‘The chemist kept telling me I should not take it despite my doctor’s advice.’


Conflicting information from pharmacists on the safety and indication for aspirin in pregnancy may negatively influence adherence, say researchers

Women with pre-existing medical comorbidities such as chronic hypertension, diabetes, autoimmune conditions, renal disease and previous preeclampsia have an increased risk of developing preeclampsia in their pregnancy.

Early initiation of aspirin, before 16 weeks of gestation, is strongly recommended in these women. This has been shown to reduce their risk of preeclampsia by 60-70%.

However researchers say conflicting information from pharmacists on the safety and indication for aspirin in pregnancy may negatively influence adherence for these women.

A recent study published in PLOS One identified pill burden and communication with healthcare providers as main factors that influence women’s adherence with aspirin in pregnancy.

Of 154 invitations sent out, 122 women (79%) completed the survey for the study led by Dr Renuka Shanmugalingam, a nephrologist and obstetric medicine physician from the South Western Sydney Local Health District in NSW.

Factors that had potential to negatively influence adherence with aspirin in pregnancy included inconsistent messaging among healthcare providers, especially from pharmacists, which was reported in 36 (30%) of women.

A sub-analysis of this study demonstrated that 54% of women discussed the use of aspirin with their pharmacist after the initial discussion with their clinician.

However, 38% of these women were unsatisfied with the outcome of their discussion with their pharmacist and this was predominantly in relation to conflicting information from pharmacists on the safety and indication for aspirin in pregnancy.

The importance of consistent communication was further corroborated by women who participated in the interviews:

The chemist kept telling me that I should not take aspirin while I was pregnant despite my doctor’s adviceThis made my husband and mother very concerned and they discouraged me from taking the aspirinMy husband was unhappy and came with me to my appointment to talk about this with my doctorMy doctor spent a lot of time to talk to us about it and put our mind at easeShe also called the chemist after we left.” (Interview participant 6aspirin adherent group,30 yo)

The chemist told me that I should not take aspirin while I was pregnant despite my doctor’s adviceThis made my husband very concerned and discouraged me from taking the aspirin (Interview participant 1aspirin non-adherent group29 yo)

 “When I was told by the first doctorI was still a bit sceptical and it’s only when I saw the second and third doctorit sunk in and I thoughtit must be important as they are all saying the same thingIt then made senseIt works well when doctors communicate the same thingit gives us confidence.” (Interview participant 2aspirin adherent group34 yo)

Dr Shanmugalingam said that consistent messaging between healthcare providers including pharmacists plays a crucial role in helping women understand the need for aspirin in their pregnancy and improves adherence with therapy.

“The current guidelines recommend the use of 150mg of aspirin (either ½ of 300mg of aspirin or 1 and ½ of non-coated aspirin) every night. Nocte dosing of aspirin is recommended based on the data that supports its chronotherapeutic effect,” she told AJP.

“Aspirin is commenced prior to 16 weeks of gestation and often ceased between 34-36 weeks of gestation. As with general aspirin use, high-risk pregnant women are advised to take aspirin with food to minimise gastrointestinal irritation.

In the event of uncertainty, it is strongly recommended that the pharmacist contacts the prescribing clinician to make clarifications.

“Recent data suggest that misinformation from pharmacist can negatively influence adherence with aspirin in pregnancy,” she emphasised.

Dr Shanmugalingam added that there are no contraindications for concurrent use of aspirin with other pregnancy safe medications.

“However, women who are on aspirin in addition to other anticoagulants, such as enoxaparin should be made aware of the increased risk of bleeding – this concurrent use, however, is often a strong medical indication in conditions such as antiphospholipid syndrome. Any uncertainty on the indication for should be discussed directly with the treating clinician,” she said.

AJP has published a CPD activity ‘Pre-eclampsia and the use of aspirin in its prevention’ this month, written by Dr Renuka Shanmugalingam, Professor Annemarie Hennessy and Dr Angela Makris.

Find out more and access the CPD activity on pre-eclampsia and the use of aspirin here

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3 Comments

  1. Brett MacFarlane
    10/11/2020

    I was lucky to be involved with Dr Shanmugalingam and her colleagues during the development of this CPD activity for AJP. I have to say that I was pretty ignorant about pre-eclampsia itself, let alone the use of aspirin to prevent it. I remember being told at uni about the risks of NSAID use (including aspirin) in pregnant women, particularly relating to the premature closing of the duct. This is a classic example of how “rules” should always be applied in the context of the patient at the center of the therapy. Particularly in the case of pregnant women for whom pharmacists tend to be highly cautious, and rightly so. This is such an important message for pharmacists.

  2. (Mary) Kay Dunkley
    10/11/2020

    Having worked in hospitals providing O&G services I am very familiar with the use of aspirin in pregnancy. This is not new and it has been used for many years. I also understand how easy it is in other pharmacy settings, such as community pharmacy, to not to be aware of this and depending on how a question is framed, to advise against use of an NSAID during pregnancy. However there are many situations in pharmacy where answers are not straight forward and discussion is required to find out the context of a question. Who is recommending the use of a medication and why? What does the patient understand about why the medication is being used? It is also important to use the special expertise of drug information services at major hospitals, especially in an area such as medication use in pregnancy and lactation, before giving advice as new information is always emerging. In addition it is essential to make use of the compulsory reference texts that must be held in pharmacies – these cover a wide range of areas of knowledge which arise in the practice of pharmacy. While a google search or a post on facebook might produce a quick response it may not be accurate. Take time to investigate and be prepared to contact the patient later when you have undertaken your research. Spend time with the patient listening to their concerns and if necessary have a discussion with the prescribing doctor. If we want to be taken seriously as health professionals do not provide a “McDonalds” level of service.

    • Ron Batagol
      10/11/2020

      Well summarised by (Mary) Kay Dunkley
      Also, for the information of pharmacists, there is also an excellent summary on the use of low-dose aspirin for the prevention of pre-eclampsia women at in high-risk, from the New Zealand Committee of RANZCOG regarding the use of low-dose aspirin in the prevention of pre-eclampsia in high-risk women:
      The link as follows:
      https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/New%20Zealand/Guidance-Aspirin-for-Prevention-of-Pre-eclampsia.pdf

      It is also important to emphasise that there are a number of Obstetric Drug Information Centres in Australia, which are listed by TGA, and readily available.

      Pharmacists can access these Obstetric Drug Information Centres to discuss any issue relating to medicines used during pregnancy and lactation, including enquires on the expert consensus of risk versus benefit with regard to specific medicines of interest.

      The link to these Centres may be found at:
      https://www.tga.gov.au/obstetric-drug-information-services.
      Ron Batagol,

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