Jagged Little Pill

STORE SHELVES GROAN UNDER ALL the medications that soothe pain and cool fever. Cardiologists have entire pharmacopeias for patients in the throes of a heart attack. And medical journals are full of reports on new nostrums that might prevent Alzheimer's disease or colon cancer. But a drug versatile enough to fit all of these categories is rare. Actually, it's unique. ""It'' is aspirin, the penny-a-pop phenom whose medical prowess is only the start of its wonders. For what other drug can reveal the very souls of a people merely by its route into their bodies? Buttoned-down Brits take theirs as a powder in water, while Americans stick to tablets. The French prefer their aspirin in suppository form; the exuberant Italians like it fizzy.

However they take it, people the world over consume some 50 billion doses every year. Now aspirin is a centenarian. In 1897 chemist Felix Hoffmann of Bayer, in Germany, got a desperate plea from his father: medicine he took for crippling rheumatism ate away his stomach. Could Felix find a safer alternative? On Aug. 10, 1897, he did, synthesizing a shelf-stable form of acetylsalicylic acid. Bayer just then was enjoying great success with its newest product, heroin (the number of repeat customers was huge). Sniffing another hit, the company marketed aspirin in 1899; within a decade it was the most-used drug in the world. Kafka found it one of the sole sources of relief from the unbearable heaviness of being.

An ad for Bayer aspirin in the 1920s promised that the little white pill ""does not affect the heart.'' Discovering the error in that claim may have been the product's salvation. Aspirin saw its share of the analgesic market plummet starting in the 1960s under assaults by acetaminophen (Tylenol) and then ibuprofen (Advil). Market share fell further when children and teens who took aspirin when they had flu or chicken pox sometimes developed Reye's syndrome, which can be fatal. But then the Food and Drug Administration rode to the rescue: aspirin, it ruled in 1985, could be used to prevent a second heart attack (one a day cuts risk by 20 percent). In 1996 it proposed OK'ing the use of aspirin during a heart attack. Taking half a tablet within 24 hours of the attack, and for 30 days afterward, cuts the death rate by about 23 percent. And by the end of the year, the FDA is expected to approve the use of aspirin to prevent a first heart attack in high-risk groups: men taking a standard 325 milligrams every day had 44 percent fewer heart attacks than men given dummy pills. The heart findings handed aspirin makers an irresistible way to distinguish their product from other NSAIDs (nonsteroidal anti-inflammatory drugs, like ibuprofen). Both prevent blood platelets from sticking together to form the clots that can cause strokes and heart attacks, explains Dr. Steve Weisman of Bayer. But only aspirin prevents clots for the life of the platelet.

More people now take aspirin for their hearts than for their pains (chart), but it may still be underused. Charles Hennekens of the Harvard School of Public Health estimates that 10,000 premature deaths could be avoided every year if all heart-attack survivors, acute and chronic, took aspirin regularly. ""Maybe if aspirin were half as effective and 10 times more expensive,'' says Hennekens, ""people would take it more seriously.'' Some have a good reason not to: 2 to 6 percent of the population suffers gastric upset or bleeding from aspirin. And last year, 17,000 Americans died of gastric bleeding just from taking aspirin or other NSAIDs, reports rheumatologist Sanford Roth of Arizona State University. Most had no warning.

Clearly, patients must weigh the heart benefits against the gastric risks of regular aspirin use. The benefits, though, may grow. People who take aspirin regularly have a lower incidence of colon cancer, and less cognitive decline if they get Alzheimer's, than those who do not. The studies are not definitive. Still, no one would be surprised if the little tablets found even more uses in their second century than they did in their first.

Aspirin isn't just for headaches anymore--or even primarily. Preventing heart disease is now its No. 1 use.

Prevention of heart disease    37.6%
Arthritis 23.3
Headache 13.8
Other pain 14.1
Body ache 12.2