I was at a long term care facility and had a patient on lisinopril 10 mg daily for hypertension as well as Aspirin 325 mg daily for cardiovascular prophylaxis.
Lexi-comp has the aspirin and lisinopril interaction rated at a C (on a scale of A-D and X being contraindicated. I’d like to get your thoughts on whether this interaction should be faxed to a physician?
Putting myself in this situation, this is a great case where a solution could be offered rather than just notifying the physician. There are two solutions that initially come to my mind.
1. This patient was a resident of a long term care facility. The facility will have a good information on the blood pressure results of this resident. The individual who was prompted with this interaction could certainly pick up the phone and inquire nursing staff about the blood pressure readings. Monitoring is so important when it comes to drug interactions, and this option tends to slip through the cracks once in a while as I’ve seen some providers almost panic and not think about what the alert is actually saying.
2. The second solution would be to ask the provider to assess the current dose of aspirin. Per Lexicomp, this interaction doesn’t occur or has minimal effect when the dose of Aspirin is less than 100 mg daily. In many cases, we can get by with a dose of 81 mg daily.
Here’s a case of Drug Induced Hypertension
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Good and thought-provoking post.
According to a widely used drug literature there is an excellent documentation of drug interaction that occurs between ACE-I and NSAIDS. The severeity is described as moderate. Concurrent use of ACE-Inhibitors, a group to which Lisinopril belongs and Aspirin and other NSAIDS may result in decreased antihypertensive efficacy. The proposed mechanism involves inhibition of prostaglandin synthesis by the latter, thereby thwarting the antihypertesnive efficacy of ACE-Inhibitors.
In an event patient needs to be on both Aspirin or other NSAIDS and ACE-Inibitor concurrently, it’s strongly advised that his/her blood pressure is closely monitored and make dose adjustements as needed. The renal function also must be checked periodically for signs of renal toxicity.
On this particular case where patient resides in a long term care facility, close monitoring of his blood pressure and renal function and adjusting his dose and /or adding another BP medication that works by a different mechanism may be more appropriate. The general understanding is that inhibition of prostaglandin by NSAIDS can and do occur independent of the dose. Thus, reducing the dose of Aspirin is less likely to have any improved outcome.
Thanks Amanuel – love your comments, feel free to share a case again sometime! – Eric
Thanks Eric for providing us with this platforum to share informations and exchange ideas vitally important to patient care.
Sent it – let me know if still troubles Thanks! Eric
Dear Eric
It is really a nice piece of scientific interaction.
I do not believe that a small dose of aspirin (81 mg) will have a significant drug-drug inreaction with ACEIs. The action of such dose of aspirin will be , primarily, within the platelets , without any appreciable effects on the kidney.
There are many studies in the literature documenting this.
Some of these are shown below.
Effects of low-dose aspirin on clinic and ambulatory blood pressure in treated hypertensive patients. Collaborative Group of the Primary Prevention Project (PPP)–Hypertension study.
Avanzini F, Palumbo G, Alli C, Roncaglioni MC, Ronchi E, Cristofari M, Capra A, Rossi S, Nosotti L, Costantini C, Pietrofeso R.
Am J Hypertens. 2000 Jun;13(6 Pt 1):611-6.
Low-dose aspirin does not interfere with the blood pressure-lowering effects of antihypertensive therapy.
Zanchetti A, Hansson L, Leonetti G, Rahn KH, Ruilope L, Warnold I, Wedel H.
J Hypertens. 2002 May;20(5):1015-22
I agree with Ali’s comments above. At one time, aspirin was also thought to attenuate the benefits of ACE inhibitors in patients with heart failure but this phenomenon has been largely discredited by more recent data [1]. Additionally, a wealth of evidence in patients with ischemic heart disease (> 90% of which were taking aspirin) suggests that ACE inhibitors confer additive reductions in cardiovascular events, including nonfatal myocardial infarction, stroke, and all-cause mortality [2]. In low-risk patients, there may be less benefit with ACE inhibitors but no evidence to suggest an increased risk with combined aspirin and ACE inhibitor therapy [3].
As Ali alluded to in his comments, the potential drug-drug interaction between aspirin and ACE inhibitors is similar to the one we are accustomed to seeing between non-steroidal anti-inflammatory drugs (NSAIDs) and ACE inhibitors. However, it is important to emphasize that aspirin does not exert appreciable “NSAID-like” effects unless used at higher doses (i.e., daily doses in excess of 325 mg, such as those used for acute pericarditis) [4]. Only about 100 mg per day of aspirin is required to exert its beneficial antiplatelet effects in patients with ischemic heart disease, which is why 81-100 mg has become the preferred dose for primary and secondary prophylaxis [5].
Regarding the patient described in the present case, doses of aspirin > 100 mg per day do not appear to provide any additional benefit over lower doses [6], but do increase the risk of bleeding [7]. Regardless of the ACE inhibitor, I think it would be reasonable to decrease this patient’s aspirin dose to 81 mg, which should provide the same degree of ischemic benefit while reducing the long-term risk of bleeding.
References
1. Levy PD, Nandyal D, Welch RD, et al. Does aspirin use adversely influence intermediate-term postdischarge outcomes for hospitalized patients who are treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers? Findings from Organized Program to Facilitate Life-Saving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J. 2010 Feb;159(2):222-230.e2.
2. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):145-53.
3. Braunwald E, Domanski MJ, Fowler SE, et al; for the PEACE Trial Investigators. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med. 2004 Nov 11;351(20):2058-68.
4. Patrono C, Rocca B. Aspirin: promise and resistance in the new millennium. Arterioscler Thromb Vasc Biol. 2008 Mar;28(3):s25-32.
5. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011 Dec 6;124(23):e574-651.
6. Mehta SR, Tanguay JF, Yusuf S, et al; CURRENT-OASIS 7 trial investigators. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010 Oct 9;376(9748):1233-43.
7. Serebruany VL, Steinhubl SR, Berger PB, et al. Analysis of risk of bleeding complications after different doses of aspirin in 192,036 patients enrolled in 31 randomized controlled trials. Am J Cardiol. 2005 May 15;95(10):1218-22.
Evaluation of the effect of angiotensin converting enzyme inhibitors and angiotensin receptors blockers on aspirin antiplatelet effect. this study showed postive interaction between ACEIs and ASA.
Thanks Eric!
I was prescribed Lisinopril for high blood pressure, which I take religiously at 7:00am. And it works well to keep my BP within the normal range.
Then one day, I overstepped and freaked out. When I checked my BP that morning, it was high but not crazy-high. So I took my normal dosage of Lisinopril, just late.
Then I noticed a bottle of low-dosage Bayer aspirin nearby, so I did an experiment. Would the aspirin, which acts as a blood-thinner, speed up the effectiveness of Lisinopril? So I retook my blood pressure again and was surprised that it had fallen to a normal level so quickly…
Did I accidentally make a discovery or was it just my imagination? I wonder if a study has done to see if taking a low-dose of aspirin along with Lisinopril shortens the time it takes to lower high blood pressure to the normal level. If no experiments have been done, they should be…
I just started Lisinopril (midday) and taking Aspirin at night (had been taking the aspirin nightly since December 2020) and I’ve noticed my numbers drop done to perfect levels.
I heard it should be a baby aspirin. Do you take a normal aspirin? An aspirin a day for the rest of your life can’t be great for the stomach, etc.