. “Safe” would mean there’s a very low risk of adverse effects and that those adverse effects that could occur are not harmful, but clearly that’s not the case, as I just demonstrated.
So what about aspirin for treatment of ET? The caveat here is I’m not a hematologist obviously, this isn’t my area of expertise, and please check with your doctor before making any changes, but there was a paper in the journal Leukemia Research in 2010, and the title of this paper was Aspirin in low-risk essential thrombocythemia, not so simple after all? The conclusion of this paper was that the risk/benefit ratio of low-dose aspirin for primary prevention of major cardiovascular events like stroke and heart attack in people with ET who are asymptomatic, which is most people, and who are under 60 years old remains unclear, and it’s even unclear for people who are over 60 years old and are symptomatic. The researchers said, “It should be emphasized that, for the time being, the net benefit of low-dose aspirin is favorable only in high-risk patients who already had major vascular events.” Once again, it’s pretty similar to the US Preventive Services Task Force recommendation where they’re saying that, yes, aspirin may benefit some people, but they’re only the highest risk people and typically people that have already had a major cardiovascular event. And of course, the reason that the researchers emphasize this risk/benefit ratio is the pretty low evidence of benefit, or at least in a pretty small group of people, versus the relatively high risk of bleeding and complications, especially in people with a history of gastrointestinal diseases.
So to answer your question, Betty, I think the evidence supporting low-dose aspirin over a long period of time is pretty weak unless your mom fits into one of these categories that I just mentioned, and I’m concerned about the safety of low-dose aspirin over a long period of time.
Drugs vs. Natural Alternatives
The good news is that there are several evidence-based alternatives to aspirin, and that’s what we’re always interested in here, of course, is treatments and remedies that have a clear scientific basis behind them. We’re not just talking about sort of woo-woo alternative remedies to conventional treatments. We’re talking about stuff that you can actually go into the scientific literature and see peer-reviewed, oftentimes randomized clinical trials supporting.
The interesting thing about these alternatives is that if you mention them to doctors, they’ll often look at you as if you’re crazy and you’ve been doing too much researching on the Internet, and they have no idea that these come right out of peer-reviewed journals and are easily accessible on PubMed. It’s an interesting phenomenon. We’ve talked about this before. I don’t necessarily blame individual doctors because it’s a crazy system when you’re seeing patients for 40 hours a week. I mean, that’s just a huge patient load. And then you’re doing another 20 or 30 hours a week of admin paperwork, emails to patients, and stuff like that. That’s a 60-hour week. If you have a family and other obligations, it’s pretty hard to stay current with the scientific literature. When I graduated from school and started practicing, it was really clear to me that I wanted research to be a big part of what I did, that I eventually imagined teaching other clinicians, and that I didn’t want to have that kind of practice. And I was fortunate to be able to set things up in such a way that I have time to research and I make that a priority, and that’s why I only see patients two or three days a week, but the general clinician doesn’t have that luxury, and they’re not often current with the scientific literature, and they’re not able to keep up with studies on all of these alternative remedies that are actually evidence based. It’s a big problem with the way our system is set up, and I just mention this in case you go into your doctor and you tell them about some of these remedies we’re going to discuss. They may raise an eyebrow, but if you’re enterprising yourself, you can just go to PubMed.org and type in some of these terms, and you can actually print out some abstracts from studies on these remedies if you’d like to talk to your doctor about them.
Steve Wright: And probably if you can mention again one more time, Chris, what was the council or the guidance body that has reversed their decision regarding baby aspirin use? Probably just at least printing that off and starting the conversation with your doctor with that is probably a good start.
Chris Kresser: Yeah, that’s the US Preventive Services Task Force, and also if you search for “low-dose aspirin safety” just in Google, you’ll find a bunch of articles in The Wall Street Journal and The New York Times that were published around 2011 because there was a big study published, I think, in 2010 about the risks of long-term aspirin use, and there was a big controversy about it at that time, and so there were a lot of articles published in the mainstream press that covered this issue pretty well. You can also just print some of those articles out, and they refer to the underlying studies, so there’s plenty of information out there.
Of course, one last thing I wanted to point out before we go on: The reason often you hear of the drugs in these situations and not the natural alternatives, in addition to the fact that doctors often don’t have the time to research those natural alternatives, is, of course, that the supplement companies do not have the marketing budgets that Big Pharma has. Big Pharma goes around to doctors’ offices with brochures about the various drugs that they offer, and there’s just constant bombardment and exposure through television and magazines and newspapers, and doctors are exposed to that continuously, and patients are exposed to it continuously, but the supplement manufacturers – and this is not necessarily a bad thing! – They don’t have the marketing muscle to get the word out about these alternatives to the same degree.
4 Natural Alternatives to Aspirin
Let’s start with diet. Of course, it’s always the starting place. Many of these conditions that people would be using aspirin for to reduce risk level are inflammatory and they involve clotting, and so with the diet the goal is an anti-inflammatory diet with all of the nutrients that are likely to create healthy blood flow and reduce coagulation. And of course, the paleo diet or a paleo template, paleo-based diet, is a really good choice from both of those perspectives. It is low in inflammatory foods like seed oils and refined grains and excess sugar. It’s nutrient dense and has a lot of the nutrients that contribute to healthy hemodynamics, blood flow, and reduce coagulation, and it’s just an all-around good starting place. But there are some specific considerations within that context. One is to make sure you’re getting enough of the long-chain omega-3 fats like EPA and DHA. These fats have well-known anticlotting effects and have been shown in some studies to be equivalent in that respect to aspirin, and so you want to make sure you’re eating up to a pound a week of cold-water fatty fish like salmon or mackerel, herring, sardines, anchovies. These are the fish that have the highest levels of EPA and DHA. You can also take fish oil or cod liver oil that contains EPA and DHA either instead of fish consumption if you can’t eat fish for any reason or in addition to it to increase the effect.
You’ll be happy to hear that dark chocolate consumption results in antiplatelet effects, so it has an anticlotting effect. The more we learn about dark chocolate, the more incredible, really, its health benefits are.
Steve Wright: Don’t you have to stay really consistent with it, too?!
Chris Kresser: Yeah, you have to eat it three times a day, every day! No. If you tolerate chocolate, there’s really little reason not to eat it every day or every other day if you are able to moderate your intake of it. We’re not talking about having a bar of chocolate every day, but a small serving every day would certainly be fine if you tolerate it.
In addition to chocolate and EPA and DHA, another consideration from a dietary perspective is just some common spices and herbs in foods that are known to inhibit thrombosis without prolonging bleeding time. And that’s the problem with aspirin, of course; it does inhibit clot formation, but it increases the risk of bleeding. These foods are garlic. Like chocolate, garlic is another food that has amazing therapeutic properties, so many different ones. Turmeric is another; thyme and rosemary, very common spices often used in cooking; and tarragon. All of these are easily available, cheap spices and foods you can emphasize in your cooking so that you’re getting an additional benefit there.
Resveratrol, which is in red wine, has been shown to have antithrombotic effects. And just a note: I know a lot of people are taking resveratrol supplements. The research on resveratrol as a supplement is a lot weaker than resveratrol in food, and there are actually even some concerns about long-term resveratrol use as a supplement. I recently posted an article written by Moises Velasquez-Manoff who we had as a guest on the show to talk about the hygiene hypothesis or old friends hypothesis a while back. He recently wrote an article that was summarizing research that demonstrated that taking antioxidant supplements does not have the same benefit as eating antioxidants in fruits and vegetables and other foods. The resveratrol thing is just one example, but there are many other examples.
In terms of supplements, nutrients that you can take that will increase the effectiveness of this natural approach, one of the main ones is called Pycnogenol, which is also referred to as pine bark extract, French maritime pine bark extract, at a dose of about 100 mg a day. It’s been shown to reduce platelet aggregation as effectively as aspirin without increasing the risk of bleeding, and it actually even has a prolonged action time, so it works over a longer period of time than aspirin does. You don’t have to take as much or take it as frequently. It’s an extract of pine bark, and it’s pretty readily available. I don’t know if you can find it at Whole Foods or local stores, but you can certainly find it online. It has some other interesting properties, too. It’s actually one of the things I tend to use in my practice for patients with histamine intolerance or mast cell activation syndrome, and it can be really useful for that. So if you’re dealing with an inflammatory condition and histamine intolerance, you can kill two birds with one stone.
Steve Wright: You use that at the same 100 mg dosage?
Chris Kresser: Yeah, you have to modulate it a little bit with histamine intolerance. It depends on the extent of the condition and other factors, but that’s a good starting place.
The other one is a mixture of long-chain alcohols that’s extracted from plant wax and that’s policosanol. The dose would be 20 mg per day, and studies have shown that that’s as effective as 100 mg of aspirin as a platelet aggregation inhibitor in terms of reducing the risk of thromboembolism. This was from a randomized clinical trial, and there are a few trials supporting policosanol for this use.
Steve Wright: Are you suggesting to stack these, or are you suggesting one or the other, supplement wise?
Chris Kresser: I would do all of the diet suggestions that I mentioned, so a paleo-based diet, dark chocolate, herbs, spices, foods, increasing omega-3 intake to a pound of fish a week, or maybe if you’re eating less than that, to do a combination of fish plus cod liver oil or fish oil. And then I would probably start by trying either pine bark extract or policosanol and then get tested again and see how your blood is, and if that’s not doing the trick, you could add the additional one.
But there are a couple other things I want to mention, too, before we finish, which is that exercise is very important for maintaining healthy hemodynamics, blood flow, and reducing the risk of clots. And stress management may play a role as well. There was an interesting 1984 study that I saw when I was looking into this that showed that yoga had a significant effect on reducing blood coagulation.
I think it’s reasonable to assume that because even just pine bark extract alone and policosanol alone have been shown to be as effective as 100 mg of aspirin, and EPA and DHA have shown to be that effective as well at the right dose, if you combine all of these diet changes that we’re talking about, the spices, herbs and foods, dark chocolate, the EPA and DHA, either the pine bark extract or the policosanol or both plus exercise and stress management, I think you’ll get a much better effect than low-dose aspirin with none of the long-term risk. That’s a win-win, and I don’t really see any downside to taking that approach, especially if you test the results and you can see in black and white that you’re achieving the same impact.
Steve Wright: Yeah, I thank you, Chris, because I’m definitely going to send this interview to several people I know, but I think this is a powerful show because it seems like dogma dies really, really hard.
Chris Kresser: Yeah.
Steve Wright: I know that the baby aspirin, which is now dogma, we’ve seen it here on the show today regarding the research you’ve quoted as well as the alternatives to the research which don’t have the long-term effects on the gut and elsewhere in the body, so thank you.
Chris Kresser: Yeah, you’re welcome. What you said is so true. It’s interesting that even when the conventional medical establishment changes its mind about something, like the US Preventive Services Task Force issues an update, it can take years for that to trickle down. It takes years to establish the dogma in the first place, and then it can take years to unwind it. We’ve seen that with saturated fat and cholesterol, we see it in so many different areas, and I think even though the guidelines were changed a couple years ago, a lot of people out there and a lot of doctors out there are still operating with the idea that prescribing low-dose aspirin or taking low-dose aspirin over a long period of time even if they’re essentially healthy and aren’t at high risk for heart disease is a good idea. Hopefully we can get the word out, and if you know people who are taking low-dose aspirin and haven’t had a heart attack and are not in the really high-risk category – and even if they are – send this to them. Give them some options, and at least this can create a springboard for discussion with their doctor.
Thanks for listening, everyone. Once again, leave us your questions at ChrisKresser.com/PodcastQuestion, and I look forward to talking to you next week.
Steve Wright: Yeah, let us know in the comments what you thought about this show and if there are any updates you’d like us to do to the new format. Also in between shows while Chris is researching the topics, he’s always posting research on his social media outlets, so you can go to Facebook.com/ChrisKresserLAc and Twitter.com/ChrisKresser and get lots of nuggets and updates and things that Chris is reading. Don’t want you to miss out there. Talk to you on the next show.
Chris Kresser: See ya.
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