Not long ago, our gynecologists attended the XXVI European Congress of Perinatal Medicine (ECPM 2018). We, together with Svetlana Silenko, Deputy Head of the Center for Obstetrics and Gynecology GMS Clinic, decided to share with you the most interesting facts heard and seen at the congress.
National Institute of Health (NICE) guidelines
Aspirin 75 mg is recommended from 12 weeks of pregnancy if there is at least one high risk:
- arterial hypertension in a previous pregnancy;
- chronic renal pathology;
- autoimmune diseases (such as APS);
- diabetes;
- chronic arterial hypertension.
Aspirin 75 mg is recommended from 12 weeks if there are two or more moderate risks:
- first pregnancy;
- age over 40 years;
- the interval between pregnancies is more than 10 years;
- family history of preeclampsia;
- multiple pregnancy;
- BMI>35.
Indications for aspirin cardio
- Primary prevention of acute myocardial infarction, taking into account aggravating risks - hypertension, diabetes mellitus, obesity, smoking.
- Prevention after a heart attack.
- Stable and unstable angina (including suspicion of acute myocardial infarction).
- Prevention of stroke (including in patients with transient cerebrovascular accident).
- Prevention of cerebrovascular accidents.
- Prevention of thromboembolism after operations on blood vessels and arteries (bypass surgery, endarterectomy, angioplasty and stenting).
- Prevention of deep vein thrombosis and thromboembolism of the pulmonary artery and its branches (including long-term immobilization as a result of extensive surgery).
Methods of application
The method of administration and dosage regimen of the drug depend on its release form and other factors. The optimal dosage regimen is determined by a specialist based on specific indications. It is advisable to take aspirin cardio tablets orally before meals with plenty of liquid, preferably at the same time, once a day.
The duration of therapy is determined by the doctor. The usually recommended dose is 100 mg 1 time per day, but the approach to the dosage regimen is individual. Depending on the indications, it may increase to 300 mg/day.
Primary prevention of acute myocardial infarction in the presence of risk factors: 100 mg/day or 300 mg every other day.
- The recommended dosage for the prevention of recurrent infarction is 100-300 mg/day.
- For unstable angina, as well as the onset of myocardial infarction, the initial dose is 100-300 mg. In this case, the first tablet is chewed to speed up absorption. The drug should be taken as soon as possible at the slightest suspicion of danger. For a month after the attack, a maintenance dose of 200-300 mg/day is recommended. Further, all treatment recommendations are prescribed by a specialist based on the patient’s vital signs.
- Prevention of stroke and cerebrovascular accident: 100-300 mg/day.
- Prevention of thromboembolism after vascular surgery: 100-300 mg/day.
- Prevention of deep vein thrombosis and pulmonary embolism: 100-200 mg/day or 300 mg every other day.
The compliance of the dosage form of a particular drug with the indications for use and dosage regimen should be strictly observed.
Recommendations of the International Federation of Gynecology and Obstetrics
Women at risk should start taking aspirin 75-150 mg as soon as possible from at least 12 weeks (up to 16 weeks) and continue until 37 weeks of pregnancy or two weeks before an earlier planned birth.
Take at night, as it has been found to be more effective when taken this way. Monitoring platelet levels or bleeding time is not advisable unless there are complaints of any bleeding. In these cases, aspirin is discontinued.
Enteric forms are used if there is a history of indications of a gastric ulcer. Low doses of Aspirin were not associated with a higher risk of bleeding and do not affect the tactics of delivery, labor management, or the choice of pain relief method
The recommended dose of aspirin by professional societies is 75-80 mg per day, but a recent meta-analysis suggests that the dose of aspirin should be 100 mg or more per day, and started before 16 weeks of gestation. Therapy should be completed at 36 weeks or if labor begins.
Medicine aspirin cardio
In addition to the fact that the drug belongs to the category of NSAIDs and has an antipyretic effect and analgesic effect, aspirin cardio is used in the primary prevention of diseases of the cardiovascular system and in the secondary prevention of myocardial infarction. Reduces the risk of developing the disease with unstable angina. The drug is prescribed for cardiovascular pathologies due to its antithrombotic effect.
The main difference between the drug and regular aspirin is that aspirin cardio is coated with a special enteric coating. Due to this, it is used for long courses in cardiology. This coating allows the active substance to be released in the intestines, thereby minimizing one of the main side effects of aspirin - damage to the gastric mucosa.
Composition of the drug
The active ingredient of the drug is acetylsalicylic acid.
Excipients include corn starch and cellulose powder.
The enteric coating contains polysorbate, sodium lauryl sulfate, talc and other compounds.
Thus, when prescribing the drug, individual intolerance to the components of the composition should be taken into account.
Release form and dosage
The drug aspirin cardio is available only in the form of enteric-coated tablets in dosages of 100 mg and 300 mg.
The number of tablets in a package can be: 20 pcs., 28 pcs., 56 pcs.
Drug interactions with daily aspirin therapy
The combination of taking aspirin with anticoagulants can significantly increase the risk of serious hemorrhagic complications. Such concomitant therapy should be carefully discussed with your doctor.
Some medications may also increase the risk of bleeding. Medicines that may interact with aspirin include:
- Heparin
- Ibuprofen (if taken regularly)
- Corticosteroids
- Clopidogrel
- Some antidepressants (clomipramine, paroxetine, etc.)
Taking certain dietary supplements may also increase the risk of bleeding. These include:
- Blueberry
- Capsaicin
- Cat claw
- Evening primrose oil
- Ginkgo
- Omega-3 fatty acids (fish oil)
Contraindications
Express contraindications include:
- allergy to the active substance and components of the drug,
- Gastrointestinal diseases, including erosions, ulcers in the acute stage,
- diseases of the bronchopulmonary system
- hemorrhagic diathesis,
- pregnancy and lactation (the 1st and 3rd trimesters are considered especially dangerous)
- aortic aneurysm
- renal or liver failure
- and children under 15 years of age.
In a shell or without?
Coated aspirin tablets are designed to pass through the stomach without disintegrating until they reach the intestines. The protective coating is thought to allow aspirin tablets to be gentler on the stomach lining, and may be useful for people with a history of gastritis or ulcers who take aspirin daily.
However, some researchers believe there is no evidence that coated aspirin reduces the risk of gastrointestinal bleeding. Moreover, there are a number of publications that such aspirin is less effective for preventing heart attacks.
Special Recommendations
Aspirin cardio and chronic diseases
Particular caution should be exercised when taking aspirin for persons suffering from diseases of the respiratory system. The fact is that taking aspirin causes a narrowing of the bronchi, which can cause so-called aspirin asthma, or provoke asthma, which is in remission.
Aspirin cardio and childhood
When taken in its pure form in children, due to their young age, the concentration of glucose in the plasma can sharply decrease, in parallel with this, the level of ketone bodies in the blood increases, plasma acidification occurs, and fatty acids accumulate in the liver. These metabolic disturbances lead to swelling of tissues and organs.
Children become more than just lethargic. Aggravating symptoms such as cramps, diarrhea, rapid breathing and palpitations may occur. Up to loss of consciousness and severe muscle hypotension. Such conditions in children can be life-threatening, so the drug is contraindicated for them.
Aspirin cardio and alcohol
The combined use of alcohol and aspirin is not recommended. Alcohol and alcohol-containing products are known for their vasodilating properties. But in combination with aspirin, the effect can be most unexpected. The risks of bleeding increase, including in diseases of the gastrointestinal tract, exacerbation of liver diseases or the occurrence of any acute symptoms associated with this organ.
Aspirin cardio and pregnancy
The active substance freely and easily penetrates the placental barrier, which can lead to negative consequences for the fetus.
When used in the first trimester, it leads to the development of a “cleft palate” (cleft palate); in the third trimester, it causes inhibition of labor, premature closure of the ductus arteriosus in the fetus, disruption of the functioning of the pulmonary vessels and hypertension in the pulmonary circulation.
Acetylsalicylic acid is also excreted in breast milk, which increases the risk of bleeding in the baby due to impaired platelet function. Therefore, the advisability of using the drug during pregnancy and lactation should be justified by the specialist making the decision on the prescription.
Aspirin? Not so simple!
– Many older people often ask for aspirin at the pharmacy. The drug has been around for over a century and is still being discussed. Why?
– Indeed, humanity has been turning to salicylates for many centuries. Initially, plants containing salicylic acid were intuitively used to treat feverish conditions and joint pain. Then salicylates began to be actively used to treat rheumatism, and they served as the basis for the creation of the drug acetylsalicylic acid - aspirin. However, at the end of the twentieth century, this medicine found a new life: acetylsalicylic acid began to be used in patients with cardiovascular diseases. Aspirin helps prevent many cases of myocardial infarction and stroke.
– Heart attack and stroke: different diseases, but the cause is the same – a blood clot!
– These cardiovascular diseases are complications of atherosclerosis, a pathological process that changes the wall of the artery, leading to the formation of changes on its inner surface and in the underlying tissue, which are called atherosclerotic plaques. They are based on deposits of lipids, cholesterol crystals and overgrown tissue cells of the vessel wall.
Atherosclerotic plaques, or atheromas, usually grow for years, are often found in practically healthy elderly people and sometimes do not cause any clinical symptoms during their gradual growth - unless they lead to a narrowing of the lumen of the artery, preventing blood supply to the heart, brain or other organs. A sharp decrease in the lumen of the vessel can sometimes occur due to hemorrhage inside the plaque, the development of inflammation and its rupture, which entails the formation of a blood clot at this site. This leads to a catastrophic decrease in the supply of oxygen with blood through the vessel supplying blood to the tissues of the organ. The stable course of the disease is disrupted. It is to prevent thrombus formation inside the artery - a key point in the development of an acute disease - that the main effect of aspirin is directed.
– What is aspirin used for and what is a platelet?
– One of the main pharmacological effects of aspirin - preventing the formation of a blood clot - is a consequence of its influence on the excessive activity of platelets that occurs in pathology, accompanied by an increased tendency to thrombus formation. Aspirin in such cases turns out to be an effective remedy.
A platelet is one of the amazing blood cells that normally participates, as its name suggests, in the process of forming a blood clot to stop bleeding when a vessel is damaged. Together with strands of fibrin protein and other blood cells, it forms the basis of a blood clot. In addition, platelets fight microbes found in the bloodstream, are involved in immune processes, and influence the course of inflammation and atherosclerosis. Their membranes contain numerous receptors designed to transmit signals into the cell and create extracellular contacts. Thanks to receptors, a huge number of biochemical transformations occur in our body, the transfer of information from one cell to another is realized, and various processes in the cell are regulated.
Platelets are capable of synthesizing a number of substances. Increased platelet activity can create a threat of thrombus formation in the arterial bed, up to its complete blockage. Acetylsalicylic acid (ASA) in low doses (75–100 mg) can suppress the synthesis of thromboxane A2 and thereby prevent the initiation of platelet activation. As a result of this pharmacological effect of aspirin, the likelihood of developing serious vascular accidents, leading to such serious diseases as myocardial infarction and stroke, is reduced. The platelet in this case acts as the main initiator of the formation of a blood clot clogging the vessel.
Research in recent years has shown that the use of plain and buffer forms of aspirin ensures maximum effectiveness of the drug due to its high bioavailability.
– Aspirin is available in various dosage forms. What is their difference?
– Drugs called “aspirin” can be divided into plain (uncoated), buffered and enteric (enteric) forms of release. Buffer forms, for example, include the drug Cardiomagnil® in the form of film-coated tablets containing ASA, which dissolves in the stomach, as well as magnesium hydroxide. Cardiomagnyl® is a drug with a long history and successful experience in use in millions of patients. Currently, there are many generics of the drug on the market, such as Trombital®, Fazostabil®, Trombomag®, etc. Enteric-soluble forms also contain ASA, but due to the presence of an acid-resistant coating, the tablet dissolves in the intestines. Enteric-soluble aspirins are represented on the Russian market by the following drugs: Thrombo ACC®, Acecardol®, Aspirin Cardio®, CardiAsk®, Ask-Cardio®, etc. It is worth noting that gastrosoluble and enteric forms of ASA have different pharmacokinetic parameters. Thus, as a result of the fact that ASA is better absorbed in an acidic environment, gastrosoluble forms are significantly superior to enteric forms in terms of bioavailability1. Also, gastro-soluble forms provide a faster and more pronounced antiplatelet effect than enteric-soluble forms, and the risk of bleeding in the latter is no lower than that of gastro-soluble forms. Moreover, after taking gastrosoluble ASA, the drug remains in the blood for a significantly shorter time, which can reduce the damaging effect on the gastrointestinal tract2.
– More and more new drugs are appearing on the shelves of pharmacies, which indicate that they are acetylsalicylic acid. Generic aspirin: are they equivalent and absolutely interchangeable - or not always?
– It is believed that copies of drugs - generics - are equivalent to the original if they contain the same substance, have the same release form with the same indications for taking the medication1.
Are all emerging generic aspirin products the same? On the one hand, they all contain equal amounts of the same active ingredient - acetylsalicylic acid, and on the other hand, they may differ in the composition of excipients. It is known that the presence of bioequivalence is not always confirmed by therapeutic equivalence, which is discovered when the drug is changed due to a decrease in clinical effectiveness or the occurrence of side effects.
One of the possible reasons for this may be differences in the content of excipients included in the tablet product, even with the same activity of the pharmaceutical substance3. Inconsistencies in the effect of the drug, unless the case is associated with the use of an obvious falsification, are usually not easy to identify: this requires a long period of observation, careful analysis of the patient's complaints, and evidence is difficult to obtain.
Research in recent years has shown that the use of plain and buffer forms of aspirin ensures maximum effectiveness of the drug due to its high bioavailability. On the other hand, the use of enteric forms leads to a decrease in bioavailability4,5. These provisions are reflected in modern clinical guidelines6.
– Moscow doctors in the SPHIROS study compared laboratory indicators of the effectiveness of the original and two generic aspirin. Tell us about it.
– The study aimed to compare the laboratory effectiveness of two generic buffer preparations of acetylsalicylic acid: Fazostabil® produced by Ozon LLC, Russia (ASK 75 mg + magnesium hydroxide 15.2 mg) and Trombital®, Pharmstandard-Leksredstva OJSC, Russia ( ASA 75 mg + magnesium hydroxide 15.2 mg) – with the original drug Cardiomagnyl® produced in Germany/Takeda Pharmaceuticals LLC Russia (ASA 75 mg + magnesium hydroxide 15.2 mg)7. The method of administration and dosage regimen of the drugs corresponded to the information provided in the approved instructions for medical use. Although the active pharmaceutical substance is the same, the drugs have different compositions of excipients. For example, Fasostabil has 4 times more weight of excipients, 7.5 times more insoluble sorbent substances, and 5 times more shell than the original Cardiomagnyl.
Patients who had indications for taking aspirin, at the discretion of the attending physician, upon admission to the hospital received one of the three drugs available at the time of the study. As a result, three groups of 25 patients each received one of the drugs were formed. Before taking the first dose and after 1 hour, 2 hours, 4 hours, 72 hours and on the 7th day of the study, blood was drawn. Treatment was carried out under the control of laboratory parameters, which included assessment of the functional activity of platelets, measurement of the concentration of salicylic acid metabolite and the level of thromboxane B2 in the blood of patients while taking drugs. In addition, a study was carried out on the comparative kinetics of dissolution of these three drugs and the release of acetylsalicylic acid into a solution simulating the acidic environment of gastric juice.
The average release profile of acetylsalicylic acid from the drug Cardiomagnil® was higher compared to Trombital and Fasostabil, for which it was not equivalent to the branded form. Cardiomagnyl® already after 5 minutes shows superiority in the ability to dissolve in an acidic environment, which was maintained throughout the entire study period. This may be due to differences in the composition and weight of excipients.
In addition, the calculation of the so-called similarity factor (f2) based on data from a study of the kinetics of the dissolution of drugs and the release of ASA from them showed that they are not equivalent to the reference drug. Thus, for the drugs Trombital® and Fasostabil®, in comparison with Cardiomagnyl, the similarity factor was less than 40, which is a low indicator and indicates that it is not identical to the original drug.
Absorption of ASA into the blood from gastro-soluble forms occurs within 30 minutes after taking the medicine. It is known that it is present in the bloodstream for no more than 12–15 minutes, exerting its effect on platelets and the endothelium of the vascular wall, after which it is rapidly hydrolyzed under the action of blood esterases to salicylic acid8. The further effect of aspirin is due to the irreversible blockade of platelet receptors. The effective concentration of salicylic acid can remain in the blood for up to 12–14 hours, so it is by its level that the likely entry of acetylsalicylic acid into the bloodstream is judged. In our study, the concentration of salicylic acid 2 hours after taking the first dose of Cardiomagnyl was significantly higher compared to generics, and this difference persisted throughout the entire study period, indicating a higher bioavailability of the original drug. It demonstrated the highest release ability. By the third day of administration, Cardiomagnyl® led to a significantly greater decrease in the functional activity of platelets and the level of thromboxane B2 compared to generic drugs. Throughout the entire observation period, Cardiomagnyl® significantly suppressed the synthesis of thromboxane B2 to a greater extent and exhibited a disaggregation activity that other drugs did not fully achieve only on the 7th day. This circumstance may be especially important in acute situations - for example, in acute coronary syndrome or in the acute period of stroke, when active antiplatelet therapy is necessary at the earliest stages of treatment.
The results obtained in this study give reason to believe that the composition of excipients, production technology, and, possibly, the characteristics of the active substance may influence the effectiveness of therapy.
Let there be no heart attacks and strokes!
1. Sagar K., Smyth M. A comparative bioavailability study of different aspirin formulations using on-line multidimensional chromatography. J Pharm Biomed Anal. 1999 Nov;21(2):383-92. 2. Cox D., Maree AO, Dooley M. et al. Effect of enteric coating on antiplatelet activity of low-dose aspirin in healthy volunteers. Stroke. 2006;37:2153-2158 3. Committee for Medicinal Products for Human Use. Guideline on the investigation of bioequivalence. London: European Medicines Agency. (2010). Available from: https://www.ema.europa.eu/pdfs/human/qwp/140198enrev1fin.pdf 4. Karha J., Rajagopal V., Kottke-Marchant K., et al. Lack of effect of enteric coating on aspirin-induced inhibition of platelet aggregation in healthy volunteers. Amer Heart J. 2006;151(5): 976.e7-976.e11. 5. Leonards JR, Levy G. Absorption and metabolism of aspirin administered in enteric-coated tablets. JAMA. 1965;193(2):99-104. 6. Roffi M., Patrono C., Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37(3):267-315. 7. Lomakin N.V., Buryachkovskaya L.I., Zolin D.A., Kazei V.I. A prospective, initiative, single-center, open-label, post-registration comparative study of the laboratory effectiveness of various forms of acetylsalicylic acid in a cardioprotective dose with a different composition of excipients: results of the SPYROS study. Rational pharmacotherapy in cardiology. 2020; (in the press). 8. Patrono C., García Rodríguez L., Landolfi R., et al. Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med. 2005;353(22):2373-2383.
