Major
acetylsalicylic acid × losartan
Antiplatelet agents (low dose) / NSAIDs (analgesic dose)×Angiotensin II receptor blockers (sartans)
Mechanism
Same as the aspirin/ACE-inhibitor pair: aspirin's NSAID effect blunts renal vasodilation, and patients with CKD or hypovolemia may develop acute kidney injury. Sartan antihypertensive effect is diminished. Antiplatelet aspirin doses of 75–100 mg barely affect renal prostaglandins. Analgesic and antipyretic doses of 500–1000 mg inhibit COX systemically and behave like other nonselective NSAIDs with respect to renal hemodynamics and BP.
Management
Antiplatelet aspirin doses of 75–100 mg are compatible – no adjustment needed. Analgesic and antipyretic doses of 500–1000 mg should be limited to the shortest possible course, with paracetamol preferred. In patients over 75 and/or with eGFR below 60 mL/min, analgesic-dose aspirin should be avoided. For NSAID courses longer than 5 days, check creatinine, potassium, and BP at 7–10 days (FDA Drug Safety Communication, July 2015).
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 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2023)— J Am Geriatr Soc 2023;71(7):2052–2081