Aspirin gets very little respect. Perhaps that’s because it is well over 100 years old, or because it is inexpensive and available over the counter. Whatever the reason, it’s our observation that people don’t tend to take acetylsalicylic acid (ASA or aspirin) seriously. Many doctors also tend to be dismissive. The United States Preventive Services Task Force (USPSTF) made headlines recently with its draft decision to discourage middle-aged and older people from taking low-dose aspirin to avoid a first heart attack or stroke. As a result, millions of people have probably decided to stop taking aspirin. That poses a potential risk. If you stop taking aspirin suddenly, you might experience serious consequences.
The USPSTF Draft Guidelines Oct. 12, 2021:
Previous recommendations from the USPSTF task force suggested that people at fairly high risk for cardiovascular disease between ages 50 and 59 might benefit from low-dose aspirin. The updated recommendations extend the age range of those who should discuss this option with their health care providers.
People between 40 and 59 whose ten-year cardiovascular disease risk is at least 10 percent are encouraged to consider aspirin on an individual basis. The panel warns that older people may be at increased risk for bleeding and should not start low-dose aspirin as a preventive.
The task force is trying to target primary prevention to people most likely to benefit and least likely to experience harm. People taking aspirin following a heart attack (secondary prevention) or on their doctor’s recommendation are not advised to stop without consulting the physician.
The panel points out that for people without cardiovascular disease, low-dose aspirin reduces the chance of heart attack and stroke, but it also increases the possibility of GI and other bleeding complications.
What Could Happen If You Stop Taking Aspirin?
We suspect that a lot of people recently read headlines like these:
“Task force says most people should not take daily aspirin to prevent a heart attack” (NPR, Oct. 13, 2021)
“Most adults shouldn’t take aspirin to prevent heart attacks and strokes, experts say” (Yahoo! news)
“Aspirin Use to Prevent 1st Heart Attack or Stroke Should Be Curtailed, U.S. Panel Says” (New York Times, Oct. 13, 2021)
“Doctors should no longer routinely start most people who are at high risk of heart disease on a daily regimen of low-dose aspirin, according to new draft guidelines by a U.S. panel of experts.“
Such headlines are likely to encourage a lot of people to stop taking aspirin quite suddenly. That worries us! No one is talking about what might happen if millions go cold turkey on aspirin.
The USPSTF Mentions “Aspirin Discontinuation”
None of the medical pundits or reports we have seen in the popular press bothered to mention the USPSTF discussion about “aspirin discontinuation.”
Here is what the task force states:
“Very little is known about any rebound thrombotic risks [blood clots] associated with aspirin discontinuation, although one cohort study has been published since the last review. A Swedish cohort study of over 600,000 adults evaluated the risk of cardiovascular events (hospitalization for MI [heart attack], stroke, or CVD [cardiovascular disease] death) associated with discontinuation of long-term, low-dose aspirin therapy. In the population taking aspirin for CVD primary prevention, discontinuation of aspirin was associated with a 28 percent increase in cardiovascular events over a median of 3 years’ followup.”
The authors of the new draft report go on to say:
“More evidence is needed on this point, and an ongoing trial testing outcomes in aspirin withdrawal was also identified, but the estimated completion date is not until 2024.”
In the meantime, though, a lot of people are likely to stop taking aspirin with no guidance on how to do that safely. Unsurprisingly, readers have questions about the best way to stop taking aspirin.
Should People With Diabetes Stop Taking Aspirin?
Q. I read your article about discontinuing daily 81 mg aspirin for those over 65. People with diabetes have been taking aspirin for years because of the increased risk of heart attacks and strokes. Is there any research on the risk of diabetics stopping the 81 mg aspirin?
A. This is an important question that doctors are still asking (JAMA Network Open, June 21, 2021). There have been few studies focused on the risks of discontinuing aspirin for people with diabetes. One such trial focused on people with type 2 diabetes (Diabetes Therapy, Oct. 2020). Stopping after short-term aspirin use did not increase the risks or heart attacks, strokes or death after a stent was put in. However, these individuals kept taking a medicine such as clopidogrel designed to prevent blood clots. That might have helped protect them from rebound clotting after discontinuing aspirin.
A Reader’s Concerns About How to Stop Taking Aspirin:
Q. I read your column about a woman who stopped aspirin and had a heart attack. Almost thirty years ago I started taking aspirin.
In December, 2015, I was getting ready to have shoulder replacement surgery. There were a lot of scans and tests to be sure everything looked good before the surgery. They ALL checked out fine. A week before the surgery, I had to stop taking my aspirin, omega-3 fish oil and OTC supplements.
Two days before the surgery, I woke up fuzzy. As it turned out, I’d had a blood clot go to my brain and cause a mild stroke. After three months of heart monitoring and tests, the neurology doctors said it was rare, but they think going off aspirin caused the blood to clot and stop up a small artery.
Serious Consequences for People Who Stop Taking Aspirin:
A. Swedish researchers reported that patients who stop low-dose aspirin appear to be more likely to suffer a heart attack or stroke (Sundstrom et al, Circulation, online, Sept. 25, 2017). They hypothesized that this may be a rebound blood-clotting effect.
Here are the Swedish researchers describing the dilemma in their own words:
“Discontinuation of secondary prevention with aspirin has been associated with higher risk of cardiovascular events in some studies, with indications of an increased risk shortly after discontinuation. Aspirin is often withdrawn because of surgery or bleeding, factors that per se may stimulate platelet aggregation and increase the risk of cardiovascular events. Effects of discontinuation in settings other than surgery or bleeding are unknown.”
The authors conclude:
“In this large nationwide patient cohort, discontinuation of long-term low-dose aspirin was associated with a >30% higher risk of cardiovascular events, corresponding to an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin. The risk appeared to increase as soon as the patients discontinued aspirin, with no safe interval.”
How Should People Stop Taking Aspirin?
The US Preventive Services Task Force did not offer any guidance about how people should stop taking aspirin. As far as we can tell, the FDA has not offered any suggestions either.
We have received a number of questions from readers of our syndicated newspaper column and visitors to this website. This one is fairly typical:
Q. I read with great interest your article on discontinuation of aspirin therapy. Many of us long term aspirin users are now in limbo.
I’m a healthy 71-year-old male who has taken 81 mg aspirin daily for 40 years for primary prevention. My doctor back then suggested it, and my current doctor will not advise me on whether or how to discontinue. Can you help?
A. We are not surprised that your physician was uncomfortable about offering advise how “whether or how” to stop taking aspirin. There is no official guidance for this reader or millions of other people who have a similar question.
And we have been unable to find any studies to show us the safest way to tell people how stop taking aspirin. This question also poses a dilemma for surgeons. They often advise patients to stop taking aspirin cold turkey prior to surgery to prevent excessive bleeding.
This too is controversial (International Journal of Surgery, Nov. 13, 2013):
“The question asked was: should patients on acetylsalicylic acid (ASA) for secondary prevention stop or continue the medication prior to elective, abdominal surgery. Using the reported search 826 papers were found of which five represented the best evidence to answer the clinical question. The strongest evidence was from a randomized controlled trial (RCT) specifically looking at elective abdominal surgery, which showed no statistically significant difference between ASA continuation and discontinuation in terms of haemorrhagic or thrombotic events…it appears that continuing ASA isn’t associated with excessive bleeding. Further adequately powered trials with well-defined end points are needed to answer this important clinical question.”
What Does the Cochrane Review Say?
We often look to the Cochrane Database of Systematic Reviews to resolve complex pharmacological questions. This independent organization sets very high standards for analyzing available data. Here is what it has to say about “continuation versus discontinuation of antiplatelet therapy” in adults undergoing non-cardiac surgery (Cochrane Database of Systematic Reviews, July 18, 2018).
Aspirin has definite antiplatelet activity and is included in the review. Here are the conclusions:
“We found low-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention, or ischaemic events [blood clots]. We found moderate-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery probably makes little or no difference to bleeding requiring transfusion. Evidence was limited to few studies with few participants, and with few events.”
We don’t know about you but we find this analysis disappointing at best and worthless at worst. The bottom line appears to be that no one knows whether stopping aspirin prior to non-cardiac surgery is a problem or not. And they certainly don’t have a proven protocol for how to stop taking aspirin.
Gradual Discontinuation of Other Drugs:
When people try to stop taking acid-suppressing drugs (PPIs) or antidepressants such as duloxetine (Cymbalta) or venlafaxine (Effexor) we generally tell them try very gradual dose tapering to avoid unpleasant withdrawal symptoms. Here is a link to our article:
In it, readers describe a tapering process that may take months to complete. They open the capsule and remove a few tiny beads of duloxetine at a time. Unfortunately, you can’t do that with aspirin pills.
How Can You Lower the Dose of Aspirin Gradually?
Low-dose aspirin pills are small and often come with a coating. That makes it almost impossible to cut them up into chunks. Trying to smash up a regular-strength tablet to get tiny doses is equally challenging.
Here is one possibility. Old-fashioned Alka-Seltzer effervescent tablets for heartburn contain 325 mg of aspirin, 1,916 mg of sodium bicarbonate (baking soda) and 1000 mg of citric acid. If you follow the instructions that come with Alka-Seltzer, you would dissolve 2 tablets in 4 ounces of water. That’s the dose for heartburn.
If someone were to just put 1 tablet in 8 ounces of water, the resulting fizzy liquid should have about 40 mg of aspirin per ounce. That is about half of a low-dose aspirin pill. One could start out the tapering process with 2 ounces (80 mg of aspirin). Then after a few days reduce the amount of liquid swallowed to 1.5 ounces (44 ml). Proceeding in this way offers a means of gradually reducing the dose of aspirin.
Should you wish to avoid spending money on expensive Alka-Seltzer tablets, there is an inexpensive alternative. Put an uncoated 325 mg aspirin tablet into 8 ounces of club soda or seltzer water. Add a small amount of baking soda (1/4 teaspoon or less) and a pinch or two of lemon juice. This will help the aspirin dissolve and create a mixture not that different from Alka-Seltzer. Stir well and then drink an ounce or so as you begin your taper.
Aspirin for a Heart Attack:
This same technique can be helpful if you fear you are having a heart attack. Even though the US Preventive Services Task Force will be discouraging people from taking low-dose aspirin for “primary” prevention, these experts are not telling people to stop taking aspirin if they have already had a heart attack. And if a doctor has recommended aspirin, the USPSTF is not contradicting that advice!
And as far as we can tell, no expert is suggesting that people should skip aspirin if they think they are having a heart attack. Emergency medical personnel still recommend that in such a situation, most people may benefit from chewing an aspirin tablet. We think that can work. So could creating a soluble aspirin mixture by adding a small dose of aspirin to club soda, as described above. Here is a link to our analysis of that approach:
What Do You Think?
What is your experience with aspirin? Has your doctor recommended a baby aspirin to prevent a second heart attack? Before you discontinue aspirin after many years, please check in with your health care provider to ask about the gradual tapering process we describe above.
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