2

Baby Aspirin (ASA 81 mg) commonly prescribes as a cardiovascular protective agent because of its unique antiplatelet effect. NSAID-NSAID interaction is a famous well known interaction.1 2 3

My question is in a patient with risk of cardiovascular disease and another disease like arthritis (which patient needs NSAIDs everyday for the pain) which is a common situation in senior patients.

based on studies/guidelines 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?

if it is what is the best nsaid choice for this situation and how should they be taken (in different hour/ dosage adjustment)?

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+50

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.

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    Excellent point regarding rivaroxaban, particularly after the recent controversies regarding the ROCKET-AF trial (see BMJ 2016;352:i575). While I do agree with all the strategies you have suggested, you may wish to consider adding opioids as additional strategy (see Ochsner J. 2010 Fall; 10(3): 179–187, ncbi.nlm.nih.gov/pmc/articles/PMC3096211) as it is commonly used by geriatrician? BR. M. Arrowsmith – M. Arrowsmith Aug 2 '16 at 10:51
  • Thanks @M.Arrowsmith. Happy to see that the controversy about ROCKET-AF was not only debated in our (intense) journal club! Anyway, it only confirms real world experience from clinical practice that rivaroxaban leads to at least the same bleeding risk (or even more?) than VKA. But let's wait for an answer from the authors... I have added your suggestion concerning the pain control, thanks for the feedback! You may also notice that I added some more details to my answer as obviously someone downvoted it (without giving a reason for it) Best wishes. S. Victor – S.Victor Aug 2 '16 at 17:15
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    Tbh I upvoted your post as it provides a clear message based on current clinical practices (uptodate +1). Well, maybe you need first to see several patients coming to the ED with UGI bleeding after taking ASA and OTC NSAID ("but my doctor never told me to stop the NSAID and anyway, I can buy it in the supermarket so why should it be dangerous?") to be sensible enough to appreciate your answer! Btw I have done some formatting and added some references, maybe this helps. Good luck, BR M. Arrowsmith – M. Arrowsmith Aug 2 '16 at 22:15
  • Thanks @M.Arrowsmith for adding some references. Of course, I can only approve your comment regarding NSAID-ASA and upper GI bleeding (+1 from one of our consultant gastroenterologist!). Thanks again for taking the time to improve my answer. All the best for your research. Best wishes. – S.Victor Aug 3 '16 at 9:37

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