Rationales and uncertainties for aspirin use in COVID-19: a narrative review

Hazem A Sayed Ahmed; Eric Merrell; Mansoura Ismail; Anwar I Joudeh; Jeffrey B Riley; Ahmed Shawkat; Hanan Habeb; Edward Darling; Reda A Goweda; Mohamed H Shehata; Hossam Amin; Gary F Nieman; Hani Aiash

doi:10.1136/fmch-2020-000741

Rationales and uncertainties for aspirin use in COVID-19: a narrative review

Fam Med Community Health. 2021 Apr;9(2):e000741. doi: 10.1136/fmch-2020-000741.

Authors

Hazem A Sayed Ahmed¹, Eric Merrell², Mansoura Ismail¹, Anwar I Joudeh³, Jeffrey B Riley⁴, Ahmed Shawkat⁵, Hanan Habeb⁶, Edward Darling⁴, Reda A Goweda^{1

7}, Mohamed H Shehata⁸, Hossam Amin⁹, Gary F Nieman¹⁰, Hani Aiash^{1

4

10}

Affiliations

¹ Department of Family Medicine, Suez Canal University Faculty of Medicine, Ismailia, Egypt.
² Department of Medicine, State University of New York Upstate Medical University, Syracuse, New York, USA.
³ Department of Internal Medicine, The University of Jordan, Amman, Jordan anwarjoudeh@gmail.com.
⁴ Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA.
⁵ Department of Critical Care, State University of New York Upstate Medical University, Syracuse, New York, USA.
⁶ Egypt Ministry of Health and Population, Cairo, Egypt.
⁷ Department of Community Medicine, Umm Al-Qura University College of Medicine, Makkah, Saudi Arabia.
⁸ Department of Family and Community Medicine, Arabian Gulf University College of Medicine and Medical Science, Manama, Bahrain.
⁹ Department of Critical Care, New York Medical College, Valhalla, New York, USA.
¹⁰ Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA.

Abstract

Objectives: To review the pathophysiology of COVID-19 disease, potential aspirin targets on this pathogenesis and the potential role of aspirin in patients with COVID-19.

Design: Narrative review.

Setting: The online databases PubMed, OVID Medline and Cochrane Library were searched using relevant headlines from 1 January 2016 to 1 January 2021. International guidelines from relevant societies, journals and forums were also assessed for relevance.

Participants: Not applicable.

Results: A review of the selected literature revealed that clinical deterioration in COVID-19 is attributed to the interplay between endothelial dysfunction, coagulopathy and dysregulated inflammation. Aspirin has anti-inflammatory effects, antiplatelet aggregation, anticoagulant properties as well as pleiotropic effects on endothelial function. During the COVID-19 pandemic, low-dose aspirin is used effectively in secondary prevention of atherosclerotic cardiovascular disease, prevention of venous thromboembolism after total hip or knee replacement, prevention of pre-eclampsia and postdischarge treatment for multisystem inflammatory syndrome in children. Prehospital low-dose aspirin therapy may reduce the risk of intensive care unit admission and mechanical ventilation in hospitalised patients with COVID-19, whereas aspirin association with mortality is still debatable.

Conclusion: The authors recommend a low-dose aspirin regimen for primary prevention of arterial thromboembolism in patients aged 40-70 years who are at high atherosclerotic cardiovascular disease risk, or an intermediate risk with a risk-enhancer and have a low risk of bleeding. Aspirin's protective roles in COVID-19 associated with acute lung injury, vascular thrombosis without previous cardiovascular disease and mortality need further randomised controlled trials to establish causal conclusions.

Keywords: COVID-19; cardiovascular diseases; global health; infectious disease medicine; respiratory system.

Publication types

Review

MeSH terms

Adult
Aged
Anti-Inflammatory Agents, Non-Steroidal* / administration & dosage
Anti-Inflammatory Agents, Non-Steroidal* / adverse effects
Anti-Inflammatory Agents, Non-Steroidal* / therapeutic use
Aspirin* / administration & dosage
Aspirin* / adverse effects
Aspirin* / therapeutic use
COVID-19* / complications
COVID-19* / physiopathology
COVID-19* / therapy
Humans
Inflammation
Middle Aged
Practice Guidelines as Topic
Thromboembolism* / drug therapy
Thromboembolism* / etiology
Thromboembolism* / prevention & control

Substances

Anti-Inflammatory Agents, Non-Steroidal
Aspirin