Experts highlight safety and efficacy of Low Dose Aspirin Therapy in reducing morbidity and mortality in various medical disorders


 Panel Discussion on Medical Uses of Aspirin at Sargodha and Faisalabad

Experts highlight safety and efficacy of Low
Dose Aspirin Therapy in reducing morbidity
and mortality in various medical disorders

From our correspondent

SARGODHA & FAISALABAD: Pakistan Aspirin Foundation in its Continuing Medical Education programme organized Panel Discussions on Medial Uses of Aspirin at Sargodha on April 20th and at Faisalabad on April 21st 2016.  The meeting at Sargodha was chaired by Prof. Siddique the senior most physician in the city while the meeting at Faisalabad was presided over by Prof. Abdul Hafeez Chaudhry a well-known cardiac physician. The panel of Experts at Faisalabad meeting included Prof. Naeem Aslam, Prof. of Cardiology at Punjab Medical College, In charge of Coronary Care Unit at Allied Hospital Faisalabad and Dr. Javed Iqbal Consultant Cardiologist and in charge of Cardiac Center at DHQ Hospital Faisalabad.

Prof. Abdul Hafeez Chaudhry moderated the Panel Discussion on Medical Uses of Aspirin organized
by Pakistan Aspirin Foundation at Faisalabad on April 21st 2016. Group photograph taken on the
occasion shows Prof. Abdul Hafeez Chaudhry along with other members of the Experts panel
Prof. Naeem Aslam and Dr. Javed Iqbal and Mr. Shaukat Ali Jawaid and some of the participants.

Copies of the Consensus Report on Guidelines on Medical Uses of Aspirin prepared by a panel of experts headed by Prof.Abdul Samad an eminent cardiologist of Pakistan in collaboration with Prof. Ejaz Ahmad Vohra and Prof. M.Akbar Chaudhry besides a Booklet in Urdu authored by late Dr. Maqbool Jafary and Mr. Shaukat Ali Jawaid Chief Editor of Pakistan Journal of Medical Sciences and Pulse International were distributed among the participants before the discussion. In his introductory remarks at both the places Mr. Shaukat Ali Jawaid General Secretary of the Pakistan Aspirin Foundation gave the background of the consensus document which gives comprehensive details about the established indications with doses in various medical disorders. It also gives details about the absolute as well as relative contra indications for the use of Aspirin therapy.

The literature on Aspirin till 2014,he  said,  was reviewed in detail before finalizing this document and each and every recommendation has been properly referenced. He also highlighted the salient features from the latest US Preventive Services Task Force on the use of Aspirin in Primary Prevention of Cardiovascular Diseases and Colorectal Cancer published on April 13th 2016. It also recommends use of Aspirin for primary prevention in patients over the age of fifty years with one or two risk factors while its efficacy in colorectal Cancer is only after it is used for a period of ten years. Since life expectancy in Pakistan is about ten years less as compared to the developed world, Pakistan Aspirin Foundation has recommended the use of Aspirin for primary prevention in patients above forty years of age. Those with one or two risk factors, must get aspirin while for others one has to calculate the risk score which can be done using the information provided in these Guidelines, he added.

Participating in the discussion at Sargodha, Dr. Jamil said that we use Low Dose Aspirin therapy in angina, after acute myocardial infarction and in all Acute Coronary Syndromes regularly.  It is a lifesaving drug for patients with heart diseases while it also has a preventive role in stroke. Our patients cannot afford expensive medications and there are compliance issues as well. Aspirin is economically priced antiplatelet agent which is also easily available everywhere. It has come as a revolution for the poor. It is also known as Poor Man’s Streptokinase or Poor Man’s statin. For the poor countries it is not less than a blessing, he remarked.

Participating in the Panel Discussion on Medical Uses of Aspirin organized by Pakistan Aspirin Foundation at Sargodha on April 20th from (L t R) are Prof. M. Siddique,
Dr. Jamil, Dr. Humaira and Dr. Nusrat.

Stroke he pointed out was a big burden and the patient often remain wheel chair bound for ten to fifteen years. Its regular use prevents stroke.  The dosage recommended for cardiovascular diseases was  75-100mg daily while for stroke the maintenance dosage is 150mg. For acute myocardial infarction one has to use the full tablet of 325mg and soluble aspirin is preferred. However, for long term use, enteric coated aspirin tablets are safe and should be preferred.

Dr Fida remarked that Aspirin has a very wide range of uses in a number of medical disorders starting from ACS, Acute MI, prevention of secondary AMI, Stroke, after angioplasty and stenting, for prevention of deep vein thrombosis and pulmonary embolism, hypertension and diabetes mellitus. However, he cautioned that one has to be careful of gastropathy. Low Dose Aspirin therapy can be used for primary prevention in patients with one or two risk factors or those who are in high-risk and family history of heart disease. One also has to be careful in cardiomyopathy and inpatients with diabetes who also suffer from atrial fibrillation, it should not be used.

Dr. Humaira and Dr.Nusrat sharing their views pointed out that Aspirin has also come as a wonder drug for the obstetricians and gynecologists.  We use it with excellent results in intra uterine growth retardation, DVT, Pulmonary embolism, in those patients who have a history of pregnancy loss, recurrent abortions and miscarriages where it is used in combination with low molecular weight heparin, bad obstetric history and infertility. It is also useful to take care of intra uterine deaths, dysfunctional uterine bleeding where it is used along with Metformin. Aspirin also improves endometrial lining. It has a good role in IVF cases as well. It is effective in pregnancy induced hypertension as well.

Dr. Munawar Jamshed participating in the discussion said that its side effects are dose dependent.Dr. Iqbal pointed out that let us not forget the brain. Its efficacy in prevention of stroke are well established and it also prevents recurrent strokes and TIAs. He further stated that if used on alternate days, it does not work since the life of the platelets is about eight to ten days and every day about 10% new platelets are formed. He further stated that there is no increased antiplatelet activity with increases dose hence one has to use 75-100mg which has been recommended in various studies.

In response to a question Mr. Shaukat Ali Jawaid clarified that in various studies doses of 75mg, 81mg and 100mg has been used. It is because in United States low dose Aspirin is mostly marketed in 81mg, in Europe and other countries it is marketed as 75mg, hence these doses have been used in various studies conducted in United States and Europe. It was also stated that one should first get the blood pressure under control and only then the patients should be prescribed low dose aspirin therapy.  In addition since most of the cardiac events take place early in the morning, it is preferable to take Aspirin after dinner at bed time to take care of early morning peaks in blood pressure.

Dr. Mumtaz referred to Aspirin resistance.  At this it was pointed out that it  wasvery expensive to study resistance to aspirin but in fact these are the patients who can be termed as non-responders.  There are some patients who do not respond to any hypertensive medication or anti-depressant. Likewise there are some patients who may not respond to Aspirin therapy as well. Dr. Zafar from WAPDA Hospital said that one has to careful while using various NSAIDs as well.


A group photograph of some of the participants in the Panel Discussion on Medical Uses of Aspirin
at Sargodha on April 20th along with Prof. Siddique who chaired the session.

Prof Siddique in his concluding remarks said that Aspirin has a wide range of indications which are now very well established. However, one has to be careful and weigh the benefit vs. harm. Higher dose of aspirin can lead to serious complications. Real problems comes with the patient comes for surgery. Now it is said that one does not need to stop aspirin therapy though previously it was recommended to stop it five to seven days before surgery. However, one has to take into account individual patient as all patients are not the same. Those who have a tendency of bleeding should not be given aspirin. In such patients one has to be very careful and do not use it unless it is indicated. There is still some controversy as regards its use in primary prevention of cardiovascular diseases but small dose is not harmful and is quite safe and effective. We can use it prophylactically. If used in combination with clopidogril, it increases the antiplatelet activity but one must be mindful of the fact that the combination of these two anti-platelets also increases the risk and side effects.

Meeting at Faisalabad

Prof.A.Hafeez Chaudhry moderated the session at Faisalabad where it was attended by cardiac physicians and a select group of family physicians besides a neurosurgeon.

Addressing the participantsProf. Naeem Aslam said that the use of low dose Aspirin therapy became very popular when ISIS study showed that when compared with Streptokinase, there was equal reduction in mortality after AMI. If Aspirin was combined with Streptokinase, the mortality reduction was also significantly increased. Now it is recommended that every patient with chest pain must have aspirin immediately whether they are at home, in office or in the hospital as it could prove lifesaving. Not to use Aspirin in such a situation is not advisable at all. In Acute Myocardial Infarction one has to use 325mg tablet of Aspirin and soluble aspirin should be preferred and if it is enteric coated, these tablets should be chewed immediately. In case of myocardial infarction one can use Aspirin, Clopidogril and Streptokinase together. However, one has to be careful about the chances of bleeding in patients with history of acute bleeding or chronic liver disease.

Responding to a question as to how long one should take Aspirin after AMI, Prof. HafeezChaudhry remarked that it has to be taken for life long. Low dose aspirin therapy should also be prescribed to all the patients after interventional procedures like angioplasty and stenting unless it is contra indicated.

Mr. Shaukat Ali Jawaid clarified that in the developed world, Aspirin is promoted direct to the patients and it is available as OTC product but keeping in view the low literacy rate in Pakistan and to ensure that it is not misused andto  promote its rational use, Pakistan Aspirin Foundation had decided from the very beginning that we will promote it through the healthcare professionals.

One of the participants pointed out that many patients come with high blood pressure and when they are asked if they were taking any drug, they say they are taking Aspirin. As such the patients’ needs to be educated that Aspirin was not a drug for control of high blood pressure. It should only be used after blood pressure has been controlled where it is effective in BP management and keeping it under control. While performing surgery one can continue with Aspirin therapy but clopidogril has to be stopped.

Dr. Javed Iqbal pointed out that one has to be extremely careful with high doses of Aspirin. We give a loading dose of 325mg of Aspirin with Heparin and 600mg of Clopidogril before PCI because after PCI patient might come with acute thrombosis.  PCI patients should take aspirin forat least one year. In case of Drug Eluting Stents, patients should take aspirin for at least one year as they are high risk cases including those who are suffering from diabetes. After stenting care, some patients may end up with coronary occlusion if anti- thrombotic therapy is stopped.

Mr. Shaukat Ali Jawaid Chief Editor Pulse International presenting
his latest book “Plight of a Medical Editor: an autobiography” to
Prof. Mohammad Siddique at Sargodha on April 20th after
the panel
discussion on Medical Uses of Aspirin.

When asked about the use of Proton Pump Inhibitors (PPIs) for H. Pylori eradication and in gastric ulcer cases, it was pointed out that one should use the PPIs at leastfor six to eight weeks. If GERD patients come, do not continua using PPIs for too long? Replying to another question about stroke patients,it was stated that if CT is available it is advisable to get the CT immediately to eliminate the chances of hemorrhagic stroke and to see that  there is no bleeding. Once it is ruled out, then use Aspirin. However, in case of an emergency and if CT facility is not available, one can take chance with one tablet of Aspirin. Let the patient stabilize and then manage it appropriately. However, it is always advisable to have CT in such patients during the first twenty four hours.

In the end Mr. Shaukat Ali Jawaid thanked Prof. Siddique and all the distinguished participants at the meeting in Sargodha. He also thanked Prof. Hafeez Chaudhry for presiding over the session at Faisalabad and Prof. Naeem Aslam and Dr. Javed Iqbal for their valuable contributions during the panel discussion. He further clarified that these are manmade Guidelines and we in Pakistan Aspirin Foundation have tried our best to come up with Evidence Based Guidelines but still it was up to the treating physicians to look at the patients and after careful history, physical examination, calculate the risk and then decide for prescribing low dose aspirin therapy. He also thanked Atco Laboratories in general and Mr. Kashif Riaz their Business Unit Head and his team in particular for making all the arrangements for these meetings and sponsoring all the CME activities of the Foundation. However, he make it clear that keeping up the professional ethics, Pakistan Aspirin Foundation from its platform does not  promote any company or patronize any particular brand name of Aspirin. It was up tothe healthcare professionals to use any aspirin preparation, he remarked.

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