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UK guidelines for aspirin
The role of aspirin in Multiple Sclerosis – minimising stroke risk and new lesion formation:
In a review of the current literature and a call for further research Avasarala and Parti 2018 explore the role of aspirin in Multiple Sclerosis [MS] with the dual goal of minimising stroke risk and preventing new lesion formation. Acute Stroke can be difficult to diagnose in people with MS due to an overlap in symptoms and a lack of clear clinical/radiological criteria but people with MS are at increased risk of cardiovascular disease (CVD) and stroke. Therefore finding therapeutic strategies to help minimise this risk is important.
The authors explain that even though MS lesions in the brain have a small vein within the MS plaque the venous aspects of MS from a clinical, pharmacological or pathological perspective have not been well researched. The authors suggest that:
“Prospective, double-blind, and placebo controlled studies must be initiated to ascertain if MS patients benefit from routine use of anti-platelet drugs to prevent stroke.”
It is hoped that the use of aspirin in people with MS could help reduce the risk of stroke and by reducing inflammation could help manage the MS as well.
For further information please see:Avasarala J and Parti N. Can aspirin minimize stroke risk and new lesion formation in multiple sclerosis? Front. Neurol. 9:613. DOI: 10.3389/fneur.2018.00613.
The purpose of this document is to keep a working list of UK guidelines with information on aspirin.
Primary prevention of cardiovascular disease
NICE CKS Antiplatelet treatment: Primary prevention of CVD Last revised October 2015 “Do not routinely prescribe antiplatelet treatment for the primary prevention of cardiovascular disease (CVD).” It does however discuss the pros and cons and cautions for prescribing antiplatelet therapy for those with high blood pressure.
SIGN 149 Risk estimation and the prevention of cardiovascular disease does not recommend aspirin for primary prevention of CVD (Published 2017).
JBS 3 2014 does not recommend aspirin for those at higher risk of CVD e.g. diabetics to use aspirin for primary prevention of CVD.
Secondary prevention of cardiovascular disease
NICE CKS Antiplatelet treatment: secondary prevention of CVD guidelines (last revised 2015) state;
“Antiplatelet treatment should be prescribed for the secondary prevention of cardiovascular events in people with:
- A previous MI
- A previous stroke or TIA
- Peripheral Arterial disease
- Atrial Fibrillation – although anticoagulants are normally used.”
SIGN 148 Acute coronary syndrome (April 16) section 4.4 p 13 recommend the use of aspirin on its own (e.g. self-administered or by ambulance staff) or in combination with other anticoagulants.
SIGN 147 Management of chronic heart failure (March 2016) section 5.11 p 26 “No firm evidence to supports the use of any antithrombotic therapy in patients with HF-REF in sinus rhythm.”
SIGN 96 management of stable angina is currently being updated and is expected Spring 2018.
NICE CG68 July 2008 (last updated: March 2017) Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. State:
126.96.36.199 “ All people presenting with acute stroke who have had a diagnosis of primary intracerebral haemorrhage excluded by brain imaging should, as soon as possible but certainly within 24 hours, be given :
- aspirin 300 mg orally if they are not dysphagic or
- Aspirin 300 mg rectally or by enteral tube if they are dysphagic.”
(See full guidance for further information re aspirin intolerance and allergy updated 2017).
NICE CG68 describes initiating long term antithrombotic treatment after this but is not specific re which drugs.
JBS 3 2014 “Antiplatelet therapy with low dose aspirin (75–100 mg) is recommended indefinitely after myocardial infarction (MI).”
JBS 3 2014 “After acute ischaemic stroke, patients should initially receive 300 mg of aspirin daily for 2 weeks, then be changed to long term clopidogrel 75 mg daily. For patients who have a contraindication or intolerance to clopidogrel, modified release dipyridamole plus aspirin is an alternative. For people who have a contraindication or intolerance to both clopidogrel and aspirin, modified release dipyridamole alone is recommended.”
JBS 3 “For patients with transient ischaemic attacks (TIAs), modified release dipyridamole 200 mg twice daily plus aspirin 75–150 mg daily is an alternative treatment option to clopidogrel. For people who have a contraindication or intolerance to aspirin, modified release dipyridamole alone is an alternative treatment option.”
Atrial fibrillation (AF)
NICE Atrial Fibrillation: management (CG180) (Published 2014 Updated August 2014) recommends that adults with AF are prescribed newer oral anticoagulants (NOACs) such as apixaban, dabigatran, etexilate, rivaroxaban or a vitamin K antagonist e.g. warfarin rather than aspirin in order to prevent stroke.
SIGN 94 Cardiac arrhythmias in coronary heart disease is currently being updated and is expected Spring 2018.
Prevention of cardiovascular events in diabetics
Diabetes UK states:
“Diabetes UK recommends that people with diabetes without known cardiovascular disease should discuss their individual risk with their healthcare team.”
JBS 3 2014 “There is no role for aspirin in primary prevention of CVD in type 1 diabetes.”
“Low dose aspirin is not recommended for primary prevention of CVD in patients with type 2 diabetes.”
NICE NG17 2015 (updated July 2016) “Do not offer aspirin for the primary prevention of cardiovascular disease to adults with type 1 diabetes.”
NICE NG28 2015 (updated May 2017) Type 2 diabetes in adults- management “Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.”
SIGN 116 2010 (last revised Nov 2017) Management of Diabetes “Low-dose aspirin is not recommended for primary prevention of vascular disease in patients with diabetes.”
Primary prevention of CVD in chronic kidney disease
JBS 3 2014 “Routine use of aspirin is not recommended for primary prevention in CKD.”
Primary prevention of colorectal cancer/all GI cancers
NICE do not currently have recommendations for aspirin for cancer prevention or have cancer prevention guidelines other than; CRC prevention: colonoscopic surveillance in adults with ulcerative colitis , Crohn’s disease or adenomas and skin cancer prevention guidelines.
SIGN 126 Diagnosis and management of colorectal cancer December 2011 (Last revision August 2016 - listed as some recommendations may be out of date) states;
3.6 CHEMOPREVENTION USING NSAIDS
“The weight of evidence (covering more than 18,000 cases) for a protective effect of aspirin use against colorectal cancer, and the consistency of the effect in studies differing in design, location, population and motivating hypothesis means that chance alone cannot explain the inverse relation between aspirin use and colorectal cancer. Detection bias, bias due to indications for use of aspirin, other confounding factors, problems in the measurement of aspirin use and publications bias individually would not provide a reasonable explanation for the findings, although a possible cumulative effect of these issues cannot be completely excluded. The evidence relating to other types of non-steroidal anti-inflammatory drug (NSAID) is much less substantial.
Detailed consideration of the total benefits in the prevention of colorectal cancer and other diseases in relation to toxicity will be required before use of aspirin in the prevention of colorectal cancer can be recommended.”