Aspirin: Antiinflammatory Drug of Choice in 2011?

Now that 40 years have passed since the introduction of ibuprofen, and 6 years since the recall of rofecoxib, we must examine the question: Are non-aspirin nonsteroidal antiinflammatory drugs (NSAID) more effective or less toxic than aspirin (acetylsalicylic acid, ASA)? We suggest that ASA, with its indisputable antiinflammatory properties and better side effect profile [with respect to cardiovascular (CV), kidney, and central nervous system (CNS) toxicities] should be reconsidered as antiinflammatory of choice in certain patient populations. The landscape of NSAID use has changed over the years, as reflected by changing prescription patterns. In this issue of The Journal , a study by Rahme and colleagues1 examines the differences in prescribing patterns pre- and post-rofecoxib removal among patients with variable degrees of gastrointestinal (GI), CV, and renal risk factors. To understand the current outlook on NSAID use and the present changing prescription practices, however, we must first take a look at the history of NSAID use. Use of ASA-like compounds predates modern times. Ancient Egyptians are credited for using willow tree bark, which they applied to stiff and painful joints. Hippocrates recommended willow tree preparations from the inner bark for alleviating symptoms of pain, fever, and inflammation. It was not until the 18th century, however, that the compound responsible for the antiinflammatory effects of willow, salicylic acid, was discovered2,3. Salicylic acid was found to have antiinflammatory properties, although it caused GI side effects. In 1899, the German chemist for Bayer Company, Felix Hoffman, perfected the process of synthesizing salicylic acid, making it less gastrotoxic, which led to the patent of the first truly synthetic drug: Aspirin3. ASA use quickly became widespread, and it was not until 1938 that endoscopic evidence of ASA-induced gastric toxicity in several patients was demonstrated4. These gastric … Address correspondence to Dr. A. Tiliakos, Division of Rheumatology, Emory University, 49 Jesse Hill Jr Drive SE, Atlanta, GA 30303. E-mail: atilia2{at}emory.edu