Wonder drugs are rare. Applying the criteria of effectiveness, usefulness and cost, I’d put paracetamol, morphine and penicillin high on my list. The number one position, however, would go to aspirin. Not only is it good for pain relief, as an anti-inflammatory and to reduce fever, it also works as a blood-thinning agent, to decrease the stickiness of platelets and reduce blood-clotting.
A few years ago two researchers argued that what we really needed was a “polypill”. This, a tablet containing several drugs which could be given to many people at low cost, was to be the mother of all wonder drugs. The researchers who proposed it, and who are now studying it, are Nicholas Wald and Malcolm Law from London’s Wolfson Institute of Preventive Medicine.
They set out a brave vision for their creation in the British Medical Journal in 2003: “The polypill strategy could largely prevent heart attacks and stroke if taken by everyone aged 55 and older and everyone with existing cardiovascular disease. It would be acceptably safe and with widespread use would have a greater impact on the prevention of disease in the western world than any other single intervention.”
The ingredients of the polypill were to be a statin (to lower cholesterol), three medications to lower blood pressure, at half dose, folic acid and aspirin. This would thin the blood, reduce heart attacks, reduce strokes and save lives.
It’s an incredibly tempting proposition. While I worry about overmedicalising, the idea that suffering could be easily prevented with standard-issue tablets and no follow-up is difficult to ignore.
But perhaps it’s too good to be true. Last month the Lancet published a new analysis of the effects of aspirin in primary prevention – in other words, in people who are at higher than average risk of heart attack or stroke but who have yet to have one. While there remained good evidence for the use of aspirin in secondary prevention – where people had already suffered a heart attack or stroke – the situation in primary prevention was much less clear. This was because of the side effects of aspirin, mainly gastric bleeding and stroke caused by bleeding into the brain. The risk of these serious side effects was in some ways small (an increase of risk from 0.07 per cent to 0.1 per cent), but it becomes more troubling when applied to a large population.
The researchers concluded that “in primary prevention without previous disease, aspirin is of uncertain net value”. Each person needs individual advice to weigh up their own particular pros and cons. Individual care, though, is exactly what the polypill is designed to avoid.
Perhaps I had better confess my bias: individual care is what I like most about practising medicine. The polypill plans to rob me of that pleasure.
Margaret McCartney is a GP in Glasgow
Margaret McCartney is joint winner of the European School of Oncology’s Best Cancer Reporter for 2009. www.cancerworld.org
For lively discussion of the latest medical issues go to Margaret McCartney’s blog at blogs.ft.com/healthblog