Is aspirin (acetylsalicylic acid) indicated in patients with factor V deficiency?

Aspirin is Contraindicated in Factor V Deficiency

Aspirin should NOT be used in patients with Factor V deficiency due to the inherently increased bleeding risk associated with this coagulopathy, which represents an absolute contraindication to antiplatelet therapy.

Understanding Factor V Deficiency as a Bleeding Disorder

Factor V deficiency is a rare inherited or acquired coagulopathy that impairs hemostasis and predisposes patients to bleeding complications 1. Key clinical features include:

• Bleeding manifestations range from mucosal surface bleeding and postoperative hemorrhage to more severe presentations including hemarthroses, intramuscular hemorrhages, and intracranial bleeding 1
• Factor V levels correlate poorly with bleeding risk, making clinical assessment challenging and necessitating a conservative approach to any intervention that could exacerbate bleeding 1
• The bleeding phenotype is generally less severe than hemophilia A or B, but still represents a significant coagulopathy requiring careful management 1, 2

Why Aspirin is Contraindicated

The 2019 ACC/AHA Guidelines explicitly state that low-dose aspirin should not be administered for primary prevention of cardiovascular disease among adults of any age who are at increased risk of bleeding (Class III: Harm recommendation) 3. The guidelines specifically list coagulopathy as a condition associated with increased bleeding risk 3.

Factor V deficiency meets this criterion as:

• Coagulopathy is explicitly listed as a contraindication to aspirin use in cardiovascular prevention guidelines 3
• Aspirin irreversibly inhibits platelet function, which would compound the existing hemostatic defect in Factor V deficiency 3
• The bleeding risk from aspirin includes gastrointestinal hemorrhage and bleeding from other sites, which are already problematic in Factor V deficiency 3, 4

Special Considerations in Myeloproliferative Disorders

Even in conditions where aspirin might otherwise be indicated (such as essential thrombocythemia), the NCCN Guidelines emphasize that aspirin should be used with caution in patients with acquired von Willebrand disease 3. This same principle applies to Factor V deficiency, where the bleeding risk must be weighed carefully.

Management Approach for Factor V Deficiency

When bleeding occurs in Factor V deficiency, appropriate management includes:

• Platelet transfusions should be the initial therapy for bleeding patients, as Factor V stored in platelet alpha-granules has greater procoagulant potential 5
• Fresh frozen plasma remains a mainstay treatment option when platelet transfusions are insufficient 1
• Antifibrinolytics can provide benefit, especially for mucosal bleeding 1
• Avoid antiplatelet agents including aspirin, which would worsen the hemostatic defect

Clinical Decision Algorithm

For any patient with Factor V deficiency being considered for aspirin:

1. Recognize Factor V deficiency as a coagulopathy that represents an increased bleeding risk 3
2. Apply the Class III: Harm recommendation from ACC/AHA guidelines against aspirin use in patients with increased bleeding risk 3
3. Even for secondary cardiovascular prevention, the bleeding risk in Factor V deficiency would likely outweigh cardiovascular benefits, requiring alternative strategies
4. Focus on managing cardiovascular risk through other means: blood pressure control, lipid management, lifestyle modifications 4

Critical Pitfall to Avoid

Do not assume that mild or asymptomatic Factor V deficiency permits aspirin use. Factor V levels correlate poorly with bleeding risk 1, and aspirin's irreversible platelet inhibition could precipitate serious bleeding even in patients who have been previously asymptomatic 3.