G6PD Deficiency and Aspirin (Ecospirin) Safety
Aspirin is safe for patients with G6PD deficiency at standard therapeutic doses, including low-dose aspirin for cardiovascular protection and higher doses for pain management. 1, 2
Evidence-Based Safety Profile
The concern about aspirin causing hemolysis in G6PD-deficient patients is largely historical and not supported by modern evidence:
A comprehensive 2010 evidence-based review found NO solid evidence to prohibit aspirin use in G6PD deficiency, listing only seven medications with proven hemolytic risk (dapsone, methylene blue, nitrofurantoin, phenazopyridine, primaquine, rasburicase, and toluidine blue—notably, aspirin is absent from this list). 1
A 1991 prospective study of 44 Mediterranean-type G6PD-deficient patients receiving long-term low-dose aspirin showed no evidence of hemolysis over three months of monitoring, with normal complete blood counts, reticulocyte counts, and serum bilirubin throughout treatment. 2
A 2024 real-world study of 31,962 G6PD-deficient patients found only 71 cases (0.2%) of major hemolysis requiring hospitalization, with 71.8% caused by fava beans, 8.5% by infections, and only 4.2% possibly medication-related (none involving aspirin). 3
Clinical Use in High-Risk Cardiovascular Situations
Aspirin has been successfully used in G6PD-deficient patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents:
Five G6PD-deficient patients received dual antiplatelet therapy (DAPT) including low-dose aspirin after PCI with drug-eluting stents without clinical complications. 4
Two patients with class II G6PD deficiency and non-ST-segment elevation acute coronary syndrome were safely treated with aspirin plus ticagrelor and PCI. 5
Other NSAIDs in G6PD Deficiency
Other NSAIDs (ibuprofen, naproxen) are also safe in G6PD deficiency:
The 2010 evidence-based review found no evidence contraindicating the use of NSAIDs in normal therapeutic doses for G6PD-deficient patients. 1
Standard NSAID dosing guidelines apply without modification for G6PD deficiency. 6, 7, 8
Practical Management Recommendations
For G6PD-deficient patients requiring aspirin or NSAIDs:
Use standard therapeutic doses without dose reduction based on G6PD status alone. 1, 2
Apply the same cardiovascular and gastrointestinal risk assessment as for non-G6PD-deficient patients when prescribing aspirin or NSAIDs. 6
Consider gastroprotection with proton pump inhibitors for patients with GI risk factors (age >60, history of peptic ulcer, concurrent anticoagulants), regardless of G6PD status. 6
Avoid NSAIDs in patients with aspirin-exacerbated respiratory disease, active peptic ulcer, severe renal impairment, or uncontrolled heart failure—these are standard contraindications unrelated to G6PD deficiency. 6
Common Pitfall to Avoid
The most important pitfall is unnecessarily withholding aspirin from G6PD-deficient patients who have clear cardiovascular indications (acute coronary syndrome, post-MI, stroke prevention), as this denies them proven life-saving therapy based on outdated concerns. 1, 4, 5 The historical association between aspirin and hemolysis in G6PD deficiency likely resulted from confounding by concurrent infections, which themselves trigger hemolytic episodes. 1, 3