Stopping use of Aspirin three to five days before surgery or endoscopic procedures is ideal in most of the cases-Prof.Aamer Zaman Khan


Stopping use of Aspirin three to five days before
surgery or endoscopic procedures is ideal in
most of the cases - Prof.Aamer Zaman Khan

Aspirin therapy is useful in colorectal cancer prevention
but in low risk patients, it offers no benefits - Dr. Abbas Raza

LAHORE: Prof. Abdus Samad along with Prof. Sardar Fakhar Imam and Prof. Bilal Zakariya chaired the second scientific session during the 6th National Conference of Pakistan Aspirin Foundation held at FJMC on October 5, 2013. Prof.Maryam Malik was the moderator of this session. Dr. Abbas Raza from AIMC was the first speaker who talked about Aspirin and Gastrointestinal Tract. He discussed in detail the spectrum of Aspirin induced mucosal injury, NSAIDs induced ulcerations, use of NSAIDs leading to gastric lesions and pointed out that it is associated with 15% gastric ulcer, 5% duodenal ulcer and 2% chronic rectal ulcers. Dual antiplatelet therapy Dr. Abbas Raza stated increases the risk while toxicity is also increased with increased dose. During the first month use, the patients may have higher complications. Its use is beneficial in colorectal cancer but in low risk patients, use of Aspirin may not have any benefits.

Prof.M.Akbar Chaudhry, Prof. Ejaz Ahmad Vohra, Prof.Saulat Siddique, Prof. Naeem Qasuri, and
Prof.Zubair Akram speaking at the 6th National Conference f Pakistan Aspirin Foundation
held at FJMC on October 5th, 2013.

Continuing Dr. Abbas Raza said that the risk of overt bleeding can increase with dual antiplatelet therapy. Studies have also shown that while use of low dose aspirin was associated with prevention of heart attacks but it also increased the risk of major GI bleeding. In case the use of Aspirin is essential, one must identify the risk factors of NSAIDs gastropathy, use gastro protective drugs, safer NSAIDs or alternative drugs if possible. The risk UGI bleeding with different formulations of Aspirin varies from 2.6% to 3.2%. It is suggested that one should reintroduce use of Aspirin after eight weeks of treatment with proton pump inhibitors (PPIs). It may not be possible in high risk CVD patients. CAPP2 study showed almost 60% decrease in colorectal cancer incidence among men who took 600mg of Aspirin daily. It is still not sure whether this benefit of prevention extends to other cancers as well, what dose to be use and for how long? He concluded his presentation by stating that absolute benefits of aspirin outweigh risks of major GI bleeding in patients with moderate to high risk coronary heart disease. Use of PPIs allows patients to get most benefit from their NSAID therapy by reducing GI risks. Aspirin-Lipoxin agonist combination therapy trials are only at animal experimental stages and it may hold promise in the days to come, he remarked.

A group of medical students of Azra Naheed Medical College photographed with members
of the experts panel during the panel discussion at National Conference of
Pakistan Aspirin Foundation held at FJMC on October 5th 2013.

Aspirin and Surgery

Prof. Muhammad Aamer Zaman Khan Prof.of Surgery at FJMC discussed the role of Aspirin in surgery. He pointed out that one should stop the use of aspirin seven to ten days before surgery or undertaking any endoscopic procedure. However, three to five days before surgery is the ideal time to stop Aspirin. In moderate to high risk patients, one can continue Aspirin therapy till the time for surgery. American College of Surgeons recommends that one should try to continue aspirin as much as possible and have platelets available for transfusion during emergency procedures both pre and post operatively. Current guidelines are that in semi-elective or urgent surgery stop one of the agents but in emergency surgery one does not have a choice, hence platelets must be available. There is no benefit of increasing aspirin dose above 100mg for most patients and it seems reasonable to use 75-81mg as periopertive dose. For non-cardiac surgery, apart from low coronary risk situations, patients on aspirin should continue their treatment throughout surgery, except when bleeding might occur. One of the studies has recommended that Aspirin is a lifelong therapy and should never be stopped before surgery when prescribed as a secondary prevention after stroke, acute coronary syndrome, MI or coronary revascularization except for surgery in closed cavities.

Continuing Prof.Aamer Zaman Khan said that the new exciting possible indications for Aspirin are its chemo preventive characteristics. Many studies have shown significant decrease in tumor genesis with Aspirin. Long term use of Low Dose Aspirin appears to be associated with lower incidence of colorectal carcinomas in patients with high cardiovascular risk. For chemoprevention, studies recommend dose of 325mg every other day while Women’s Health Study has recommended 100mg every other day. At present it is advisable to give Aspirin after discussing its potential benefits with the patients, he added. Regular use of Aspirin is also associated with reduction in incidence of venous thromboembolism in cancer patients besides prevention of recurrence of VTE.

Emerging issues and Resistance
to Aspirin, other antiplatelet

Dr. Shahbaz Kureshi consultant cardiologist from Islamabad highlighted the emerging issues of Aspirin resistance as well as non-responders. Non-responders, he stated, are a sub-group of patients taking therapeutic doses of Aspirin and not responding. Congestive Heart Failure patients are resistant to Aspirin. Similarly End Stage Kidney Disease patients may also not respond to Aspirin therapy. Aspirin resistance is significantly associated with major adverse events during long term follow up. Aspirin non-responders have increased stiffness of elastic type arteries. Treatment of aspirin resistant patients by adding omega-3 fatty acids or increasing the aspirin dose seems to improve the response to aspirin and it effectively reduces platelet reactivity.

Group photograph of speakers and chairpersons of the second scientific session of
Aspirin Conference held at FJMC Lahore from (L to R) are Prof. Maryam Malik,
Prof. Aamar Zaman Khan, Mr. Lateef Sheikh, Prof.Sardar Fakhar Imam,
Dr.Shahbaz Kureshi, Prof.Abdus Samad, Prof.S.H.Shafqat, Prof.Ejaz Ahmad Vohra,
Prof.Bilal Zakariya and Prof. Muneeza Qayum.

Prof. Ejaz Ahmad Vohra in his presentation stated that the physicians should know in which patients to use Aspirin therapy and how to use it and which are the patients who will benefit with long term use of low dose aspirin therapy. One should be aware of the fact that aspirin is known to cause hemolytic anemia in G6PD deficiency. Aspirin is the most cost effective antiplatelet agent with proven safety and efficacy. Referring to long term safety of Aspirin use, he referred to a study published in Lancet which reported that more than seventy thousand people fond 46% reduction in risk for adenocarcinoma, common malignancy of lung, colon and prostate. Oxford review of fifty one studies showed that taking aspirin for five years reduces the risk of death from cancer by 37% and developing cancer by 25% as compared to those who did not use aspirin. He was of the view that we should encourage middle age people with high risk of CVD to start taking low dose aspirin on regular basis.
Dr. Rehan Umer from KIHD Karachi talked about Antiplatelet therapy and pointed out that managing antiplatelet therapy for patients for ACS is complex. Current therapeutic options and approaches are suboptimal and recurrence rate is high, bleeding remains an issue. Prevention of bleeding is as important as prevention of ischemia. ACS patients who can benefit most from antiplatelet therapy also have the greater risk of bleeding complications. An ideal antiplatelet drug should be effective without risk of bleeding, have no resistance, offer simple dosage, no side effects, no drug interactions and available at reasonable price. It is important for healthcare professionals to be aware of drug interactions and bleeding.
Prof. Javed Akram President of Pakistan Aspirin Foundation was the last speaker in this session who talked about the use of Statins. He pointed out that studies have suggested that decrease in CHD related mortality rates was associated with the reduction in modifiable risk factors and improvements in evidence based therapies. Statins play an important role in stabilizing the arteriosclerotic plaques and in atherosclerosis regression. The use of Statins as a primary prevention is still ambiguous because of inconsistent findings in various research studies. In patients without established cardiovascular disease but with cardiovascular risk factors, Statins use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events. He concluded his presentation by stating that Statins play an important role in reducing clinical relevant cardiovascular outcomes across broad populations most likely by reducing the LDL-C levels. The current guidelines aim to establish target LDL-C reductions to improve a patients long-term reduction in clinical events. Statins are effective for primary and secondary prevention of cardiovascular events. In addition Statins also show reduction in all cause mortality. Statins are relatively safe to use with low incidence of major adverse events.

Prof. Bilal Zakirya who was chairing the session in his concluding remarks said that Aspirin remains the most used drug in cardiovascular field and it has also been found to be effective in primary prevention. Prof. Abdus Samad the other chairperson opined that Aspirin was not an old drug but has emerged as a gold standard for antiplatelet therapy. Cardiologists use Aspirin a lot. It is useful in primary prevention in patients with higher risk of developing any cardiac events. We have been working with PharmEvo to develop a risk calculation formula. If the GPs learn to calculate this risk, it will enhance their practice as patients are very much interested to know their risk of developing a heart disease. He had a word of advice for the speakers and asked them to avoid repetition which is not at all liked by the participants.

Panel Discussion

In the afternoon session the panel discussion on the use, safety and efficacy of antiplatelet agents with special reference to Aspirin was chaired by Prof. Abdus Samad. This session was moderated by Dr. Bilal Mohayudin. Members of the Experts Panel included Prof. Sardar Fakhar Imam, Prof. S.H.Shafqat, Prof. Nazeer Memon, Prof. Zaman Sheikh, Mr.Lateef Sheikh, Prof. M.Akbar Chaudhry, Dr.Shahid Karim, Prof. Maryam Malik and Prof. Tujamal. Dr. Bilal Mohayudin pointed out that so far Pakistan Aspirin Foundation has failed to convince the laboratories to start testing antiplatelet agents. It is important that these tests should be done. Prof. Abdus Samad responded by saying that what we see is mostly industry driven research. It is time that we should tell them what they should be doing but another panelist remarked that the industry can also push physicians for research which suits their own requirements. However, it was emphasized that tests for antiplatelet agents should be available. The patients need to be educated how to safely use this antiplatelet and justify the use of various devices, implants. Prof. Samad further stated that the recent European Guidelines suggest that the antiplatelet tests should be done only in high risk cases i.e in patients who have had acute myocardial infarction or Acute Coronary Syndrome and are going to have stents inserted. These tests are not required for every patient, he remarked.

Members of the Experts Panel during the Panel Discussion at Aspirin Conference held at JMC on October 5th from
(L to R) are Prof Sardar Fakhar Imam, Prof.Nazeer Memon, Prof.Abdus Samad, Prof. Zaman Sheikh, 
Mr. Lateef Sheikh, Prof.Akbar Chaudhry, Prof.Javed Akram, Prof. Tujamal, Prof. Maryam Malik, 
Dr. Shahid Karim and Prof. S.H.Shafqat.

Responding to another question it was stated that we will use any new drug only if we have some studies reporting its safety and efficacy. Mr. Lateef Sheikh said that what we saw at Punjab Institute of Cardiology leading to numerous deaths was a total system failure. We need to supervise the supply chain management. We need to look at the way drugs are handled by healthcare facilities. If a drug is not working, it is known as non-responders but it is not an adverse drug reaction, he remarked.
Prof. Nazeer Memon opined that low dose aspirin is available in various dosages i. e, 75mg, 81mg and 100mg and all of them are effective. Sometimes patients complain that they are suffering from indigestion and stop taking Aspirin though it is not related to this drug. It is difficult to say if the drug is not working. It was further suggested that healthcare professionals should take proper history, clinical examination and order essential investigations, take ECG and if need be one can increase the dose of one of the antiplatelet agents. Prof. Zaman Sheikh said that it is difficult to see the response of Aspirin. To the best of his knowledge there has been no study of Aspirin in Type one or Type two diabetics. Prof. S.H. Shafqat referred to the availability of counterfeit drugs which look alike but are not at all effective. Hence we must advise the patients to be careful of these counterfeits. Mr. Lateef Sheikh opined that how drugs are handled in pharmacies and hospitals also matters. Prof. Shafqat also stated that he had seen one patient who developed renal failure with prolonged use of Aspirin. Prof. Akbar Chaudhry said that we must calculate the risk before starting the patient on low dose aspirin therapy for long term use.
Prof. Samad opined that the political problems need political answers and it is upto the administration to solve them to improve the patient care and ensure patient safety. Risk evaluation was also essential for use of Aspirin and Statins for primary prevention. He also narrated a story that one of his patients said that ever since he has started taking these drugs, he has become handsome. His wife also confirmed this. I asked him to get his hemoglobin which was 7.5, which meant he was not aware of the blood loss due to bleeding. Hence we must educate the patients and be careful of such incidents. Prof. Maryam Malik said that in most cases the family physicians know the patient and their family and are also aware of their disease, but at times they do have their limitations. Prof. Javed Akram said that for long term use, a dose of 75mg of enteric coated aspirin is quite safe and effective in ACS patients but in diabetics the recommended dose is 150mg. Asthma and active ulcer disease are some of the contra indications for use of Aspirin. When we need blood donors, and if the entire population is taking antiplatelet agents, it will become a problem. People should be asked to stop taking aspirin or any other antiplatelet agent ten days before they donate blood. The people should be educated to take a 300mg soluble Aspirin or chew it in case of chest pain. During the deliberations it was also emphasized that Pakistan Aspirin Foundation should convince the laboratories to start antiplatelet tests. Sometimes the patients spend more on investigations than on drugs. It is important that basic investigations must be done but one should avoid un-necessary investigations. Prof. S.H.Shafqat remarked that almost about 80% of diseases can be diagnosed with good detailed history and clinical examination and investigations are needed just to confirm those.

Press Briefing

On Sunday 6th October a session with the media was also organized at Lahore Press Club where Prof. Javed Akram President of Pakistan Aspirin Foundation, Prof. M.Akbar Chaudhry, Prof.Zaman Sheikh and Mr.Shaukat Ali Jawaid highlighted the aims and objectives of the Foundation. They called upon the media personnel to play their role in educating the public on the use of Aspirin. The public should be informed to immediately take a soluble Aspirin tablet when they have chest pain as it could prove life saving and always keep Aspirin with them at home and in office. Long term use of Low Dose Aspirin therapy they were told is extremely safe and effective in reducing the morbidity and mortality in a variety of medical disorders which has been proved in numerous research studies.