New data and talk of OTC label changes will reignite debate about whether NSAIDs reduce the cardiovascular (CV) protective effect of aspirin..
Many of us remember when FDA warned that ibuprofen may interact with aspirin. This is because aspirin binds to COX-1 to inhibit platelet aggregation and nonselective NSAIDs can compete for the same receptor. OTC ibuprofen labels even say it may decrease aspirin's CV benefit. Now FDA will likely require a similar warning for OTC naproxen labels due to a recent study suggesting naproxen may interfere with the antiplatelet effects of aspirin 81 mg/day.
Continue to limit NSAIDs in patients at high CV risk. But put this interaction in perspective. Using a chronic NSAID with aspirin only leads to a small decrease in platelet inhibition. It doesn't seem to reduce aspirin's CV benefit. If patients on low-dose aspirin need a chronic NSAID, don't be too concerned about the interaction. Emphasize adherence to aspirin instead. But tell worried patients that taking nonenteric-coated aspirin about 30 minutes before the NSAID may let aspirin reach platelets first.
Don't increase the aspirin dose or use a different antiplatelet medication like clopidogrel (Plavix, etc). There's no evidence either approach leads to better CV outcomes, but may cause more bleeding. Reassure patients that aspirin does not interact with PRN or topical NSAIDs, or with celecoxib (Celebrex), since it's COX-2 selective. Consider adding a PPI for patients who need aspirin and any chronic NSAID, since the combo increases GI bleeding risk, even with celecoxib.
References
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Reed GW, Abdallah MS, Shao M, Wolski K, Wisniewski L, Yeomans N, Lüscher TF, Borer JS, Graham DY, Husni ME, Solomon DH, Libby P, Menon V, Lincoff AM, Nissen SE. Effect of Aspirin Coadministration on the Safety of Celecoxib, Naproxen, or Ibuprofen. J Am Coll Cardiol. 2018 Apr 24;71(16):1741-1751. Available at: https://www.sciencedirect.com/science/article/pii/S0735109718333163?via%3Dihub
Gurbel PA, Bliden KP, Zhu J, Troullos E, Centofanti R, Jarvis S, Venkataraman P, Tantry US. Thromboxane inhibition during concurrent therapy with low-dose aspirin and over-the-counter naproxen sodium. J Thromb Thrombolysis. 2018 Jan;45(1):18-26. Available at: https://link.springer.com/article/10.1007/s11239-017-1593-y
Concomitant Use of Ibuprofen and Aspirin: Potential for Attenuation of the Anti- Platelet Effect of Aspirin. [online] Available at: https://www.fda.gov/media/76636/download
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