A systematic review of aspirin in primary prevention: is it time for a new approach?

Association of prophylactic low-dose aspirin use with all-cause and cause-specific mortality in cancer patients

The long-term use of aspirin for preventing cardiovascular disease has been recommended for decades. However, there is currently uncertainty regarding the long-term effects of aspirin use on the risk of all-cause, cardiovascular, and cancer mortality in cancer patients. The aim of this work was to analyze the connection between the prophylactic use of low-dose aspirin and the risk of all-cause death, cardiovascular death, and carcinoma death in carcinoma patients in the United States. A cohort study was conducted using National Health and Nutrition Examination Survey (NHANES) data (2011-2012, 2013-2014, 2015-2016, and 2017-2018) and associated mortality data. The 95% confidence intervals (CIs) and hazard ratios (HRs) between non-aspirin use and prophylactic low-dose aspirin use and the risk of death were measured via Cox proportional hazard regression models. A total of 1819 participants were included in the present research, of whom 945 were nonaspirin users and 874 were prophylactic aspirin users. Compared with non-aspirin users, prophylactic low-dose aspirin users had a decreased risk of all-cause death (HR = 0.647, 95% CI = 0.489-0.857). There was no statistically significant difference in the risk of cardiovascular death (HR = 0.623, 95% CI = 0.362-1.074) or cancer death (HR = 0.709, 95% CI = 0.410-1.226). Prophylactic use of low-dose aspirin may lower all-cause mortality in individuals with cancer but does not have a substantial effect on cardiovascular risk or cancer-specific mortality in this patient population.

Frailty and polypharmacy in the community-dwelling elderly with multiple chronic diseases

BACKGROUND

Both multi-morbidity (MM) and polypharmacy (PP) are common in the elderly and pose a challenge for health and social care systems. However, high-quality patient-centred care requires context-bound understanding of the patterns and use of medications in those with MM. Therefore, the aim of this study was to investigate the prevalence of PP in community-dwelling elderly, and the factors associated with MM, PP, excessive polypharmacy (EPP), and the types of drugs used.

METHODS

We analysed data of 164 community-dwelling subjects aged ≥60 years from January to December 2020 at a general hospital in a rural area of Taiwan. MM was defined as >4 diagnoses of chronic health conditions. Non-polypharmacy (NP), PP, and EPP were defined as <5, 5-8, and >8 prescriptions, respectively. Other variables including basic activities of daily living (BADL), severity of frailty, depressive mood, screening for intellectual impairment, and nutritional status were also analysed.

RESULTS

Of the 164 participants, 34.8% had >4 diagnoses, 66.5% had PP, and 26.2% had EPP. The patients with >4 diagnoses had worse performance in BADL, higher levels of frailty, and more prescriptions than those with fewer diagnoses. The EPP group had worse performance in BADL, a higher level of frailty, more comorbidities, and higher prevalences of diabetes mellitus and chronic kidney disease compared to the NP and PP groups. After adjusting for covariates, we further found a higher number of medications associated with having more comorbidities, and a higher level of frailty associated with having a greater number of medications.

CONCLUSION

We found relationships between frailty and PP, and between PP and MM, but frailty did not associate with MM. Since frailty, PP, and MM may be viewed as an inevitable trinity of ageing, reducing PP could be a method to both prevent frailty and disentangle this trinity in the elderly.

Chronic Pancreatitis and Risk of Atherosclerotic Cardiovascular Disease: A US Cohort Propensity-Matched Study

OBJECTIVES

Worldwide prevalence of chronic pancreatitis (CP) has risen in recent years, with data suggesting an increased risk of atherosclerotic cardiovascular disease (ASCVD) in these patients. We assessed the incidence and risk of ASCVD in patients with CP.

METHODS

We compared the risk of ischemic heart disease, cerebrovascular accident, and peripheral arterial disease between CP and non-CP cohorts after propensity matching of known risk factors of ASCVD using TriNetX, a multi-institutional database. We also evaluated the risk of outcomes of ischemic heart disease including acute coronary syndrome, heart failure, cardiac arrest, and all-cause mortality between CP and non-CP cohorts.

RESULTS

Chronic pancreatitis cohort was also found to have an increased risk of ischemic heart disease (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.03-1.12), cerebrovascular accident (aOR, 1.12; 95% CI, 1.05-1.20), and peripheral arterial disease (aOR, 1.17; 95% CI, 1.1-1.24). Chronic pancreatitis patients with ischemic heart disease were also found to have an increased risk of acute coronary syndrome (aOR, 1.16; 95% CI, 1.04-1.30), cardiac arrest (aOR, 1.24; 95% CI, 1.01-1.53), and mortality (aOR, 1.60; 95% CI, 1.45-1.77).

CONCLUSIONS

Chronic pancreatitis patients are at a higher risk of ASCVD when compared with the general population, matched for confounding etiological, pharmacological, and comorbid variables.

Medical Countermeasure Requirements to Meet NASA's Space Radiation Permissible Exposure Limits for a Mars Mission Scenario

The space radiation environment consists of a complex mixture of ionizing particles that pose significant health risks to crew members. NASA currently requires that an astronaut's career Risk of Exposure Induced Death (REID) for cancer mortality should not exceed 3% at the upper 95% confidence level. This career radiation limit is likely to be exceeded for even the shortest round-trip mission scenario to Mars. As such, NASA has begun to pursue more vigorously approaches to directly reduce radiation risks, despite the large uncertainties associated with such projections. A recent study considered cohort studies of aspirin and warfarin as possible medical countermeasures (MCMs) acting to reduce background cancer mortality rates used in astronaut risk projections. It was shown that such MCMs can reduce the REID for specific tissues in restricted time intervals over which the drugs were administered; however, the cumulative effect on total lifetime REID was minimal. As an extension, the present work addresses more general MCM requirements that would be needed to meet current NASA radiation limits for a Mars mission scenario. A sensitivity analysis is performed within the major components of the NASA cancer risk model that would likely be modified by MCM interventions. This includes the background cancer incidence and mortality rates, epidemiologically based hazard rates derived from acute terrestrial exposures, and radiation quality factors used to translate terrestrial exposures to space radiation. Relationships between possible MCMs and each of these components are discussed. Results from this study provide important information regarding MCM requirements needed to meet NASA limits for planned Mars missions. Insight into the types of countermeasures expected to yield greatest reductions in crew risk is also gained.

Intravenous lipo-prostaglandin E1 administration for patients with acute central retinal artery occlusion

Objective

This study aimed to investigate the anatomical and functional changes in patients with central retinal artery occlusion (CRAO) (n=21) treated with 10 µg/day intravenous liposomal prostaglandin E1 (lipo-PGE1).

Methods and analysis

We used best-corrected visual acuity (BCVA), central retinal thickness with spectral domain optical coherence photography, optical intensity ratio (OIR) with imageJ software and retinal vessel diameter with fundus photography as indicators. Data were analysed using Tukey’s multiple comparisons, Wilcoxon test or Spearman’s correlation analysis as appropriate.

Results

BCVA was significantly improved at 1 month and 3 months after the initial visit (from 2.18±0.60 to 1.54±0.84 and 1.53±0.88, p=0.030 and p=0.027, respectively). The ratio of retinal vein diameter to optic disc diameter increased in the first month (from 0.40%±0.13% to 0.52%±0.16%, p=0.005). In addition, the OIR at the initial visit was significantly correlated with BCVA at 3 months (p=0.006, r=0.58). No severe adverse effects were observed.

Conclusion

The results showed that visual acuity and retinal vein constriction improved after lipo-PGE1 therapy. In addition, the OIR in the initial phase can be an indicator of visual prognosis after treatment with PGE1 in patients with CRAO.

Unlabeled aspirin as an activatable theranostic MRI agent for breast cancer

Rationale: Chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) is emerging as an alternative to gadolinium-based contrast MRI. We have evaluated the possibility of CEST MRI of orthotopic breast tumor xenografts with unlabeled aspirin's conversion to salicylic acid (SA) through various enzymatic activities, most notably inhibition of cyclooxygenase (COX)-1/-2 enzymes. Methods: We measured the COX-1/-2 expression in four breast cancer cell lines by Western Blot analysis and selected the highest and lowest expressing cell lines. We then performed CEST MRI following aspirin treatment to detect SA levels and ELISA to measure levels of downstream prostaglandin E2 (PGE2). We also injected aspirin into the tail vein of mice growing orthotopic tumor xenografts which expressed high and low COX-1/-2 and acquired SA CEST MR images of these tumor xenografts for up to 70 minutes. Tumors were then harvested to perform Western Blot and ELISA experiments to measure COX-1/-2 expression and PGE2 levels, respectively. Results: Western Blots determined that SUM159 cells contained significantly higher COX-1/-2 expression levels than MDA-MB-231 cells, in line with higher levels of downstream PGE2. SA CEST MRI yielded similar contrast at approximately 3% for both cell lines, independent of COX-1/-2 expression level. PGE2 levels decreased by about 50% following aspirin treatment. Results from our mouse study aligned with cultured cells, the overall SA CEST MRI contrast in both MDA-MB-231 and SUM159 tumor xenograft models was 5~8% at one hour post injection. PGE2 levels were ten times higher in SUM159 than MDA-MB-231 and decreased by 50%. The CEST contrast directly depended on the injected dose, with ~6%, ~3% and ~1.5% contrast observed following injection of 100 µL of 300 mM, 200 mM and 150 mM aspirin, respectively. Conclusions: Our data demonstrate the feasibility of using aspirin as a noninvasive activatable CEST MRI contrast agent for breast tumor detection.

Drug-based therapeutic strategies for COVID-19-infected patients and their challenges

Emerging epidemic-prone diseases have introduced numerous health and economic challenges in recent years. Given current knowledge of COVID-19, herd immunity through vaccines alone is unlikely. In addition, vaccination of the global population is an ongoing challenge. Besides, the questions regarding the prevalence and the timing of immunization are still under investigation. Therefore, medical treatment remains essential in the management of COVID-19. Herein, recent advances from beginning observations of COVID-19 outbreak to an understanding of the essential factors contributing to the spread and transmission of COVID-19 and its treatment are reviewed. Furthermore, an in-depth discussion on the epidemiological aspects, clinical symptoms and most efficient medical treatment strategies to mitigate the mortality and spread rates of COVID-19 is presented.

Mechanochemical synthesis insights and solid-state characterization of quininium aspirinate, a glass-forming drug-drug salt

Quinine (an antimalarial) and aspirin (a nonsteroidal anti-inflammatory drug) were combined into a new drug-drug salt, quininium aspirinate, C20H25N2O2+·C9H7O4-, by liquid-assisted grinding using stoichiometric amounts of the reactants in a 1:1 molar ratio, and water, EtOH, toluene, or heptane as additives. A tetrahydrofuran (THF) solution of the mechanochemical product prepared using EtOH as additive led to a single crystal of the same material obtained by mechanochemistry, which was used for crystal structure determination at 100 K. Powder X-ray diffraction ruled out crystallographic phase transitions in the 100-295 K interval. Neat mechanical treatment (in a mortar and pestle, or in a ball mill at 20 or 30 Hz milling frequencies) gave rise to an amorphous phase, as shown by powder X-ray diffraction; however, FT-IR spectroscopy unambiguously indicates that a mechanochemical reaction has occurred. Neat milling the reactants at 10 and 15 Hz led to incomplete reactions. Thermogravimetry and differential scanning calorimetry indicate that the amorphous and crystalline mechanochemical products form glasses/supercooled liquids before melting, and do not recrystallize upon cooling. However, the amorphous material obtained by neat grinding crystallizes upon storage into the salt reported. The mechanochemical synthesis, crystal structure analysis, Hirshfeld surfaces, powder X-ray diffraction, thermogravimetry, differential scanning calorimetry, FT-IR spectroscopy, and aqueous solubility of quininium aspirinate are herein reported.

Chemoprevention in Barrett's esophagus and esophageal adenocarcinoma

There has been a dramatic increase in the incidence of Barrett's esophagus and esophageal adenocarcinoma over the past several decades with a continued rise expected in the future. Several strategies have been developed for screening and surveillance of patients with Barrett's esophagus and endoscopic treatment of Barrett's associated dysplasia and early esophageal cancer; however, they have not made a substantial impact on the incidence of cancer. Herein, chemoprevention becomes an attractive idea for reducing the incidence of cancer in Barrett's patients. Several agents appear promising in preclinical and observational studies but very few have been evaluated in randomized controlled trials. Strongest evidence to date is available for proton-pump inhibitors and Aspirin that have been evaluated in a large randomized controlled trial. Other agents such as statins, metformin, ursodeoxycholic acid, and dietary supplements have insufficient evidence for chemoprevention in Barrett's patients.

Pleiotropic Effects of Acetylsalicylic Acid after Coronary Artery Bypass Grafting-Beyond Platelet Inhibition

Acetylsalicylic acid (ASA) is one of the most frequently used medications worldwide. Yet, the main indications for ASA are the atherosclerosis-based cardiovascular diseases, including coronary artery disease (CAD). Despite the increasing number of percutaneous procedures to treat CAD, coronary artery bypass grafting (CABG) remains the treatment of choice in patients with multivessel CAD and intermediate or high anatomical lesion complexity. Taking into account that CABG is a potent activator of inflammation, ASA is an important part in the postoperative therapy, not only due to ASA antiplatelet action, but also as an anti-inflammatory agent. Additional benefits of ASA after CABG include anticancerogenic, hypotensive, antiproliferative, anti-osteoporotic, and neuroprotective effects, which are especially important in patients after CABG, prone to hypertension, graft occlusion, atherosclerosis progression, and cognitive impairment. Here, we discuss the pleiotropic effects of ASA after CABG and provide insights into the mechanisms underlying the benefits of treatment with ASA, beyond platelet inhibition. Since some of ASA pleiotropic effects seem to increase the risk of bleeding, it could be considered a starting point to investigate whether the increase of the intensity of the treatment with ASA after CABG is beneficial for the CABG group of patients.

The Use of Aspirin in Contemporary Primary Prevention of Atherosclerotic Cardiovascular Diseases Revisited: The Increasing Need and Call for a Personalized Therapeutic Approach

The use of aspirin has been widely accepted for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in all patient populations, as the benefits linked to the reduction of clinical events outweigh the risk of major bleeding. However, despite the undisputable, though modest, potential of aspirin to reduce atherothrombotic events, its overall efficacy and safety in primary ASCVD prevention remains debatable, despite being used for this purpose for decades. The net clinical benefit of aspirin was brought into question by three recent large contemporary randomized controlled trials evaluating its role in various primary prevention populations (individuals with diabetes [ASCEND], an elderly population [ASPREE], and middle-aged adults at high estimated cardiovascular risk [ARRIVE]) and numerous large meta-analyses published during the past year. As a result, the usual generalized recommendations for the use of aspirin in patients with estimated intermediate to high ASCVD risk but without overt ASCVD have already been removed from most international guidelines. Since the primary prevention framework encompasses heterogenous groups of subjects with variable absolute ASCVD risk, a more individualized approach based on the best possible estimated ratio between the potential health benefits from fewer atherothrombotic events and harms because of potential increases in major bleeding is warranted in clinical practice. With this compromise, clinicians can better decide on the personalized use of aspirin in patients at high risk of major adverse cardiovascular events.

Aspirin as a Potential Geroprotector: Experimental Data and Clinical Evidence

Aging is a biological process with effects at the molecular, cellular, tissue, organ, system, and organismal levels and is characterized by decline in physical function and higher risks of age-related diseases. The use of anti-aging drugs for disease prevention has become a high priority for science and is a new biomedicine trend. Geroprotectors are compounds which slow aging and increase lifespan of the organism in question. The common painkiller aspirin, a member of the non-steroidal anti-inflammatory drug (NSAID) family, is one of the potential geroprotective agents. Aspirin is often used in treatment of mild to moderate pain. It has anti-inflammatory and anti-pyretic properties and acts as an inhibitor of cyclooxygenase which results in inhibition of prostaglandin. Acetylsalicylic acid as an active compound of aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Aspirin has shown life-extending effects in numerous model organisms. This chapter reviews the evidence for clinical efficacy of aspirin including cardiovascular disease prevention, anti-cancer effects, and improvement of cognitive function. However, there are some limitations of these therapies, including the risk of excessive bleeding. We have also summarized numerous experimental and analytical data that support health and longevity benefits of aspirin treatment by affecting pro-longevity pathways.

Aspirin and the risk of nondigestive tract cancers: An updated meta-analysis to 2019

Aspirin has been associated with a reduced risk of colorectal and other selected digestive tract cancers, but the evidence for other neoplasms is still controversial. To provide an up-to-date quantification of the role of aspirin on lung, breast, endometrium, ovary, prostate, bladder, and kidney cancer, we conducted a systematic review and meta-analysis of all observational studies published up to March 2019. We estimated pooled relative risk (RR) of cancer or cancer death for regular aspirin use vs non-use by using random-effects models, and, whenever possible, we investigated dose- and duration-risk relations. A total of 148 studies were considered. Regular aspirin use was associated to a reduced risk of lung (RR = 0.88, 95% confidence interval [CI] = 0.79-0.98), breast (RR = 0.90, 95% CI = 0.85-0.95), endometrial (RR = 0.91, 95% CI = 0.84-0.98), ovarian (RR = 0.91, 95% CI = 0.85-0.97) and prostate (RR = 0.93, 95% CI = 0.89-0.96) cancer. However, for most neoplasms, nonsignificant risk reductions were reported in cohort and nested case-control studies and there was between-study heterogeneity. No association was reported for bladder and kidney cancer. No duration-risk relations were observed for most neoplasms, except for an inverse duration-risk relation for prostate cancer. The present meta-analysis confirms the absence of appreciable effect of regular aspirin use on cancers of the bladder and kidney and quantifies small and heterogeneous inverse associations for other cancers considered.

Repurposing existing drugs for COVID-19: an endocrinology perspective

BACKGROUND

Coronavirus Disease 2019 (COVID-19) is a multi-systemic infection caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), that has become a pandemic. Although its prevailing symptoms include anosmia, ageusia, dry couch, fever, shortness of brief, arthralgia, myalgia, and fatigue, regional and methodological assessments vary, leading to heterogeneous clinical descriptions of COVID-19. Aging, uncontrolled diabetes, hypertension, obesity, and exposure to androgens have been correlated with worse prognosis in COVID-19. Abnormalities in the renin-angiotensin-aldosterone system (RAAS), angiotensin-converting enzyme-2 (ACE2) and the androgen-driven transmembrane serine protease 2 (TMPRSS2) have been elicited as key modulators of SARS-CoV-2.

MAIN TEXT

While safe and effective therapies for COVID-19 lack, the current moment of pandemic urges for therapeutic options. Existing drugs should be preferred over novel ones for clinical testing due to four inherent characteristics: 1. Well-established long-term safety profile, known risks and contraindications; 2. More accurate predictions of clinical effects; 3. Familiarity of clinical management; and 4. Affordable costs for public health systems. In the context of the key modulators of SARS-CoV-2 infectivity, endocrine targets have become central as candidates for COVID-19. The only endocrine or endocrine-related drug class with already existing emerging evidence for COVID-19 is the glucocorticoids, particularly for the use of dexamethasone for severely affected patients. Other drugs that are more likely to present clinical effects despite the lack of specific evidence for COVID-19 include anti-androgens (spironolactone, eplerenone, finasteride and dutasteride), statins, N-acetyl cysteine (NAC), ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), and direct TMPRSS-2 inhibitors (nafamostat and camostat). Several other candidates show less consistent plausibility. In common, except for dexamethasone, all candidates have no evidence for COVID-19, and clinical trials are needed.

CONCLUSION

While dexamethasone may reduce mortality in severely ill patients with COVID-19, in the absence of evidence of any specific drug for mild-to-moderate COVID-19, researchers should consider testing existing drugs due to their favorable safety, familiarity, and cost profile. However, except for dexamethasone in severe COVID-19, drug treatments for COVID-19 patients must be restricted to clinical research studies until efficacy has been extensively proven, with favorable outcomes in terms of reduction in hospitalization, mechanical ventilation, and death.

Role of risk attitude and time preference in preventive aspirin use adherence

BACKGROUND

Poor adherence to medication that is taken chronically for the prevention of cardiovascular disease (CVD) continues to occur. Poor adherence is a primary barrier to treatment success and affects not only the patient but also the health care system.

OBJECTIVE

We aim to explore the impacts of risk attitudes and time preferences on the decisions of patients to begin and comply with aspirin therapy for CVD prevention.

METHODS

Three hundred fifty-seven patients who used low-dose aspirin for CVD prevention under the guidance of their doctors completed the survey. The risk attitudes and time preferences of the patients were elicited using a multiple price list experiment. Logistic regression models were used to examine the predictors of adherence to aspirin use.

RESULTS

Risk-seeking behaviours were significantly associated with both nonparticipation (P < .01) and lower compliance (P < .05) in patients. The coefficient for time preference was only significant at the 0.05 level for the decision to initiate aspirin use, which indicated that more impatient patients were less likely to begin with the use of aspirin. Forgetfulness in using aspirin on time and a lack of knowledge (as well as a lack of belief in the use of aspirin) could largely explain the poor adherence to aspirin therapy.

CONCLUSIONS

The identification of risk seekers and of those individuals who discount the future to a lesser degree may help providers to formulate tailored strategies to their patients, thus effectively enhancing their adherence to treatment.

A methodology for investigating the impact of medical countermeasures on the risk of exposure induced death

The space radiation environment is composed of ionizing particles that may pose health risks to crew members during Low Earth Orbit (LEO) and deep space missions. NASA has established astronaut career radiation limits for cancer of 3% Risk of Exposure Induced Death (REID) at the 95% confidence level. The REID is the increased lifetime risk of death from cancer due to radiation exposure in comparison to an unexposed background population and has been traditionally mitigated by passive shielding design concepts and limiting safe days in space. Additional reduction in radiation exposure risk may be achieved with Medical Countermeasures (MCM). Recent meta-analyses have demonstrated the efficacy of aspirin in the reduction of the background colorectal cancer incidence and mortality rates for specific cohorts. Additional studies of warfarin in patients greater than 50 years of age have indicated statistically significant decreases in stomach, bladder, brain, prostate, and lung cancer incidence as compared to control groups. While ultimate selection of suitable countermeasures will be the responsibility of flight surgeons, this paper presents a general methodology for incorporating MCM into the NASA Space Radiation Cancer Risk model and includes modifications of the background mortality rates (hazard rates) and the radiation risk coefficients to numerically quantify the benefits of MCM. As examples of the method, aspirin and warfarin will be employed as MCM in a sensitivity analysis to compute the REID for astronauts embarking on a one-year deep space mission scenario.

Aspirin and the risk of colorectal and other digestive tract cancers: an updated meta-analysis through 2019

BACKGROUND

Aspirin has been associated with a reduced risk of colorectal cancer, and possibly of a few other digestive tract cancers. The quantification of risk reduction and the optimal dose and duration of aspirin use for the prevention of colorectal and other digestive tract cancers remains unclear.

METHODS

To provide an up-to-date quantification of this association, we conducted a systematic review and meta-analysis of all observational studies on aspirin and cancers of the digestive tract sites published through March 2019. We estimated the pooled relative risk (RR) of cancer for regular aspirin use versus non-use using random-effects models, and, whenever data were available, we investigated the dose- and duration-risk relations.

RESULTS

Regular aspirin use is associated with a reduced risk of colorectal cancer [RR = 0.73, 95% confidence interval (CI) = 0.69-0.78, 45 studies], squamous-cell esophageal cancer (RR = 0.67, 95% CI = 0.57-0.79, 13 studies), adenocarcinoma of the esophagus and gastric cardia (RR = 0.61, 95% CI = 0.49-0.77, 10 studies), stomach cancer (RR = 0.64, 95% CI = 0.51-0.82, 14 studies), hepato-biliary tract cancer (RR = 0.62, 95% CI = 0.44-0.86, five studies), and pancreatic cancer (RR = 0.78, 95% CI = 0.68-0.89, 15 studies), but not of head and neck cancer (RR = 0.94, 95% CI = 0.76-1.16, 10 studies). The associations are somewhat stronger in case-control than in cohort and nested case-control studies and are characterized by some between-study heterogeneity. Risk estimates are consistent across sex, geographical areas, and other selected covariates. For colorectal cancer, an aspirin dose between 75 and 100 mg/day conveys a risk reduction of 10%, and a dose of 325 mg/day of 35%. For all neoplasms, except head and neck cancer, inverse duration-risk relations with aspirin use are found.

CONCLUSION

The present comprehensive meta-analysis supports and further quantifies the inverse association between regular aspirin use and the risk of colorectal and other digestive tract cancers, including some rare ones. The favorable effect of aspirin increases with longer duration of use, and, for colorectal cancer, with increasing dose.

Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: a cross-sectional study

BACKGROUND

Polypharmacy carries the risk of adverse events, especially in people with multimorbidity.

OBJECTIVE

To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention.

METHODS

Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease.

RESULTS

Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention.

CONCLUSION

There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety.

Aspirin and its pleiotropic application

Aspirin (acetylsalicylic acid), the oldest synthetic drug, was originally used as an anti-inflammatory medication. Being an irreversible inhibitor of COX (prostaglandin-endoperoxide synthase) enzymes that produce precursors for prostaglandins and thromboxanes, it has gradually found several other applications. Sometimes these applications are unrelated to its original purpose for example its use as an anticoagulant. Applications such as these have opened opportunities for new treatments. In this case, it has been tested in patients with cardiovascular disease to reduce the risk of myocardial infarct. Its function as an anticoagulant has also been explored in the prophylaxis and treatment of pre-eclampsia, where due to its anti-inflammatory properties, aspirin intake may be used to reduce the risk of colorectal cancer. It is important to always consider both the risks and benefits of aspirin's application. This is especially important for proposed use in the prevention and treatment of neurologic ailments like Alzheimer's disease, or in the prophylaxis of myocardial infarct. In such cases, the decision if aspirin should be applied, and at what dose may be guided by specific molecular markers. In this revived paper, the pleiotropic application of aspirin is summarized.

Health Benefits of Anti-aging Drugs

Aging, as a physiological process mediated by numerous regulatory pathways and transcription factors, is manifested by continuous progressive functional decline and increasing risk of chronic diseases. There is an increasing interest to identify pharmacological agents for treatment and prevention of age-related disease in humans. Animal models play an important role in identification and testing of anti-aging compounds; this step is crucial before the drug will enter human clinical trial or will be introduced to human medicine. One of the main goals of animal studies is better understanding of mechanistic targets, therapeutic implications and side-effects of the drug, which may be later translated into humans. In this chapter, we summarized the effects of different drugs reported to extend the lifespan in model organisms from round worms to rodents. Resveratrol, rapamycin, metformin and aspirin, showing effectiveness in model organism life- and healthspan extension mainly target the master regulators of aging such as mTOR, FOXO and PGC1α, affecting autophagy, inflammation and oxidative stress. In humans, these drugs were demonstrated to reduce inflammation, prevent CVD, and slow down the functional decline in certain organs. Additionally, potential anti-aging pharmacologic agents inhibit cancerogenesis, interfering with certain aspects of cell metabolism, proliferation, angioneogenesis and apoptosis.

Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Elderly Japanese Patients with Atherosclerotic Risk Factors: Subanalysis of a Randomized Clinical Trial (JPPP-70)

INTRODUCTION

This post hoc subanalysis of the randomized Japanese Primary Prevention Project investigated whether once-daily low-dose aspirin versus no aspirin reduced the risk of cardiovascular events (CVEs) in patients aged ≥ 70 years with atherosclerotic risk factors.

METHODS

Patients aged < 70 years (young-old) or ≥ 70 years (old) with hypertension, dyslipidemia, or diabetes participated between 2005 and 2007. Patients were randomized 1:1 to receive 100 mg enteric-coated aspirin once daily or no aspirin plus standard of care. The primary outcome was a composite of death from cardiovascular causes plus nonfatal stroke and nonfatal myocardial infarction. The secondary outcome was a composite of the primary outcome plus transient ischemic attack, angina pectoris, and arteriosclerotic disease requiring medical or surgical intervention. Old (n = 7971) and young-old (n = 6493) patients were followed up for a median 5.02 years.

RESULTS

Aspirin did not reduce the risk of primary (hazard ratio [HR] 0.92 [95% confidence interval {CI} 0.74-1.16]; P = 0.50) or secondary (0.85 [0.70-1.04]; P = 0.11) outcomes in patients aged ≥ 70 years. In old men with high-density lipoprotein < 40 mg/dL, treatment with low-dose aspirin was associated with a reduction in the incidence of the primary endpoint compared with the group not receiving aspirin (10/260 vs 22/250; HR 0.44 [95% CI 0.20-0.93]; P = 0.03). This subgroup was also found to contain significant larger proportions of patients with elevated body mass index, patients with diabetes mellitus, and smokers (P < 0.001). Old patients also showed differences in bleeding outcomes. Serious extracranial hemorrhage requiring transfusion or hospitalization occurred significantly more frequently in the aspirin-treated group than in the non-aspirin-treated group (35 [0.88%] vs 18 [0.45%]; HR 1.96 [1.11-3.46]; P = 0.020). Gastrointestinal hemorrhage occurred significantly more frequently in the aspirin-treated group than the non-aspirin-treated group (63 [1.58%] vs 18 [0.45%]; relative risk [RR] 3.5 [2.08-5.90]; P < 0.0001). Cerebral hemorrhage (intracranial hemorrhage) tended to occur more frequently in the aspirin-treated group than the non-aspirin-treated group (22 [0.55%] vs 11 [0.28%]; RR 2.01 [0.97-4.14]; P = 0.058). Cerebral hemorrhage occurred significantly more frequently in old patients than in young-old patients (33 [0.41%] vs 10 [0.15%]; HR 2.7 [1.34-5.53]; P = 0.0055). Gastrointestinal hemorrhage occurred in a slightly higher proportion of old patients compared with young-old patients (81 [1.02%] vs 53 [0.82%]; RR 1.2 [0.88-1.76]; P = 0.21).

DISCUSSION/CONCLUSIONS

Aspirin did not reduce the risk of the primary or secondary outcomes in old patients. Aspirin treatment may have reduced CVEs within a high CVE risk elderly population subgroup. Aspirin treatment in such a group requires caution, because of the increased risk of intracranial hemorrhage, severe extracranial hemorrhage requiring hospitalization or transfusion, and gastrointestinal bleeding in old patients receiving aspirin therapy.

CLINICAL TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov [NCT00225849].

Platelets, inflammation and anti-inflammatory effects of antiplatelet drugs in ACS and CAD

Platelets play a pivotal role in chronic inflammation leading to progression of atherosclerosis and acute coronary events. Recent discoveries on novel mechanisms and platelet-dependent inflammatory targets underpin the role of platelets to maintain a chronic inflammatory condition in cardiovascular disease. There is strong and clinically relevant crosslink between chronic inflammation and platelet activation. Antiplatelet therapy is a cornerstone in the prevention and treatment of acute cardiovascular events. The benefit of antiplatelet agents has mainly been attributed to their direct anti-aggregatory impact. Some anti-inflammatory off-target effects have also been described. However, it is unclear whether these effects are secondary due to inhibition of platelet activation or are caused by direct distinct mechanisms interfering with inflammatory pathways. This article will highlight novel platelet associated targets that contribute to inflammation in cardiovascular disease and elucidate mechanisms by which currently available antiplatelet agents evolve anti-inflammatory capacities, in particular by carving out the differential mechanisms directly or indirectly affecting platelet mediated inflammation. It will further illustrate the prognostic impact of antiplatelet therapies by reducing inflammatory marker release in recent cardiovascular trials.

Is anti-platelet therapy always necessary in asymptomatic 30-40% carotid stenosis?

Asymptomatic mild carotid artery stenosis is relatively frequent and associated with an increased risk of cardiovascular events. Its recognition is clinically relevant for appropriate prevention strategies. These include a healthy lifestyle approach and a careful pharmacologic control of cardiovascular risk factors, such as hypertension, hypercholesterolemia, and diabetes. Furthermore, interventions able to reduce the risk of atherothrombotic events, such as antiplatelet drugs, should be considered. Noninvasive imaging of carotid artery plaque and stenosis severity and morphology may add relevant information for the risk stratification of these subjects.

Comparative effectiveness of chemopreventive interventions for colorectal cancer: protocol for a systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer worldwide and is associated with substantial socioeconomic burden. Despite considerable research, including numerous randomised controlled trials (RCTs) and systematic reviews assessed the effect of various chemopreventive interventions for CRC, there remains uncertainty regarding the comparative effectiveness of these agents. No network meta-analytic study has been published to evaluate the efficacies of these agents for CRC. Therefore, the aim of this study is to summarise the direct and indirect evidence for these interventions to prevent CRC in average-high risk individuals, and to rank these agents for practical consideration.

METHODS

We will acquire eligible studies through a systematic search of MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, CINAHL plus, IPA and clinicaltrials.gov website. The Cochrane Risk of Bias Tool will be used to assess the quality of included studies. The primary outcomes are the incidence of CRC, the incidence/recurrence of any adenoma or change in polyp burden (number or size). Quantitative synthesis or meta-analysis will be considered. We will also construct a network meta-analysis (NMA) to improve precision of the comparisons among chemo-preventive interventions by combining direct and indirect evidence. The probability of each treatment being the best and/or safest, the number-needed-to-treat [NNT; 95% credible interval (CrIs)], and the number-needed-to-harm (NNH; 95% CrIs) will be calculated to provide measures of treatment efficacy. The GRADE approach will be used to rate the quality of evidence of estimates derived from NMA.

RESULTS

This protocol has been registered (registration number: CRD42015025849) with the PROSPERO (International Prospective Register of Systematic Reviews). The procedures of this systematic review and NMA will be conducted in accordance with the PRISMA-compliant guideline. The results of this systematic review and NMA will be submitted to a peer-reviewed journal for publication.

CONCLUSIONS

To the best of our knowledge, this study will be the first NMA to identify the comparative effectiveness of interventions for the prevention of CRC. The results of our study will update evidence for chemoprevention of CRC, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.

Drugs for Primary Prevention of Atherosclerotic Cardiovascular Disease: An Overview of Systematic Reviews

IMPORTANCE

The Million Hearts initiative emphasizes ABCS (aspirin for high-risk patients, blood pressure [BP] control, cholesterol level management, and smoking cessation). Evidence of the effects of drugs used to achieve ABCS has not been synthesized comprehensively in the prevention of primary atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To compare the efficacy and safety of aspirin, BP-lowering therapy, statins, and tobacco cessation drugs for fatal and nonfatal ASCVD outcomes in primary ASCVD prevention.

EVIDENCE REVIEW

Structured search of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), MEDLINE, EMBASE, and PROSPERO International Prospective Systematic Review Trial Register to identify systematic reviews published from January 1, 2005, to June 17, 2015, that reported the effect of aspirin, BP-lowering therapy, statin, or tobacco cessation drugs on ASCVD events in individuals without prevalent ASCVD. Additional studies were identified by searching the reference lists of included systematic reviews, meta-analyses, and health technology assessment reports. Reviews were selected according to predefined criteria and appraised for methodologic quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool (range, 0-11). Studies were independently reviewed for key participant and intervention characteristics. Outcomes that were meta-analyzed in each included review were extracted. Qualitative synthesis was performed, and data were analyzed from July 2 to August 13, 2015.

FINDINGS

From a total of 1967 reports, 35 systematic reviews of randomized clinical trials were identified, including 15 reviews of aspirin, 4 reviews of BP-lowering therapy, 12 reviews of statins, and 4 reviews of tobacco cessation drugs. Methodologic quality varied, but 30 reviews had AMSTAR ratings of 5 or higher. Compared with placebo, aspirin (relative risk [RR], 0.90; 95% CI, 0.85-0.96) and statins (RR, 0.75; 95% CI, 0.70-0.81) reduced the risk for ASCVD. Compared with placebo, BP-lowering therapy reduced the risk for coronary heart disease (RR, 0.84; 95% CI, 0.79-0.90) and stroke (RR, 0.64; 95% CI, 0.56-0.73). Tobacco cessation drugs increased the odds of continued abstinence at 6 months (odds ratio range, 1.82 [95% CI, 1.60-2.06] to 2.88 [95% CI, 2.40-3.47]), but the direct effects on ASCVD were poorly reported. Aspirin increased the risk for major bleeding (RR, 1.54; 95% CI, 1.30-1.82), and statins did not increase overall risk for adverse effects (RR, 1.00; 95% CI, 0.97-1.03). Adverse effects of BP-lowering therapy and tobacco cessation drugs were poorly reported.

CONCLUSIONS AND RELEVANCE

This overview demonstrates high-quality evidence to support aspirin, BP-lowering therapy, and statins for primary ASCVD prevention and tobacco cessation drugs for smoking cessation. Treatment effects of each drug can be used to enrich discussions between health care professionals and patients in primary ASCVD prevention.