The purpose of this document is to keep a working list of UK guidelines with information on aspirin. The guidelines themselves should be read for further information.

Primary prevention of cardiovascular disease

NICE CKS Antiplatelet treatment: Primary prevention of CVD Last revised September 2018 “Do not routinely prescribe antiplatelet treatment for the primary prevention of cardiovascular disease (CVD).” It then states “Consider prescribing aspirin in people with a high risk of stroke or myocardial infarction.” The guidelines remind readers that aspirin is not licensed for the primary prevention of CVD and that people can reduce their CVD risk by other means such as smoking cessation or taking at statin. The guidelines emphasise “if aspirin is being considered, discuss the likely benefits (reduced CVD risk) and risks (such as gastrointestinal bleeding) with the person.”

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 September 2018) state;

“Antiplatelet treatment should be prescribed for the secondary prevention of cardiovascular events in people with”:

• Acute coronary syndrome (ACS)
• Angina
• A previous MI
• A previous stroke or transient ischaemic attack (TIA).
• Peripheral Arterial disease
• Atrial Fibrillation – although anticoagulants are normally used.
• Stent implantation

SIGN 148 Acute coronary syndrome (April 16) section 4.4 p 13 recommends 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 states “No firm evidence to support the use of any antithrombotic therapy in patients with HF-REF in sinus rhythm.”

SIGN 151 Management of stable angina states (published April 2018) “All patients with stable angina due to atherosclerotic disease should receive long-term standard aspirin and statin therapy”.

NICE CG68 July 2008 (last updated: March 2017) Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. State:

1.4.2.1 “ 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 regarding 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 June 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.

Prevention of cardiovascular events in diabetics

Diabetes UK states:

“Diabetes UK has published its new recommendation that people with diabetes who do not have a history of cardiovascular disease (CVD) should speak to their healthcare team before taking aspirin as protection from future heart disease.

Although aspirin has been shown to safely reduce the risk of CVD in people with diabetes who already have a history of the diabetes complication, this is not the case for people without a history of CVD.

It has recently been suggested that an increased risk of bleeding associated with aspirin may outweigh its potential to protect against CVD in people without a history of CVD.”

https://www.diabetes.org.uk/about_us/news_landing_page/diabetes-uks-new-aspirin-guidelines

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 August 2019 ) 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.”

Aspirin and pre-eclampsia

The International Federation of Gynaecology and Obstetrics recommend that women identified as high risk of pre-eclampsia during first trimester screening should be given aspirin prophylaxis (150mg at night from 11-14 weeks gestation until delivery or the diagnosis of pre-eclampsia). They do not advocate a policy of low-dose aspirin for all pregnant women.

Poon LC, Shennan A, Hyett JA et al The International federation of Gynaecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention. Int J Gynecol Obstet 2019; 145 (Suppl.1) 1-33. @ https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.12802

A recent Cochrane review concluded that low dose aspirin does slightly reduce the risk of pre-eclampsia and its complications but that further research is required to identify those most likely to benefit.

Duley L, Meher S and Hunter KE et al. Antiplatelet agents for preventing pre-eclampsia and its complications Cochrane Database of Systematic Reviews Oct 2019 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004659.pub3/full

NICE 2019 recommends that women who are at high risk of pre-eclampsia take 75-150mg of aspirin daily from 12 weeks until the birth of the baby. They define women at high risk as those with; hypertension during a previous pregnancy, chronic kidney disease, an auto immune disease (e.g. systemic lupus erythematosus or antiphospholipid syndrome), diabetes (type 1 or 2) and/or chronic hypertension. In addition, they advise women with more than one moderate risk factor for pre-eclampsia to take low-dose aspirin from 12 weeks until birth. Moderate risk factors for pre-eclampsia are; first pregnancy, age 40 or above, a pregnancy interval of more than 10 years, obesity, family history of pre-eclampsia and a multiple foetus pregnancy.

NICE NG133 Hypertension in pregnancy: diagnosis and management. 2019 @ https://www.nice.org.uk/guidance/ng133/chapter/Recommendations