Moderate
Acetylsalicylic acid × Enalapril
Antiplatelet agents (low dose) / NSAIDs (analgesic dose)×Angiotensin-converting enzyme inhibitors (ACEi)
Mechanism
High aspirin doses (above 1 g/day) weaken the hypotensive and cardioprotective effects of the ACE-I via vasodilator prostaglandin suppression. At cardioprotective doses (75–100 mg/day), the clinical effect is minimal.
Symptoms
Gradual blood pressure rise at high aspirin doses. At cardioprotective doses, no significant changes.
Management
Cardioprotective aspirin doses (75–100 mg) are acceptable without adjustment. At high aspirin doses, monitor blood pressure and increase enalapril if needed. Alternative analgesic: paracetamol.
Sources
- FDA: FDA Drug Safety Communication: FDA strengthens warning that non-aspirin NSAIDs can cause heart attacks or strokes (2015)– FDA Drug Safety Communication, July 9, 2015
- AHA: Use of Nonsteroidal Antiinflammatory Drugs: An Update for Clinicians. A Scientific Statement From the American Heart Association (2007)– Circulation 2007;115(12):1634–1642
- AGS: American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (2023)– By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2023;71(7):2052-2081.