Recommending Low-Dose Aspirin Therapy

Review current guidelines for this cardioprotective measure.

Pharmacists are likely to encounter patients seeking guidance about low-dose aspirin regimens. Many physicians continue to recommend low-dose aspirin therapy to prevent thromboembolic events such as heart attack and stroke in high-risk patients due to aspirin’s inhibitory effects on platelet function.^1-3

Results from various clinical studies have associated low-dose aspirin therapy with a decrease in the incidence and risk of death associated with heart attack, unstable angina, transient ischemic attack, and stroke.⁴ Recent studies suggest that low-dose aspirin therapy may also have other health benefits in addition to cardioprotective effects, but more research is needed (Table 1^5-8).

Expert Recommendations

The US Preventive Services Task Force (USPSTF) recommends aspirin therapy for men aged 45 to 79 years when the potential benefit of a reduced risk of heart attack outweighs the potential harm of increased risk of gastrointestinal hemorrhage.⁹ The task force also recommends aspirin therapy for women aged 55 to 79 years when the potential benefit of a reduced risk of ischemic stroke outweighs the potential harm.⁹

In addition, the USPSTF concludes that the current evidence is insufficient to determine the balance of benefit and harm of aspirin therapy for the prevention of cardiovascular disease in men and women 80 years and older.⁹ The task force recommends against aspirin therapy for stroke prevention in women who are younger than 55 years and for heart attack prevention in men who are younger than 45 years.⁹ More information about the USPSTF recommendations regarding aspirin therapy can be found at http://phrmcyt.ms/QH0cmn.

According to the 2012 American Diabetes Association (ADA) Standards of Care, aspirin therapy (75-162 mg/day) should be considered as a primary prevention strategy in patients with type 1 or type 2 diabetes who are at increased cardiovascular risk (10-year risk >10%).^10,11 This recommendation includes most men 50 years and older and women 60 years and older who have at least 1 additional major risk factor, such as having a family history of cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria.^7,8

The 2012 ADA Standards of Care also state that aspirin should not be recommended for cardiovascular disease prevention for adults with diabetes at low cardiovascular disease risk (10-year risk <5%, such as in men aged 50 years or younger and women 60 years or younger with no major additional cardiovascular disease risk factors) because the potential adverse effects from bleeding likely offset the potential benefits.^10,11

The American College of Cardiology and the American Heart Association (AHA) recommend that those at high risk of having a heart attack should take low-dose aspirin daily if recommended by their primary health care provider.¹² The AHA also recommends that heart attack survivors take low-dose aspirin regularly to decrease the risk of another heart attack.¹²

Low-Dose Aspirin Products

The low-dose aspirin products currently on the market range in strength from 81 to 162 mg and are available in both chewable and enteric-coated form (Table 2).

For example, Ecotrin (GSK) is available in enteric-coated form, and St. Joseph low-dose aspirin is available in both chewable and enteric-coated formulations. Bayer and other manufacturers have formulated a low-dose aspirin product geared toward women that contains 81 mg of aspirin and a calcium carbonate buffer.

Counseling Points

During counseling, pharmacists should encourage patients to assess their cardiovascular risk factors with their primary health care providers before starting low-dose aspirin therapy, because its risks and benefits vary from individual to individual. This is particularly critical if the patient has other medical conditions or is currently taking any other medications, including alternative medications or supplements. Before recommending low-dose aspirin therapy, it is imperative for pharmacists to assess the patient’s allergy history and concurrent medical and medication history in order to screen for potential contraindications and drug interactions.

Those with an allergy to aspirin or other salicylates, a history of stomach ulcers and gastrointestinal bleeding, blood clotting disorders, uncontrolled hypertension, or hepatic or renal disease should be advised to avoid using aspirin and to consult their primary health care provider.^2,13-16 Patients who consume more than 3 alcoholic drinks per day should also be advised not to use aspirin because of the increased risk of gastrointestinal bleeding.^2,13-16 In addition, use of aspirin may trigger asthma attacks in some patients who are sensitive to it; these patients should discuss these issues with their primary health care provider.^13-16

Prior to using aspirin, patients should be counseled thoroughly regarding the proper use of aspirin products, potential adverse effects, and the importance of adherence and routine monitoring by their primary health care provider. Patients should be reminded to alert all health care providers, including their physician, dentist, and pharmacist, about their aspirin use and to never abruptly stop aspirin therapy without first consulting their physician.

By taking a proactive role in their cardiovascular health and addressing modifiable risk factors such as being overweight, using alcohol and tobacco, having a diet high in saturated fat and cholesterol, and having a sedentary lifestyle, patients can take steps to improve their overall health.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Remington T. Headache. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Aspirin for the heart. Bayer Aspirin website. http://stage.wonderdrug.com/asp_hd.htm. Accessed October 23, 2012.
• Kavanagh L, et al. Prevention and management of TURP- related hemorrhage: drugs that increase hemorrhage risk. Medscape website. www.medscape.org/viewarticle/747746_2. Accessed October 23, 2012.
• Aspirin for the prevention of cardiovascular disease: recommendation statements. Am Fam Physician. 2011;83(12):1464-1468. www.aafp.org/afp/2011/0615/p1464.html. Accessed October 22, 2012.
• Aspirin may help preserve brain function in older women with heart disease. Medline Plus website. www.nlm.nih.gov/medlineplus/news/fullstory_129927.html. Accessed October 22, 2012.
• Reinberg S. Daily ASA may cut cancer death, another study finds. Health Day website. http://consumer.healthday.com/Article.asp?AID=667585. Accessed October 22, 2012.
• Colon cancer and ASA. Medline Plus website. www.nlm.nih.gov/medlineplus/videos/news/Aspirin_Colon_102512-1.html. Accessed October 22, 2012.
• Aspirin may be targeted therapy for colon cancer. Medline Plus. www.medscape.com/viewarticle/773125. Accessed October 22, 2012.
• Aspirin for the prevention of cardiovascular disease. US Preventive Services Task Force website. www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm. Accessed October 23, 2012.
• 2012 Standards of Care in Diabetes. American Diabetes Association website. http://care.diabetesjournals.org/content/35/Supplement_1/S4.full. Accessed October 22, 2012.
• Aspirin for primary prevention in diabetes. Medscape website. www.medscape.com/viewarticle/736151. Accessed October 23, 2012.
• Aspirin and heart disease. American Heart Association website. www.heart.org/HEARTORG/Conditions/HeartAttack/PreventionTreatmentofHeartAttack/Aspirin-and-Heart-Disease_UCM_321714_Article.jsp. Accessed October 22, 2012.
• Aspirin therapy. Bayer Aspirin website. www.iamproheart.com/Bayer-Aspirin/Aspirin-Regimen-Benefits?WT.mc_id=IAPS120664&WT.srch=1. Accessed October 24, 2012.
• Aspirin drug information. US National Library of Medicine PubMed Health website. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000802/. Accessed October 24, 2012.
• St. Joseph Aspirin product information. St. Josephs Health Products LLC website. http://stjosephproducts.com/products/aspirin/. Accessed October 23, 2012.
• Ecotrin product information. Prestige Brands website. www.ecotrin.com/. Accessed October 23, 2012.