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# Aspirin, Enteric-Coated
## Overview
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) with analgesic, antipyretic, and antiplatelet properties. The enteric coating is designed to prevent gastric irritation by delaying absorption until it reaches the small intestine.
## Primary Indications
* **Cardiovascular Prevention:** Secondary prevention of myocardial infarction (MI) and stroke in patients with established atherosclerotic cardiovascular disease. Primary prevention in select high-risk individuals if benefits outweigh risks.
* **Peri-operative Prophylaxis:** Short-term use after certain cardiac procedures (e.g., coronary artery bypass grafting, percutaneous coronary intervention).
* **Pain and Inflammation:** Mild to moderate pain, fever, and inflammatory conditions (though other NSAIDs may be preferred for non-cardiac indications due to GI risk).
## Adult Dosing
* **Cardiovascular Prevention (Secondary):** 75-162 mg once daily. Higher doses (e.g., 325 mg) may be used initially in certain acute settings.
* **Cardiovascular Prevention (Primary):** Dosing varies based on risk assessment; typically 81 mg once daily. Shared decision-making is crucial.
* **Post-PCI/CABG:** Typically 75-325 mg once daily, often in conjunction with a P2Y12 inhibitor. Duration depends on clinical scenario and local protocols.
* **Pain/Inflammation:** 325-650 mg every 4-6 hours as needed, or 500-1000 mg every 4-6 hours. Maximum daily dose generally 4000 mg.
## Pediatric Dosing
Aspirin is generally **contraindicated** in children and adolescents due to the risk of Reye's syndrome, particularly during viral infections (e.g., influenza, varicella). Exceptions exist for specific conditions under strict medical supervision (e.g., Kawasaki disease, rheumatologic conditions). Consult specialized pediatric guidelines for these rare indications.
## Dose Adjustments
* **Renal Impairment:** Use with caution. May require dose reduction in severe renal impairment (CrCl < 30 mL/min). Not recommended in end-stage renal disease if alternatives exist.
* **Hepatic Impairment:** Use with caution. Not recommended in severe hepatic impairment.
## Contraindications
* Hypersensitivity to aspirin, salicylates, NSAIDs, or any component of the formulation.
* Children and adolescents with viral infections (risk of Reye's syndrome).
* Active peptic ulceration or recent GI bleeding.
* History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs.
* Bleeding disorders or concurrent use of anticoagulants (relative contraindication requiring careful risk-benefit assessment).
* Severe renal or hepatic impairment.
* Third trimester of pregnancy (can cause premature closure of ductus arteriosus).
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, heartburn, nausea, vomiting, abdominal pain, gastritis, peptic ulceration, GI bleeding (can be occult or overt). The enteric coating reduces but does not eliminate GI risk.
* **Hemorrhagic:** Increased risk of bleeding (e.g., bruising, epistaxis, prolonged bleeding time).
* **Hypersensitivity:** Bronchospasm (especially in asthmatics), urticaria, angioedema, anaphylaxis.
* **Auditory:** Tinnitus, hearing loss (often dose-related).
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes.
* **Reye's Syndrome:** In children and adolescents with viral infections.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, DOACs) and Antiplatelets (e.g., clopidogrel, prasugrel):** Increased risk of bleeding. Requires careful monitoring and risk-benefit assessment.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs:** Additive risk of GI toxicity and nephrotoxicity. Avoid concurrent use if possible.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of bleeding, particularly GI bleeding.
* **Methotrexate:** Aspirin can increase methotrexate toxicity by impairing renal clearance.
* **Uricosuric agents (e.g., probenecid):** Aspirin can decrease the efficacy of these agents.
* **Alcohol:** Increased risk of GI bleeding.
## Monitoring
* **Bleeding:** Monitor for signs/symptoms of GI bleeding (melena, hematemesis, abdominal pain) or other occult bleeding.
* **Renal Function:** Periodic monitoring of serum creatinine and BUN, especially in patients with risk factors for renal impairment.
* **Liver Function:** Periodic monitoring of LFTs, especially with long-term use or in patients with hepatic risk factors.
* **Tinnitus:** Can be an early sign of salicylate toxicity.
## Clinical Pearls
* Enteric-coated aspirin should be swallowed whole and not crushed, chewed, or broken to maintain the integrity of the coating.
* The primary benefit of enteric coating is reduced gastric irritation, but it does not eliminate the risk of GI bleeding or ulceration.
* For acute cardiovascular events (e.g., suspected MI), non-enteric coated aspirin is often preferred to ensure rapid absorption.
* The decision to initiate aspirin for primary cardiovascular prevention requires careful assessment of individual risk factors and bleeding risk, and should be a shared decision between patient and clinician.
* Discontinue aspirin at least 5-7 days before elective surgery, depending on the procedure and bleeding risk.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions. Dosing and indications may vary based on patient-specific factors and local protocols.
