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## Ecospirin (Aspirin, Enteric-Coated)
### Overview
Ecospirin is an enteric-coated formulation of aspirin, a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis. Enteric coating delays dissolution until the small intestine, potentially reducing gastric irritation.
### Primary Indications
* **Cardiovascular Prevention:** Prevention of myocardial infarction (MI), stroke, and cardiovascular death in patients with established cardiovascular disease or at high risk.
* **Analgesia and Antipyresis:** Mild to moderate pain and fever. (Note: Lower doses are typically used for cardiovascular prevention.)
* **Anti-inflammatory:** Rheumatic diseases, though higher doses are required.
### Adult Dosing
* **Cardiovascular Prevention:** 75-162 mg once daily. Higher doses up to 325 mg may be used in specific acute settings (e.g., suspected acute MI) before switching to a lower maintenance dose.
* **Analgesia/Antipyresis:** 325-650 mg every 4-6 hours as needed. Maximum dose: 4000 mg/day.
* **Anti-inflammatory:** 3000-6000 mg/day divided into 3-4 doses. Maximum dose: 8000 mg/day (requires close monitoring).
### Pediatric Dosing
* **Analgesia/Antipyresis:** 10-15 mg/kg/dose every 4-6 hours. Maximum dose: 650 mg/dose or 4000 mg/day.
* **Inflammatory Conditions (e.g., Juvenile Idiopathic Arthritis):** Dosing varies widely based on condition and severity; consult specific pediatric rheumatology guidelines. Doses can range from 40-100 mg/kg/day divided into 4 doses.
* **Kawasaki Disease:** Dosing depends on the phase of illness (acute vs. convalescent) and temperature. Typically high dose (80-100 mg/kg/day divided into 4 doses) during fever, then low dose (3-5 mg/kg/day once daily) for extended period. Dosing requires close monitoring.
* **Reye's Syndrome:** Aspirin is **contraindicated** in children and adolescents with viral infections due to the risk of Reye's syndrome.
### Dose Adjustments
* No dose adjustment is typically needed for hepatic or renal impairment, but caution is advised. High doses or prolonged use in severe renal impairment may be problematic.
### Contraindications
* Known hypersensitivity to aspirin or other NSAIDs.
* Children and adolescents with viral infections (risk of Reye's syndrome).
* Active peptic ulceration or gastrointestinal bleeding.
* Severe hepatic impairment.
* Severe renal impairment (CrCl < 30 mL/min).
* History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs.
* Use in the third trimester of pregnancy.
* Hemophilia or other bleeding disorders.
### Adverse Effects
* **Common:** Dyspepsia, heartburn, nausea, vomiting, abdominal pain.
* **Serious:** Gastrointestinal bleeding, ulceration, perforation; tinnitus (especially at higher doses); bronchospasm; hypersensitivity reactions; hepatotoxicity; nephrotoxicity; Reye's syndrome (in children/adolescents with viral illness). Increased bleeding risk.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin, DOACs):** Increased risk of bleeding.
* **Antiplatelets (e.g., clopidogrel, prasugrel, ticagrelor):** Additive antiplatelet effect, increased bleeding risk.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs:** Increased risk of GI adverse effects and potential for reduced aspirin's cardioprotective effect if taken concomitantly without proper timing.
* **Selective Serotonin Reuptake Inhibitors (SSRIs):** Increased risk of bleeding.
* **Methotrexate:** Aspirin may decrease methotrexate clearance, increasing toxicity.
* **Uricosuric Agents (e.g., probenecid):** Aspirin may decrease the efficacy of uricosuric agents.
* **Valproic Acid:** Aspirin may displace valproic acid from plasma protein binding sites, increasing free valproic acid levels.
### Monitoring
* **For Cardiovascular Prevention:** Monitor for signs and symptoms of bleeding (e.g., melena, hematemesis, bruising).
* **For Higher Doses (Analgesic/Anti-inflammatory):** Monitor for tinnitus, hearing loss, signs of GI distress or bleeding, renal function, and liver function.
* **In Children:** Monitor for Reye's syndrome symptoms (vomiting, lethargy, confusion, seizures) if used during a viral illness.
### Clinical Pearls
* The enteric coating delays absorption and onset of action but does not eliminate the risk of GI upset or bleeding, especially with chronic use or higher doses.
* For patients needing both antiplatelet and anti-inflammatory effects, separate administration times (aspirin 1 hour before or 8 hours after ibuprofen) may be considered to minimize interference with aspirin's cardioprotective effects, although evidence is mixed.
* Discontinue aspirin at least 5-7 days before elective surgery due to its irreversible antiplatelet effect.
* Patients with asthma and nasal polyps are at higher risk for aspirin-induced bronchospasm.
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*Please verify the current prescribing information for definitive guidance.*
