Prescription Of Low-dose Aspirin Research Articles

Association between use of low-dose aspirin and detection of colorectal polyps and cancer in a screening setting.

The possible protective effect of aspirin on risk of colorectal cancer (CRC) is still highly debated. We used data from Bowel Cancer Screening in Norway, a trial randomizing individuals from general population, aged 50-74 years, to flexible sigmoidoscopy or faecal immunochemical test (FIT), to study the association between aspirin use and detection of CRC and two CRC precursors: adenomas and advanced serrated lesions (ASL). Prescriptions of low-dose aspirin were obtained from Norwegian prescription database. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Among 64,889 screening participants (24,159 sigmoidoscopy, 40,730 FIT), 314 (0.5%) had CRC, 6,208 (9.6%) adenoma and 659 (1.0%) ASL. Overall and short-term use (<3 years) of low-dose aspirin, versus no use, were not associated with any colorectal lesion. Long-term use (≥3 years) was associated with lower detection of CRC (overall OR 0.66, 95%CI 0.46-0.93; sigmoidoscopy: 0.56, 0.33-0.97; FIT: 0.72, 0.45-1.15), adenomas in sigmoidoscopy arm (overall OR 0.95, 95%CI 0.87-1.03; sigmoidoscopy: 0.89, 0.80-0.99; FIT: 1.03, 0.89-1.18), but not ASLs. We did not observe significant differences in the effect of aspirin according to the location of colorectal lesions. Our results suggest that long-term use of aspirin might have a protective effect against adenomas and colorectal cancer, but not ASLs.

Relationship between risk factor profile and prescription of low-dose aspirin for preeclampsia prevention.

The purpose of this study was to assess obstetrician-gynecologist utilization of low-dose aspirin for women at increased risk for hypertensive disorders of pregnancy using guidelines developed by the American College of Obstetricians and Gynecologists and supported by the United States Preventive Services Task Force. Further, the study evaluated prescribing practices in relation to specific risk factor profiles to identify which women are at highest risk of not receiving recommended therapy. This was a retrospective cohort study reviewed and approved by the local Institutional Review Board. Electronic health records of women with singleton pregnancies who delivered between February and August 2020 were reviewed to identify risk factors for preeclampsia. Women were eligible for aspirin prophylaxis if they had at least one "high" risk factor or multiple "moderate" risk factors, as defined by the United States Preventive Services Task Force guidelines. Associations of interest were addressed using Pearson Chi-squared tests and multinomial logistic regression. 970 patients were included and 301 pregnant persons(31%) met criteria for low-dose aspirin prophylaxis; of these, 92 (31%) were given this recommendation. Those eligible for prophylaxis by presence of multiple "moderate" risk factors alone are least likely (0-6%) to receive indicated aspirin prophylaxis. Low-dose aspirin is an underutilized tool for preventing preeclampsia. Women with a combination of "moderate" risk factors are most likely to not receive indicated aspirin prophylaxis. Efforts should be made to encourage broader uptake of the recommendations for aspirin prophylaxis among obstetrician-gynecologists. What is already known on this subject? Low-dose aspirin has been shown to reduce preeclampsia risk in pregnant persons. This preventive measure has been recommended by most national and international organizations including the American College of Obstetricians and Gynecologists and the United States Preventive Services Task Force. Yet despite widespread support of this recommendation, uptake is not universal among obstetric care providers. What this study adds? This study identifies those who are most likely to experience a missed opportunity for aspirin prophylaxis, thus providing a suggestion for where provider education or other efforts to increase adherence to this guideline may be most impactful.

Active prescription of low-dose aspirin during or prior to hospitalization and mortality in COVID-19: A systematic review and meta-analysis of adjusted effect estimates

BackgroundThis study aimed to investigate whether the active prescription of low-dose aspirin during or prior to hospitalization affects mortality in patients with coronavirus disease 2019 (COVID-19). Aspirin is often prescribed for secondary prevention in patients with cardiovascular disease and other comorbidities that might increase mortality, and may therefore falsely demonstrate increased mortality. To reduce bias, only studies that performed an adjusted analysis were included in this review. MethodsA systematic literature search of PubMed, Scopus, Embase and Clinicaltrials.gov was performed, from inception until 16 April 2021. The exposure was active prescription of low-dose aspirin during or prior to hospitalization. The primary outcome was mortality. The pooled adjusted effect estimate was reported as relative risk (RR). ResultsSix eligible studies were included in this meta-analysis, comprising 13,993 patients. The studies had low-to-moderate risk of bias based on the Newcastle–Ottawa Scale. The meta-analysis indicated that the use of low-dose aspirin was independently associated with reduced mortality {RR 0.46 [95% confidence interval (CI) 0.35–0.61], P < 0.001; I2 = 36.2%}. Subgroup analysis on in-hospital low-dose aspirin administration also showed a significant reduction in mortality [RR 0.39 (95% CI 0.16–0.96), P < 0.001; I2 = 47.0%]. ConclusionUse of low-dose aspirin is independently associated with reduced mortality in patients with COVID-19, with low certainty of evidence.

Risk factors for re-presentation for postpartum hypertension in patients without a history of hypertension or preeclampsia

Re-presentation for evaluation of hypertension following discharge after delivery is common. However, a subset of patients who re-present for evaluation of postpartum hypertension do not have a history of hypertension. Identification of those at risk may help guide postpartum management and prevent re-presentations to the hospital. This study aimed to establish risk factors for re-presentation for hypertension within 30 days of discharge after delivery in patients without a history of hypertension compared with women who did not re-present and to distinguish from risk factors for re-presentation for another reason. Subjects were identified through data extraction from a single institution between January 2012 and December 2018. We included subjects without an International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision code for (1) chronic hypertension or (2) a hypertensive disorder of pregnancy during their delivery encounter who re-presented to the hospital within 30 days. Thus, the re-presentation group was divided into the following 2 groups: those who re-presented for hypertension and those who re-presented for any other reason. Each re-presentation group was compared with the cohort of patients who delivered within the study window and did not re-present using the Student t test or Wilcoxon tests for continuous variables and chi-square or Fisher's exact tests for categorical variables. Multivariable regression was also performed on all potentially important risk factors. Factors that emerged as uniquely significant in the re-presentation group for hypertension were maternal age of ≥40 years and antenatal prescription of low-dose aspirin. Black race and body mass index of ≥30 kg/m2, although significant in both re-presentation groups, were more strongly predictive of re-presentation for hypertension. These factors remained independently significant when compared with each other in a multivariable analysis. There are identifiable risk factors for postpartum re-presentation for hypertension in patients without a history of hypertension. Upon discharge, providers may consider close blood pressure monitoring and follow-up in patients who have any of the following risk factors: age of ≥40 years, black race, body mass index of ≥30 kg/m2, or those who were prescribed low-dose aspirin in pregnancy.

Long-term persistence to low-dose aspirin for cardiovascular prevention in routine clinical practice in United Kingdom and Germany

Abstract Background Low-dose aspirin is effective in the prevention of ischemic vascular events and studies have shown a preventative effect on colorectal cancer (CRC). Discontinuation of low-dose aspirin is associated with increased risk of ischaemic vascular events. However, data on long-term persistence to low-dose aspirin from routine clinical practice are limited. Purpose To assess the long-term persistence to low-dose aspirin therapy in the primary and secondary cardiovascular (CVD) prevention population Methods This retrospective cohort study used data from United Kingdom (UK) – The Health Improvement Network database and Germany (DE) – IQVIA Disease Analyzer and analyzed using an adaptation of Observational Health Data Sciences and Informatics (OHDSI) ATLAS Tool. Patients 18 years or older, with at least two prescriptions of low-dose aspirin (75–100mg) within the first year of index date during the study period between 2007 and 2018, and with at least 12 months of observation before and after the index date were included in the study. The patients with a CVD diagnosis or a CABG/PCI procedure before the index date or a prescription of dual antiplatelet at index date were classified as secondary CVD prevention. The remaining patients were classified as potential primary CVD prevention. The index date was first prescription of low-dose aspirin. Persistence was calculated if the gap between two prescriptions exceeds 60 days. Patients with such gaps still receiving prescription after 60 days were plotted based on the number of gaps identified during the follow-up and if no prescription was recorded then they were considered discontinued. Results The total number of patients receiving low-dose aspirin was 327,806 (183,089 in UK and 144,717 in DE with up to 10 years of follow-up). A total of 112,887 and 101,704 received low-dose aspirin for secondary CVD prevention; 70,202 and 43,013 potentially for primary CVD prevention in UK and DE, respectively. Persistence at two years with a few gaps was 67% and 59% in UK and DE for secondary CVD prevention; 57% and 53% for primary CVD prevention, respectively. With multiple Gaps, 50% and 36% still receive prescription low-dose aspirin for 10 years in UK and DE, respectively for secondary CVD prevention. For Primary prevention, 36% and 32% receive prescription of aspirin for 10 years with multiple gaps in UK and DE (Figure). Conclusion After the initial drop in persistence the patients tend to continue their low-dose aspirin treatment for long-term, although with multiple gaps. Overall, the persistence was higher in secondary compared to primary CVD prevention. Improving persistence to low-dose aspirin therapy in the initial years may help in continuity of their treatment over long-term. Persistence might be underestimated due to potential over the counter use of low-dose aspirin. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer AG

Long-term adherence to low-dose aspirin therapy for cardiovascular prevention in routine clinical practice in United Kingdom and Germany

Abstract Background Low-dose aspirin is effective in the prevention of ischemic vascular events and studies have shown a preventative effect on colorectal cancer (CRC). However, adherence to therapy is likely an important factor for these benefits to be seen and non-adherence is associated with sub-optimal outcomes. Purpose To assess the long-term adherence to low-dose aspirin therapy in the primary and secondary cardiovascular (CVD) prevention population Methods This retrospective cohort study used data from United Kingdom (UK) – The Health Improvement Network Database and Germany (DE) – IQVIA Disease Analyzer and analyzed using an adaptation of Observational Health Data Sciences and Informatics (OHDSI) ATLAS Tool. Patients 18 years or older, with at least two prescriptions of low-dose aspirin (75–100mg) within the first year of index date during the study period between 2007 and 2018, and with at least 12 months of observation before and after the index date were included in the study. The patients with a CVD diagnosis or a CABG/PCI procedure before the index date or a prescription of dual antiplatelet at index date were classified as secondary CVD prevention. The remaining patients were classified as potential primary CVD prevention. The index date was first prescription of low-dose aspirin. Adherence was calculated using medication possession ratio (MPR) which is number of days of medication supplied within the refill interval divided by number of days in the refill interval. Long term adherence was divided in three categories namely patients with ≤2 years, 2-≤5 years, and 5-≤10 years of follow-up. Results The total number of patients receiving low-dose aspirin was 327,806 (183,089 in UK and 144,717 in DE with up to 10 years of follow-up). A total of 112,887 and 101,704 received low-dose aspirin for secondary CVD prevention; 70,202 and 43,013 potentially for primary CVD prevention in UK and DE, respectively. Median adherence to low-dose aspirin in UK and DE for patients with ≤2 years of follow-up was 88% and 80% for secondary CVD prevention, respectively; 84% and 74% for 2-≤5 years; and 75% and 59% for 5-≤10 years, respectively. Median adherence to low-dose aspirin in UK and DE for patients with ≤2 years was 76% and 75% for potential primary CVD prevention; 65% and 66% for 2-≤5 years; 49% and 49% for 5-≤10 years, respectively (Figure). Conclusion The long-term adherence to low dose aspirin was quite high with more than half the patients being adherent to their treatment. Overall, the adherence was higher in secondary compared to primary CVD prevention. The estimates for adherence might be underestimated due to potential over the counter use of low-dose aspirin. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer AG

Influence of co-initiation of antiulcer drugs onpersistence and adherence to low-dose aspirin: A retrospective cohort study using aJapanese claims database .

The purpose of this study was to examine whether co-initiation of antiulcer drugs (AUDs) and low-dose aspirin (LDA) therapy is beneficial for good adherence to LDA therapy. A retrospective cohort study was conducted using the JMDC claims database. Patients for whom LDA therapy was newly initiated between January 2005 and April 2016 were selected from the JMDC database. The selected patients were divided into LDA and LDA+AUD groups and were followed up from the first prescription of LDA or LDA+AUD until the earliest of the following events: discontinuation or the end of the observation period. Unadjusted and multivariable Cox proportional hazards models controlling for all demographic and clinical characteristics were applied to examine whether the addition of an AUD to LDA improved adherence. A 1:1 propensity score matching analysis was conducted to balance confounders between the two groups. After the propensity score matching analysis, 4,089 patients were matched in each therapy group. The Kaplan-Meier curves for the rate of LDA continuation showed a sharp decline just after the initiation of LDA therapy. A significant difference was observed in the incidence of LDA therapy discontinuation between the LDA+AUD and LDA groups (HR: 0.87, 95% CI: 0.82-0.92), and the median duration of LDA therapy in the LDA+AUD and LDA groups were 18 and 11 months (log-rank test: p<0.0001), respectively. The therapy persistence rate in the LDA+AUD group was significantly higher than that in the LDA group.

66 The Use of Proton Pump Inhibitors in An Older Population in A Tertiary Hospital: A Patient Safety Issue?

Abstract Background PPIs form part of the most commonly prescribed medications in Ireland. There has been emerging concern regarding the risks associated with their chronic use. PPI use has been linked with clostridium difficile infection, pneumonia, hypomagnesaemia, nephrotoxicity, hyponatraemia as well as many other GI and non GI pathologies including dementia. Therefore there has been emerging concern regarding their chronic use. The aim of our audit was to identify the spot prevalence and appropriateness of PPI use for gastro-protection in an older population of medical inpatients in accordance with NICE 2014 PPI guidance “Management of dyspepsia in adults in primary care.” Methods We audited the prevalence of PPI use in medically admitted patients aged ≥65 years at our institution and the use of PPIs within this population. Patients' admission proforma, clinical notes, and drug kardex were reviewed. We collected: age, gender, past medical history, drug list, and laboratory results. This data was used to identify the prevalence and appropriateness of PPI use. Results The total number of medically admitted patients aged ≥65 years was 107. 52(48.5%) were prescribed PPIs. Of the 52, only 7(13.4%) had an appropriate indication: Five patients had concomitant prescription of low dose Aspirin ± clopidogrel and a documented history of gastritis/esophagitis/duodenitis. One patient had a hiatus hernia and gastro-esophageal reflux disease. One patient had chronic NSAID use due to arthritis. Subgroup analysis showed 46/52 were prescribed high dose PPI without indication. Conclusions Our audit confirms this showing that almost 50% of patients aged ≥ 65y admitted to our hospital have been prescribed PPIs. Furthermore, PPI prescriptions were only appropriate in 13.4%. In line with recent guidelines, NICE PPI guidance 2014 and AGA Best Practice Guidelines, our data shows there is scope to rationalise PPI use in older people with resultant cost savings and reduction in complications.

From first-trimester screening to risk stratification of evolving pre-eclampsia in second and third trimesters of pregnancy: comprehensive approach.

Preeclampsia and associated hypertensive disorders of pregnancy represent a leading cause of global maternal and neonatal morbidity and mortality. Identification of women at high risk for developing preterm-preeclampsia and prophylaxis with low-dose aspirin has the potential to significantly reduce the rate of preterm-preeclampsia. In addition, risk assessment and monitoring of women in the second and third trimester of pregnancy, to aid in early detection of evolving disease, timely referral to specialist care, and active monitoring of women with confirmed or suspected preeclampsia is essential for improving maternal and neonatal outcomes. The angiogenesis-related biomarkers sFlt-1 and PlGF have been shown to have clinical value to aid in the prediction, diagnosis, and risk stratification of preeclampsia when used either alone or in combination with other risk factors. However, currently there is no consensus on the optimum strategy to link first trimester screening for preterm-preeclampsia with appropriate second and third trimester risk assessment strategies. This opinion paper will outline the current evidence for first trimester preeclampsia screening and prevention, as well as the evidence for various risk stratification approaches for detection of evolving preeclampsia through the second and third trimesters of pregnancy, and proposes a potential model integrating these tools. This article is protected by copyright. All rights reserved.

Evidence-Based Prevention of Preeclampsia: Commonly Asked Questions in Clinical Practice.

In this review, we discuss the recent literature regarding the prevention of preeclampsia and aim to answer common questions that arise in the routine antenatal care of pregnant women. Prescription of low-dose aspirin for high-risk patients has been shown to reduce the risk of preeclampsia (PE). A daily dose between 100 and 150 mg taken in the evening should be initiated prior to 16 weeks of gestation and can be continued until delivery. Calcium supplementation seems to be advantageous but currently it is only considered for patients with poor dietary intake and high risk for PE. Recent data about heparin are still conflicting, and therefore, heparin can currently not be recommended in the prevention of PE.

Aspirin use and ovarian cancer mortality in a Danish nationwide cohort study

Background:Increasing data suggest that aspirin use may improve cancer survival; however, the evidence is sparse for ovarian cancer.Methods:We examined the association between postdiagnosis use of low-dose aspirin and mortality in a nationwide cohort of women with epithelial ovarian cancer between 2000 and 2012. Information on filled prescriptions of low-dose aspirin, dates and causes of death, and potential confounding factors was obtained from nationwide Danish registries. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for ovarian cancer-specific or other-cause mortality associated with low-dose aspirin use.Results:Among 4117 patients, postdiagnosis use of low-dose aspirin was associated with HRs of 1.02 (95% CI: 0.87–1.20) for ovarian cancer mortality and 1.06 (95% CI: 0.77–1.47) for other-cause mortality. Hazard ratios remained neutral according to patterns of low-dose aspirin use, including prediagnosis use or established mortality predictors.Conclusions:Low-dose aspirin use did not reduce mortality among ovarian cancer patients.

Clinical implications of low-dose aspirin on vasospastic angina patients without significant coronary artery stenosis; a propensity score-matched analysis

BackgroundHigh-dose aspirin has been reported to exacerbate coronary artery spasm in patients with vasospastic angina. We investigated clinical implications of low-dose aspirin on vasospastic angina patients without significant coronary artery stenosis. MethodsWe included patients without significant coronary artery stenosis on coronary angiography (CAG) and with positive results on intracoronary ergonovine provocation test between January 2003 and December 2014. A total of 777 patients were divided into two groups according to prescription of low-dose aspirin at discharge: aspirin group (n=321) and non-aspirin group (n=456). The major adverse cardiovascular events (MACE), defined as composite outcomes of cardiac death, acute myocardial infarction, revascularization, or rehospitalization requiring CAG or medication change due to recurrent angina were compared. ResultsThe aspirin group had significantly higher incidence of MACE (22.8% versus 12.1%; p=0.04) and had higher tendency for rehospitalization (20.6% versus 11.2%; p=0.08). All-cause mortality and cardiac death were similar between the two groups. After propensity score matching, the aspirin group had greater risk of MACE (hazard ratio [HR] 1.54; 95% confidence interval [CI], 1.04–2.28; p=0.037) and rehospitalization requiring CAG (HR, 1.33; 95% CI, 1.13–4.20; p=0.03), and a higher tendency for rehospitalization (HR, 1.40; 95% CI, 0.94–2.09; p=0.12). ConclusionIn vasospastic angina without significant coronary artery stenosis, patients taking low-dose aspirin are at higher risk of MACE, driven primarily by tendency toward rehospitalization. Low-dose aspirin might be used with caution in vasospastic angina patients without significant coronary artery stenosis.

O29. The impact of low dose aspirin after positive first trimester screening for pre-eclampsia

Introduction Pre-eclampsia is a major cause of maternal and perinatal morbidity and mortality. The prophylactic use of low dose aspirin (50–150mg/day) is associated with a reduction in the incidence or severity of pre-eclampsia between 50–90% if the treatment begins before the 16th week of gestation. Promising multifactorial screening models in first trimester of pregnancy are in use to predict pre-eclampsia, especially early onset disease before the 34th week of gestation. Objectives Combining this issues we conducted an observational study and evaluated the outcome of women on low dose aspirin after a positive first trimester screening test for pre-eclampsia based on two different risk calculations models. Methods We have completed outcome data of 401 women with performed multifactorial screening test for pre-eclampsia at 12–14 weeks of gestation in a clinical setting, from June 2012 until September 2014 using two different risk-calculation software. In the first time period until October 2013 we used the Pre-eclampsia Predictor™ Software by PerkinElmer (group PE). Thereafter the prediction algorithm in Viewpoint® (group VP) was used to calculate the risk for pre-eclampsia. Women who were screened positive for the development of early and late onset of pre-eclampsia (early: 34th week of gestation e.g. late > 34th week of gestation) in the group PE and for early onset pre-eclampsia ( 34th week of gestation) in the group VP were prescribed low dose aspirin (75–100mg/day) starting before 16 gestational weeks and until 34 completed weeks of gestation. Descriptive and explorative statistical analyses were performed. A two-sided p -value of less than 0.05 was considered as significant. Results There were 214 women in the PE group and 187 in the VP group. In the PE group 17 (7.9%) women were screened positive for early onset pre-eclampsia and 46 (21.5%) for late onset pre-eclampsia. In the VP group 44 (23.5 %) were screened positive for early onset pre-eclampsia. Regarding screening positive for early onset pre-eclampsia groups differ significant ( p =0.000). Comparing prescription of low dose aspirin and outcome of pre-eclampsia (4 (1.8%) cases in the PE and 5 (2,7%) cases in the VP group) there were no significant differences between the two groups. There were no cases of early onset or severe form of pre-eclampsia in both groups. Conclusion The both used predication algorithms are not similar but were similarly applied so that the outcomes of women were not different. Using a multifactorial first trimester screening test with subsequent administration of low dose aspirin in a screening-positive group of pregnant women is a promising strategy to reduce early onset and severe forms of pre-eclampsia, but cut offs of algorithms should be improved.

Difference in risk of gastrointestinal complications between users of enteric-coated and buffered low-dose aspirin

Difference in the risk of gastrointestinal (GI) complications between users of enteric-coated and buffered low-dose aspirin (LDA) is unclear. The purpose of the study is to examine the difference in risk of GI damage between enteric-coated and buffered LDA products. A large and chronologically organized receipt database constructed by a database vendor was utilized. Prescription and event sequence symmetry analysis was used to identify the risk of LDA-induced GI complications over the period from January 2005 to July 2011. LDA use in combination with H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) was examined by prescription sequence symmetry analysis. Likewise, symmetry analysis was undertaken to evaluate the association between the diagnosis of GI disease and the prescription of LDA products. In July 2011, enteric-coated LDA users were more frequently co-administered PPIs than buffered LDA users (25.4% vs. 14.4%). Prescription sequence symmetry analysis of acid inhibitor use found no significant associations with enteric-coated LDA use and buffered LDA use. The event sequence symmetry analysis of ulcer, gastritis and duodenitis, and melena found significant associations with entericcoated LDA use, with adjusted sequence ratios (ASRs) of 1.58 (1.23 - 2.06), 1.30 (1.03 - 1.65), and 14.38 (2.19 - 607.95), respectively, at the 6-month interval. At the 12-month interval, analysis of ulcers and melena found significant associations for enteric-coated LDA users, with ASRs of 1.39 (1.13 - 1.73) and 20.83 (3.33 - 863.25), respectively. Our findings do not support that there is no difference in the risk of GI complications between enteric-coated LDA and buffered LDA, but rather may imply that the risk of GI complications associated with enteric-coated LDA is higher than that with buffered LDA.

Aspirin Use After Diagnosis Improves Survival in Older Adults with Colon Cancer: A Retrospective Cohort Study

To assess survival in relation to aspirin use after diagnosis in older adults with colon cancer. Subgroup analysis of a previously published cohort and retrospective study. Individuals registered in the Eindhoven Cancer Registry (ECR) between 1998 and 2007, linked to prescriptions of low-dose aspirin (80 mg) registered in a community pharmacy database. Five hundred thirty-six individuals aged 70 and older diagnosed with colon cancer with or without aspirin use after diagnosis. Survival was analyzed with user status as a time-dependent covariate. Multivariate Poisson regression survival models were used to study the effect of aspirin on overall survival. One hundred seven participants (20.0%) started aspirin after being diagnosed with colon cancer; 429 (80.0%) were not prescribed aspirin. Three hundred thirty-nine participants (63.2%) had died by the end of follow-up. Aspirin use after diagnosis was associated with longer overall survival (rate ratio (RR) = 0.51, 95% confidence interval (CI) = 0.38-0.70, P < .001). Multivariate proportional hazards regression analysis revealed that aspirin use was associated with longer overall survival (adjusted RR = 0.59, 95% CI = 0.44-0.81, P = .001). Aspirin use after the diagnosis of colon cancer in older adults was associated with longer survival. Low-dose aspirin could be used as an effective adjuvant therapy in older adults with colon cancer.

Reconsidering low-dose aspirin therapy for cardiovascular disease: a study protocol for physician and patient behavioral change

BackgroundThere are often disparities between current evidence and current practice. Decreasing the gap between desired practice outcomes and observed practice outcomes in the healthcare system is not always easy. Stopping previously recommended or variably recommended interventions may be even harder to achieve than increasing the use of a desired but under-performed activity. For over a decade, aspirin has been prescribed for primary prevention of cardiovascular disease and for patients with the coronary artery disease risk equivalents; yet, there is no substantial evidence of an appropriate risk-benefit ratio to support this practice. This paper describes the protocol of a randomized trial being conducted in six primary care practices in the Denver metropolitan area to examine the effectiveness of three interventional strategies to change physician behavior regarding prescription of low-dose aspirin.MethodsAll practices received academic detailing, one arm received clinician reminders to reconsider aspirin, a second arm received both clinician and patient messages to reconsider aspirin. The intervention will run for 15 to 18 months. Data collected at baseline and for outcomes from an electronic health record will be used to assess pre- and post-interventional prescribing, as well as to explore any inappropriate decrease in aspirin use by patients with known cardiovascular disease.DiscussionThis study was designed to investigate effective methods of changing physician behavior to decrease the use of aspirin for primary cardiovascular disease prevention. The results of this study will contribute to the small pool of knowledge currently available on the topic of ceasing previously supported practices.Trial RegistrationClinicalTrials.gov: NCT01247454

Prophylactic use of gastro‐protective agents in patients on low‐dose aspirin

Low-dose aspirin is commonly prescribed for the prevention of thrombotic events in high-risk patients. Even at doses as low as 80–160 mg day−1−1, aspirin leads to upper gastrointestinal (GI) complications in 0.6–1.2% patients per year [1]. Most epidemiological studies have reported a relative risk of upper gastrointestinal complications with low-dose aspirin of between 2.0 and 2.6 [2, 3]. Despite this, routine coprescription of gastro-protective agents with aspirin or other NSAIDs is usually not advocated [1, 4]. Gastro-protective drugs have been suggested for patients at increased risk of upper GI complications, e.g. history of ulcer or upper GI bleeding, age >70 years, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori infection [3]. During a routine prescription audit, we came across prescriptions of low dose aspirin accompanied by gastro protective agents. The current study was planned to evaluate the practice of prescribing gastro-protective drugs in our hospital, Pondicherry Institute of Medical Sciences (PIMS), a medical college cum hospital in South India. Prescription information was obtained from duplicate prescriptions at the outpatient pharmacy. Randomly selected prescriptions were scrutinized from 10th April 2007 to 14th May 2007. Diagnoses were obtained from the Medical Records Section. A total of 44 prescriptions, representing 40 patients, containing low dose aspirin were collected. Of these, 31 were men. Ages varied from 24 to 78 years, with four patients over the age of 70 years. The indication for low dose aspirin was an increased risk for thrombosis due to cardiovascular disease in all 40 patients, with concurrent diabetes mellitus in 12. There were no patients with a history of, or active, peptic ulcer disease. The dose of aspirin was 75 mg and 150 mg daily in 36 and four patients, respectively. Duration of aspirin therapy ranged from 2 to 90 days, with a mean duration of 28 days. Only one patient was on concurrent NSAID, a combination of ibuprofen and acetaminophen (Combiflam). Four patients were receiving acetaminophen, including the one on Combiflam, who was prescribed acetaminophen individually in addition to the fixed dose combination. All prescriptions of Combiflam and acetaminophen were for less than 4 days. No patient was prescribed a corticosteroid. Fifteen (37.5%) patients were prescribed a gastro-protective drug (Table 1). Histamine H2-receptor antagonists were prescribed in 11 patients. Of these, eight patients (including the patient on Combiflam) received ranitidine, while three were receiving famotidine. Four patients were prescribed a proton pump inhibitor (PPI), i.e. pantoprazole. None of the patients over 70 years of age received any gastro-protective drug. Table 1 Gastro-protective drugs prescribed in patients on low-dose aspirin Prophylactic use of gastro-protective agents is usually not indicated in patients on low-dose aspirin unless there is a risk factor for gastrointestinal complications. Despite this, we found a substantial number of patients (37.5%) were being prescribed such drugs. Only one out of 15 had a recognized risk factor for peptic ulcer disease, i.e. concurrent use of NSAID. On the other hand, patients above 70 years may be at a higher risk of upper gastrointestinal complications with aspirin, and may be considered suitable candidates for gastro-protective therapy [5, 6]. Despite this, four elderly patients were not on any antiulcer drug. The choice and dosage of gastro-protective drug was also questionable. Although histamine H2-receptor antagonists can be used for prevention of aspirin and other NSAID-induced peptic ulcers, most authorities recommend PPIs at standard doses as drugs of first choice for this purpose [4, 7]. Moreover, if used, histamine H2-receptor antagonists need to be prescribed at double doses, i.e. ranitidine 300 mg twice daily or famotidine 40 mg twice daily, as standard doses are not effective in reducing the incidence of NSAID induced gastric ulcers [7]. However standard and even low doses of histamine H2-receptor antagonists were being prescribed in the present study. A change in this prescribing practice is required, for more appropriate use of gastro-protective drugs along with low dose aspirin.

Review article: a cardiologist's view of the risks and benefits of cyclo-oxygenase-2 inhibitors, aspirin and other non-steroidal anti-inflammatory drugs

Cyclo-oxygenase-2 inhibitors are very interesting drugs, capable of inhibiting the main source of inflammatory prostaglandins in the joint while also avoiding gastrointestinal complications. Unfortunately, double-blind studies have clearly demonstrated that cyclo-oxygenase-2 agents increase cardiovascular risk. This phenomenon appears to be a class effect although it seems to be less pronounced with celecoxib. These adverse cardiovascular events are mainly due to an elevated thrombotic risk and are possibly linked to the increase in blood pressure. The decision about whether to continue with cyclo-oxygenase-2 treatment can only be undertaken after consideration of both the cardiovascular risk and the gastrointestinal risk of an individual patient. In contrast, low-dose aspirin continues to be the simplest and most effective way to prevent cardiovascular disease. However, the increased risk of adverse gastrointestinal events associated with aspirin use, such as gastrointestinal bleeding and intracerebral bleeding, must not be forgotten. Ideally, the prescription of low-dose aspirin should be avoided for low cardiovascular risk patients and reserved for those patients with high or intermediate cardiovascular risk. In these patients, the risk of gastrointestinal events should prompt the prescription of a gastroprotectant, such as a proton-pump inhibitor, to be taken concomitantly, which will help avoid the significant problem of non-compliance in high cardiovascular risk patients.

Screening with a uterine Doppler in low risk pregnant women followed by low dose aspirin in women with abnormal results: a multicenter randomised controlled trial

Objectives To assess whether systematic screening with an uterine artery Doppler in low risk pregnant women followed by the prescription of low dose aspirin in cases with abnormal results reduced the incidence of intrauterine growth restriction and pre-eclampsia. Design A multicentre randomised trial. Population 3317 low risk pregnant women. In the Doppler group, the uterine artery Doppler was performed between 20 and 24 weeks. Women with abnormal results received 100 mg of aspirin daily until the 35th week. Main outcome measures Intrauterine growth restriction was defined as birthweight below the tenth and the third centile according to gestational age. Pre-eclampsia was defined as hypertension associated with proteinuria > 0.5g/L. Results Intrauterine growth restriction, whether defined by the third or tenth centile, did not differ significantly between the two groups (RR = 1.22 [0.73 - 2.04] and 1.18 [0.93 - 1.51] respectively). Screening with uterine artery Doppler did not affect birthweight or any of the criteria of perinatal morbidity. There was no effect on the incidence of pre-eclampsia (RR = 1.99 [0.97 - 4.09]) or hypertensive disorders. These results were the same for nulliparae and multiparae. Conclusions There is no justification for screening with uterine artery Doppler in a low risk population, even if abnormal results are followed by aspirin treatment and increased prenatal surveillance. Future studies must assess predictive tests that can be performed early in pregnancy and can identify populations at very high risk of pre-eclampsia and intrauterine growth restriction. Only when all of these conditions are fulfilled, aspirin or other treatments may prove its efficacy.

Changing prescribing behaviour: early low dose aspirin in suspected acute myocardial infarction

Introduction: Evidence obtained from large clinical trials would be of limited value, if such evidence does not reach the provider of care, and even when it reaches them, if they do not change their clinical behaviour accordingly. The aim of our study was to assess the effectiveness of intervention, aimed at changing prescribing behaviour of general practitioners (GPs) with regard to early low dose aspirin in patients with suspected acute myocardial infarction (MI). Methods: A total of 96 GPs were sent a questionnaire assessing their knowledge and practices with regard to use of low dose aspirin in acute MI in November 1995 (Q1), June 1996 (Q2) and September 1996 (Q3). An `intervention' was carried out with a view to changing GP prescribing of low dose aspirin is suspected acute MI after the first two questionnaires were sent. Results: The results of this study seem to show that an intensive `intervention' achieved success in changing prescribing behaviour of GPs. Although the intervention resulted in a overall significant increase in the prescription of low dose aspirin in suspected acute MI, it was seen that in the GPs who were aged <40 years the success achieved with the `intervention' was greater when compared with that seen in those older than 40 years. Conclusion: Dissemination of information on new practices in medicine are important in the process of continuing medical education for doctors. A `personal intervention' such as is described in this study seems to have good effect.