Gastrointestinal effects of aspirin

Abstract

Aspirin is being used as an effective analgesic and anti-inflammatory agent at doses >325 mg daily. At low doses (75–325 mg daily), aspirin is the key antiplatelet drug in the pharmacological prevention of cardiovascular diseases. Topical and systemic effects of aspirin in the gastrointestinal mucosa are associated with mucosal damage in the upper and lower gastrointestinal tract. The risk of upper gastrointestinal bleeding with aspirin is increased with old age, male sex, ulcer history and concomitant medication with NSAIDs, cyclooxygenase 2 selective inhibitors, corticosteroids or other antithrombotic agents. In some patients, the cardiovascular benefits of low-dose aspirin might be overcome by the risk of gastrointestinal complications, but withdrawal of aspirin therapy can precipitate a cardiovascular event. These patients will need concomitant therapy with antisecretory agents, especially PPIs, to reduce the gastrointestinal risk. Eradication of Helicobacter pylori infection might be an additional option in patients with a history of ulcer. Furthermore, there is growing evidence that long-term use of aspirin decreases the risk of colorectal cancer, even at low doses. As aspirin is one of the most prescribed drugs worldwide and its clinical impact is huge, physicians need to consider the benefits and harms for each individual patient in order to maximize the benefits of aspirin.

Key Points

  • Low-dose aspirin prevents cardiovascular morbidity and mortality in at-risk patients with a history of cardiovascular disease, but can increase the risk of upper and lower gastrointestinal complications

  • Enteric-coated or buffered aspirin preparations are also associated with a risk of gastrointestinal complications; nonaspirin antiplatelet therapy also increases the risk of upper gastrointestinal bleeding

  • Aspirin-induced damage to the gastrointestinal tract can cause clinical bleeding in some patients, especially in those with risk factors, including age >70 years or a history of peptic ulcer

  • Aspirin-induced gastrointestinal damage can be reduced by the use of co-therapy with antisecretory agents, especially PPIs

  • Although infection with Helicobacter pylori might be a risk factor for aspirin-induced ulcer bleeding, the effect of H. pylori eradication on gastrointestinal outcomes in at-risk patients requires further investigation

  • The incidence of mortality from cardiovascular disease far exceeds that associated with gastrointestinal hemorrhage; however, the benefits of aspirin may be reduced in patients with a high risk of gastrointestinal complications

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Figure 1: The effects of different compounds on the risk of upper gastrointestinal bleeding with aspirin, as indicated by the number of hospitalizations for upper gastrointestinal bleeding.
Figure 2: A proposed treatment algorithm for low-dose aspirin users based on recommendations presented in the American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association 2008 consensus.
Figure 3: The effect of aspirin on long-term risk of death due to colorectal cancer in randomized trials of aspirin versus control.

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Acknowledgements

The authors acknowledge the support of grants PI08 and P1301 from Instituto de Salud Carlos III and grant B01 from the Government of Aragón.

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Both authors contributed equally to all aspects of this article.

Correspondence to Angel Lanas.

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Competing interests

A. Lanas is a consultant for AstraZeneca, Bayer, Nicox and Pfizer. A. Lanas has received grant/research support from AstraZeneca and has been a speaker for Pfizer. A. Lanas is involved in the adjudication committee of the ARRIVE trial conducted by Bayer. C. Sostres declares no competing interests.

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Sostres, C., Lanas, A. Gastrointestinal effects of aspirin. Nat Rev Gastroenterol Hepatol 8, 385–394 (2011). https://doi.org/10.1038/nrgastro.2011.97

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