Aspirin (Acetylsalicylic Acid): Uses, Dosage & Side Effects
A widely used NSAID and antiplatelet agent for cardiovascular prevention, pain relief, and anti-inflammatory therapy
Aspirin (acetylsalicylic acid) is one of the oldest and most widely used medications in the world. In low doses (75–160 mg), it acts as an antiplatelet agent to prevent blood clots and reduce the risk of heart attacks and strokes. At higher doses (300–500 mg), it provides analgesic, antipyretic, and anti-inflammatory effects. Aspirin is listed on the WHO Model List of Essential Medicines and is a cornerstone of cardiovascular prevention endorsed by the ESC, AHA, and ACC guidelines. While effective and accessible, aspirin carries significant risks including gastrointestinal bleeding and must not be given to children under 16 due to the risk of Reye’s syndrome.
Quick Facts: Aspirin
Key Takeaways
- Low-dose aspirin (75–160 mg daily) is a proven cardiovascular protector: It irreversibly inhibits platelet aggregation, significantly reducing the risk of recurrent heart attacks and strokes in patients with established cardiovascular disease.
- Do not give aspirin to children under 16: Aspirin use in children and adolescents is associated with Reye’s syndrome, a rare but potentially fatal condition affecting the brain and liver.
- Gastrointestinal bleeding is the most significant risk: Even at low doses, aspirin can cause stomach ulcers and serious bleeding. Report any signs of unusual bleeding, black stools, or blood in vomit to your doctor immediately.
- Many drug interactions exist: Aspirin interacts with anticoagulants (warfarin, heparin), other NSAIDs (ibuprofen), methotrexate, SSRIs, and blood pressure medications. Always inform your doctor of all medications you are taking.
- Never stop aspirin suddenly: If you are on long-term low-dose aspirin therapy, abrupt discontinuation can cause a dangerous rebound increase in blood clot risk. Always consult your doctor before stopping.
What Is Aspirin and What Is It Used For?
Aspirin (acetylsalicylic acid) is a medication that belongs to two drug classes: NSAIDs (non-steroidal anti-inflammatory drugs) and antiplatelet agents. At low doses, it prevents blood clots by inhibiting platelet aggregation. At higher doses, it relieves pain, reduces fever, and decreases inflammation.
Aspirin has been used in medicine for over 120 years and remains one of the most important drugs in modern pharmacology. Its active ingredient, acetylsalicylic acid, works by irreversibly inhibiting the cyclooxygenase (COX) enzymes – primarily COX-1 – which are essential for the production of thromboxane A2 in platelets and prostaglandins throughout the body. This dual mechanism gives aspirin its unique combination of antiplatelet and anti-inflammatory properties.
Platelets (thrombocytes) are small cells in the blood that play a crucial role in blood clotting. When a blood clot forms inside an artery, it can block blood flow and cut off the oxygen supply to vital organs. In the heart, this causes a heart attack (myocardial infarction); in the brain, it causes a stroke. Low-dose aspirin prevents excessive platelet clumping, reducing the risk of these life-threatening events.
Approved Uses of Aspirin
Aspirin is prescribed for several important medical indications, each requiring different dosages and treatment durations:
- Secondary prevention of heart attack: Reducing the risk of recurrent myocardial infarction in patients who have already had a heart attack
- Stroke prevention: Reducing the risk of ischemic stroke and transient ischemic attacks (TIAs)
- Unstable and stable angina pectoris: Preventing cardiovascular events in patients with chest pain due to coronary artery disease
- Acute myocardial infarction: Immediate treatment during a heart attack to limit damage
- Post-surgical thrombosis prevention: Preventing blood clots after coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and stent placement
Current guidelines from the ESC (2021) and USPSTF (2022) have become more cautious about using aspirin for primary prevention (in people who have never had a cardiovascular event). The bleeding risk often outweighs the cardiovascular benefit in otherwise healthy individuals. Aspirin for primary prevention should only be considered after an individual risk-benefit assessment by a physician, typically in patients aged 40–70 with high cardiovascular risk and low bleeding risk.
How Aspirin Works
Aspirin exerts its effects through irreversible acetylation of the cyclooxygenase enzymes. At low doses (75–160 mg), it selectively inhibits COX-1 in platelets, blocking the production of thromboxane A2 – a powerful promoter of platelet aggregation and vasoconstriction. Because platelets cannot synthesize new COX-1 (they lack a nucleus), this inhibition lasts for the entire lifespan of the platelet, approximately 7–10 days. This is why even a single daily low dose provides continuous antiplatelet protection.
At higher doses (300–500 mg and above), aspirin also inhibits COX-2 in various tissues, reducing the production of prostaglandins that mediate pain, fever, and inflammation. This dose-dependent dual action explains why different doses of aspirin are used for different clinical purposes.
What Should You Know Before Taking Aspirin?
Before taking aspirin, you must be aware of several important contraindications and precautions. Do not take aspirin if you are allergic to salicylates or NSAIDs, have active peptic ulcer disease, a bleeding disorder, severe liver or kidney impairment, or are in the last trimester of pregnancy.
Contraindications – Do Not Take Aspirin If You:
- Are allergic to acetylsalicylic acid, other salicylates, or any non-steroidal anti-inflammatory drug (NSAID)
- Have experienced an asthma attack, angioedema (swelling of the face, lips, throat, or tongue), or severe allergic reaction after taking salicylates or NSAIDs
- Currently have or have had a peptic ulcer (stomach or duodenal ulcer) or any active bleeding, including stroke
- Have a bleeding disorder or problems with blood clotting
- Have severe liver or kidney disease
- Suffer from gout (aspirin can raise uric acid levels at low doses)
- Are in the last three months of pregnancy and taking doses above 100 mg per day
- Are taking methotrexate at doses above 15 mg per week
Warnings and Precautions
Talk to your doctor or pharmacist before taking aspirin if you have any of the following conditions, as they may require dose adjustments, additional monitoring, or an alternative treatment:
- Kidney, liver, or heart problems: Aspirin may worsen fluid retention, reduce kidney function, or increase the risk of complications in these conditions
- History of stomach or intestinal problems: Previous ulcers, gastritis, or gastrointestinal bleeding increase the risk of further injury
- High blood pressure: Uncontrolled hypertension increases the risk of bleeding complications
- Asthma, hay fever, or nasal polyps: Aspirin can trigger bronchospasm in sensitive individuals (aspirin-exacerbated respiratory disease, or AERD)
- History of gout: Low-dose aspirin can increase uric acid levels and trigger gout attacks
- Heavy menstrual bleeding: Aspirin may prolong or increase menstrual blood loss
- Upcoming surgery: Inform your surgeon or dentist that you are taking aspirin, as it increases bleeding risk during and after procedures. Your doctor may advise temporary discontinuation before elective surgery
Aspirin must not be given to children or adolescents under 16 years of age unless specifically prescribed by a doctor. Aspirin use in this age group, particularly during or following viral infections (influenza, chickenpox), is associated with Reye’s syndrome – a rare but potentially life-threatening condition that causes swelling of the brain and liver. Use paracetamol (acetaminophen) or ibuprofen instead for fever and pain in children.
You should ensure that you stay well hydrated while taking aspirin. Taking aspirin when dehydrated (feeling thirsty, dry mouth) can worsen kidney function. This is particularly important in elderly patients, those with kidney disease, and during hot weather or vigorous exercise.
Pregnancy and Breastfeeding
Aspirin use during pregnancy requires careful medical supervision and should only be taken under a doctor’s direction. The risks vary depending on the trimester and dose:
Last trimester (weeks 28–40): Aspirin doses above 100 mg per day are contraindicated in the last three months of pregnancy. Higher doses can cause kidney and heart problems in the unborn baby, affect blood clotting in both mother and child, and delay or prolong labor. If low-dose aspirin (100 mg or less) is prescribed by your doctor during this period, the pregnancy must be closely monitored.
First and second trimester (weeks 1–27): Aspirin should be avoided unless absolutely necessary and prescribed by your doctor. If treatment is needed, the lowest effective dose should be used for the shortest possible time. From week 20 onwards, prolonged aspirin use can cause kidney problems in the fetus, potentially leading to low amniotic fluid levels (oligohydramnios) or premature constriction of the ductus arteriosus.
Breastfeeding: Aspirin passes into breast milk. You should not take aspirin while breastfeeding unless your doctor has specifically prescribed it.
Driving and Operating Machinery
Aspirin has no known effects on the ability to drive or use machines. However, if you experience side effects such as dizziness or headache, you should exercise caution until you know how aspirin affects you.
Alcohol
Consuming alcohol while taking aspirin may increase the risk of gastrointestinal bleeding and prolong bleeding time. Patients on aspirin therapy should limit alcohol intake and discuss their drinking habits with their doctor.
How Does Aspirin Interact with Other Drugs?
Aspirin interacts with many medications. The most clinically important interactions include increased bleeding risk with anticoagulants (warfarin, heparin), reduced cardioprotective effect when combined with ibuprofen, and increased toxicity of methotrexate and lithium. Always inform your doctor about all medications you are taking.
Aspirin has a broad interaction profile because of its effects on platelet function, prostaglandin synthesis, and renal clearance. Some interactions increase the risk of bleeding, while others reduce the effectiveness of aspirin or the co-administered drug. The following table summarizes the most important drug interactions:
Major Interactions (Clinically Significant)
| Drug / Class | Interaction | Clinical Significance |
|---|---|---|
| Warfarin, heparin, clopidogrel | Significantly increased bleeding risk due to combined anticoagulant and antiplatelet effects | Close monitoring of INR required; may need dose adjustment |
| Ibuprofen and other NSAIDs | Ibuprofen can block aspirin’s access to COX-1, reducing its cardioprotective antiplatelet effect; combined GI bleeding risk increased | Take aspirin 30 min before or 8 hours after ibuprofen; avoid chronic co-use |
| Methotrexate (<15 mg/week) | Aspirin reduces renal clearance of methotrexate, increasing its plasma levels and toxicity | Monitor for methotrexate toxicity; contraindicated at methotrexate doses >15 mg/week |
| SSRIs (sertraline, paroxetine) | SSRIs impair platelet serotonin uptake; combined with aspirin, the GI bleeding risk is markedly increased | Consider gastroprotection (PPI) if combination is necessary |
| Corticosteroids | Increased risk of gastrointestinal ulceration and bleeding; corticosteroids can also increase aspirin clearance | Use gastroprotection; monitor for GI symptoms |
Other Important Interactions
| Drug / Class | Interaction | Clinical Significance |
|---|---|---|
| ACE inhibitors, diuretics | Aspirin can reduce the antihypertensive effect of ACE inhibitors and the diuretic effect of furosemide and thiazides | Monitor blood pressure; dose adjustment may be needed |
| Lithium | Aspirin reduces renal excretion of lithium, increasing plasma levels and risk of toxicity | Monitor lithium levels closely |
| Digoxin | Aspirin can increase plasma levels of digoxin by reducing renal clearance | Monitor digoxin levels |
| Cyclosporine, tacrolimus | Increased risk of nephrotoxicity when combined with aspirin | Monitor kidney function regularly |
| Sulfonylureas (glibenclamide) | Aspirin may enhance the blood sugar-lowering effect of sulfonylureas | Monitor blood glucose; may need dose adjustment |
| Probenecid (gout medication) | Aspirin antagonizes the uricosuric effect of probenecid | Avoid combination; use alternative antiplatelet if needed |
| Acetazolamide | Aspirin can increase acetazolamide toxicity by reducing its renal clearance and displacing it from protein binding | Monitor for signs of acetazolamide toxicity |
| Metamizole (dipyrone) | Metamizole can reduce aspirin’s antiplatelet effect by competing for COX-1 binding | Use caution in patients taking aspirin for cardiac protection |
| Antacids | Systemic antacids can increase renal excretion of aspirin, reducing its plasma levels | Separate doses by at least 2 hours |
What Is the Correct Dosage of Aspirin?
The dosage of aspirin depends on the indication. For cardiovascular prevention, the typical dose is 75–160 mg once daily. For acute heart attack, a loading dose of 150–450 mg is given immediately. Always follow your doctor’s instructions and do not change the dose without medical advice.
Aspirin dosing varies substantially depending on the clinical indication. Low-dose aspirin for cardiovascular prevention and high-dose aspirin for pain relief represent different therapeutic uses with different safety profiles. The following dosing information applies to adult patients unless otherwise stated.
Adults – Cardiovascular Prevention
Prevention of Heart Attack
The recommended dose is 75–160 mg once daily, taken at approximately the same time each day. This dose provides effective, sustained inhibition of platelet aggregation while minimizing the risk of gastrointestinal side effects. Your doctor will determine the optimal dose based on your individual risk profile.
Prevention of Stroke
The recommended dose is 75–325 mg once daily. Higher doses within this range may be recommended for certain patients, although current guidelines generally favor lower doses (75–100 mg) to minimize bleeding risk while maintaining efficacy.
Stable or Unstable Angina Pectoris
The recommended dose is 75–160 mg once daily as part of a comprehensive cardiovascular treatment plan, often in combination with other antiplatelet or antianginal medications as directed by your cardiologist.
After Cardiac Surgery (CABG, PCI, Stent)
The recommended dose is 75–160 mg once daily, typically initiated within 24 hours of the procedure and continued long-term. After stent placement, aspirin is usually combined with a second antiplatelet agent (dual antiplatelet therapy, DAPT) for a period determined by your cardiologist.
Acute Heart Attack (Emergency Treatment)
The recommended dose is 150–450 mg, taken as soon as possible after the onset of symptoms. The tablet should be chewed (not swallowed whole) for faster absorption. This initial loading dose is critical for rapidly inhibiting platelet aggregation during an acute coronary event. Emergency medical services should be called immediately.
Elderly Patients
The same doses apply as for adults. However, aspirin should be used with particular caution in elderly patients, who are at higher risk of gastrointestinal bleeding and other adverse effects. Treatment should be reviewed regularly by the prescribing physician, and the lowest effective dose should be used. Renal function should be monitored, particularly in patients over 75 years of age.
Children and Adolescents
Aspirin should not be given to children or adolescents under 16 years of age unless specifically prescribed by a doctor, due to the risk of Reye’s syndrome. In rare circumstances where aspirin is indicated in pediatric patients (such as Kawasaki disease), dosing is strictly determined by a specialist physician.
How to Take Aspirin
Aspirin tablets should be swallowed whole with a glass of water, preferably with or after food to reduce the risk of stomach irritation. Do not crush, chew, or break enteric-coated tablets, as the coating protects the stomach lining. The exception is during an acute heart attack, where the tablet should be chewed for rapid absorption.
Missed Dose
If you forget to take a dose, skip the missed dose and take your next dose at the usual time. Do not take a double dose to make up for a forgotten dose. If you miss doses frequently, consider setting a daily alarm or using a pill organizer to help maintain your schedule.
Overdose
If you have taken too much aspirin or if a child has accidentally ingested aspirin, seek emergency medical attention immediately. Show any remaining tablets or the empty packaging to the medical team.
Symptoms of aspirin overdose include:
- Ringing in the ears (tinnitus) and hearing loss
- Headache, dizziness, and confusion
- Nausea, vomiting, and abdominal pain
- Rapid breathing (hyperventilation)
- Fever and sweating
- Restlessness, seizures, and hallucinations
- Low blood sugar, coma, and cardiovascular shock
Severe aspirin overdose can be fatal. Treatment may include activated charcoal, intravenous fluids, urinary alkalinization, and in severe cases, hemodialysis.
What Are the Side Effects of Aspirin?
Like all medicines, aspirin can cause side effects, although not everybody gets them. The most common side effects are digestive problems and increased tendency to bleed. Serious side effects requiring immediate medical attention include signs of gastrointestinal bleeding (black stools, blood in vomit), severe allergic reactions, and unusual bleeding or bruising.
The side effects of aspirin are primarily related to its inhibition of prostaglandin synthesis (which protects the stomach lining) and its antiplatelet effects (which increase bleeding tendency). The risk of side effects increases with higher doses, longer duration of treatment, and in elderly patients. If you experience any serious side effects, stop taking aspirin and contact your doctor immediately.
- Sudden wheezing, swelling of lips, face, or body, rash, fainting, or difficulty swallowing (severe allergic reaction)
- Skin redness with blisters or peeling, possibly with fever and joint pain (Stevens-Johnson syndrome, toxic epidermal necrolysis)
- Abnormal bleeding: coughing up blood, blood in vomit or urine, or black tarry stools
Common Side Effects
May affect up to 1 in 10 people
- Indigestion (dyspepsia), heartburn, nausea
- Increased tendency to bleed (prolonged bleeding from cuts, easy bruising)
Uncommon Side Effects
May affect up to 1 in 100 people
- Hives (urticaria) and skin rash
- Runny nose (rhinitis)
- Breathing difficulties (dyspnea)
Rare Side Effects
May affect up to 1 in 1,000 people
- Severe gastrointestinal bleeding (stomach, intestines), cerebral hemorrhage
- Changes in blood cell counts
- Nausea and vomiting
- Bronchospasm and asthma attacks
- Inflammation of blood vessels (vasculitis)
- Bruising with purple discoloration (purpura)
- Severe skin reactions: erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome)
- Severe allergic reactions including angioedema (swelling of face, lips, tongue) or anaphylactic shock
- Abnormally heavy or prolonged menstrual periods
Frequency Not Known
Cannot be estimated from available data
- Tinnitus (ringing in the ears) or hearing impairment
- Headache and dizziness
- Stomach or duodenal ulcers and perforation
- Prolonged bleeding time
- Impaired kidney function
- Fluid retention (edema) causing swelling of hands, feet, legs, or face
- Impaired liver function
- Elevated uric acid levels in the blood (hyperuricemia)
If you experience any side effects, talk to your doctor or pharmacist. You can also report side effects directly to your national medicines regulatory authority (e.g., FDA MedWatch in the US, Yellow Card Scheme in the UK, or EMA EudraVigilance in the EU). Reporting helps to continuously monitor the benefit-risk balance of medicines.
How Should You Store Aspirin?
Store aspirin at room temperature (below 25°C / 77°F) in the original packaging. Keep out of reach and sight of children. Do not use after the expiry date printed on the packaging.
Proper storage is essential to maintain the effectiveness and safety of aspirin. Follow these guidelines to ensure your medication remains in optimal condition:
- Temperature: Store at room temperature, not exceeding 25°C (77°F). Avoid exposing aspirin to excessive heat or direct sunlight.
- Moisture: Keep in the original blister pack or tightly closed container to protect from moisture. Do not store in the bathroom or near water sources.
- Children: Keep aspirin out of the sight and reach of children at all times.
- Expiry date: Do not use aspirin after the expiry date (EXP) stated on the packaging. The expiry date refers to the last day of the stated month.
- Signs of deterioration: Aspirin tablets that have a strong vinegar-like smell may have degraded into acetic acid and salicylic acid. Do not use tablets that appear discolored, crumbled, or have an unusual odor.
- Disposal: Do not dispose of medications in household waste or sewage. Return unused or expired medication to your pharmacy for safe disposal to protect the environment.
What Does Aspirin Contain?
Each aspirin tablet contains the active ingredient acetylsalicylic acid. The tablets are available in multiple strengths (commonly 75 mg and 500 mg) and contain inactive excipients such as microcrystalline cellulose, maize starch, colloidal anhydrous silica, and stearic acid.
Active Ingredient
The active substance is acetylsalicylic acid. Depending on the product and indication, each tablet contains either 75 mg (low-dose for cardiovascular prevention) or 500 mg (for pain relief). Other strengths available include 100 mg, 150 mg, 160 mg, 300 mg, and 325 mg depending on the manufacturer and country.
Inactive Ingredients (Excipients)
The excipients may vary between manufacturers but commonly include:
- Microcrystalline cellulose: A filler and binder that gives the tablet its form
- Maize (corn) starch: A disintegrant that helps the tablet break down in the stomach
- Colloidal anhydrous silica: A flow agent that prevents powder from clumping during manufacturing
- Stearic acid: A lubricant that prevents the tablet from sticking to machinery during production
Enteric-coated formulations may contain additional coating agents such as methacrylic acid copolymers, talc, and triethyl citrate, which create an acid-resistant layer that protects the stomach lining by delaying dissolution until the tablet reaches the small intestine.
Tablet Appearance
Aspirin tablets are typically white, round or oval, biconvex tablets. The exact size, shape, and markings vary between manufacturers and strengths. Some tablets have a break line (score) on one side to allow even splitting. Enteric-coated tablets may have a smooth, shiny appearance due to the protective coating.
Frequently Asked Questions About Aspirin
Low-dose aspirin (75–100 mg) is specifically formulated for cardiovascular prevention. At this dose, aspirin primarily inhibits platelet aggregation by irreversibly blocking COX-1 in platelets, reducing the production of thromboxane A2. Regular-dose aspirin (300–500 mg) provides analgesic, antipyretic, and anti-inflammatory effects by also inhibiting COX-2 in tissues. The key difference is that low-dose aspirin offers sustained antiplatelet protection with a lower risk of gastrointestinal side effects, while regular-dose aspirin provides broader symptom relief but with higher risk of adverse effects.
This is a clinically important question. Ibuprofen can interfere with aspirin’s cardioprotective antiplatelet effect. Ibuprofen competes for the same COX-1 binding site on platelets, and if taken before aspirin, it can reversibly occupy the active site, preventing aspirin from irreversibly acetylating the enzyme. The FDA advises taking aspirin at least 30 minutes before or at least 8 hours after ibuprofen to maintain aspirin’s antiplatelet benefit. Additionally, combining aspirin with ibuprofen or other NSAIDs significantly increases the risk of gastrointestinal bleeding. Always consult your doctor before using these medications together.
Aspirin should not be given to children or adolescents under 16 years of age because of the risk of Reye’s syndrome. This rare but potentially fatal condition causes acute swelling of the brain (encephalopathy) and fatty degeneration of the liver. It is most commonly triggered when aspirin is given during or shortly after a viral illness, particularly influenza or chickenpox. Since the link between aspirin and Reye’s syndrome was identified in the 1980s, the incidence has dropped dramatically due to widespread avoidance of aspirin in children. Paracetamol (acetaminophen) and ibuprofen are the recommended alternatives for fever and pain in children.
Low-dose aspirin for secondary cardiovascular prevention is typically prescribed as a long-term or lifelong treatment. If you have had a heart attack, stroke, or have been diagnosed with cardiovascular disease, your doctor has prescribed aspirin to reduce the ongoing risk of further events. It is crucial that you never stop aspirin suddenly without consulting your doctor, as abrupt discontinuation can trigger a rebound increase in platelet aggregation, significantly raising the risk of a new blood clot. If aspirin needs to be stopped (for example, before surgery), your doctor will plan a gradual approach and may recommend a bridging strategy.
If you suspect aspirin overdose, seek emergency medical attention immediately. Early symptoms include ringing in the ears (tinnitus), hearing impairment, headache, dizziness, and confusion, followed by nausea, vomiting, and abdominal pain. A severe overdose can rapidly progress to hyperventilation, fever, seizures, metabolic acidosis, low blood sugar, coma, and cardiovascular shock. The prognosis depends on how quickly treatment begins. Emergency treatment may include gastric decontamination with activated charcoal (if within 1–2 hours of ingestion), intravenous fluid replacement, alkalinization of the urine to enhance aspirin excretion, and in severe cases, hemodialysis.
Aspirin use during pregnancy is a complex topic that requires medical supervision. In the last trimester (weeks 28–40), aspirin doses above 100 mg per day are contraindicated because they can cause kidney and heart problems in the fetus, impair blood clotting in both mother and baby, and delay labor. In the first and second trimester, aspirin should only be used if the benefit clearly outweighs the risk. Low-dose aspirin (75–150 mg) is sometimes prescribed by obstetricians for the prevention of preeclampsia in high-risk pregnancies, but this is done under close medical monitoring. If you are pregnant or planning pregnancy, always discuss aspirin use with your doctor.
References
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