Taking low-dose aspirin and NSAIDs can be a challenge

I have many patients who are taking low-dose (81 mg) aspirin (ASA) daily and who wonder if they can take a Non-Steroidal Ant-Iinflammatory Drug (NSAID) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) for pain or fever.

I warn them that adding an NSAID increases their gastrointestinal (GI) risk … and can possibly increase their cardiovascular (CV) risk. So, is there a safe way to add NSAIDs to daily ASA? Here’s what the experts at Prescriber’s Letter say:

  • NSAIDs with COX-1 activity (naproxen, ibuprofen, etc) seem to have a lower cardiovascular risk than those with more COX-2 activity (celecoxib, diclofenac, etc).
  • But COX-1 NSAIDs can interfere with aspirin’s antiplatelet effects if they bind to platelets first. Aspirin irreversibly inhibits platelets, so its effects are more consistent and longer-lasting.
  • Try to use other analgesics (such as acetaminophen [Tylenol]) first for pain in daily aspirin users.
  • If an NSAID is needed, lean towards naproxen (Aleve) … it seems to have the lowest cardiovascular risk. Use the lowest effective dose for the shortest time possible.
  • Or suggest ibuprofen if it’s only needed occasionally.
  • Advise patients to take PLAIN aspirin about one hour BEFORE naproxen or ibuprofen … so aspirin can bind to platelets first.
  • Don’t opt for ENTERIC-COATED aspirin with naproxen or ibuprofen. In this case, separating the doses may not help avoid the interaction.
  • Add a proton pump inhibitor (PPI, such as omperazole) if GI bleeding is a concern.

Regarding the last point, PPIs are not necessary for most patients taking daily aspirin. The Los Angeles Times “Booster Shots” blog reported that although some physicians recommend that all patients taking an aspirin once-a-day should also take a proton pump inhibitor to reduce the risk of gastrointestinal bleeding, a study in the Archives of Internal Medicine backs my advice to my patients that a PPI is NOT justified for most patients.

The researchers used a “mathematical model to compare the costs and outcomes of low-dose aspirin therapy with and without” PPIs.

They found that daily aspirin treatment “was less costly and more effective than no treatment in men ages 45 and older who had” a 10% or more risk for a heart attack.

Adding a PPI, however, was “not cost-effective for men with an average risk of gastrointestinal bleeding but may be cost-effective for men with a higher risk of bleeding.”

Despite all the above information, I recommend that you discuss these matters with your personal physician who can advise you as what would be best in your individual case.

PPIs may not be necessary for some patients taking daily aspirin.
The Los Angeles Times (2/14, Roan) “Booster Shots” blog reported that although some physicians recommend that patients taking an aspirin once-a-day to prevent heart attacks should take a proton pump inhibitor to reduce the risk of gastrointestinal bleeding, a study in the Archives of Internal Medicine, suggest adding a PPI may not be justified for most patients. The researchers used a “mathematical model to compare the costs and outcomes of low-dose aspirin therapy with and without” PPIs. They found that daily aspirin treatment “was less costly and more effective than no treatment in men ages 45 and older who had” a 10% or more risk for a heart attack. Adding a PPI, however, was “not cost-effective for men with an average risk of gastrointestinal bleeding but may be cost-effective for men with a higher risk of bleeding.”

2 thoughts on “Taking low-dose aspirin and NSAIDs can be a challenge

  1. Withheld at the Request of the Writer

    Dr. Walt,

    Please check the information on your article on NSAIDs and ASA.

    Updated information shows that Celebrex is LESS likely to cause CV events than traditional NSAIDs and does NOT intefere with the synthesis of ASA. Some studies in Europe show astronomically higher (2.8 FOLD) greater chance of a CV event with traditional NSAIDs vs Celexicob.

    Consider me an enthusiastic reader of your Webpage.

  2. waltlarimore Post author

    Thanks for the note. Since the information in this particular blog came from the PharmDs at the Prescriber’s Letter, let me run your feedback by them. Will let you know what I learn. Deeply appreciate your feedback and support.

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