Healthcare professionals must balance risk and benefits before prescribing any medication-Prof. Khawaja Saadiq Hussain

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Healthcare professionals must balance risk
and benefits before prescribing any
medication-Prof. Khawaja Saadiq Hussain
Aspirin like any other drug has its own side effects, hence
must be used carefully in its well established indications

LAHORE: Healthcare professionals must balance the risk and benefits before prescribing any medication. Aspirin like any other drug has its own side effects hence members of the medical profession should be careful and use it judiciously in its well established indications. This was stated by Prof. Khawaja Saadiq Hussain an eminent physician former Principal of King Edward Medical College and former President of College of Physicians and Surgeons Pakistan. In his concluding remarks at the first scientific session of the 6th National Conference of Pakistan Aspirin Foundation which he chaired along with Prof. Mahmood Ali Malik another noted physician and former Principal of King Edward Medical College, Prof. Khawaja Saadiq Hussain said that Aspirin was very economically priced, safe and effective drug which is easily available everywhere. This conference was held at FJMC Lahore on October 5th and it attracted a large number of members of the medical and nursing profession while many medical students from Azra Naheed Medical College and few postgraduates were also present.

Prof. Kh. Saadiq Hussain along with Prof.Mahmood Ali Malik chaining
the first scientific session of National Conference of Pakistan Aspirin Foundations
held at FJMC on October 5th2013. Also sitting on the dais along with them are
speakers of this session Prof. Saulat Siddique, Prof. Naeem Qasuri,
Prof. M. Akbar Chaudhry and Prof. Muneeza Qayum.

Prof. Khawaja Saadiq Hussian further stated that according to reports over one hundred billion tablets of Aspirin are used daily all over the world for various indications. It has been in clinical use for now over hundred years and its use was now being seen more and more ever since it’s antiplatelet activities were discovered proving it to be a life saving drug in acute myocardial infarction. It is useful in a wide variety of medical disorders including cardiovascular diseases but he cautioned that one must be careful if its side effects as well. It is advisable to look at individual patient, take proper detailed history and do comprehensive clinical examination before prescribing any medication. Patient education was also extremely important he added.

Prof. Kh. Saadiq and Prof.Mahmood Ali Malik being presented
flower Bouquet on arrival at FJMC for the Aspirin Conference.
Also seen on right is Prof. Sardar Fakhar Imam Principal FJMC
and Chairman of the organizing committee of the conference.

Prof. Muneeza Qayum Prof. of Pharmacology at FJMC was the first speaker in this session which was moderated by Prof. Zubair Akram. In her most comprehensive presentation Prof, Muneeza Qayum discussed the historical perspective as well as mechanism of action and pharmacokinetics of Aspirin. She dealt at length how this wonderful molecule was discovered by Dr. Felix Hoffman and first used by various people for different conditions including arthritis. Since then its antiplatelet properties have been further highlighted and now it is extensively used to treat a variety of medical disorders where it has proved to reduce morbidity and mortality.
Prof. Zubair Akram Prof. of Cardiology at Allama Iqbal Medical College gave an update on use of Aspirin in cardiovascular diseases with particular reference to Acute Coronary Syndrome and secondary prevention of cardiovascular diseases. It has proved its life saving properties in acute myocardial infarction and studies have shown upto 30% reduction in mortality. However, if it was combined with clopidogrel, the mortality reduction is increased upto 43%.

Prof. Bilal Zakariya along with Prof. Sardar Fakhar Imam Principal JMC
and Prof. Abdus Samad chairing one of the scientific sessions during the
Aspirin Conference. On extreme left is Prof.Maryam Malik moderator of the session.

Prof. Naeem Qasuri Prof.of Neurology at King Edward Medical University gave an update on use of Aspirin in cerebrovascular diseases and highlighted the safety and efficacy of Aspirin in acute ischaemic stroke, TIAs besides secondary prevention of stroke. Prof. Naeem Qasuri suggested that it was advisable to go for the option of managing various risk factors and removal of potential causes. Judicious use of anti-coagulants and antiplatelet can be extremely helpful. He also referred to various markers and contra indications for the use of these medications. He also gave details of International Stroke Trial and CAST stroke trial in China which showed 36% reduction in mortality in stroke. CAST trial included 21,106 patients and it also showed the beneficial effects of Aspirin. In both these trials which included over forty thousand patients, there was mortality reduction of seven per thousand and four per thousand respectively. It also showed further reduction in stroke and death. Speaking about secondary prevention he highlighted the results of ESPS2 trial. Some studies have showed that there was no benefit of Aspirin in primary prevention of stroke but other studies like ATC trial showed 25% risk reduction in secondary prevention. Dual antiplatelet therapy did not show any significant reduction in stroke but it was associated with 7% increase in hemorrhagic stroke. The risk of bleeding was 1% to 2.1%. Combined use of Aspirin and Clopidogrel increases the risk of hemorrhagic stroke. For secondary prevention a dose of 75-150mg a day is recommended but it is twice as effective in a combination of extended release form. He also referred to Aspirin resistance and non-responders and said that as per some studies one third of patients may not respond to Aspirin. Further studies have showed that use of Aspirin results in 22% relative risk reduction whiles with the use of Warfarin the relative risk reduction is increased upto 68%, he added.

Prof. Akbar Chaudhry in his presentation on use of Aspirin in primary prevention of Ischaemic Heart Disease and Stroke said that cardiovascular diseases will remain the number one cause of death globally and by 2030 it is estimated that 23.6 million people will die from CVD mainly from heart diseases and stroke. The largest percentage of increase of these deaths will be in Eastern Mediterranean Region in which Pakistan is located. Speaking about the risk factors he mentioned hypertension, diabetes mellitus, dyslipidemia, obesity, metabolic syndrome and smoking etc. For countries like Pakistan it is not curative but preventive strategies which is the solution. As regards guidelines for primary prevention it includes risk intervention like smoking cessation, physical activity, diet therapy, weight control, blood pressure control, lipid control, diabetes control besides Aspirin therapy.

Prof. Aamar Zaman Khan, Mr.Lateef Sheikh, Prof. Maryam Malik, Dr.Rehan Umar and Dr.Abbas Raza
speaking at the 6th National Conference f Pakistan Aspirin Foundation held at FJMC on October 5th, 2013.

Currently Aspirin is extensively used in cardiovascular diseases followed by arthritis, headache, body aches and as antipyretics. The established uses of Aspirin include Acute Myocardial Infarction, Acute Coronary Syndrome, Secondary prevention of MI, Primary prevention of CAD, TIAs and Stroke, Hypertension and diabetes. Elaborating the use of Aspirin in primary prevention of CAD, he said that if the absolute ten years risk is less than 6%, there is no need for Aspirin therapy but if it is upto 9%, it should be left at patient’s choice but if the ten years risk is more than 10%, these patients must be put on low dose Aspirin Therapy, he added. Women Health Study showed that it reduced 17% stroke, reduction of ischaemic stroke was 24% but what was more important was the fact that it reduced non-fatal stroke by 19% in women besides 22% reduction in TIAs. Meta analysis of six studies also showed that Aspirin lead to 17% stroke reduction in women as compared to 14% reduction of stroke in men. Referring to the Aspirin Awareness and Usage Study (AAUS) conducted in Pakistan, Prof. Akbar Chaudhry said that at the time of discharge only 50% of ACS patients were prescribed Aspirin, only 20.8% of patients were prescribed Aspirin by their Family Physicians while only 16% patients took Aspirin at home when they suffered from chest pain. This is a very dismal picture but these figures are six years old and over these years use of Aspirin has increased due to the CME activities by Pakistan Aspirin Foundation. Summing up the overall benefits of low dose Aspirin Therapy Prof. Akbar Chaudhry said that risk of serious vascular events is reduced by 46% in unstable angina, 33% in stable angina, 23% in peripheral arterial diseases and 53% in patients undergoing angioplasty. Aspirin with its life saving properties in cardiovascular diseases does not fail to surprise us all as a miracle chemical. With the every passing day, we see a variety of new indications emerging for the use of Aspirin but we need more data to start their routine use in those indications, Long term use of low dose aspirin therapy is extremely safe, effective and could go a long way in reducing morbidity and mortality. To prevent significant number of first MIs in men and Stroke in women and premature deaths, low dose aspirin should be used while in high risk individuals, Statins should be added to Aspirin.

Use of Aspirin in Hypertension

Prof. Saulat Siddique Prof. of Cardiology at Shaikh Zayed Postgraduate Medical Institute Lahore highlighted the use of Aspirin in Hypertension. He first described the complications of hypertension which is a risk factor for TIAs and Stroke, retinopathy, peripheral vascular disease, LVH, CHD, HF and renal failure. A large number of meta analysis have shown that antiplatelet treatment is highly beneficial in secondary CV prevention but in patients with low risk, antiplatelet treatment is associated with only a very little excess of benefits over harm. Some trials have also shown that bed time use of Aspirin lowers the blood pressure but some other studies have also showed increase in risk of developing hypertension in Aspirin users. In Pakistan only about 3% of hypertensive’s have controlled their blood pressure and as we know hypertension is a major risk factor for not only stroke but myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension can cause vascular and renal damage leading to treatment resistant state. Low Dose Aspirin therapy is useful in control of hypertension and primary CV events, he added.

 

On left a group of medical students from Azra Naheed Medical College photographed with
Prof.M.Akbar Chaudhry Principal ANMC during the national conference of Pakistan Aspirin
Foundation held at FJMC while on right the picture shows Prof. S. H.Shafqat,
Prof.Abdus Samad and Prof.Kh.Saadiq Hussain.

Benefits of Aspirin in Diabetes

Prof. Mahmood Ali Malik highlighted the benefits of Aspirin in Diabetes Mellitus. He pointed out that people with Type-2 diabetes are at high risk of cardiovascular events from the time of diagnosis and this risk is often present in the pre-diabetic phase of the disease. Hence an approach that focuses on early risk factor identification and management to prevent or delay accelerated atherosclerosis and thrombosis in diabetes is an attractive strategy. Atherosclerosis can be prevented or delayed by controlling hyperglycemia, hypertension and dyslipidaemias while for thrombosis the use of Aspirin is recommended. Low dose aspirin therapy, Prof. Mahmood Ali Malik stated is indicated as a preventive strategy in all high-risk diabetic patients regardless of blood pressure or blood lipid level. All diabetic patients who have had one major vascular event like myocardial infarction, stroke or TIA, history of angina, vascular surgery, atrial fibrillation and valvular heart diseases are high risk individuals, he added. Continuing Prof. Mahmood Ali Malik said that prolonged Aspirin therapy has been shown to offer significant protection against myocardial infarction, stroke, and vascular death in patients with clinically apparent vascular disease. Effects of Aspirin treatment on survival in non-insulin dependent diabetic patients with CAD were studied which showed that it was associated with a significant reduction in cardiac and total mortality among NIDDM patients with CAD. Absolute benefit of Aspirin was greater in diabetic patients as compared to those without diabetes. Use of Aspirin in patients with diabetic retinopathy is safe as EDRTS study has shown that there was no significant increase in gastrointestinal bleeding or hemorrhagic stroke. The recommended dose is 75-325mg and all of them are equally effective. There is some advantage of initial loading dose and for long term safety one should use enteric coated aspirin tablets. However, aspirin is contra indicated in patients who have allergy to Aspirin, have bleeding tendency, are on anticoagulant therapy, have recent gastrointestinal bleeding or have clinically active hepatic disease.
The presentations were followed by lively discussion. Responding to one of the questions Prof. Javed Akram remarked that in Dengue Fever patients, one should not use Aspirin but paracetamol. Similarly patients with ulcer should also not be put on Aspirin therapy.