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The hidden risks of prophylactic aspirin

Posted by plosmedicine on 30 Mar 2009 at 23:50 GMT

Author: 'Michal R.' 'Pijak'
Position: Consultant in Internal Medicine, Rheumatology, Allergy and Clinical Immunology
Institution: University Hospital,Limbova 5, 83305 Bratislava, Slovkaia
Submitted Date: January 25, 2006
Published Date: January 27, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

I read with great interest the study by Stafford et al.(1) examining utilization rates of aspirin in US Ambulatory Care. The authors rightly point out that " The widespread aspirin underutilization could be partly due to uncertainties in risk assessment. " I would like to mention two important points regarding this issue.

First, many older patients chronically use nonsteroidal anti-inflammatory drugs (NSAIDs) concomitantly with aspirin. This can be a problem since the formation of endogenous lipoxin analogues triggered by aspirin is sensitive to inhibition by both "coxibs" and conventional NSAIDs. (2) This interaction might explain the high rate of aspirin resistance and the differences in cardiovascular effects between individual NSAIDs and their use in combination with aspirin, as we have previously pointed out. (3)

Second, there is evidence that sudden aspirin withdrawal may increase the risk of atherothrombotic events to patients with cerebrovascular (4) and coronary artery disease (5). Interestingly, similar risks are reported after the cessation of therapy with certain NSAIDs(6) suggesting that there may be some common mechanism responsible for these withdrawal-related cardiovascular and cerebrovascular events.


1. Nelson MR, Liew D, Bertram M, Vos T. Epidemiological modelling of routine use of low dose aspirin for the primary prevention of coronary heart disease and stroke in those aged > or =70. BMJ 2005;330:1306.

2. Fiorucci S, Distrutti E, Mencarelli A, Rizzo G, Lorenzo AR, Baldoni M, et al. Cooperation between aspirin-triggered lipoxin and nitric oxide (NO) mediates antiadhesive properties of 2-(Acetyloxy)benzoic acid 3-(nitrooxymethyl)phenyl ester (NCX-4016) (NO-aspirin) on neutrophil-endothelial cell adherence. J Pharmacol Exp Ther. 2004;309:1174-82.

3. Pijak MR, Huzicka I, Gazdik F. The risk for myocardial infarction with cyclooxygenase-2 inhibitors. Ann Intern Med 2005;143:616-7.

4. Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J. Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol 2005;62:1217-20.

5. Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005;45:456-9.

6. Fischer LM, Schlienger RG, Matter CM, Jick H, Meier CR. Discontinuation of nonsteroidal anti-inflammatory drugs is associated with an increased risk of acute myocardial infarction. Arch Intern Med 2004;164:2472-6.

No competing interests declared.