Развитие симптоматики сосудистого заболевания существенно повышает риск атеротромботических осложнений. Несмотря на появление новых антитромбоцитарных препаратов, для пациентов с сердечно-сосудистыми заболеваниями ацетилсалициловая кислота (АСК) остается базовым антиагрегантом. При вторичной профилактике польза низких (75–100 мг) и средних (150–325 мг) доз АСК убедительно доказана. Сравнение антитромбоцитарной эффективности низких доз разных форм АСК показало, что кишечнорастворимое покрытие замедляет высвобождение и абсорбцию АСК. В отличие от обычной АСК, после первой дозы кишечнорастворимой формы степень ацетилирования циклооксигеназы-1 не достигает максимального значения. Однако при повторном ежедневном приеме ацетилирование тромбоцитарной циклооксигеназы кумулирует и приводит к достаточному угнетению ее активности и ингибированию функции тромбоцитов к 6-му дню. Проблемой длительного использования АСК для профилактики сердечно-сосудистых событий являются увеличение частоты гастротоксических побочных явлений и повышение риска больших кровотечений. Большинство проведенных исследований не выявили достоверного снижения риска кровотечений из верхних отделов желудочно-кишечного тракта при применении специальных форм АСК. Основную роль в развитии токсического действия АСК на слизистую оболочку верхних отделов желудочно-кишечного тракта отводят системным механизмам.
The development of symptoms of vascular disease significantly increases the risk of atherothrombotic complications. Despite the emergence of new antiplatelet drugs, for patients with cardiovascular diseases, acetylsalicylic acid (ASA) remains the basic antiplatelet agent. With secondary prophylaxis, the benefits of low (75–100 mg) and medium (150–325 mg) doses of ASA have been convincingly proven. A comparison of the antiplatelet efficacy of low doses of different forms of ASA showed that the enteric coating slows the release and absorption of ASA. Unlike conventional ASA, after the first dose of the enteric form, the degree of acetylation of cyclooxygenase-1 does not reach the maximum value. However, upon repeated daily intake, the acetylation of platelet cyclooxygenase cumulates and leads to a sufficient inhibition of its activity and inhibition of platelet function by the 6th day. The problem of prolonged use of ASA for the prevention of cardiovascular events is an increase in the frequency of gastrotoxic side effects and an increased risk of major bleeding. Most of the studies conducted did not reveal a significant reduction in the risk of bleeding from the upper gastrointestinal tract when using special forms of ASA. The main role in the development of the toxic effect of ASA on the mucous membrane of the upper gastrointestinal tract is assigned to systemic mechanisms.
1. 10 ведущих причин смерти в мире. The World Health Report 24 May 2018.
[10 vedushchikh prichin smerti v mire. The World Health Report 24 May 2018 (in Russian).]
2. Heart Protection Study Collaborative Group. MRC–BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high–risk individuals: a randomised placebo–controlled trial. Lancet 2002; 360: 7–22.
3. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–421.
4. Рагино Ю.И., Волков А.М., Чернявский А.М. Стадии развития атеросклеротического очага и типы нестабильных бляшек – патофизиологическая и гистологическая характеристика. Рос. кардиол. журн. 2013; 5 (103): 88–95.
[Ragino Iu.I., Volkov A.M., Cherniavskii A.M. Stadii razvitiia ateroskleroticheskogo ochaga i tipy nestabil'nykh bliashek – patofiziologicheskaia i gistologicheskaia kharakteristika. Ros. kardiol. zhurn. 2013; 5 (103): 88–95 (in Russian).]
5. Баркаган З.С., Костюченко Г.И. Метаболически-воспалительная концепция атеротромбоза и новые подходы к терапии больных. Бюллетень СО РАМН. 2006; 2 (120): 132–8.
[Barkagan Z.S., Kostiuchenko G.I. Metabolicheski-vospalitel'naia kontseptsiia aterotromboza i novye podkhody k terapii bol'nykh. Biulleten' SO RAMN. 2006; 2 (120): 132–8 (in Russian).]
6. Schrör K, Rauch BH. Aspirin and lipid mediators in the cardiovascular system. Prostaglandins Other Lipid Mediat 2015; 121 (A): 17–23.
7. Serhan CN. Pro-resolving lipid mediators are leads for resolution physiology. Nature 2014; 510 (7503): 92–101.
8. Antiplatelet Trialists`Collaboration. Collaborative overview of randomized of antiplatelet therapy: Prevention of death, myocardial infarction, and stroke by prolonged anti-platelet in various categories of patients. BMJ 1994; 308: 81–106.
9. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2 (8607): 349–60.
10. Welsh RC, Roe MT, Steg PG et al. A critical reappraisal of aspirin for secondary prevention in patients with ischemic heart disease. Am Heart J 2016; 181: 92–100.
11. Jezovnik МК, Poredos Р. Aspirin, still first-line in secondary prevention of cardiovascular complications in peripheral artery disease. E-journal of the ESC Council for Cardiology Practice 2013; 11 (13).
12. Collaborative meta-analysis of randomized of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 342: 71–86.
13. Patrono C. Low-dose aspirin in primary prevention: cardioprotection, chemoprevention, both, or neither? Eur Heart J 2013; 34 (44): 3403–11.
14. Johnston A, Jones WS, Hernandez AF. The ADAPTABLE Trial and Aspirin Dosing in Secondary Prevention for Patients with Coronary Artery Disease. Curr Cardiol Rep 2016; 18 (8): 81.
15. Серик С.А. Аспирин в первичной и вторичной профилактике сердечно-сосудистых заболеваний: эффективность и безопасность. Раціональна фармакотерапія. 2017; 3 (44): 28–44.
[Serik S.A. Aspirin v pervichnoi i vtorichnoi profilaktike serdechno-sosudistykh zabolevanii: effektivnost' i bezopasnost'. Ratsіonal'na farmakoterapіia. 2017; 3 (44): 28–44 (in Russian).]
16. Haastrup PF, Grønlykke T, Jarbøl DE. Enteric coating can lead to reduced antiplatelet effect of low-dose acetylsalicylic acid. Basic Clin Pharmacol Toxicol 2015; 116 (3): 212–5.
17. Cayla G, Collet JP, Silvain J et al. Prevalence and clinical impact of Upper Gastrointestinal Symptoms in subjects treated with low dose aspirin: the UGLA survey. Int J Cardiol 2012; 156 (1): 69–75.
18. Ridker PM, Hennekens CH, Tofler GH et al. Anti-platelet effects of 100 mg alternate day oral aspirin: a randomized, double-blind, placebo-controlled trial of regular andenteric coated formulations in men and women. J Cardiovasc Risk 1996; 3 (2): 209–12.
19. Endoa H, Sakaib E, Higurashib T. Differences in the severity of small bowel mucosal injury based on the type of aspirin as evaluated by capsule endoscopy. Digestive Liver Dis 2012; 44: 833–8.
20. Бокарев И.Н., Попова Л.В. Безопасность разных форм ацетилсалициловой кислоты в профилактике сердечно-сосудистых заболеваний. Consilium Medicum. 2014; 16 (5): 79–84.
[Bokarev I.N., Popova L.V. Bezopasnost' raznykh form atsetilsalitsilovoi kisloty v profilaktike serdechno-sosudistykh zabolevanii. Consilium Medicum. 2014; 16 (5): 79–84 (in Russian).]
21. Баркаган З.С., Котовщикова С.Ф. Сравнительный анализ основных и побочных эффектов различных форм ацетилсалициловой кислоты. Южно-Рос. мед. журн. 1999; 2–3: 38–43.
[Barkagan Z.S., Kotovshchikova S.F. Sravnitel'nyi analiz osnovnykh i pobochnykh effektov razlichnykh form atsetilsalitsilovoi kisloty. Iuzhno-Ros. med. zhurn. 1999; 2–3: 38–43 (in Russian).]
22. Banoob DW, McCloskey WW, Webster W. Risk of gastric injury with enteric-versus nonenteric-coated aspirin. Ann Pharmacother 2002; 36 (1): 163–6.
23. Walker J, Robinson J, Stewart J, Jacob S. Does enteric-coated aspirin result in a lower incidence of gastrointestinal complications compared to normal aspirin? Interact Cardiovasc Thorac Surg 2007; 6 (4): 519–22.
24. Uemura N, Sugano K, Hiraishi H et al. MAGIC Study Group. Risk factor profiles, drug usage, and prevalence of aspirin-associated gastroduodenal injuries among high-risk cardiovascular Japanese patients: the results from the MAGIC study. J Gastroenterol 2014; 49 (5): 814–24.
25. Kelly JP, Kaufman DW, Jurgelon JM et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996; 348: 1413–6.
26. Sørensen HT, Mellemkjaer L, Blot WJ et al. Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin. Am J Gastroenterol 2000; 95 (9): 2218–24.
27. De Abajo FJ, García Rodríguez LA. Risk of upper gastrointestinal bleeding and perforation associated with low-dose aspirin as plain and enteric-coated formulations. BMC Clin Pharmacol 2001; 1 (1).
28. García Rodríguez LA, Hernández-Díaz S, de Abajo F.J. Association between aspirin and upper gastrointestinal complications: systematic review of epidemiologic studies. Br J Clin Pharmacol 2001; 52 (5): 563–71.
29. Bhatt DL, Scheiman J, Abraham NS et al. American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52 (18): 1502–17.
30. Iwamoto J, Saito Y, Honda A, Matsuzaki Y. Clinical features of gastroduodenal injury associated with long-term low-dose aspirin therapy. World J Gastroenterol 2013; 19 (11): 1673–82.
31. Lavie CJ, Howden CW, Scheiman J, Tursi J. Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Curr Probl Cardiol 2017; 42 (5): 146–64.
32. Guo W, Lu W, Xu Y et al. Relationship between adverse gastric reactions and the timing of enteric-coated aspirin administration. Clin Drug Investig 2017; 37 (2): 187–93.
33. García Rodríguez LA, Lin KJ, Hernández-Díaz S, Johansson S. Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications. Circulation 2011; 123 (10): 1108–15.
34. Antithrombotic Trialists’ (ATT) Collaboration, Baigent C., Blackwell L., Collins R., et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373 (9678): 1849–60.
35. De Berardis G, Lucisano G, D’Ettorre A et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA 2012; 307 (21): 2286–94.
36. Whitlock EP, Burda BU, Williams SB et al. Bleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164 (12): 826–35.
37. Park K, Bavry AA. Aspirin: its risks, benefits, and optimal use in preventing cardiovascular events. Cleve Clin J Med 2013; 80 (5): 318–26.
38. Alberts MJ, Bergman DL, Molner E et al. Antiplatelet effect of aspirin in patients with cerebrovascular disease. Stroke 2004; 35 (1): 175–8.
39. Cox D, Maree AO, Dooley M et al. Effect of enteric coating on antiplatelet activity of low-dose aspirin in healthy volunteers. Stroke 2006; 37 (8): 2153–8.
40. Мартынов А.И., Акатова Е.В., Урлаева И.В., Николин О.П. Истинная резистентность и псевдорезистентность к аспирину. Рациональная фармакотерапия в кардиологии. 2013; 9 (3): 301–5.
[Martynov A.I., Akatova E.V., Urlaeva I.V., Nikolin O.P. Istinnaia rezistentnost' i psevdorezistentnost' k aspirinu. Ratsional'naia farmakoterapiia v kardiologii. 2013; 9 (3): 301–5 (in Russian).]
41. Patrignani P, Tacconelli S, Piazuelo E et al. Reappraisal of the clinical pharmacology of low-dose aspirin by comparing novel direct and traditional indirect biomarkers of drug action. J Thromb Haemost 2014; 12 (8): 1320–30.
42. Grosser T, Fries S, Lawson JA et al. Drug resistance and pseudoresistance: an unintended consequence of enteric coating aspirin. Circulation 2013; 127 (3): 377–85.
43. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2 (8607): 349–60.
44. Schrör K. General Aspects. Acetylsalicylic Acid. Weinheim, Germany: Wiley-VCH Verlag GmbH & Co. KGaA, 2016; p. 1–50.
________________________________________________
1. 10 vedushchikh prichin smerti v mire. The World Health Report 24 May 2018 (in Russian).
2. Heart Protection Study Collaborative Group. MRC–BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high–risk individuals: a randomised placebo–controlled trial. Lancet 2002; 360: 7–22.
3. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–421.
4. Ragino Iu.I., Volkov A.M., Cherniavskii A.M. Stadii razvitiia ateroskleroticheskogo ochaga i tipy nestabil'nykh bliashek – patofiziologicheskaia i gistologicheskaia kharakteristika. Ros. kardiol. zhurn. 2013; 5 (103): 88–95 (in Russian).
5. Barkagan Z.S., Kostiuchenko G.I. Metabolicheski-vospalitel'naia kontseptsiia aterotromboza i novye podkhody k terapii bol'nykh. Biulleten' SO RAMN. 2006; 2 (120): 132–8 (in Russian).
6. Schrör K, Rauch BH. Aspirin and lipid mediators in the cardiovascular system. Prostaglandins Other Lipid Mediat 2015; 121 (A): 17–23.
7. Serhan CN. Pro-resolving lipid mediators are leads for resolution physiology. Nature 2014; 510 (7503): 92–101.
8. Antiplatelet Trialists`Collaboration. Collaborative overview of randomized of antiplatelet therapy: Prevention of death, myocardial infarction, and stroke by prolonged anti-platelet in various categories of patients. BMJ 1994; 308: 81–106.
9. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2 (8607): 349–60.
10. Welsh RC, Roe MT, Steg PG et al. A critical reappraisal of aspirin for secondary prevention in patients with ischemic heart disease. Am Heart J 2016; 181: 92–100.
11. Jezovnik МК, Poredos Р. Aspirin, still first-line in secondary prevention of cardiovascular complications in peripheral artery disease. E-journal of the ESC Council for Cardiology Practice 2013; 11 (13).
12. Collaborative meta-analysis of randomized of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 342: 71–86.
13. Patrono C. Low-dose aspirin in primary prevention: cardioprotection, chemoprevention, both, or neither? Eur Heart J 2013; 34 (44): 3403–11.
14. Johnston A, Jones WS, Hernandez AF. The ADAPTABLE Trial and Aspirin Dosing in Secondary Prevention for Patients with Coronary Artery Disease. Curr Cardiol Rep 2016; 18 (8): 81.
15. Serik S.A. Aspirin v pervichnoi i vtorichnoi profilaktike serdechno-sosudistykh zabolevanii: effektivnost' i bezopasnost'. Ratsіonal'na farmakoterapіia. 2017; 3 (44): 28–44 (in Russian).
16. Haastrup PF, Grønlykke T, Jarbøl DE. Enteric coating can lead to reduced antiplatelet effect of low-dose acetylsalicylic acid. Basic Clin Pharmacol Toxicol 2015; 116 (3): 212–5.
17. Cayla G, Collet JP, Silvain J et al. Prevalence and clinical impact of Upper Gastrointestinal Symptoms in subjects treated with low dose aspirin: the UGLA survey. Int J Cardiol 2012; 156 (1): 69–75.
18. Ridker PM, Hennekens CH, Tofler GH et al. Anti-platelet effects of 100 mg alternate day oral aspirin: a randomized, double-blind, placebo-controlled trial of regular andenteric coated formulations in men and women. J Cardiovasc Risk 1996; 3 (2): 209–12.
19. Endoa H, Sakaib E, Higurashib T. Differences in the severity of small bowel mucosal injury based on the type of aspirin as evaluated by capsule endoscopy. Digestive Liver Dis 2012; 44: 833–8.
20. Bokarev I.N., Popova L.V. Bezopasnost' raznykh form atsetilsalitsilovoi kisloty v profilaktike serdechno-sosudistykh zabolevanii. Consilium Medicum. 2014; 16 (5): 79–84 (in Russian).
21. Barkagan Z.S., Kotovshchikova S.F. Sravnitel'nyi analiz osnovnykh i pobochnykh effektov razlichnykh form atsetilsalitsilovoi kisloty. Iuzhno-Ros. med. zhurn. 1999; 2–3: 38–43 (in Russian).
22. Banoob DW, McCloskey WW, Webster W. Risk of gastric injury with enteric-versus nonenteric-coated aspirin. Ann Pharmacother 2002; 36 (1): 163–6.
23. Walker J, Robinson J, Stewart J, Jacob S. Does enteric-coated aspirin result in a lower incidence of gastrointestinal complications compared to normal aspirin? Interact Cardiovasc Thorac Surg 2007; 6 (4): 519–22.
24. Uemura N, Sugano K, Hiraishi H et al. MAGIC Study Group. Risk factor profiles, drug usage, and prevalence of aspirin-associated gastroduodenal injuries among high-risk cardiovascular Japanese patients: the results from the MAGIC study. J Gastroenterol 2014; 49 (5): 814–24.
25. Kelly JP, Kaufman DW, Jurgelon JM et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996; 348: 1413–6.
26. Sørensen HT, Mellemkjaer L, Blot WJ et al. Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin. Am J Gastroenterol 2000; 95 (9): 2218–24.
27. De Abajo FJ, García Rodríguez LA. Risk of upper gastrointestinal bleeding and perforation associated with low-dose aspirin as plain and enteric-coated formulations. BMC Clin Pharmacol 2001; 1 (1).
28. García Rodríguez LA, Hernández-Díaz S, de Abajo F.J. Association between aspirin and upper gastrointestinal complications: systematic review of epidemiologic studies. Br J Clin Pharmacol 2001; 52 (5): 563–71.
29. Bhatt DL, Scheiman J, Abraham NS et al. American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52 (18): 1502–17.
30. Iwamoto J, Saito Y, Honda A, Matsuzaki Y. Clinical features of gastroduodenal injury associated with long-term low-dose aspirin therapy. World J Gastroenterol 2013; 19 (11): 1673–82.
31. Lavie CJ, Howden CW, Scheiman J, Tursi J. Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Curr Probl Cardiol 2017; 42 (5): 146–64.
32. Guo W, Lu W, Xu Y et al. Relationship between adverse gastric reactions and the timing of enteric-coated aspirin administration. Clin Drug Investig 2017; 37 (2): 187–93.
33. García Rodríguez LA, Lin KJ, Hernández-Díaz S, Johansson S. Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications. Circulation 2011; 123 (10): 1108–15.
34. Antithrombotic Trialists’ (ATT) Collaboration, Baigent C., Blackwell L., Collins R., et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373 (9678): 1849–60.
35. De Berardis G, Lucisano G, D’Ettorre A et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA 2012; 307 (21): 2286–94.
36. Whitlock EP, Burda BU, Williams SB et al. Bleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164 (12): 826–35.
37. Park K, Bavry AA. Aspirin: its risks, benefits, and optimal use in preventing cardiovascular events. Cleve Clin J Med 2013; 80 (5): 318–26.
38. Alberts MJ, Bergman DL, Molner E et al. Antiplatelet effect of aspirin in patients with cerebrovascular disease. Stroke 2004; 35 (1): 175–8.
39. Cox D, Maree AO, Dooley M et al. Effect of enteric coating on antiplatelet activity of low-dose aspirin in healthy volunteers. Stroke 2006; 37 (8): 2153–8.
40. Martynov A.I., Akatova E.V., Urlaeva I.V., Nikolin O.P. Istinnaia rezistentnost' i psevdorezistentnost' k aspirinu. Ratsional'naia farmakoterapiia v kardiologii. 2013; 9 (3): 301–5 (in Russian).
41. Patrignani P, Tacconelli S, Piazuelo E et al. Reappraisal of the clinical pharmacology of low-dose aspirin by comparing novel direct and traditional indirect biomarkers of drug action. J Thromb Haemost 2014; 12 (8): 1320–30.
42. Grosser T, Fries S, Lawson JA et al. Drug resistance and pseudoresistance: an unintended consequence of enteric coating aspirin. Circulation 2013; 127 (3): 377–85.
43. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2 (8607): 349–60.
44. Schrör K. General Aspects. Acetylsalicylic Acid. Weinheim, Germany: Wiley-VCH Verlag GmbH & Co. KGaA, 2016; p. 1–50.
Авторы
А.А. Кириченко*, Е.Ю. Эбзеева
ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия
*andrey.apollonovich@yandex.ru