aspirin + NSAID FYI

[howe928]

aspirin + NSAID
http://www.cks.nhs.uk/nsaids_prescri..._and_an_nsaid#

Nonsteroidal anti-inflammatory drugs (standard or coxibs) - prescribing issues - Management
What should I do for a person who requires low-dose aspirin and an NSAID?

If possible, avoid the concomitant use of low-dose aspirin and a nonsteroidal anti-inflammatory drug (NSAID):
If loss of antiplatelet effect is a major concern, consider switching low-dose aspirin to clopidogrel.
Consider whether paracetamol and/or codeine can be used.
Low-dose aspirin for cardiovascular protection almost always has priority over an NSAID.
If an NSAID is required, see People at increased risk and establish whether the NSAID is likely to be required for short-term or long-term use:
If gastrointestinal adverse effects are a major concern, prescribe a proton pump inhibitor.
For short-term or long-term NSAID use, CKS prefers naproxen or ibuprofen.

Basis for recommendation
These recommendations reflect advice from the Commission on Human Medicines (formerly the Committee on Safety of Medicines) that the combination of low-dose aspirin and an NSAID should only be used if absolutely necessary [CSM, 2002a; CSM, 2003]. Similar advice is given by the US Food and Drug Administration (FDA), by an authoritative reference manual on drug interactions, and by the British National Formulary [Baxter, 2006; FDA, 2006a; FDA, 2006b; BNF 55, 2008]:

The National Institute for Health and Clinical Excellence
considers that all NSAIDs may antagonize the cardioprotective effects of aspirin.
All NSAIDs are associated with an increased risk of thrombotic adverse events; however naproxen and ibuprofen may be slightly more favourable than most other NSAIDs, based on the evidence for cardiovascular thrombotic risks associated with coxibs and standard NSAIDs [CHM, 2006; MHRA, 2007]:
There is concern (based on laboratory studies) that regular ibuprofen use could antagonize the antiplatelet effect of low-dose aspirin. The Medicines and Healthcare products Regulatory Agency (MHRA) keeps this issue under continual review, but because no clinical evidence suggests an important risk, the MHRA has not updated its prescribing advice [MeReC, 2007].

The US FDA, however, advises that [FDA, 2006a; FDA, 2006b]:
With occasional use of ibuprofen, there is little risk of reducing the antiplatelet effect of low-dose aspirin because aspirin has a long-lasting effect on platelets.
When ibuprofen is used with immediate-release aspirin, their administration should be staggered to minimize interaction (e.g. ibuprofen 400 mg, administered at least 30 minutes after aspirin ingestion or more than 8 hours before aspirin ingestion).
Gastrointestinal (GI) safety options with long-term NSAID use:
Evidence indicates that the risk of GI bleeding is significantly lower when aspirin is used with a proton pump inhibitor (PPI) than when clopidogrel is used instead of aspirin [Chan et al, 2005].
The Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE) trial found that clopidogrel 75 mg/day was less likely to cause adverse GI effects than aspirin 325 mg/day, but absolute differences were small [CAPRIE Steering Committee, 1996]

[johnep]

Very interesting, but perhaps better to provide link than whole article.
johnep

[Shaeeb]

I agree with Johnep on this one.

Regarding the article...it will also depend on the NSAID that is being used, e.g. Ibuprofen being the safest and Azopropazone being on the other end of the scale.

It also depends on the patient and the severity of the condition being treated. In all cases just stick to the guidelines and like the CSM warning mentions to only initiate such a combination if absolutely necessary which will lie with the prescriber.

Like always the very old and the very young are high risk groups so avoid it at best in those patients who fall in to each class.

If it can't be avoided then monitor the patients more regularly.