Aspirin (Acetylsalicylic acid)

75, 81, 100, 325 and 500 mg tablets (PO)

Executive Summary

(November 11, 2023)

 

Acetylsalicylic acid (ASA), also known as aspirin, is an NSAID with analgesic and anti-inflammatory effects that inhibit platelet aggregation. It is frequently prescribed in EDs worldwide as part of the standard treatment for acute coronary syndromes (26) and other acute vascular conditions (17, 20).


Adult dose for acute coronary syndromes (7, 26)


Adult dose for acute ischemic stroke, transient ischemic attack (17, 25)

Delay antiplatelet therapy for at least 24 hours in patients who have undergone IV fibrinolysis (alteplase or tenecteplase) and have had a control CT scan to rule out hemorrhagic conversion. Standard of care should involve consulting a vascular neurologist to guide treatment.


When hemorrhagic stroke has been ruled out in patients not eligible for fibrinolytic therapy, initiate aspirin therapy as soon as possible.

Adult dose

Adult dose for acute coronary syndromes (7, 26)


Comment:

Pharmacological co-therapy, including anticoagulants, dual antiplatelet therapy (DAPT), vasodilators, etc., may be deemed appropriate on an individual basis. This determination depends on various variables such as STEMI and non-STEMI scenarios, early or delayed PCI strategies, or the indication for fibrinolytics.


Adult dose for acute ischemic stroke, transient ischemic attack (17, 25)

Delay antiplatelet therapy for at least 24 hours in patients who have undergone IV fibrinolysis (alteplase or tenecteplase) and have had a control CT scan to rule out hemorrhagic conversion. Standard of care should involve consulting a vascular neurologist to guide treatment.


When hemorrhagic stroke has been ruled out in patients not eligible for fibrinolytic therapy, initiate aspirin therapy as soon as possible.


Comments:

There is no consensus regarding a specific dosing regimen. Guidelines and systematic reviews suggest that aspirin is beneficial within a range of 160 to 300 mg in the acute phase of treatment (17, 25). Typically, a subsequent maintenance dose of 75 to 100 mg/day is recommended.


Adult dose for acute pericarditis (9, 19)

750 - 1000 mg every 8 hours PO for 1-2 weeks.

Indications


ASA for acute coronary syndromes

Effectiveness


Guidelines summary

ASA for acute ischemic stroke and transient ischemic attack





Cautions




Overview of adverse effects and warnings (12, 28)

The adverse effects of NSAIDs are primarily attributed to the inhibition of prostaglandins, which play a significant role in protecting mucous tissues, regulating kidney blood flow, and influencing various cardiovascular effects.

ASA overdose: salicylate toxicity

The following content is based on references 6, 8, 16, and 18:

Overview

Salicylate toxicity is a notable concern due to its potential to cause morbidity and mortality. This risk is particularly significant considering the presence of this compound in various commonly used substances, such as analgesics, antiplatelet agents, creams, and household products. Salicylate can be encountered in the form of acetylsalicylic or methylsalicylic acid.


Clinical presentation


Toxic and lethal doses


Mechanism of toxicity


Management
The cornerstone of management is to create pH conditions that enhance the removal of salicylate from the central nervous system (CNS). This goal is accomplished through sodium bicarbonate infusion, hemodialysis, and the avoidance of a relative increase in pCO2, which would worsen the pH. Management interventions: 

Mechanism of action and pharmacology

Mechanism of action


Pharmacology

Pregnancy and lactation

Aspirin use during pregnancy

Pregnancy risk classification


Lactation

When aspirin is administered in low doses for antiplatelet purposes during breastfeeding (81 mg/day), available data indicates that the transfer of ASA into milk is minimal, to the extent that it remains undetectable even through sophisticated methods (14).

References

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EMDrugs Team