Drug interactions of Aspirin (Antiplatelet)

Aspirin is an antiplatelet drug and it produces antiplatelet activity in lower doses (75-100 mg daily), while Higher dose of Aspirin (Up to 3600 mg daily in divided doses) is required for it’s analgesic effects.

1. Drug Interactions of Antiplatelets ( Part 1 ) ( Drug Interactions of Aspirin) D r P.Naina Mohamed P h D Pharmacologist

2. Introduction Antiplatelets are the drugs which decrease the aggregation of platelets and inhibit the thrombus formation. Aspirin is an antiplatelet drug and it produces antiplatelet activity in lower doses (75-100 mg daily), while Higher dose of Aspirin (Up to 3600 mg daily in divided doses) is required for it’s analgesic effects. aspirin has been prescribed for the primary prevention of cardiovascular events in low risk patients, In recent years. Interaction between one or more coadministered medications leading to change in their effectiveness or toxicity, is termed as “ Adverse drug interaction ”. Antiplatelets can interact with prescription drugs, Over-the-counter (OTC) medications, Herbal products, Dietary supplements, Vitamins, Foods, Diseases, and Genetics (family history ).

3. Mechanism of Platelet Aggregation https ://www.ncbi.nlm.nih.gov/books/NBK53449 /

4. Antiplatelets Irreversible cyclooxygenase (COX) inhibitors Aspirin ADP receptor inhibitors (Thienopyridines) Clopidogrel  Prasugrel Ticlopidine ADP receptor inhibitors (Non-Thienopyridines) Ticagrelor cangrelor Elinogrel Adenosine reuptake inhibitors Dipyridamole Glycoprotein IIB/IIIA inhibitors  (IV use only) Abciximab   Eptifibatide   Tirofiban Phosphodiesterase inhibitors Cilostazol Protease-activated receptor-1 (PAR-1) antagonists Vorapaxar  

5. Mechanism of Antiplatelet Activity of Aspirin 75-100 mg daily dose of Aspirin is capable of providing cardioprotection through its antiplatelet activity. https ://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195738 /

6. Aspirin & Live Influenza Virus Vaccine Symptoms of Reye's syndrome include drowsiness, confusion, seizures, coma and In severe cases, Reye's syndrome can result in death. Avoid administration of aspirin or aspirin-containing therapy for at least 4 weeks following vaccination with influenza live virus. http :// www.webmd.com/drugs/2/drug-1082-3/aspirin-tablet/details/list-interaction-details/dmid-1297/dmtitle-salicylates-influenza-virus-vaccine-live/intrtype-drug

7. Aspirin & Ketorolac Concomitant use of aspirin and ketorolac is contraindicated due to cumulative risks of serious GI adverse events (peptic ulcers, gastrointestinal bleeding and GI perforation ). https:// link.springer.com/article/10.2165%2F00003088-198917050-00003

8. Aspirin & Chicken Pox (Varicella) vaccine People should avoid using salicylates for 6 weeks after getting varicella vaccine.  https :// www.cdc.gov/vaccines/vpd/varicella/hcp/recommendations.html

9. Aspirin & Dichlorphenamide Serum bicarbonate concentrations should be estimated regularly. https ://www.ncbi.nlm.nih.gov/pmc/articles/PMC1442363 /

10. Aspirin & Antidiabetics monitor the patient's blood glucose and monitor the patient for clinical signs of hypoglycemia. https ://www.ncbi.nlm.nih.gov/pmc/articles/PMC4175901 /

11. Aspirin & Methotrexate If concomitant administration of Aspirin and Methotrexate is necessary, monitor closely for Methotrexate toxicity. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0016427 /

12. Aspirin & Ibuprofen daily aspirin users should be advised to ingest aspirin at least 2 hours prior to ibuprofen. https ://www.researchgate.net/publication/47788995_Antiplatelet_drug_interactions

13. Aspirin & NSAIDs closely monitor the patients for GI bleeding and ingest aspirin at least 2 hours prior to an interacting NSAID. http :// www.tandfonline.com/doi/abs/10.1517/14740338.2014.924924?journalCode=ieds20

14. Aspirin & Warfarin monitor the prothrombin time (PT) or international normalized ratio (INR) and watch the patient for signs of bleeding If aspirin and warfarin must be used together. https :// link.springer.com/article/10.1007%2Fs11239-009-0413-4

15. Aspirin & Coumarins frequent monitoring of the prothrombin time (PT) is indicated, If concurrent use of Aspirin and Coumarins cannot be avoided. https :// www.ncbi.nlm.nih.gov/pmc/articles/PMC1499595/pdf/bmjcred00617-0036.pdf

16. Aspirin & Fibrinolytics close monitoring for bleeding is recommended, If concomitant use is required . https :// www.ncbi.nlm.nih.gov/pubmed/1834805

17. Aspirin & Antiplatelets Monitor the signs and symptoms of active bleeding, If coadministration cannot be avoided. http :// onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2010.02299.x/abstract;jsessionid=3DFE9823DD3790D3C64469AEC534BB43.f04t04

18. Aspirin & Treprostinil monitor for signs and symptoms of bleeding. https ://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555423 /

19. Aspirin & Anagrelide Close monitoring of signs and symptoms of bleeding may be warranted. https :// www.ncbi.nlm.nih.gov/pubmed/16398570

20. Aspirin & Cilostazol If concurrent use is required, administer aspirin and cilostazol with care and Monitor for signs and symptoms of blood loss. http :// www.sciencedirect.com/science/article/pii/S1078588409000446

21. Aspirin & ACE Inhibitors the clinician should weigh the benefits against the risks of combining these two agents. http :// onlinelibrary.wiley.com/doi/10.1111/j.1527-5299.2000.80174.x/full

22. Aspirin & Corticosteroids Monitor patients for decreased effectiveness of aspirin. https:// link.springer.com/article/10.2165%2F00003088-198917050-00003

23. Aspirin & GTN (Nitroglycerin) monitor for an exaggerated response to nitroglycerin, as evidenced by headache and syncope. https :// www.ncbi.nlm.nih.gov/pubmed/6420164

24. Conclusion Drug interactions can result in significant morbidity and mortality and thus minimizing the risk for drug interactions should be a goal in drug therapy. The patients on antiplatelet therapy should bring a list of all of the drugs they are taking including prescription drugs, over-the-counter drugs, and any supplements, herbal or otherwise, during their visit to the doctor or pharmacist. The risk of adverse effects could be reduced by healthcare professionals through the screening , education, and follow up on suspected drug interactions. If possible, the patients are recommended to fill all their prescriptions at one pharmacy. Pharmacists can play a crucial role in identifying possible drug interactions by asking patients about their herbal and other alternative medicine product use.

25. References Stockley’s Drug Interactions, 9e Karen Baxter Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 12e Laurence L. Brunton , Bruce A. Chabner , Björn C. Knollmann Basic & Clinical Pharmacology, 12e Bertram G. Katzung , Susan B. Masters, Anthony J. Trevor A Manual of Adverse Drug Interactions J.P. Griffin, P.F. D'Arcy Clinical Manual of Drug Interaction Principles for Medical Practice Gary H. Wynn‏, Jessica R. Oesterheld ‏, Kelly L. Cozza ‏, Scott C. Armstrong ‏ Handbook of Drug Interactions: A Clinical and Forensic Guide Ashraf Mozayani , Lionel Raymon

26. References http://www.micromedexsolutions.com https :// link.springer.com/article/10.2165%2F00003088-198917050-00003 http :// onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2010.02299.x/full https :// www.academic.oup.com/eurheartj/article/24/19/1707/495173/Drug-drug-interactions-involving-antiplatelet http:// www.nature.com/nrcardio/journal/v8/n10/full/nrcardio.2011.128.html http:// www.sciencedirect.com/science/article/pii/S2211594312000974 https:// www.researchgate.net/publication/47788995_Antiplatelet_drug_interactions http ://reference.medscape.com/drug-interactionchecker https://www.drugs.com/drug_interactions.html http://www.webmd.com/interaction-checker/ http://www.rxlist.com/drug-interaction-checker.htm https :// www.nps.org.au/australian-prescriber/articles/warfarin-antiplatelet-drugs-and-their-interactions