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UK Guidelines aspirin

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Summary of UK guidelines for aspirin

May 2021

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 for primary prevention of cardiovascular disease [Last revised August 2020] “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.”

For further information see:

https://cks.nice.org.uk/topics/antiplatelet-treatment/

NICE also recommend reading their advice on managing antiplatelet-induced dyspepsia:

https://cks.nice.org.uk/topics/antiplatelet-treatment/management/secondary-prevention-of-cvd/#managing-antiplatelet-induced-dyspepsia


Secondary prevention of cardiovascular disease

NICE CKS Antiplatelet treatment for the secondary prevention of CVD [last revised August 2020] suggests antiplatelet treatment for people who have had:

  • Acute coronary syndrome [initially dual antiplatelets – aspirin 75 mg daily plus ticagrelor 90 mg twice daily for 12 months]
  • Angina [usually low-dose aspirin 75 mg daily]
  • Atrial fibrillation [AF] but notes that anticoagulants are usually prescribed
  • Myocardial infarction [dual antiplatelet e.g. aspirin plus initial second antiplatelet with aspirin continued indefinitely]
  • Stent implantation [aspirin 75-100 mg daily in combination with a second agent for a variable length of time depending on bleeding risk and if ACS or stable coronary artery disease and then aspirin alone].
  • Stroke or TIA – in people who have had a stroke or TIA [clopidogrel is the preferred antiplatelet medication but if contraindicated give modified release [MR] dipyridamole combined with low-dose aspirin or if not able to take MR dipyridamole then use aspirin alone].
  • Peripheral artery disease [clopidogrel 75 mg daily is the preferred antiplatelet but if contraindicated give low-dose aspirin]


Guidance around managing dyspepsia including Heliocobacter pylori testing and PPI usage is also included. The guidelines explain that risk factors for having a GI bleed include:

  • Taking high dose aspirin
  • Older age [especially over 70 years]
  • History of GI bleed, ulcer or perforation
  • Heliocobacter pylori infection
  • Concomitant use of other medicines that increase the risk of a GI bleed

 

Please see

https://cks.nice.org.uk/topics/antiplatelet-treatment/management/secondary-prevention-of-cvd/

For further information about aspirin for secondary CVD prevention.

NICE Acute coronary syndromes guidelines

https://www.nice.org.uk/guidance/ng185

Recommend:

  • Offer aspirin after an myocardial infarction (MI) and continue it indefinitely unless the individual is intolerant to aspirin or has an indication for anticoagulant ( for those on anticoagulation see https://www.nice.org.uk/guidance/ng185/chapter/Recommendations#antiplatelet-therapy-for-people-with-an-ongoing-separate-indication-for-anticoagulation )
  • Offer aspirin to people who have had an MI within the last 12 months and continue it indefinitely
  • Unless contraindicated use dual antiplatelet therapy for 12 months after an MI unless this is contraindicated
  • People with a history of dyspepsia should be offered management for this see NICE guidance on gastro-oesophageal reflux disease and dyspepsia in adults (CG184) https://www.nice.org.uk/guidance/cg184

 

Chest pain

NICE CG95 March 2010 [last updated Nov 2016] recent-onset chest pain of suspected cardiac origin: assessment and diagnosis states that people with suspected acute coronary syndrome should be offered a loading dose of 300 mg of aspirin as soon as possible [unless they are allergic to it]. If this is achieved before hospitalisation a written record that is has been given should be sent with the patient.

https://www.nice.org.uk/guidance/cg95/resources/recentonset-chest-pain-of-suspected-cardiac-origin-assessment-and-diagnosis-pdf-975751034821

 

Stroke and TIA

NICE NG128 May 2019 Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.

https://www.nice.org.uk/guidance/ng128/resources/stroke-and-transient-ischaemic-attack-in-over-16s-diagnosis-and-initial-management-pdf-66141665603269

states:

1.1.4. “Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.’
Further information about this decision can be found at:

https://www.nice.org.uk/guidance/ng128/resources/stroke-and-transient-ischaemic-attack-in-over-16s-diagnosis-and-initial-management-pdf-66141665603269

and

https://www.nice.org.uk/guidance/ng128/evidence/a-aspirin-pdf-6777399566

The same guidelines recommend aspirin for people with acute ischaemic stroke, as soon as possible within 24 hours, where a diagnosis of intracerebral haemorrhage has been excluded using brain imaging. For those without dysphagia give aspirin 300 mg orally and those with dysphagia can be give the same dose rectally or via an enteral tube. Aspirin 300 mg daily should be continued until long term antithrombotic treatment is agreed 2 weeks post stroke or at discharge.

A proton pump inhibitor is recommended in addition to aspirin for those with dyspepsia linked to aspirin use.

For further details on aspirin use and stroke read the full guidance.

 

Atrial fibrillation (AF)

NICE Atrial Fibrillation: diagnosis and management (NG196) (Published 27 April 2021) https://www.nice.org.uk/guidance/NG196 states that ‘for most people the benefit of anticoagulation outweighs the bleeding risk.’ They recommend offering anticoagulation with a direct-acting oral anticoagulant (DOAC), to adults with AF and a CHA2DS2-VASc score of 2 or more. Offer warfarin if a DOAC such as apixaban, dabigatran, edoxaban and rivaroxaban are contraindicated or not tolerated. The guidelines state that aspirin monotherapy should not be offered solely for the purposes of stroke prevention in people with AF. NICE offer guidance for antiplatelet therapy in people with a separate indication for anticoagulant therapy in their NICE (NG185) Acute coronary syndromes guidelines.

https://www.nice.org.uk/guidance/ng185 .

 

Prevention of cardiovascular events in diabetics

NICE NG17 2015 (updated December 2020) states “Do not offer aspirin for the primary prevention of cardiovascular disease to adults with type 1 diabetes.” https://www.nice.org.uk/guidance/ng17/resources/type-1-diabetes-in-adults-diagnosis-and-management-pdf-1837276469701

NICE NG28 2015 (updated December 2020) Type 2 diabetes in adults- management state “Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.” https://www.nice.org.uk/guidance/ng151/resources/user-guide-and-data-sources-pdf-8834927870

 

Primary prevention of colorectal cancer/all GI cancers

NICE NG151 Colorectal cancer guidelines recommend daily aspirin for 2 years or more to help prevent colorectal cancer in people with Lynch syndrome. https://www.nice.org.uk/guidance/ng151/resources/colorectal-cancer-pdf-66141835244485

The guidance explains that this is an off-label use of aspirin, they do not make a recommendation on exact dose as work is ongoing to establish this however, they observe that commonly used doses of aspirin in current practice are 150 mg or 300 mg. Further information on the recommendation explains that the multi-country randomised controlled trial used 600 mg of aspirin daily for more than 2 years. Further information on the NICE evidence review for aspirin use in the prevention of colorectal cancer in people with Lynch syndrome can be found at: https://www.nice.org.uk/guidance/ng151/evidence/a1-effectiveness-of-aspirin-in-the-prevention-of-colorectal-cancer-in-people-with-lynch-syndrome-pdf-7029391214

In order to help people with Lynch syndrome decide if they would like to take daily aspirin to help reduce the chance of developing bowel cancer NICE have produced a patient decision aid.

https://www.nice.org.uk/guidance/ng151/resources/user-guide-and-data-sources-pdf-8834927870

 

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 Cochrane review from 2019 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

 

Further resources


Antiplatelet treatment: Low dose aspirin last revised August 2020

https://cks.nice.org.uk/topics/antiplatelet-treatment/prescribing-information/low-dose-aspirin/

 

 

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Daniel José Piñeiro

ASSOCIATE
Name
Daniel José Piñeiro
Academic Affiliations:
Full Professor of Medicine, Universidad de Buenos Aires, Argentina Trustee, Board of Trustees, American College of Cardiology
Professional Setting:
My academic experience includes more than 40 years as a practicing medical doctor, teacher, and researcher. I have fulfilled these appointments in settings of vital social engagement and impact, most notably at the Hospital de Clínicas “José de San Martín” of the Universidad de Buenos Aires, a public hospital with high academic recognition. Additionally, I currently hold the position of Full Professor of Medicine at that same University.
Academic Activities:
  • International Meetings Participations: 180
  • Books-Editor: 1
  • Books Chapters: 39
  • Refereed Full Articles: 118 (listed in Pubmed: 29)
  • Refereed Abstracts: 221
  • Editorial Boards: 10
Profesional Associations:
  • 2005 President, Sociedad Argentina de Cardiología.
  • 2011-2013 President, Inter-American Society of Cardiology.
  • 2011-2013 Member (ex-officio), Board of Directors, World Heart Federation
  • 2017-2018 Member (at large), Board of Directors, World Heart Federation
  • 2018-2021 Trustee, Board of Trustees, American College of Cardiology
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Chia

John Chia

Name
John Chia MBBS (Spore), MRCP (UK), FAMS (Spore)
Academic Affiliations:

Adjunct Associate Professor DUKE-NUS Graduate Medical School,
Consultant Oncologist Curie Oncology Singapore,
Visiting Consultant National Cancer Centre Singapore.

Discipline:

Medical Oncology

Scientific Interests:
  • Aspirin as adjuvant therapy in established cancers
  • Adoptive T cell therapy and Dendritic cell vaccines in the treatment of solid tumors
  • Clinical Trial Design and Management
Declaration of Conflicts of Interest:

In the past 3 years, I have received consultant fees from Tessa Therapeutics, Aslan Pharmaceuticals, Novartis, and AstraZeneca.

I received grant support for investigator-initiated research from:

  • National Medical Research Council Singapore
  • Bayer AG

I hold shares in:  Roche, BMS, AstraZeneca, Incyte, Teva Pharmaceuticals, Trillium Therapeutics, Compugen, Arrowhead pharmaceuticals, Emergex, QuantumDx and Halozyme Therapeutics

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Badimon

Lina Badimon

Name
Lina Badimon BSc, PharmD, PhD, FESC, FAHA
Academic Affiliations:
Director of the Cardiovascular Science Program (ICCC) at the Hospital Santa Creu and San Pau, IIB-Sant Pau; CIBER CV. Director of the Cardiovascular Research Chair of the Autonomous University of Barcelona and Director of the UNESCO Chair in Biomedical Sciences Training and Research.
Discipline:
Pharmacology, Cardiovascular Disease
Scientific Interests:
Cardio-metabolic diseases, thrombosis, atherosclerosis and ischemic heart disease
Declaration of Conflicts of Interest:

I received consultant and speakers fees from Amgen, AstraZeneca, Bayer, Lilly and Sanofi.

    Return to Scientific Advisory Board
    Ge

    Junbo Ge

    Name

    Junbo Ge

    Ge Junbo, male, was born in Wulian, Shandong province on Nov. 8, 1962. He is the member of Chinese Academy of Sciences, professor and doctoral supervisor. He received his doctor’s degree of Medicine from German Mayence University in 1993 and now works as the director for Shanghai Institute of Cardiovascular Disease and the Center for Stem Cells and Tissue Engineering, Fudan University. He is also the designate chairman of the Cardiovascular Disease Branch of Chinese Medical Association, council member of the Cardiovascular Angiography and Interventions Association, international consultant of the American Heart Association. In Dec. 2013, he was appointed as the vice president of Tongji University.

    Prof. Ge has been engaged in clinical and scientific research work of cardiovascular disease since 1987, and his research area covers the pathogenesis of coronary heart disease, early diagnosis and treatment plan optimization.

    Return to Scientific Advisory Board
    Langley

    Ruth Langley

    Name
    Ruth Langley PhD, FRCP
    Academic Affiliations:
    Professor of Oncology and Clinical Trials, MRC Programme Leader and Chair of the Cancer Group, MRC Clinical Trials Unit at UCL, honorary consultant in medical oncology at the Brighton and Sussex University Hospital.
    Discipline:
    Medical oncologist; trialist
    Scientific Interests:
    • Aspirin
    • Gastro-oesophageal malignancy
    • Transdermal oestrogen in the treatment of prostate cancer
    • Trials methodology
    Declaration of Conflicts of Interest:
    Has received honorarium from Bayer
    Return to Scientific Advisory Board
    Chan

    Andrew T Chan

    Name
    Andrew T. Chan MD, MPH
    Academic Affiliations:
    Chief, Clinical and Translational Epidemiology Unit, Vice Chair, Division of Gastroenterology, Massachusetts General Hospital, Boston, Co-leader, Cancer Epidemiology Program, Dana-Farber/Harvard Cancer Center, Boston.
    Discipline:
    Gastroenterology
    Scientific Interests:
    • The role of aspirin in the prevention of colorectal cancer and other cancers
    • The role of the gut microbiome in colorectal cancer and other chronic gastrointestinal diseases, including inflammatory bowel disease and diverticulitis
    • The role of diet and lifestyle in colorectal cancer and other chronic gastrointestinal cancers
    Declaration of Conflicts of Interest:

    AACR Honors Dr. Andrew T. Chan With 2019 AACR-Waun Ki Hong Award

    Click here to find the press release.

    I received consultant Bayer and Pfizer, Inc.

    I received grant support for investigator-initiated research from:

    • National Institutes of Health
    • National Cancer Institute
    • Crohn’s and Colitis Foundation
    • Bayer AG
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    Gaziano

    Mike Gaziano

    Name
    J Michael Gaziano MD, MPH
    Academic Affiliations:

    Professor of Medicine, Harvard Medical School; Chief Division of Aging, Brigham and Women’s Hospital; Director of Preventive Cardiology and Director of Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System.
    Discipline: Cardiology and Epidemiology

    Scientific Interests:
    I am a chronic disease epidemiologist with a particular interest in the roles that individual lifestyle choices (diet, exercise, smoking), metabolic factors (obesity, high cholesterol, and hypertension), and biochemical and genetic markers play on the risk of cardiovascular disease and other chronic illnesses. Also, of interest is the impact that vascular disease has on other organ systems, including cognitive dysfunction and renal disease. I have an interest in the design of large-scale trials and observational studies nested in large health care systems using big data analytic techniques.
    Declaration of Conflicts of Interest:

    I received consultant and speaker fees Bayer.

    I received grant support as a principal investigator or co-investigator for research from the VA, DOD, NIH, Merck and Kowa.

    Return to Scientific Advisory Board
    Pierre A Web Photo

    Pierre Amarenco

    Name

    Pierre Amarenco, MD, FAHA, FAAN

    Academic Affiliations:
    • Professor of Neurology at Paris-Diderot Sorbonne University 
    • Chairman of the Department of Neurology and Stroke Center; Bichat University Hospital
    • Co-Director INSERM Unit-698 “Clinical Research in Atherothrombosis”
    Discipline:

    Neurology and Vascular Neurology

    Scientific Interests:
    • Understanding and preventing stroke and vascular diseases
    • Clinical trials in prevention of vascular diseases
    • Carotid intima-media thickness studies
    • Lipid trials: prevention and therapeutic –protective- evaluation
    Declaration of Conflicts of Interest:

    N/A

    Return to Scientific Advisory Board
    CarloPatrono

    Carlo Patrono

    CHAIR
    Name
    Carlo Patrono MD, FESC, FRCP
    Academic Affiliations:
    Adjunct Professor of Pharmacology at the Catholic University School of Medicine in Rome (Italy) and at the Perelman School of Medicine of the University of Pennsylvania in Philadelphia (USA).
    Discipline:
    Clinical Pharmacology
    Scientific Interests:
    • Studying platelet activation and inhibition in diabetes mellitus
    • Studying platelet activation and inhibition in myeloproliferative neoplasms
    • Investigating the mechanism of action of low-dose aspirin in preventing colorectal cancer
    Declaration of Conflicts of Interest:

    I received consultant and speakers fees from Acticor Biotech,  Amgen,  Bayer, GlaxoSmithKline,  Tremeau,  Zambon.

    I received grant support for investigator-initiated research from:

    • AIFA (Italian Drug Agency)
    • Bayer AG
    • Cancer Research UK
    • European Commission, FP6 and FP7 Programmes

      Return to Scientific Advisory Board

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