When I first became a GP, most of the medicines I prescribed were to treat symptoms, not to stop people getting them. But these days we have a host of medicines designed to keep you in good health, even if you feel fine. But which ones, if any, should you be taking?
Even though cardiovascular disease - heart attack and stroke - is still the UK's biggest killer, we have almost halved death rates from it in little over 20 years. Much of the credit for that must go to the preventive medicines so many of us take every day.
We know it's hard to remember to take tablets every day - and even harder if they don't serve an immediate purpose, like relieving pain. But it is important to take prescribed medicines regularly. If you're getting side-effects from them, speak with your GP rather than stopping them. And if you have trouble remembering all your tablets, your pharmacist may be able to help by providing a 'dossete box' to organise your pills or even packaging them up weekly for you.
The heart disease magic bullet
Never has one small tablet caused so much confusion. Twenty years ago, we discovered that if you'd had a heart attack or stroke, taking 75 mg (a quarter of a full-strength aspirin tablet) cut your risk of another one by almost 25%. This advice remains unchanged by recent research studies - everyone who has suffered a heart attack or stroke should continue to take 75 mg aspirin a day unless there is a medical contra-indication.
Doctors started recommending lots of people take 75 mg aspirin a day - until we realised that the risks of internal bleeding from aspirin might outweigh the benefits for some people. Indeed, a series of new studies in the New England Journal of Medicine suggests that an aspirin-a-day could do more harm than good for healthy elderly people.
The end of the line for aspirin in healthy over-70s
The studies involved volunteers aged over 70 (or over 65 among people of Afro-Carribean and Hispanic descent) who did not have a history of cardiovascular disease, dementia or disability - so the results do not apply to anyone who has had a heart attack, stroke or TIA (sometimes called a 'mini stroke'). Over 19,000 people took part, and were followed up for almost five years to assess their risk of being diagnosed with cardiovascular disease or dementia, or of dying.
The results showed clearly that unlike people who have existing cardiovascular disease, taking a daily aspirin tablet (in this case 100 mg a day) did not reduce the risk of having a heart attack or stroke, of developing another disability including dementia, or of dying. In fact, mortality rates in the aspirin group were slightly higher than in the placebo group. In addition, people taking aspirin were more likely to suffer internal bleeding due to aspirin's well-known irritant effects on the stomach.
So as far as recommendations to take aspirin 'just in case' if you're aged over 70 and don't have cardiovascular disease goes, Professor Perry Wilson sums up the mood among doctors neatly:
"Aspirin, my old friend: Goodnight, sweet prince, and flights of platelets sing thee to thy rest."
Aspirin and atrial fibrillation
Atrial fibrillation, or AF, is the most common abnormal heart rhythm in the UK, affecting over a million people. Without treatment, you're about five times more likely to have a stroke if you have AF than if you don't: the gold standard treatments to prevent this are warfarin and, more recently, the newer anticoagulants dabigatran, apixaban, rivaroxaban and edoxaban.
Until a few years ago, aspirin was thought to be a safer alternative to anticoagulation, and was routinely prescribed for older people in particular. However, aspirin is almost entirely ineffective at preventing AF-related strokes and national guidance from the National Institute for Health and Care Excellence (NICE) now recommends that it isn't used.
Aspirin and diabetes
People with diabetes used to be prescribed aspirin fairly routinely, on the basis that diabetes increases your risk of cardiovascular disease. However, several recent studies have called the 'risk-benefit' ratio of aspirin for people with diabetes into question, and the most recent shows that the increased risk of bleeding with aspirin basically offsets any benefits in terms of reduced heart attacks. NICE now recommends that people with type 2 diabetes shouldn't take aspirin regularly either, unless they've had a heart attack.
Aspirin and bowel cancer
Recent years have also seen a flurry of studies suggesting a possible role for low-dose aspirin (about 75 mg a day) in reducing bowel cancer in some people. Recent results of a study following over 135,000 people for up to 32 years suggested that taking this dose for at least five years might reduce the risk by as much as 19%. But again, the benefit was partly offset by an increased risk of bleeding from the gut. So while people with a strong family history of bowel cancer might want to consider this option, it's worth checking out with a doctor first for a full look at your individual risks.
Statins cut your risk of heart attack or stroke - it's a fact. Until 2014, national guidelines also recommended statins for anyone with a one in five chance of having a heart attack or stroke in the next 10 years (based on your age, gender, blood pressure, cholesterol levels, etc). Now they're recommended if your 10-year risk is more than one in 10.
This move has been controversial - in real terms, a lot of people at this level of risk will have to take statins to stop one of them getting a heart attack. What's more, statins (like every other tablet) cause side-effects in some people, with muscle aches being perhaps the most notorious where statins are concerned. But even here, things aren't as clear-cut as you might think.
If you've had a stroke or heart attack (and usually if you have type 2 diabetes) your doctor will strongly recommend you take a statin for life. If not, some healthy lifestyle choices could cut your risk enough for you to forget your statin!
These tablets used to be used widely to treat high blood pressure - now we have more effective alternatives. But they're still recommended long-term if you've had a heart attack, heart failure, or some abnormal heart rhythms.
Proton pump inhibitors
Do you take a regular medicine for heartburn or indigestion, with a name ending in '-azole' (omeprazole, lansoprazole, etc)? If so, like millions of other Britons, you're taking a proton pump inhibitor, or PPI.
Some people take the odd tablet when they get a bout of indigestion; others take them regularly to keep heartburn at bay. If you've taken a PPI for years and haven't had any indigestion, your doctor may recommend trying to tail them off. If you're taking some medicines like anti-inflammatory painkillers (ibuprofen, etc) your doctor may recommend you take a PPI as long as you're taking the anti-inflammatory, to reduce the risk of stomach inflammation.
Can I help myself?
Some risk factors for heart attack and stroke - like getting older - you can't change (apparently ignoring your birthdays doesn't count!). But some will make a huge difference.
Smoking is the (very) obvious one; but keeping your weight in the healthy range, exercising regularly and eating a heart-healthy diet will all help. With regular weight-bearing exercise and plenty of calcium in your diet you're less likely to need tablets to prevent worsening 'thinning' of the bones (osteoporosis), and by avoiding excess alcohol and spicy foods indigestion may be a thing of the past.