Is it right and safe to prescribe this combination (NSAID like
diclofenac + baby Aspirin) specially with the knowledge that this
combination gonna be used for a long time?
While NSAID are associated with many side effects (alteration in renal function, hypertension, hepatic function and platelet function), the most deleterious effects of aspirin and other NSAID are gastric and duodenal mucosa damages which are associated with a considerable morbidity and mortality 12. Recently, two distinct studies have shown that low dose aspirin did not show a statistically significant difference in terms of gastrointestinal bleeding risk compared to other NSAID 23. While I couldn’t find a study providing evidence regarding the relationship between time-exposure to NSAID + ASA and the occurrence of adverse event, the co-administration of NSAID and low dose aspirin should be taken with caution. Moreover, even in patients not under aspirin, long term use of NSAID is not recommended (both for its lack of long term analgesic effect as well as potential cardiovascular and renal side effects)4.
What is the best nsaid choice for this situation and how should they
be taken (in different hour/ dosage adjustment)
Several strategies can be used. Here current recommendations 12:
- using anti-inflammatory or analgesic drugs that have minimal effects on COX-1 at usual doses, such as acetaminophen (=paracetamol), or non-acetylated salicylates
- for very short term use of NSAID, prescribing either a potent inhibitor of gastric acid production such as a proton pump inhibitor or a prostaglandin E analog such as misoprostol together with the NSAID.
- as suggested by @M. Arrowsmith, opioids, in particular products combining paracetamol and opioid, are considered as alternatives in pain control in elderly patients 5
As a side note:
Several studies have shown that selective COX2 Inhibitors are associated with lower risk of GI bleeding compared to other NSAID (but not compared to plavebo) but most of these substances were removed from the market as numerous trials have reported increased risk of stroke and myocardial infarction 6
Regarding enteric coated and buffered aspirin: while some studies reported reduced endoscopic sign of gastrointestinal bleedings, no protection against clinically relevant end point of gastrointestinal bleeding were reported 7.
Finally, regarding what was suggested in a previous answer concerning rivaroxaban, this has to be taken with extreme caution in my opinion. In particular because, to my knowledge, no study so far has provided sufficient evidence regarding the use of rivaroxaban in the primary or secondary prevention of cardiovascular disease. Moreover, rivaroxaban is probably one of the DOAC which showed the most unconvincing results regarding major bleeding outcomes (as well as clinically relevant nonmajor bleeding) in the studies assessing its safety and efficacy in patients with non valvular atrial fibrillation 8.
