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Aspirin for Cirrhosis from Medscape
BOSTON — Will wonder drugs never cease? Aspirin, already touted for its cardiovascular and anti-inflammatory prowess, seems to be flexing its muscles against liver fibrosis, particularly in people at risk for chronic liver disease, according to new research.
"Clinical equipoise is emerging that may justify prospective randomized trials of aspirin and, potentially, other antiplatelet drugs such as antifibrotic agents," Gordon Jiang, MD, a gastroenterology fellow at the Beth Israel Deaconess Medical Center in Boston, and colleagues state in a scientific poster here at The Liver Meeting 2014.
In a population-based cross-sectional study of more than 14,000 adults, there was "a consistent association between aspirin use and less liver fibrosis," Dr. Jiang and colleagues report.
The team drew on the National Health and Nutrition Examination Survey (NHANES) III to look at the association between aspirin, ibuprofen, and liver fibrosis. Fibrosis was measured with four validated noninvasive indices: Fibrosis-4, the nonalcoholic fatty liver disease fibrosis score, the aspartate aminotransferase/platelet ratio index, and the Forns Index.
To see if the association between aspirin and fibrosis protection is stronger in patients most at risk for fibrosis, they did additional analyses in patients with viral hepatitis, heavy drinkers, and patients with fatty liver disease.
On the four measures, the use of aspirin was consistently associated with lower stages of liver fibrosis. In contrast, there was virtually no link between ibuprofen use and liver fibrosis.
Similarly, in an analysis of patients with and without chronic liver disease (hepatitis B or C infection, more than 5 alcoholic drinks per day, or suspected nonalcoholic steatohepatitis), aspirin but not ibuprofen was consistently associated with lower stages of fibrosis.
For patients with or at risk for liver disease, compared with those without risk factors, there was about a 5-fold increase in the negative coefficient for the interaction between aspirin use and liver fibrosis. This suggests that the protective effect of aspirin is much larger in patients with chronic liver disease, said researcher Yury Popov, MD, PhD, assistant professor of medicine at the Beth Israel Deaconess Medical Center.
The researchers acknowledge that the study was limited by the observational design, and by that fact that the NHANES III data were limited to 1 month of drug use, "whereas the protection against liver fibrosis likely requires long-term use."
They speculate that the antiplatelet activity of aspirin, rather than its anti-inflammatory properties, likely account for its positive effects on fibrosis.
"Our observations support emerging experimental and clinical evidence for a pathologic link between platelet activation and liver fibrosis," they write.
In a separate study, also presented here, another group of researchers report that "platelets drive liver fibrosis through the direct activation of hepatic stellate cells in chronically injured liver."
"We also found that aspirin in the long term, at the low dose — the antiplatelet dose — is reducing — well actually, preventing — fibrosis in the mouse model," Dr. Popov, who was involved in both studies, told Medscape Medical News.
More potent antiplatelet agents — such as clopidogrel (Plavix), prasugrel (Effient), and others currently in the pipeline — could have an even stronger effect against fibrosis, said Athan Kuliopulos, MD, PhD, professor of medicine at the Tufts University Sackler School of Biomedical Sciences in Boston, who was not involved with the study.
"And this is just liver fibrosis," he told Medscape Medical News. "What does it mean for outcome?"
He said that if, as he and his colleagues theorize, platelet activation or action is a primary cause of fibrosis, it might be possible to "bypass the platelet entirely," and target the factor Xa protease.
Dr. Jiang has disclosed no relevant financial relationships. Dr. Popov reports consulting for and receiving research grants from Gilead Sciences. Dr. Kuliopulos is the CEO of Oasis Pharmaceuticals.
The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD). Abstract 449, presented November 8, 2014; abstract 778, presented November 9, 2014.
"Clinical equipoise is emerging that may justify prospective randomized trials of aspirin and, potentially, other antiplatelet drugs such as antifibrotic agents," Gordon Jiang, MD, a gastroenterology fellow at the Beth Israel Deaconess Medical Center in Boston, and colleagues state in a scientific poster here at The Liver Meeting 2014.
In a population-based cross-sectional study of more than 14,000 adults, there was "a consistent association between aspirin use and less liver fibrosis," Dr. Jiang and colleagues report.
The team drew on the National Health and Nutrition Examination Survey (NHANES) III to look at the association between aspirin, ibuprofen, and liver fibrosis. Fibrosis was measured with four validated noninvasive indices: Fibrosis-4, the nonalcoholic fatty liver disease fibrosis score, the aspartate aminotransferase/platelet ratio index, and the Forns Index.
To see if the association between aspirin and fibrosis protection is stronger in patients most at risk for fibrosis, they did additional analyses in patients with viral hepatitis, heavy drinkers, and patients with fatty liver disease.
On the four measures, the use of aspirin was consistently associated with lower stages of liver fibrosis. In contrast, there was virtually no link between ibuprofen use and liver fibrosis.
Similarly, in an analysis of patients with and without chronic liver disease (hepatitis B or C infection, more than 5 alcoholic drinks per day, or suspected nonalcoholic steatohepatitis), aspirin but not ibuprofen was consistently associated with lower stages of fibrosis.
For patients with or at risk for liver disease, compared with those without risk factors, there was about a 5-fold increase in the negative coefficient for the interaction between aspirin use and liver fibrosis. This suggests that the protective effect of aspirin is much larger in patients with chronic liver disease, said researcher Yury Popov, MD, PhD, assistant professor of medicine at the Beth Israel Deaconess Medical Center.
The researchers acknowledge that the study was limited by the observational design, and by that fact that the NHANES III data were limited to 1 month of drug use, "whereas the protection against liver fibrosis likely requires long-term use."
They speculate that the antiplatelet activity of aspirin, rather than its anti-inflammatory properties, likely account for its positive effects on fibrosis.
"Our observations support emerging experimental and clinical evidence for a pathologic link between platelet activation and liver fibrosis," they write.
In a separate study, also presented here, another group of researchers report that "platelets drive liver fibrosis through the direct activation of hepatic stellate cells in chronically injured liver."
"We also found that aspirin in the long term, at the low dose — the antiplatelet dose — is reducing — well actually, preventing — fibrosis in the mouse model," Dr. Popov, who was involved in both studies, told Medscape Medical News.
More potent antiplatelet agents — such as clopidogrel (Plavix), prasugrel (Effient), and others currently in the pipeline — could have an even stronger effect against fibrosis, said Athan Kuliopulos, MD, PhD, professor of medicine at the Tufts University Sackler School of Biomedical Sciences in Boston, who was not involved with the study.
"And this is just liver fibrosis," he told Medscape Medical News. "What does it mean for outcome?"
He said that if, as he and his colleagues theorize, platelet activation or action is a primary cause of fibrosis, it might be possible to "bypass the platelet entirely," and target the factor Xa protease.
Dr. Jiang has disclosed no relevant financial relationships. Dr. Popov reports consulting for and receiving research grants from Gilead Sciences. Dr. Kuliopulos is the CEO of Oasis Pharmaceuticals.
The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD). Abstract 449, presented November 8, 2014; abstract 778, presented November 9, 2014.
They sure do change their minds. Remember the stay away from coffee era? Now, it protects against HCC!!! Go figure!
I also feel that unless I had a specific heart problem, I would never take a statin drug. For me, who has a healthy heart, the harshness on the liver would not be worth it. The only time I pop a low dose aspirin is the few times I felt a sharp pain in my chest and didn't know what the cause was. But, since it was never discovered that there was anything to it other than like a pulled muscle (like a pec), or one of my typical anxiety attacks, nothing happened. But, I do keep a small container of chewable 81mg aspirin in my purse for an unexpected 'event'. I've heard it can be the difference between life and death. But, as far as taking it on a daily basis, it causes me too many gastric/stomach burning issues and I was also told to not take NSAIDS/ or aspirin unless ABSOLUTELY necessary. Anyway, these doctors seem to change their minds alot, you know? Susan400
The issue with aspirin is it lowers platelets which may already be low in cirrhotics. Like basset says, you should always check with your own doc as they know your medical history. Your doctor may feel it is worthwhile to take the aspirin since it is such a low dose if your platelets are not below normal and you are at elevated risk for cardiac problems or stroke. It is definitely a question for the doctor.
I have cirhossis. My hepatologist at the liver transplant education clinic told all of us pretty much what Lynn posted: no NSAIDS, asprin included, under any circumstamces. If we were in severe pain due to back problems etc. we could take Tylenol at the recommended dose for a short time.
The study is interesting, but I think anyone with liver disease should check with their own doctor before taking any medication.
The study is interesting, but I think anyone with liver disease should check with their own doctor before taking any medication.
I thought aspirin put you at risk for bleeding problems?? Is that not true any longer? I'm confused. Susan400
Honestly Lynn, I'm already 67 so I will probably die of something else before my platelets are back up there. So as long as progression is stopped, I am good. You never know though. Research is moving rapidly in this area. Yelp, as usual time tells all. :)
Your platelets are low due to liver damage and portal hypertension I assume you must have based on your platelet counts. Because of the amount of damage to your liver it will take possibly many years if ever for yours and my livers to experience enough improvement to reverse the scarring of cirrhosis.
Eradicating hep c only stops future liver damage it does not fix your liver. If you have cirrhosis before treatment you will still have cirrhosis.
This is unknow territory with so many people beating hep c so maybe you could have normal platelet counts someday especially if you have less damage. Only time will tell.
Eradicating hep c only stops future liver damage it does not fix your liver. If you have cirrhosis before treatment you will still have cirrhosis.
This is unknow territory with so many people beating hep c so maybe you could have normal platelet counts someday especially if you have less damage. Only time will tell.
Good points flyinlynn. When I read this earlier I was thinking I should go buy some baby aspirin not even thinking about my low platelets (65-85). Interesting tidbit is my platelets actually went up to 85 from 65 when I started S/O. But what's more interesting is how quickly I forget things like I can't take aspirin, etc.
I recently asked my doctor about how long it will take my platelets to go up if I reach SVR and he said a long time if ever. Not sure why though cause everything else in my labs is presently perfect.
I recently asked my doctor about how long it will take my platelets to go up if I reach SVR and he said a long time if ever. Not sure why though cause everything else in my labs is presently perfect.
Yes for you it might be doable good luck!
I will need to wait till I am hopefully cured and maybe with time my platelets can get above 100.
I will need to wait till I am hopefully cured and maybe with time my platelets can get above 100.
Thanks guys. I know about the recommended drugs and I know aspirin is contraindicated in cirrhotics. Although my platelets were always a bit above 100 and since SVR have been in low normal range. The dose is so small I am thinking it would be ok but I will check, Lynn. Thanks.
Hi OH
Yes but in cirrhosis one of the common symploms is low platelets for example mine are 80 to 90.
The recommended med for pain management for mild pain like headaches for people with cirrhosis is tylenol but just watch the dosing.
I was surprized when my doctor told me to take tylenol and nothing else but things change when you cross over into having cirrhosis. The doctors are less concerned about liver damage at that point and more concerned of a serious bleeding event like vomiting blood which can cause death.
Lynn
Yes but in cirrhosis one of the common symploms is low platelets for example mine are 80 to 90.
The recommended med for pain management for mild pain like headaches for people with cirrhosis is tylenol but just watch the dosing.
I was surprized when my doctor told me to take tylenol and nothing else but things change when you cross over into having cirrhosis. The doctors are less concerned about liver damage at that point and more concerned of a serious bleeding event like vomiting blood which can cause death.
Lynn
As long as your platelets are above 100 you can take aspirin.
My hepatology nurse said it was fine while I was doing treatment with the above caveat.
I've always preferred it to Tylenol and it does not damage our livers.
My hepatology nurse said it was fine while I was doing treatment with the above caveat.
I've always preferred it to Tylenol and it does not damage our livers.
Hi Worried Mon
My understanding is that those of us with cirrhosis can't take aspirin or NSAID's such as Aspirin, Advil or Aleve due to our increased risk of bleeding out.I definitely recommend you ask your liver specialist if they think you can. For me I doubt I can especially as I have had esophageal varicies that I had to have banded. I have been advised specifically to only take Tylenol in limited amounts for pain management and nothing else.
http://www.cpmc.org/learning/documents/cirrhosis-ws.html
Avoiding Certain Medications: Patients with cirrhosis should not take Non-Steroidal Anti-Inflammatory Drugs (NSAID) such as Advil (Ibuprofen), Motrin (Ibuprofen), or aspirin-type drugs. Tylenol (Acetaminophen) is safe if you take less than six 325 mg tablets each day (2,000 mg per day). Because cirrhosis patients are at increased risk of ulcer disease, you should discuss with your doctor about taking an anti-ulcer drug.
And also:
http://umm.edu/health/medical/reports/articles/cirrhosis
Discuss all medications with your doctor. Before you take any medications, (including nonprescription pain relievers such as acetaminophen), ask your doctor if they are safe for you. Liver damage affects the metabolism of drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen should not be used by patients with cirrhosis as they can trigger bleeding, worsen the condition, and potentially cause kidney failure.
My understanding is that those of us with cirrhosis can't take aspirin or NSAID's such as Aspirin, Advil or Aleve due to our increased risk of bleeding out.I definitely recommend you ask your liver specialist if they think you can. For me I doubt I can especially as I have had esophageal varicies that I had to have banded. I have been advised specifically to only take Tylenol in limited amounts for pain management and nothing else.
http://www.cpmc.org/learning/documents/cirrhosis-ws.html
Avoiding Certain Medications: Patients with cirrhosis should not take Non-Steroidal Anti-Inflammatory Drugs (NSAID) such as Advil (Ibuprofen), Motrin (Ibuprofen), or aspirin-type drugs. Tylenol (Acetaminophen) is safe if you take less than six 325 mg tablets each day (2,000 mg per day). Because cirrhosis patients are at increased risk of ulcer disease, you should discuss with your doctor about taking an anti-ulcer drug.
And also:
http://umm.edu/health/medical/reports/articles/cirrhosis
Discuss all medications with your doctor. Before you take any medications, (including nonprescription pain relievers such as acetaminophen), ask your doctor if they are safe for you. Liver damage affects the metabolism of drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen should not be used by patients with cirrhosis as they can trigger bleeding, worsen the condition, and potentially cause kidney failure.
I think I am going to start taking 81mg. Have any of you with cirrhosis been told it is ok to take it by your hep doc? I am without a doc right now as mine has past away.
Hey there! This is really interesting. Thank you so much for sharing this. I am going to be watching the progress
Dee
Dee
I to take 81 mg aspirin to reduce the chance of stroke. Recommended by cardiologist back in August. Better blood flow through your body appears to have beneficial results.
Good to know, as I have been taking low dose asprin for 10 years for afib, and have recently switched to Xarelto. My liver appeared in good shape in the ultrasound and blood panel before Tx, and maybe that is one of the reasons. Yay!
Who knew? I have been taking 81mg Aspirin for a number of years - first because it was thought to help prevent heart problems (later found to be true in men but not in women), then because there is evidence aspirin does help reduce the chance of stroke in women.
It surely is nice to know that it might be helping, slowing or, possibly, even preventing Fibrosis!
Pat
It surely is nice to know that it might be helping, slowing or, possibly, even preventing Fibrosis!
Pat
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