PRODUCT MONOGRAPH

pms-ASA
(Acetylsalicylic acid chewable tablets, USP)
81 mg

Praxis ASA EC 81 mg Daily Low Dose

(Acetylsalicylic acid delayed-release tablets, USP)
81 mg

Platelet aggregation inhibitor

Pharmascience, Inc Date of Preparation:

6111 Royalmount Ave # 100 July 18, 2006
Montreal, Quebec Date of Revision:
H4P 2T4 July 30, 2009

Control No. 131594

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 PRODUCT MONOGRAPH

pms-ASA
(Acetylsalicylic acid chewable tablets, USP)
81 mg
Praxis ASA EC 81 mg Daily Low Dose
(Acetylsalicylic acid delayed release tablets, USP)
81 mg

THERAPEUTIC OR PHARMACOLOGICAL CLASSIFICATION

Platelet aggregation inhibitor.

ACTION AND CLINICAL PHARMACOLOGY

ASA interferes with the production of prostaglandins in various organs and tissues through
acetylation of the enzyme cyclo-oxygenase. Prostaglandins are themselves powerful irritants and
produce headaches and pain on injection in man. Prostaglandins also appear to sensitize pain
receptors to other noxious substances such as histamine and bradykinin. By preventing the
synthesis and release of prostaglandins in inflammation, ASA may avert the sensitization of pain
receptors.

The antipyretic activity of ASA is due to its ability to interfere with the production of
prostaglandin E 1 in the brain. Prostaglandin E 1 is one of the most powerful pyretic agents
known.

The inhibition of platelet aggregation by ASA is due to its ability to interfere with the production
of thromboxane A 2 within the platelet. Thromboxane A 2 is largely responsible for the
aggregating properties of platelets.

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 INDICATIONS AND CLINICAL USE

Acetylsalicylic acid (ASA) is indicated for the following uses, based on its platelet aggregation
inhibitory properties:

-For reducing the risk of morbidity and death in patients with unstable angina and in those
with previous myocardial infarction.

-For reducing the risk of transient ischemic attacks (TIA) and for secondary prevention of
atherothrombotic cerebral infarction;

In addition, pms-ASA 81 mg and Praxis ASA EC 81 mg Daily Low Dose 81 mg are also
indicated for the following uses, based on its platelet aggregation inhibitory properties:

-For reducing the risk of vascular mortality in patients with a suspected acute myocardial
infarction.
-For reducing the risk of a first non-fatal myocardial infarction in individuals deemed to be
at sufficient risk of such an event by their physician. There is no evidence for a reduction
in the risk of first fatal myocardial infarction. ASA does not reduce the risk of either
cardiovascular mortality or first strokes, fatal or non-fatal. The decrease in the risk of first
non-fatal myocardial infarction must be assessed against a much smaller but significant
increase in the risk of haemorrhagic stroke as well as gastrointestinal bleeding.

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 CONTRAINDICATIONS

Use of pms-ASA 81 mg and Praxis ASA EC 81 mg Daily Low Dose 81 mg is contraindicated in

patients:
- who are hypersensitive to this drug or to any ingredient in the formulation or component of
the container. For a complete listing, see COMPOSITION and AVAILABILITY OF
DOSAGE FORMS sections of the product monograph.
- with a history of asthma induced by the administration of salicylates or substances with a
similar action, notably non-steroidal anti-inflammatory drugs
- also taking methotrexate at doses of 15 mg/week or more
- during their last trimester of pregnancy
- with any Hemorrhagic diathesis
- with an Active peptic ulcer.

WARNINGS AND PRECAUTIONS

General
ASA is one of the most frequent causes of accidental poisonings in toddlers and infants. Tablets
should be kept well out of the reach of children.
Salicylates should be administered cautiously to patients with:
- Hypersensitivity to anti-inflammatory or antirheumatic drugs or other allergens
- impaired renal function or hepatic function
- a history of chronic or recurrent gastrointestinal ulcerations and bleeds
- a history of bleeding tendencies, significant anemia and/or hypothrombinemia

Hypersensitivity
Acetylsalicylic acid (ASA) may precipitate bronchospasm and induce asthma attacks or other
hypersensitivity reactions. Risk factors are present bronchial asthma, hay fever, nasal polyps, or
chronic respiratory disease. This applies also for patients showing allergic reactions (e.g.
cutaneous reactions, itching, urticaria) to other substances.

4
Hematologic
Due to effect on platelet aggregation, ASA may be associated with an increased risk of bleeding.
Caution is necessary when salicylates and anticoagulants are prescribed concurrently, as
salicylates can depress the concentration of prothrombin in the plasma.

Peri-Operative Considerations
Due to its inhibitory effect on platelet aggregation ASA may lead to an increased bleeding
tendency during and after surgical operations (including minor surgeries, e.g. dental extractions).

Special Populations
Pregnant Women:
Use of salicylates in the first 3 months of pregnancy has been associated in several
epidemiological studies with an elevated risk of malformations (cleft palate, heart
malformations). After normal therapeutic doses this risk seems to be low: a prospective study
with exposure of about 32,000 mother-child pairs has not yielded any association with the risk of
malformations.

Salicylates should be taken during pregnancy only after strict risk benefit evaluation.

In the last 3 months of pregnancy, administration of salicylates in high doses (>300mg/day) can
lead to prolongation of the gestation period, premature closure of the arterial duct and inhibition
of uterine contractions. An increased hemorrhagic tendency has been observed in both mother
and child.

Administration of ASA in high doses (> 300 mg/d) shortly before birth, can lead to intracranial
hemorrhages, particularly in premature babies.

Nursing Women:
Acetylsalicylic acid (ASA) and its metabolites pass into breast milk in small quantities. Since
no adverse effects on the infant have been observed after occasional use, interruption of breast-

5
feeding is usually unnecessary. However, on regular use or on intake of high doses, breast
feeding should be discontinued early.

Pediatrics:
A possible association between Reye's syndrome and the use of salicylates has been suggested
but not established. Reye's syndrome has also occurred in many patients not exposed to
salicylates. Acetylsalicylic acid (ASA) should not be used in children and teenagers for viral
infections with or without fever without consulting a physician. In certain viral illnesses,
especially influenza A, influenza B and varicella, there is a risk of Reye's syndrome, a very
rare but possibly life-threatening illness requiring immediate medical action. The risk may be
increased when ASA is given concomitantly; however, no causal relationship has been proven.
Should persistent vomiting occur with such diseases; this may be a sign of Reye's syndrome.

Low Uric Acid Excretion:

At low doses, ASA reduces excretion of uric acid. This can trigger gout in patients who already
tend to have low uric acid excretion.

Monitoring and Laboratory Tests:

Salicylates can produce changes in thyroid function tests.
Isolated cases of liver function disturbances (transaminases increase) have been described.

ADVERSE REACTIONS

Many adverse reactions due to ASA ingestion are dose-related. The following is a list of adverse
reactions that have been reported in the literature and from both clinical and post-marketing
experience.

Gastrointestinal: (the frequency and severity of these adverse effects are dose-related): nausea,
vomiting, diarrhea, gastrointestinal bleeding and/or ulceration, dyspepsia, heartburn,
hematemesis and melena.
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Ear: tinnitus, vertigo, hearing loss.

Hematologic: leukopenia, thrombocytopenia, purpura, anemia.

Dermatologic and hypersensitivity: urticaria, angioedema, pruritus, skin eruptions, asthma,

anaphylaxis.

Miscellaneous: mental confusion, drowsiness, sweating, thirst.

DRUG INTERACTIONS

Overview
Acetylsalicylic acid (ASA) should be used with caution with other products that have
anticoagulation or antiplatelet effects, as these effects may be potentiated. Drugs that bind to
protein binding sites should also be used cautiously since ASA may displace drugs from their
protein, binding site.

Methotrexate, used at 15mg/week or less: Salicylates may retard the elimination of

methotrexate by decreasing renal clearance of methotrexate, displacing methotrexate from
protein binding sites, and thereby increasing its hematological toxicity.

Anti-coagulants, e.g. warfarin, heparin: Caution is necessary when salicylates and

anticoagulants are prescribed concurrently, as salicylates can depress the concentration of
prothrombin in the plasma.
Oral hypoglycemics, e.g. insulin, sulfonylureas: Large doses of salicylates have a hypoglycemic
action and may enhance the effect of oral hypoglycemic agents. Diabetics receiving concurrent
salicylate and hypoglycemic therapy should be monitored closely; reduction of the sulfonylurea
hypoglycemic drug dosage may be necessary.
Diuretics: Sodium excretion produced by spironolactone may be decreased by salicylate
administration.

7
Uricosuric Agents: Salicylates in large doses are uricosuric agents; smaller amounts may
depress uric acid clearance and thus decrease the uricosuric effects of other drugs.
Valproic Acid: Salicylates may alter valproic acid (VPA) metabolism and may displace VPA
from protein binding sites, possibly intensifying the effects of VPA. Caution is recommended
when VPA is administered concomitantly with salicylates.
Glucocorticoids (systemic), except hydrocortisone used as replacement therapy in
Addison's disease: Decreased blood salicylate levels during corticosteroid treatment and risk of
salicylate overdose after this treatment is stopped via increased elimination of salicylates by
corticosteroids.
Angiotensin Converting Enzyme (ACE) Inhibitors: The hyponatremic and hypotensive
effects of ACE inhibitors may be diminished by the concomitant administration of ASA due to
its indirect effect on the rennin-angiotensin conversion pathway. The potential interaction may
be related to the dose of ASA (3g/day or more).
Digoxin: Plasma concentrations of digoxin are increased due to a decrease in renal excretion.

ASA and other NSAIDs:

The use of other non-steroidal anti-inflammatory drugs with salicylates at high doses ($3g/day)
may increase the risk of ulcers and gastrointestinal bleeding due to a synergistic effect.
Ibuprofen: Ibuprofen may interfere with the cardioprotective effects and platelet aggregation
inhibitory properties of ASA. Patients should talk to their doctor if they are on an ASA regimen
and take ibuprofen for pain. Studies have shown that single doses and multiple doses of
ibuprofen may interfere with the anti-platelet effects of low dose ASA.

Drug-Food Interactions
Interactions with food have not been established.

Drug-Herb Interactions
Interactions with herb have not been established.

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Drug-Laboratory Interactions
Salicylates can produce changes in thyroid function tests.

Drug-Lifestvle Interactions
Patients taking ASA daily are at an increased risk of developing gastrointestinal bleeding
following the ingestion of alcohol.

DOSAGE AND ADMINISTRATION

Platelet aggregation inhibitor:

- For suspected acute myocardial infarction: An initial dose of at least 160 -162.5 mg
chewed or crushed to ensure rapid absorption as soon as a myocardial infarction is
suspected. The same dose should be given as maintenance over the next 30 days. After
30 days, consider further therapy based on dosage and administration for prevention of
recurrent MI (see Prior Myocardial Infarction).

- For the prevention of a first non-fatal myocardial infarction: 80 - 325 mg daily according
to the individual needs of the patient, as determined by the physician.

- For reducing the risk of morbidity and death in patients with unstable angina and in those
with previous myocardial infarction: 80 - 325 mg daily according to the individual needs
of the patient, as determined by the physician.

- For reducing the risk of transient ischemic attacks (TIA) and for secondary prevention of
atherothrombotic cerebral infarction: 80 - 325 mg daily according to the individual needs
of the patient, as determined by the physician.

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 PHARMACEUTICAL INFORMATION

Drug Substance
Proper Name: Acetylsalicylic acid

Chemical Names: 2-(Acetyloxy) benzoic acid;

Salicylic acid acetate.

Structure:

OH
O
O
CH3

Molecular Formula: C9H8O4

Molecular Weight: 180.16

Description: White granules, commonly tabular or needle-like, or white crystalline

powder. Odorless or having a faint odor.

Solubility: Slightly soluble in water; freely soluble in alcohol; soluble in chloroform

and ether; sparingly soluble in absolute ether.

pK value (25°C): 3.49

Melting Point: 135°C (rapid heating)

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 COMPOSITION

pms-ASA: Each chewable tablet contains 81 mg acetylsalicylic acid as active

ingredient. Non-medicinal ingredients: DC Yellow #10, FDC Red
#40, mannitol, orange flavor, pregelatinized starch, sodium saccharin,
stearic acid.

Praxis ASA EC 81 mg Daily Low Dose:

Each enteric-coated tablet contains 81 mg acetylsalicylic acid as active
ingredient. Non-medicinal ingredients: Colloidal silicon dioxide, FD & C
Blue #1, hydroxypropyl methylcellulose, lactose, methacrylic acid
copolymer type C, methylated silica, methylcellulose,
polydimethylsiloxane, polyethylene glycol, pregelatinized starch,
siliconemulsion, sodium lauryl sulfate, sorbitan tristearate, stearic acid,
talc, titanium dioxide, triethyl citrate.

AVAILABILITY OF DOSAGE FORM

pms-ASA: Each chewable, salmon coloured, round, biconvex tablet,

embossed “ASAPHEN 81” contains 81 mg acetylsalicylic acid.
In packages of 30 and 120 tablets.

Praxis ASA EC 81 mg Daily Low Dose Each round, blue coated tablet contains 81 mg
acetylsalicylic acid. In packages of 24, 30, 100,
120, 150, 180, 225, 250 255 and 1000 tablets and in
blister packs of 7 tablets.

STABILITY AND STORAGE RECOMMENDATIONS

Store at room temperature (15°-30°C).

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 PATIENT INFORMATION TO BE DISTRIBUTED ONLY BY
PHYSICIANS/PHARMACISTS

pms-ASA 81 mg
(Acetylsalicylic Acid Tablets USP)
Praxis ASA EC 81 mg Daily Low Dose 81 mg
(Acetylsalicylic Acid Delayed Release Tablets USP)
This leaflet is a summary and will not tell you everything about pms-ASA 81 mg and Praxis
ASA EC 81 mg Daily Low Dose 81 mg. Contact your doctor or pharmacist if you have any
questions about the drug.

This section provides you with information about pms-ASA 81 mg acetylsalicylic acid
(chewable) tablets, Praxis ASA EC 81 mg Daily Low Dose 81 mg acetylsalicylic acid (enteric
coated) tablets and how to take this medication. Please read carefully before you take this
medication.

Your physician has recommended pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose
81 mg for doctor-supervised adult long-term preventative therapy.

Follow your physician's instructions concerning the use of pms-ASA 81 mg or Praxis ASA EC
81 mg Daily Low Dose 81 mg as well as any lifestyle changes, e.g. diet and/or exercise, that
he/she may have recommended. Always contact your physician if you experience any
difficulties while taking this product.

pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg contains acetylsalicylic

acid, commonly referred to as ASA, as its active ingredient. Plain (uncoated) ASA, particularly
when taken regularly, may cause stomach upset in some people. The special enteric coating of
Praxis ASA EC 81 mg Daily Low Dose 81 mg tablets allows them to pass intact through the
stomach and on into the intestine before they dissolve which may reduce the risk of stomach
upset.

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Your physician has specifically recommended pms-ASA 81 mg or Praxis ASA EC 81 mg Daily
Low Dose 81 mg because it contains a special, low-dose, formulation of ASA. Other
medications such as acetaminophen or ibuprofen that are meant to relieve pain do not have the
same preventative action as pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg
which has been specifically formulated for your condition.

DIRECTIONS FOR USE

It is very important that you take this medication as directed by your physician. If you have not
seen a physician, do not take this medication until you have done so.

Dosage:
1 to 4 tablets daily of pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg,
depending on your doctor's instructions. You should take this medication at the same time every
day to help you to remember to take it. For maximum effectiveness, it is very important to take
pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg every day, as directed by
your physician. Do not take more tablets than your physician recommends.

Praxis ASA EC 81 mg Daily Low Dose 81 mg tablets must be swallowed whole for the
medication to work properly. Praxis ASA EC 81 mg Daily Low Dose 81 mg tablets have a
special enteric coating designed to help prevent stomach upset. To benefit from this
protection, the tablets should not be crushed or broken unless in the case of a heart attack.
pms-ASA 81 mg tablets are chewable and therefore must be chewed well and swallowed.

NON-MEDICINAL INGREDIENTS
pms-ASA 81 mg
DC Yellow #10, FDC Red #40, mannitol, orange flavor, pregelatinized starch, sodium saccharin,
stearic acid.
Praxis ASA EC 81 mg Daily Low Dose 81 mg
Colloidal silicon dioxide, FD & C Blue #1, hydroxypropyl methylcellulose, lactose, methacrylic
acid copolymer type C, methylated silica, methylcellulose, polydimethylsiloxane, polyethylene

13
glycol, pregelatinized starch, silicon emulsion, sodium lauryl sulfate, sorbitan tristearate, stearic
acid, talc, titanium dioxide, triethyl citrate.

ANSWERS TO COMMONLY ASKED QUESTIONS

WHY WAS ASA RECOMMENDED BY MY DOCTOR?

FOR PREVENTION OF A SECOND HEART ATTACK OR STROKE (DAILY THERAPY)
It can be used to prevent a second stroke or heart attack. If you have experienced either a stroke
or a heart attack you may be at risk for a second one. There are certain risk factors that can place
you at an increased risk:
-Overweight -Stress
-Smoking -High blood cholesterol
-Inactive (sedentary) lifestyle -High blood pressure

These can be discussed with your physician in order to complement the effectiveness of pms-
ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg.

Your doctor may recommend changes in diet, exercise and lifestyle for your benefit in avoiding a
second heart attack or stroke.
If you experience any difficulties with your treatment always discuss with your doctor or
pharmacist.

USE DURING A HEART ATTACK

If you think you are having a heart attack, call an ambulance immediately, and chew (pms-ASA
81 mg) or crush (Praxis ASA EC 81 mg Daily Low Dose 81 mg) and ingest 2 tablets. It is
important to chew or crush the product, to ensure this medicine works quickly. Then get to a
hospital immediately for medical attention. Taking ASA at the first signs and symptoms can
reduce your risk of dying from the heart attack.

The signs and symptoms of a heart attack include:

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 1. uncomfortable pressure, fullness, squeezing or pain in the center of the chest

that lasts more than a few minutes, or goes away quickly and comes back,

2. pain that spreads to the shoulders, neck or arms,

3. chest discomfort with lightheadedness, fainting, sweating, nausea or shortness

of breath.

At the hospital, the doctor will then recommend appropriate therapy

WHAT IF I FORGET TO TAKE MY MEDICATION?

If you forget to take your medication at the usual time, take it when you remember. Do not take
extra medication to compensate for a missed dosage unless instructed by your physician.

SIDE EFFECTS AND WHAT TO DO ABOUT THEM

Like all medication, ASA may occasionally produce unwanted side effects. You should call
your doctor if you experience any of the following: nausea, vomiting, stomach irritation, ringing
or buzzing in the ears or pain, or if you notice that you are bruising more easily than you were
before starting a daily dose of ASA.

Regular daily use of alcohol while on ASA daily therapy may increase your risk of
developing gastrointestinal bleeding.

SERIOUS SIDE EFFECTS AND WHAT TO DO ABOUT THEM

Stop use and call your doctor if you experience an allergic reaction (skin rash, hives,
itching or breathing difficulties); stomach bleeding, loss of hearing or bleeding.

WHEN IT SHOULD NOT BE USED

ASA should not be used if you:

- Are allergic to ASA or any ingredient within the formulation.

15
 - Have an active stomach ulcer

- Have a history of asthma induced by salicylates or other anti-

inflammatory drugs

- Are using methotrexate at doses of 15mg/week or more

- Are in the last trimester of pregnancy

- Are prone to bleeding.

WHAT ELSE SHOULD I KNOW BEFORE TAKING THIS MEDICINE?

Your doctor will ask you many questions about your health, lifestyle, and medications before
recommending pms-ASA 81 mg or Praxis ASA EC 81 mg Daily Low Dose 81 mg.

This is why it is very important that you tell your doctor all such information. If you have
forgotten to tell your doctor about any of the following, call your doctor or pharmacist before
you take this medicine.

- Allergy to salicylates - Are pregnant or breast-feeding

- Asthma - Will be having surgery in five to seven days

- Stomach problems - Are taking other medications containing salicylates or

acetaminophen

- Peptic ulcer - Are taking anti-inflammatory drugs, anticonvulsants,

anti-diabetics or gout medication

- Severe liver/kidney disease - Are taking or planning to take this medication while

consuming alcohol

- Severe anemia - History of blood clotting defects or receiving blood thinners

_____________________________________________________________________________
Ibuprofen may interfere with the protective benefits of ASA. Talk to your doctor if you are on an
ASA regimen and taking ibuprofen for pain.

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CAUTION

This product is not recommended for children or teenagers. This package contains enough
drug to seriously harm a child. Keep out of children's reach. Do not administer to children and
teenagers for chicken pox or flu symptoms before a doctor is consulted. Reye's syndrome, which
can occur in children or teenagers, is a rare but serious illness reported to be associated with
ASA.

It is especially important not to use this medication during the last 3 months of pregnancy
unless specifically directed to do so by your physician because it may cause problems in the
unborn child or complications during delivery.

Call your doctor before taking this drug when nursing.

In case of accidental overdose call a doctor or hospital immediately, even if there are no

symptoms.

HOW TO STORE IT

Keep out of reach of children

Store at room temperature 15-30EC

REPORTING SUSPECTED SIDE EFFECTS

To monitor drug safety, Health Canada through the Canada Vigilance Program
collects information on serious and unexpected effects of drugs. If you suspect you have
had a serious or unexpected reaction to this drug you may notify Canada Vigilance by:

Toll-free telephone: 866-234-2345

Toll-free fax: 866-678-6789

Online: www.healthcanada.gc.ca/medeffect

17
By email: [email protected]

By regular mail:

Canada Vigilance National Office

Marketed Health Products Safety and Effectiveness

Information Bureau

Marketed Health Products Directorate

Health Products and Food Branch

Tunney's Pasture, AL 0701C

Ottawa ON K1A OK9

NOTE: Should you require information related to the management of the side effects,
please contact your health care provider before notifying Canada Vigilance. The Canada
Vigilance Program does not provide medical advice.

Product Monograph is available to health professionals upon request.

For further information or questions about this product, contact Pharmascience Inc.,
Montreal, Canada at their Medical Information Hotline between 8:30 am and 4:30 pm,
Eastern Standard Time, Monday to Friday. Call toll-free at 1-888-550-6060.

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 PHARMACOLOGY

Absorption, distribution, metabolism and excretion:

When ASA is taken orally, it is rapidly absorbed from the stomach and proximal small intestine.
The gastric mucosa is permeable to the non-ionized form of acetylsalicylic acid, which
passes through the stomach wall by a passive diffusion process.

Optimum absorption of salicylate in the human stomach occurs in the pH range of 2.15 to 4.10.

Absorption in the small intestine occurs at a significantly faster rate than in the stomach. After
an oral dose of 0.65 g ASA, the plasma acetylsalicylate concentration in man usually reaches a
level between 0.6 and 1.0 mg% in 20 minutes after ingestion and drops to 0.2 mg% within an
hour. Within the same period of time, half or more of the ingested dose is hydrolyzed to salicylic
acid by esterases in the gastrointestinal mucosa and the liver, the total plasma salicylate
concentration reaching a peak between one or two hours after ingestion, averaging between 3
and 7 mg%. Many factors influence the speed of absorption of ASA in a particular individual at
a given time; tablet disintegration, solubility, particle size, gastric emptying time, psychological
state, physical condition, nature and quantity of gastric contents, etc., all affect absorption.

Distribution of salicylate throughout most body fluids and tissues proceeds at a rapid rate after

absorption. Aside from the plasma itself, fluids which have been found to contain substantial
amounts of salicylate after oral ingestion include spinal, peritoneal and synovial fluids, saliva
and milk. Tissues containing high concentrations of the drug are the kidney, liver, heart and
lungs. Concentrations in the brain are usually low, and are minimal in feces, bile and sweat.

The drug readily crosses the placental barrier. At clinical concentrations, from 50% to
90% of the salicylate is bound to plasma proteins especially albumin, while acetylsalicylic
acid itself is bound to only a very limited extent. However, ASA has the capacity of
acetylating various proteins, hormones, DNA, platelets and hemoglobin, which at least
partly explains its wide-ranging pharmacological actions.

19
The liver appears to be the principal site for salicylate metabolism, although other tissues may
also be involved. The three chief metabolic products of ASA or salicylic acid are salicyluric
acid, the ether or phenolic glucuronide and the ester or acyl glucuronide. A small fraction is also
converted to gentisic acid and other hydroxybenzoic acids. The half-life of ASA in the
circulation is from 13 to 19 minutes so that the blood level drops quickly after absorption is
complete. However, the half-life of the salicylate ranges between 3.5 and 4.5 hours, which
means that 50% of the ingested dose leaves the circulation within that time.

Excretion of salicylates occurs principally via the kidney, through a combination of

glomerular filtration and tubular excretion, in the form of free salicylic acid, salicyluric acid, as
well as phenolic and acyl glucuronides. Salicylate can be detected in the urine shortly after its
ingestion but the full dose requires up to 48 hours for complete elimination. The rate of
excretion of free salicylate is extremely variable, reported recovery rates in human urine ranging
from 10% to 85%, depending largely on urinary pH. In general, it can be stated that acid urine
facilitates reabsorption of salicylate by renal tubules, while alkaline urine promotes excretion of
the drug.

Effects on platelets: relation to hemostasis and thrombosis.

Platelets play an important role in normal hemostasis and clinical pathologic and experimental
evidence indicates that their aggregation may play an equally important role in the evolution of a
variety of disease states including cerebrovascular disease, ischemic heart disease and
myocardial infarction. ASA inhibits platelet aggregation by irreversibly acetylating platelet
cyclo-oxygenase, thereby blocking the production of prostaglandin endoperoxides PGG2 and
PGH2 which are precursors of the major platelet-aggregating material, thromboxane A2, which is
also a powerful vasoconstrictor. However, ASA does not prevent the adherence of platelets to
damaged vessel walls or the release of granule contents from these adherent platelets. As the
anuclear platelets are unable to synthesize new enzyme molecules to replace those that have been
inactivated, inhibition of platelet aggregation by ASA thus persist for the life of the platelets.

Daily administration of 20 to 40 mg of ASA to healthy volunteers reduced platelet

20
thromboxane production but inhibited platelet aggregation only partially. When administered to

patients recovering from myocardial infarction, 50 mg ASA daily had the same effects on
thromboxane production, platelet aggregation and bleeding times as 324 mg daily. Other studies
show that ASA doses of 40 to 325 mg daily suppressed thromboxane production by at least 80
%, but 80 mg ASA daily was the lowest dose required for maximum cumulative thrombocyte
function inhibition. The protective effect of ASA against experimentally induced thrombosis or
atherosclerosis has been demonstrated in several animal models.

Besides inhibiting the biosynthesis of thromboxane A2 by platelets, ASA also interferes with the
production of prostacyclin (PGI2) by vascular endothelial cells, the above-mentioned
prostaglandin endoperoxides being common precursors of both thromboxane A2 and
prostacyclin. This latter compound is one of the most powerfully acting platelet deaggregators
and vasodilators and thus it would appear that the interference with the hemostatic processes by
ASA depends on the thromboxane-prostacyclin balance. In fact, it has been suggested that under
some conditions, high doses of ASA may be thrombogenic. However, in contrast to platelets,
the vascular endothelial cells are able to regenerate cyclo-oxygenase in a relatively short time
and therefore therapeutic doses of ASA are likely to produce a lesser inhibition of the vascular
prostacyclin system than of the platelet thromboxane-forming mechanism. In fact, there is no
clinical evidence to indicate that high doses of ASA would result in an increased risk of
thromboembolism. Indeed, quite the contrary was observed and, in a controlled study,
paradoxical shortening of the bleeding time was not observed at a daily ASA dose 3.6 g. Lower
dosages of ASA make selective blocking of the TxA2-synthesis without a simultaneous blocking
of PGI2-production possible.

The use of ASA in patients with a suspected acute myocardial infarction was investigated in

a large multicenter trial involving over 17,000 patients. Treatment with ASA resulted in a
23% reduction in the risk of vascular mortality versus placebo at 5 weeks. This use
translates to a reduction of 24 deaths and 14 non-vascular events per 1000 patients treated.

21
The effect of time to therapy revealed that patients treated with ASA “early” (0 to 4 hours)
versus “late” (5 to 24 hours) after symptom onset experienced reductions in the odds of vascular
death of 25% versus 21%, versus placebo at 5 weeks. ‘Early’ treatment with ASA resulted in
the saving of 4 additional lives per 1000 patients versus ‘late’ treatment.

Long term follow-up (up to 10 years) of patients in this study established that the early
survival advantage to ASA persisted long term, and that this prolonged benefit was additive
to that of fibrinolytic therapy.

The use of ASA for secondary prevention of thrombotic events is supported by a

comprehensive overview of a number of clinical trials involving patients who already had some
type of vascular disease (myocardial infarction, unstable angina, stroke or transient cerebral
ischemia). Overall, these studies point to a 26-28% reduction of the combined endpoints of MI,
stroke, or vascular deaths by treatment with ASA alone at doses of 75 to 325 mg daily. Studies
which directly compared low doses with higher doses (30-1200 mg/day), indicated that the
incidence of gastrointestinal adverse effects were significantly less common with the lower
doses.

Recent discussions have focused on the efficacy of ASA for the primary prevention of
myocardial infarction and stroke. Two large scale randomized trials, aimed at evaluating
prophylactic use of ASA, were conducted among apparently healthy male physicians (22,000 in
the United States and 5,000 in the United Kingdom respectively and their results have been
published. In the summary overview of the combined results presented by the principal
investigators, the authors state that:

“...Taken together, these two primary-prevention studies demonstrate a significant (P<0.0001)

reduction in nonfatal myocardial infarction of about one third.”

On the other hand, the same two studies have not indicated any reduction in overall vascular

22
mortality and also suggested a slight increase in the risk of non-fatal disabling stroke. Current
controversy exists about the applicability of these findings, obtained in a selected population, to

the general public. As well, the optimum dosage regimen still remains an open question in this

regard. Thus, the use of ASA for primary prevention should remain, in the words of the
principal investigators:

“A matter of judgment in which the physician considers the cardiovascular risk profile
of the patient and balances the known hazards of aspirin...against the clearly established
reduction in the incidence of a first myocardial infarction.”

TOXICOLOGY

The clinical and pathological signs of poisoning from toxic and lethal oral doses of ASA have
been extensively described for man, much less extensively for other species.

The acute toxicity of ASA in animals has been studied and reviewed in detail by Boyd. The
signs of poisoning in rats from doses in the lethal range are due to varying degrees of
gastroenteritis, hepatitis, nephritis, pulmonary edema, encephalopathy, shock and minor toxic
effects on other organs and tissues. Death is due to convulsions or cardiovascular shock. The
major difference between species appears to be the ability to vomit toxic doses seen in man, cats
and dogs, but not in mice, rats and rabbits. Otherwise, the pathological reaction to toxic doses of
ASA is similar in all species in which such studies have been reported. The acute oral LD50
values have been reported as being over 1.0 g/kg in man, cat and dog, 0.92 g/kg in female and
1.48 g/kg in male albino rats, 1.19 g/kg in guinea pig, 1.1 g/kg in mouse and 1.8 g/kg in rabbit.

Chronic toxicity studies were reported in mice and rats. When ASA was administered at 2 to 20
times the maximum tolerated clinical dose to mice for up to one year, a dose-related deleterious
effect was observed on mean survival time, number of young born and number of young raised
to wearing age, no evidence of carcinogenic effect was found.

23
The chronic oral LD50 in male albino rats has been reported as 0.24g/kg/day when given for 100
days. At these daily doses ASA produced no anorexia and no loss of body weight. It did produce
polydipsia, aciduria, diuresis, drowsiness, hyperreflexia, piloeraction, rapid and deep respiration,
tachycardia, and during the second month, soft stools, epistaxis, sialorrhea, dacryorrhea and
death in hypothermic coma. Autopsy disclosed the presence of a hypertrophied stomach, renal
congestion, mild hepatitis and pneumonitis. While teratogenic effects were noted in animals at
near lethal doses, there is no evidence to indicate that ASA is teratogenic in man.

24
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