Can I start low‑dose aspirin (81 mg daily) in a patient with a platelet count of 136 × 10⁹/L who has no active bleeding, no aspirin allergy, no recent major surgery, no history of peptic ulcer disease, and no uncontrolled hypertension?

Yes, you can safely start aspirin 81 mg daily in a patient with a platelet count of 136 × 10⁹/L

A platelet count of 136 × 10⁹/L is not a contraindication to aspirin therapy, as this falls within the normal range (normal is typically 150-400 × 10⁹/L, though mild thrombocytopenia begins below 150). The established contraindications to aspirin focus on bleeding tendency, active bleeding, aspirin allergy, recent gastrointestinal bleeding, and clinically active hepatic disease—not on specific platelet count thresholds in this range 1.

Key Contraindications to Aspirin (None Apply Here)

The American Diabetes Association clearly defines who should NOT receive aspirin therapy 1:

• Aspirin allergy (not present in your patient)
• Bleeding tendency (not present)
• Active anticoagulant therapy (not mentioned)
• Recent gastrointestinal bleeding (not present)
• Clinically active hepatic disease (not present)

A platelet count of 136 × 10⁹/L does not constitute a "bleeding tendency" requiring aspirin avoidance. This is a borderline-low normal count that does not significantly impair hemostasis 1.

Optimal Dosing Strategy

Use aspirin 75-100 mg daily (81 mg in the U.S.) for maintenance therapy, as this dose provides equivalent or superior cardiovascular benefit compared to higher doses while minimizing bleeding risk 1.

• The 2025 ACC/AHA guidelines recommend maintenance doses of 75-100 mg daily (nonenteric coated) for patients with acute coronary syndromes 1
• The American Diabetes Association confirms that 75-162 mg/day is optimal, with lower doses reducing side effects without sacrificing efficacy 1, 2
• The ADAPTABLE trial (38% diabetes patients) showed no difference in cardiovascular events between 81 mg and 325 mg daily, supporting use of the lower dose 1

Clinical Context Matters

Determine whether this is for primary or secondary prevention, as this affects the strength of recommendation 1:

For Secondary Prevention (Established CVD):

• Strongly recommended for patients with history of MI, stroke, TIA, peripheral vascular disease, or coronary revascularization 1
• Benefits far outweigh bleeding risks in this population 2

For Primary Prevention:

• Consider in patients aged 50-70 years with additional cardiovascular risk factors (hypertension, smoking, dyslipidemia, family history of CVD, albuminuria) through shared decision-making 1, 2
• Not recommended for patients <50 years without additional risk factors or >70 years due to bleeding risk outweighing benefits 2

Bleeding Risk Assessment

The main concern with aspirin is gastrointestinal bleeding, not thrombocytopenia at this platelet level 3, 4:

• Baseline bleeding risk with low-dose aspirin is approximately 1-2 cases per 1,000 patient-years 5
• Risk factors that increase bleeding include: advanced age (>70 years), concomitant NSAIDs or anticoagulants, history of peptic ulcer disease, uncontrolled hypertension, and Helicobacter pylori infection 3, 4, 6
• Your patient has none of these risk factors, making aspirin particularly safe 3

Monitoring Recommendations

• No routine platelet monitoring is required for patients on aspirin monotherapy with baseline counts in this range 1
• Monitor for signs of bleeding (melena, hematemesis, easy bruising) clinically 5
• Consider H. pylori testing and eradication if the patient develops dyspepsia or has high ulcer risk 4
• Proton pump inhibitor co-therapy is not routinely needed unless additional gastrointestinal risk factors are present 4

Common Pitfalls to Avoid

• Do not withhold aspirin based solely on a platelet count of 136 × 10⁹/L—this is not a contraindication 1
• Do not use enteric-coated aspirin for acute loading doses (if applicable), as non-enteric formulations should be chewed for faster absorption 1, 5
• Do not automatically prescribe aspirin for all diabetes patients—primary prevention requires risk stratification and shared decision-making 2
• Do not use aspirin doses >162 mg daily for chronic prevention, as higher doses increase bleeding without improving efficacy 1