HCPs are keen to promote Low Dose Aspirin Therapy in its well established indications


 HCPs are keen to promote Low Dose Aspirin
Therapy in its well established indications

Experts in group discussion highlight the safety, efficacy of this
most cost effective antiplatelet therapy which reduces morbidity
and mortality in various diseases

MULTAN: Pakistan Aspirin Foundation organized Group Discussions on Medial Uses of Aspirin at Rahim Yar Khan on November 16th, at Bahawalpur on November 17th and at Multan on November 18th 2015.It was attended by a select group of cardiologists, physicians, surgeons, gynecologists, neuro physicians, General Practitioners besides plastic surgeons. These meetings were sponsored by M/s Atco Laboratories and it generated lot of useful discussion providing an opportunity to the participants to share their knowledge and experience with the use of Aspirin.

Pakistan Aspirin Foundation, it may be mentioned here, has been organizing seminars for the last many years all over the country to create awareness among the healthcare professionals as well as general public about the usefulness of this highly economically priced anti-platelet therapy which reduces morbidity and mortality in a number of diseases. It has also been called as Poor Man’s Statin and Poor Man’s Streptokinase and just one tablet of 325mg taken immediately after acute myocardial infarction could prove lifesaving. This was first established by Dr. Peter Elwood the eminent Scottish Physician who published his findings in Lancet in 1974 and since then there has been a large number of studies on Aspirin in various diseases. Apart from cardiovascular diseases and cerebrovascular diseases i.e. Acute Coronary Syndrome, Coronary Artery Diseases, TIAs and Stroke, there are a large number of emerging indications for Aspirin therapy which are being studied and reported in the medical literature.

The Experts Panel of Pakistan Aspirin Foundation headed by Prof.Abdus Samad an eminent cardiologist and former General Secretary of Pakistan Cardiac Society who retired as Prof. of Cardiology from NICVD a few years ago has revised and updated its Consensus Report on Medical Uses of Aspirin which was published in December 2014. The copies of these guidelines as well as another highly useful informative booklet in Urdu on Aspirin the lifesaving miracle drug, are being distributed among the healthcare professionals. These group discussions were organized in the light of these guidelines and the main objective was to hear from the participants about their practice of using Aspirin therapy. They were also provided copies of these Guidelines and the booklet on Aspirin.

The first group discussion was organized at Rahim Yar Khan.  In his introductory remarks Mr.Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation gave background information of Pakistan Aspirin Foundation and then highlighted salient features of this Consensus Report. The well-established indications for Aspirin therapy are:

1.       Acute  Myocardial Infarction
2.       Acute Coronary Syndrome
3.       Secondary prevention of AMI
4.       Primary prevention of CAD
5.       Acute Ischemic Strokes
6.       Transient Ischemic Attacks(TIAs)
7.       Primary and secondary prevention of strokes
8.       Hypertension
9.       Diabetes Mellitus
10.     Acute Rheumatic Fever
11.     Prophylaxis against  DVT and Pulmonary Embolism

Some of the emerging indications for Aspirin Therapy include Phospholipids Antibody Syndrome, Pregnancy Induced Hypertension, Colorectal Cancer and Insulin resistance etc. The guidelines also give details about the mechanism of action of Aspirin, its pharmacokinetics, dosage in various diseases, side effects and contra indications. All the information included in this document has been properly referenced.  Enteric coated Aspirin therapy is preferred because of its safety and long term use.

Absolute Contra-indications

Aspirin should not be used if the patient has Hypersensitivity to Aspirin or other Salicylate, Hemorrhagic diathesis, documented acute gastric or duodenal ulcer and in pregnancy after 36 weeks of gestation.  Relative contraindications include G6PD deficiency, breast feeding, chronic or recurrent peptic ulcer, bronchial asthma, severe renal or hepatic damage etc.

Sharing their experience participants at Rahim Yar Khan Meeting said that they use Aspirin therapy in ACS, AMI, TIAs, Stroke. However, there was some discussion on the use of Aspirin in primary prevention, some felt it should be used while others were of the view that still there was not enough evidence for its use.  Consensus Report on Medical Uses of Aspirin therapy contains over half a dozen studies in primary prevention with different results. Mr.Shaukat Ali Jawaid pointed out that the results of a multicenter multicounty study of Aspirin in primary prevention (ARRIVE) will be available soon which will give us a clear message. However, physicians are using it in primary prevention as well. Aspirin is also used in combination with clopidogrel in certain conditions which enhances its usefulness and efficacy in further reducing the morbidity and mortality. Dr. Shaukat Ali Rao, Dr.Abdul Majid, Prof. Tariq Rehan, Dr. Akhtar Malik, Dr. Ghulam Fareed, Dr. Abid Shah, Dr. Haque Nawaz Rahi  and many others shared their experience.  Prof.Tariq Rehan said that they stop Aspirin a few days before elective surgery.  There was discussion on various doses of Aspirin being used and mentioned in the literature at which it was stated that any dose above 50mg has adequate antiplatelet effect hence 75mg, 81mg or 100mg were all effective.

Dr. Shahadat Hussain moderated the discussion at Bahawalpur. Dr. Altaf highlighted its use in diabetes and hypertension besides antiphospholipid syndrome. Dr. Shahid said they use it in TIAs and stroke besides Deep Vein Thrombosis and pulmonary embolism. Dr. Asifa Shahid said that Aspirin was very beneficial in complicated pregnancy, in patients with poor fetal outcome, even it is advised to use it in pre conception period about three months prior to conception. It is suggested that the pregnant women should be prescribed calcium, aspirin and folic acid regularly. Aspirin can be discontinued three months after pregnancy. Dr.Fahad plastic surgeon said that they do stop aspirin during surgery but once wound healing starts; use of aspirin allows adequate blood supply. Dr.Waseem said they use Aspirin in Hypertension and DVT. However, it was emphasized that one must make sure to control blood pressure first and then start low dose aspirin therapy.

Prof. Munir Azhar Chaudhry in his detailed discourse said that Aspirin was safe and an effective antiplatelet therapy in thrombosis, antiphospholipid syndrome, auto immune disorders, scleroderma, cardiomyopathies as well apart from ACS and CAD. However, it is contraindicated in chronic liver failure and cardiac failure as there was an additional risk of bleeding.  One of the general practitioners opined that after the age of forty years, regular use of low dose aspirin was desirable. As regards use of Aspirin in primary prevention it was generally felt that one should calculate the risk score and if it was more than 10%, only then Aspirin therapy should be used. Dr.  Shahadat opined that since the platelets have a half-life of six days, one should always weigh the benefits and risks as regards side effects. If the benefits outweigh the risks, then aspirin therapy should be started. He suggested calculating the risk scores in men over forty five years and women over fifty five years before putting them on regular low dose aspirin therapy. Low dose aspirin has to be taken daily and not once, twice or three times a week. Others who actively participated in the discussion included Dr. Sarwar Khalid, Dr. Aftab Jameel, Dr. Akram Ahsan, Dr. Arif Ali Zaidi and Dr.Shaukat Ali. Prof.Haroon Khursheed Pasha, Principal of QAMC and Prof. Javed Iqbal Head of the Dept. of Surgery at QAMC  also came to the meeting venue for a while and left soon after since they were having a meeting with the Audit team.

Winding up the discussion Prof. Usman Ghani emphasized that  Aspirin remains the ideal anti platelet agent and the most cost effective  antiplatelet in atherosclerosis, IHD, prevention of recurrence of acute myocardial infarction. Those patients who have many other risk factors like diabetes, smoking, obesity, strong history of sudden death, family history of CAD should benefit from the regular use of low dose aspirin therapy. However one should be careful in case of hemorrhages. Similarly those patients who have bleeding diathesis, active ulcer are seen with bleeding from the whole stomach and these hemorrhages could be catastrophic. Always control the blood pressure first and then start using low dose aspirin therapy. It can be safely used in pregnancy induced hypertension. Some patents may complain of bleeding from gums and have many other similar problems hence in such cases one should always avoid use of aspirin. However, those with sedentary life style, high LDL cholesterol can benefit from Aspirin. Stroke and strong family history of IHD are highly disabling diseases. Hence use of aspirin in these patents, if there are no contra indications, can reduce the morbidity and mortality.

Dr. Tariq Abbas from CPI Institute of Cardiology moderated the group discussion at Multan.  The meeting was very well attended by cardiologists from institute of cardiology, cardiac surgeons, faculty members from Nishtar Medical College Multan, eminent Family Physicians besides gynecologists. Participating in the discussion cardiac surgeon Dr.Haider Zaman said that Aspirin is a wonder drug. We use it regularly in post CABG. It is also used after stenting and angioplasty.  Another participant opined that we use it with other anti-coagulants in high risk cases for dilatation of the vessels. American Heart Association has also recommended the use of low dose aspirin therapy in may cardiac diseases including post CABG. It is also recommended for primary prevention. Others who actively participated in the deliberations included Prof. Ajmal Malik,  Dr. Ali Bin Saeed, Dr. Abdul Sattar, Dr. Saeed Ahmed, Dr. Nisar and Dr. Sadaf.

The participants were of the view that in high risk cases with other co morbidities like hypertension, diabetes one can use aspirin therapy for primary prevention. Its efficacy in pregnancy induced hypertension was also highlighted.  However, it was emphasized that every drug has certain side effects which must be kept in mind. The first and foremost duty of the healthcare professionals is education of patient, advising them to modify their life style, use healthy balanced diet and also do regular exercise.  Promotion of health and healthy life style should be given due importance and preference. It was also pointed out that one can use low dose aspirin therapy in Gout because it will ensure protection from cardiac diseases in these elderly patients who are also suffering from many other co morbidities. It was further stated that low dose aspirin therapy should be taken at bed time as it will take care of early morning spike in blood pressure since most of the acute myocardial infarction occurs early in the morning. The dose recommended for patients with stroke was 150mg daily.

Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation addressing the participants of these group discussions at all the places emphasized that they were extremely grateful to Atco Laboratories for sponsoring their CME programmes for the last many years. However, keeping up the professional ethics, the Foundation does not have any company bias and does not patronize any particular brand of aspirin. It is up to the healthcare professionals to choose any aspirin preparation.

Mr. Akhtar Tahir Director Marketing from Atco Laboratories thanked the participants of these group discussions at Rahim Yar Khan, Bahawalpur and Multan for sparing their precious time to share their knowledge and experience. Atco Laboratories, he said was very conscious of quality control and to ensure production of high quality drugs, it has made huge investments in modernization and expansion of its drug manufacturing plant. Hence they can use with confidence drugs produced by Atco Laboratories at its state of the art most modern drug manufacturing facility as we follow current Good Manufacturing Practices to ensure availability of high quality cost effective medications.  Earlier Mr. Kashif Riaz Business Unit Head in Atco Laboratories welcomed the participants of the meeting on behalf of Atco and Pakistan Aspirin Foundation.

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