Can aspirin (acetylsalicylic acid) be given to patients with systemic lupus erythematosus (SLE)?

Aspirin Use in Systemic Lupus Erythematosus (SLE)

Low-dose aspirin may be considered for primary prevention of cardiovascular disease in patients with SLE, particularly in those with antiphospholipid antibodies, as it may reduce the risk for incident cardiovascular disease (HR 0.24). 1

Indications for Aspirin in SLE

Cardiovascular Disease Prevention

• SLE is an independent risk factor for cardiovascular disease due to both traditional and disease-related risk factors 1
• Low-dose aspirin has shown benefit in primary prevention of cardiovascular events in SLE patients:
  • A retrospective study demonstrated a hazard ratio of 0.24 for incident cardiovascular disease 1, 2
  • However, this benefit must be balanced against potential bleeding risks, especially in light of recent studies in diabetics and elderly populations 1

Antiphospholipid Antibodies (aPL)

• For SLE patients with aPL, a meta-analysis supports a protective role of low-dose aspirin for primary thrombosis prophylaxis 1
• The clearest benefit appears in patients with high-risk aPL profiles:
  • Triple aPL positivity
  • Lupus anticoagulant
  • High titers of anticardiolipin antibodies 1

Considerations and Limitations

Aspirin Resistance

• Up to 19.2% of SLE patients may exhibit aspirin resistance 3
• Associated factors include:
  • Metabolic syndrome
  • Obesity
  • Higher C-reactive protein levels 4
• This resistance may limit effectiveness in some patients

Bleeding Risk Assessment

• The decision to use aspirin must balance thrombotic risk against bleeding risk 1
• In patients with lupus anticoagulant and very low bleeding risk (≤1% per year), oral anticoagulants may provide greater benefit than aspirin 5

Special Populations

• During high-risk periods for thrombosis (pregnancy, postoperative periods), SLE patients with aPL may benefit from additional anticoagulant treatment such as low-molecular weight heparin 1

Practical Recommendations

1. Primary Prevention: Consider low-dose aspirin for all SLE patients for primary prevention of cardiovascular events, especially those with:

   • Antiphospholipid antibodies
   • Traditional cardiovascular risk factors 1, 2

2. Monitoring: For patients on aspirin therapy:

   • Monitor for bleeding complications
   • Consider testing for aspirin resistance in patients with metabolic syndrome or obesity 4, 3

3. Duration: Long-term use (>5 years) of aspirin appears to provide sustained cardiovascular protection (HR: 0.24) 2

4. Combination Therapy: Consider combining aspirin with hydroxychloroquine for enhanced cardiovascular protection, as hydroxychloroquine use for >5 years also reduces cardiovascular risk (HR: 0.27) 2

Pitfalls and Caveats

• Aspirin alone may be insufficient for SLE patients with high-risk aPL profiles who may require more intensive anticoagulation 1
• NSAIDs (including aspirin) may increase risk of renal side effects in SLE patients with nephritis 6
• The antiplatelet effect of aspirin may be suboptimal in SLE patients with metabolic syndrome 4

In conclusion, while aspirin can be given to patients with SLE, its use should be targeted primarily to those who would benefit most—patients with antiphospholipid antibodies or cardiovascular risk factors—while carefully considering individual bleeding risk.