About Aspirin
GI Risk

GI Symptoms May Lead to Discontinuation of Aspirin When Taken for Secondary Prevention of CV Events

Daily aspirin remains a gold standard for secondary prevention of CV events, but can lead to GI AEs.1-4

Guidelines recommend GI risk assessment and PPI co-prescription for patients with5:

  • History of ulcer
  • Aged 60 years
  • Dual antiplatelet and/or concomitant anticoagulant therapies during aspirin use

AE, adverse event, CV, cardiovascular, GI, gastrointestinal. PPI, proton pump inhibitor.

GI Symptoms and Aspirin Discontinuation

Enteric-coated (EC) aspirin shows a similar risk of upper GI bleeding vs plain aspirin

EC and plain aspirin (≤325 mg/day) have a comparable risk for GI bleeding6

Comparable risk for GI bleeding between EC and plain aspirin

Even low-dose aspirin regimens can cause upper GI AEs7

  • 2.6x increased risk of upper GI bleeding (≤100 mg/day) vs no aspirin

GI AEs can increase the risk of aspirin discontinuation4,*

  • 1.7x increased risk with dyspepsia or gastritis
  • 1.8x increased risk with esophageal ulcer
  • 5.5x increased risk with peptic ulcer

*Based on odds ratio calculation of aspirin discontinuation vs non-discontinuation.4

Yosprala (aspirin/omeprazole) Learn about Yosprala
Indications and Usage

Yosprala, a combination of aspirin and omeprazole, is indicated for patients who require aspirin for secondary prevention of cardiovascular and cerebrovascular events and who are at risk of developing aspirin-associated gastric ulcers.

The aspirin component of Yosprala is indicated for:

  • Reducing the combined risk of death and nonfatal stroke in patients who have had ischemic stroke or transient ischemia of the brain due to fibrin platelet emboli
  • Reducing the combined risk of death and nonfatal MI in patients with a previous MI or unstable angina pectoris
  • Reducing the combined risk of MI and sudden death in patients with chronic stable angina pectoris
  • Use in patients who have undergone revascularization procedures (Coronary Artery Bypass Graft [CABG] or Percutaneous Transluminal Coronary Angioplasty [PTCA]) when there is a pre-existing condition for which aspirin is already indicated

The omeprazole component of Yosprala is indicated for decreasing the risk of developing aspirin-associated gastric ulcers in patients at risk for developing aspirin-associated gastric ulcers due to age ( 55) or documented history of gastric ulcers.

Limitations of Use:
  • Yosprala contains a delayed-release formulation of aspirin and it is not for use as the initial dose of aspirin therapy during onset of acute coronary syndrome, acute myocardial infarction, or before percutaneous coronary intervention (PCI), for which immediate-release aspirin therapy is appropriate
  • Yosprala has not been shown to reduce the risk of gastrointestinal bleeding due to aspirin
  • Yosprala is not interchangeable with the individual components of aspirin and omeprazole
Important Safety Information
Contraindications

Yosprala is contraindicated in:

  • Patients with known allergy to aspirin and other nonsteroidal anti-inflammatory drug products (NSAIDs) and in patients with the syndrome of asthma, rhinitis, and nasal polyps. Aspirin may cause severe urticaria, angioedema, or bronchospasm (asthma)
  • Pediatric patients with suspected viral infections, with or without fever, because of the risk of Reye’s syndrome with concomitant use of aspirin in certain viral illnesses
  • Patients with known hypersensitivity to aspirin, omeprazole, substituted benzimidazoles, or to any of the excipients in the formulation
  • Proton pump inhibitor (PPI)–containing products, including Yosprala, are contraindicated in patients receiving rilpivirine-containing products
Warnings and Precautions
Coagulation Abnormalities

Even low doses of aspirin can inhibit platelet function leading to an increase in bleeding time. This can adversely affect patients with inherited (hemophilia) or acquired (liver disease or vitamin K deficiency) bleeding disorders. Monitor patients for signs of increased bleeding.

Gastrointestinal Adverse Reactions

Aspirin is associated with serious gastrointestinal (GI) adverse reactions, including inflammation, bleeding ulceration and perforation of the upper and lower GI tract. Other adverse reactions with aspirin include stomach pain, heartburn, nausea, and vomiting.

Although minor upper GI symptoms, such as dyspepsia, are common and can occur anytime during therapy, monitor patients for signs of ulceration and bleeding, even in the absence of previous GI symptoms. Inform patients about the signs and symptoms of GI adverse reactions.

If active and clinically significant bleeding from any source occurs in patients receiving Yosprala, discontinue treatment.

Bleeding Risk with Use of Alcohol

Counsel patients who consume three or more alcoholic drinks every day about the bleeding risks involved with chronic, heavy alcohol use while taking Yosprala.

Interaction with Clopidogrel

Avoid concomitant use of Yosprala with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as omeprazole, that interfere with CYP2C19 activity. Co-administration of clopidogrel with 80-mg omeprazole reduces the pharmacological activity of clopidogrel, even when administered 12 hours apart. When using Yosprala, consider alternative anti-platelet therapy.

Interaction with Ticagrelor

Maintenance doses of aspirin above 100 mg reduce the effectiveness of ticagrelor in preventing thrombotic cardiovascular events. Avoid concomitant use of ticagrelor with the 325-mg/40-mg tablet strength of Yosprala.

Renal Failure

Avoid Yosprala in patients with severe renal failure (glomerular filtration rate less than 10 mL/minute). Regular use of aspirin is associated in a dose-dependent manner with an increased risk of chronic renal failure. Aspirin use decreases glomerular filtration rate and renal blood flow especially with patients with pre-existing renal disease.

Presence of Gastric Malignancy

In adults, response to gastric symptoms with Yosprala does not preclude the presence of gastric malignancy. Consider additional gastrointestinal follow-up and diagnostic testing in adult patients who experience gastric symptoms during treatment with Yosprala or have a symptomatic relapse after completing treatment. In older patients, also consider an endoscopy.

Acute Interstitial Nephritis

Acute interstitial nephritis has been observed in patients taking PPIs including omeprazole. Acute interstitial nephritis may occur at any point during PPI therapy and is generally attributed to an idiopathic hypersensitivity reaction. Discontinue Yosprala if acute interstitial nephritis develops.

Clostridium difficile-Associated Diarrhea

Published observational studies suggest that PPI-containing therapy like Yosprala may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve.

Use the lowest dose and shortest duration of Yosprala appropriate to the condition being treated.

Bone Fracture

Several published observational studies suggest that PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Use the lowest dose and shortest duration of Yosprala therapy appropriate to the condition being treated.

Cutaneous and Systemic Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including omeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematous cases were CLE.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving Yosprala, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks.

Hepatic Impairment

Long-term moderate to high doses of aspirin may result in elevations in serum ALT levels. These abnormalities resolve rapidly with discontinuation of aspirin. Systemic exposure to omeprazole is increased in patients with hepatic impairment. Avoid Yosprala in patients with any degree of hepatic impairment.

Cyanocobalamin (Vitamin B12) Deficiency

Daily treatment with any acid-suppressing medications over a long period of time (eg, longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B12) caused by hypo- or achlorhydria. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed in patients treated with Yosprala.

Hypomagnesemia

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI. For patients expected to be on prolonged treatment or who take Yosprala with medications such as digoxin or drugs that may cause hypomagnesemia (eg, diuretics), consider monitoring magnesium levels prior to initiation of Yosprala and periodically during treatment.

Reduced Effect of Omeprazole with St. John’s Wort or Rifampin

Drugs which induce the CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease concentrations of omeprazole. Avoid concomitant use of Yosprala with St. John’s Wort or rifampin.

Interactions with Diagnostic Investigations for Neuroendocrine Tumors

Serum chromogranin A (CgA) levels increase secondary to omeprazole-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic interventions for neuroendocrine tumors. Temporarily discontinue treatment with Yosprala at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (eg, for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.

Interaction with Methotrexate

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of Yosprala may be considered in some patients.

Premature Closure of Fetal Ductus Arteriosus

NSAIDs including aspirin, may cause premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including Yosprala, in pregnant women starting at 30 weeks of gestation (third trimester).

Abnormal Laboratory Tests

Aspirin has been associated with elevated hepatic enzymes, blood urea nitrogen and serum creatinine, hyperkalemia, proteinuria, and prolonged bleeding time.

Adverse Reactions

Most common adverse reactions in adults (incidence 2% and more common in Yosprala treated patients) are: gastritis, nausea, diarrhea, gastric polyps, and non-cardiac chest pain. Less common adverse reactions were 2 patients with upper GI bleeding (gastric or duodenal) and 2 patients with lower GI bleeding (hematochezia and large intestinal hemorrhage) and one additional patient experienced obstruction in the small bowel.

Drug Interactions

See the full prescribing information for the complete list of drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with Yosprala and instructions for preventing or managing them.

Use in Specific Populations
  • Pregnancy: Use during the third trimester of pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Avoid use of Yosprala in pregnant women starting at 30 weeks of gestation (third trimester)
  • Lactation: Breastfeeding not recommended

To report SUSPECTED ADVERSE EVENTS, contact Aralez Pharmaceuticals at 1-866-207-6592 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Please click here for full Prescribing Information.

References: 1. Smith SC Jr, Benjamin EJ, Bonow RO, et al; World Heart Federation and the Preventive Cardiovascular Nurses Association. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update—a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124(22):2458-2473. 2. Kulik A, Ruel M, Jneid H, et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. 3. Levine GN, Bates ER, Bittl JA, et al; Focused Update Writing Group. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease [published online ahead of print March 23, 2016]. Circulation. 4. Martin-Merino E, Johansson S, Bueno H, Garcia Rodríguez LA. Discontinuation of low-dose acetylsalicylic acid therapy in UK primary care: incidence and predictors in patients with cardiovascular disease. Pragmat Obs Res. 2012;3:1-9. 5. 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. Circulation. 2008;118(18):1894-1909. 6. Kelly JP, Kaufman DW, Jurgelon JM, Sheehan J, Koff RS, Shapiro S. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet. 1996;348(9039):1413-1416. 7. Valkhoff VE, Sturkenboom MC, Hill C, Veldhuyzen van Zanten S, Kuipers EJ. Low-dose acetylsalicylic acid use and the risk of upper gastrointestinal bleeding: a meta-analysis of randomized clinical trials and observational studies. Can J Gastroenterol. 2013;27(3):159-167.

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Indications and Usage

Yosprala, a combination of aspirin and omeprazole, is indicated for patients who require aspirin for secondary prevention of cardiovascular and cerebrovascular events and who are at risk of developing aspirin-associated gastric ulcers.

The aspirin component of Yosprala is indicated for:

  • Reducing the combined risk of death and nonfatal stroke in patients who have had ischemic stroke or transient ischemia of the brain due to fibrin platelet emboli
  • Reducing the combined risk of death and nonfatal MI in patients with a previous MI or unstable angina pectoris
  • Reducing the combined risk of MI and sudden death in patients with chronic stable angina pectoris
  • Use in patients who have undergone revascularization procedures (Coronary Artery Bypass Graft [CABG] or Percutaneous Transluminal Coronary Angioplasty [PTCA]) when there is a pre-existing condition for which aspirin is already indicated

The omeprazole component of Yosprala is indicated for decreasing the risk of developing aspirin-associated gastric ulcers in patients at risk for developing aspirin-associated gastric ulcers due to age ( 55) or documented history of gastric ulcers.

Limitations of Use:
  • Yosprala contains a delayed-release formulation of aspirin and it is not for use as the initial dose of aspirin therapy during onset of acute coronary syndrome, acute myocardial infarction, or before percutaneous coronary intervention (PCI), for which immediate-release aspirin therapy is appropriate
  • Yosprala has not been shown to reduce the risk of gastrointestinal bleeding due to aspirin
  • Yosprala is not interchangeable with the individual components of aspirin and omeprazole
READ MORE
READ MORE
Important Safety Information
Contraindications

Yosprala is contraindicated in:

  • Patients with known allergy to aspirin and other nonsteroidal anti-inflammatory drug products (NSAIDs) and in patients with the syndrome of asthma, rhinitis, and nasal polyps. Aspirin may cause severe urticaria, angioedema, or bronchospasm (asthma)
  • Pediatric patients with suspected viral infections, with or without fever, because of the risk of Reye’s syndrome with concomitant use of aspirin in certain viral illnesses
  • Patients with known hypersensitivity to aspirin, omeprazole, substituted benzimidazoles, or to any of the excipients in the formulation
  • Proton pump inhibitor (PPI)–containing products, including Yosprala, are contraindicated in patients receiving rilpivirine-containing products
Warnings and Precautions
Coagulation Abnormalities

Even low doses of aspirin can inhibit platelet function leading to an increase in bleeding time. This can adversely affect patients with inherited (hemophilia) or acquired (liver disease or vitamin K deficiency) bleeding disorders. Monitor patients for signs of increased bleeding.

Gastrointestinal Adverse Reactions

Aspirin is associated with serious gastrointestinal (GI) adverse reactions, including inflammation, bleeding ulceration and perforation of the upper and lower GI tract. Other adverse reactions with aspirin include stomach pain, heartburn, nausea, and vomiting.

Although minor upper GI symptoms, such as dyspepsia, are common and can occur anytime during therapy, monitor patients for signs of ulceration and bleeding, even in the absence of previous GI symptoms. Inform patients about the signs and symptoms of GI adverse reactions.

If active and clinically significant bleeding from any source occurs in patients receiving Yosprala, discontinue treatment.

Bleeding Risk with Use of Alcohol

Counsel patients who consume three or more alcoholic drinks every day about the bleeding risks involved with chronic, heavy alcohol use while taking Yosprala.

Interaction with Clopidogrel

Avoid concomitant use of Yosprala with clopidogrel. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as omeprazole, that interfere with CYP2C19 activity. Co-administration of clopidogrel with 80-mg omeprazole reduces the pharmacological activity of clopidogrel, even when administered 12 hours apart. When using Yosprala, consider alternative anti-platelet therapy.

Interaction with Ticagrelor

Maintenance doses of aspirin above 100 mg reduce the effectiveness of ticagrelor in preventing thrombotic cardiovascular events. Avoid concomitant use of ticagrelor with the 325-mg/40-mg tablet strength of Yosprala.

Renal Failure

Avoid Yosprala in patients with severe renal failure (glomerular filtration rate less than 10 mL/minute). Regular use of aspirin is associated in a dose-dependent manner with an increased risk of chronic renal failure. Aspirin use decreases glomerular filtration rate and renal blood flow especially with patients with pre-existing renal disease.

Presence of Gastric Malignancy

In adults, response to gastric symptoms with Yosprala does not preclude the presence of gastric malignancy. Consider additional gastrointestinal follow-up and diagnostic testing in adult patients who experience gastric symptoms during treatment with Yosprala or have a symptomatic relapse after completing treatment. In older patients, also consider an endoscopy.

Acute Interstitial Nephritis

Acute interstitial nephritis has been observed in patients taking PPIs including omeprazole. Acute interstitial nephritis may occur at any point during PPI therapy and is generally attributed to an idiopathic hypersensitivity reaction. Discontinue Yosprala if acute interstitial nephritis develops.

Clostridium difficile-Associated Diarrhea

Published observational studies suggest that PPI-containing therapy like Yosprala may be associated with an increased risk of Clostridium difficile-associated diarrhea, especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve.

Use the lowest dose and shortest duration of Yosprala appropriate to the condition being treated.

Bone Fracture

Several published observational studies suggest that PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Use the lowest dose and shortest duration of Yosprala therapy appropriate to the condition being treated.

Cutaneous and Systemic Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) and systemic lupus erythematosus (SLE) have been reported in patients taking PPIs, including omeprazole. These events have occurred as both new onset and an exacerbation of existing autoimmune disease. The majority of PPI-induced lupus erythematous cases were CLE.

Avoid administration of PPIs for longer than medically indicated. If signs or symptoms consistent with CLE or SLE are noted in patients receiving Yosprala, discontinue the drug and refer the patient to the appropriate specialist for evaluation. Most patients improve with discontinuation of the PPI alone in 4 to 12 weeks.

Hepatic Impairment

Long-term moderate to high doses of aspirin may result in elevations in serum ALT levels. These abnormalities resolve rapidly with discontinuation of aspirin. Systemic exposure to omeprazole is increased in patients with hepatic impairment. Avoid Yosprala in patients with any degree of hepatic impairment.

Cyanocobalamin (Vitamin B12) Deficiency

Daily treatment with any acid-suppressing medications over a long period of time (eg, longer than 3 years) may lead to malabsorption of cyanocobalamin (vitamin B12) caused by hypo- or achlorhydria. This diagnosis should be considered if clinical symptoms consistent with cyanocobalamin deficiency are observed in patients treated with Yosprala.

Hypomagnesemia

Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI. For patients expected to be on prolonged treatment or who take Yosprala with medications such as digoxin or drugs that may cause hypomagnesemia (eg, diuretics), consider monitoring magnesium levels prior to initiation of Yosprala and periodically during treatment.

Reduced Effect of Omeprazole with St. John’s Wort or Rifampin

Drugs which induce the CYP2C19 or CYP3A4 (such as St. John’s Wort or rifampin) can substantially decrease concentrations of omeprazole. Avoid concomitant use of Yosprala with St. John’s Wort or rifampin.

Interactions with Diagnostic Investigations for Neuroendocrine Tumors

Serum chromogranin A (CgA) levels increase secondary to omeprazole-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic interventions for neuroendocrine tumors. Temporarily discontinue treatment with Yosprala at least 14 days before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (eg, for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.

Interaction with Methotrexate

Literature suggests that concomitant use of PPIs with methotrexate (primarily at high dose) may elevate and prolong serum levels of methotrexate and/or its metabolite, possibly leading to methotrexate toxicities. In high-dose methotrexate administration, a temporary withdrawal of Yosprala may be considered in some patients.

Premature Closure of Fetal Ductus Arteriosus

NSAIDs including aspirin, may cause premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including Yosprala, in pregnant women starting at 30 weeks of gestation (third trimester).

Abnormal Laboratory Tests

Aspirin has been associated with elevated hepatic enzymes, blood urea nitrogen and serum creatinine, hyperkalemia, proteinuria, and prolonged bleeding time.

Adverse Reactions

Most common adverse reactions in adults (incidence 2% and more common in Yosprala treated patients) are: gastritis, nausea, diarrhea, gastric polyps, and non-cardiac chest pain. Less common adverse reactions were 2 patients with upper GI bleeding (gastric or duodenal) and 2 patients with lower GI bleeding (hematochezia and large intestinal hemorrhage) and one additional patient experienced obstruction in the small bowel.

Drug Interactions

See the full prescribing information for the complete list of drugs with clinically important drug interactions and interaction with diagnostics when administered concomitantly with Yosprala and instructions for preventing or managing them.

Use in Specific Populations
  • Pregnancy: Use during the third trimester of pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Avoid use of Yosprala in pregnant women starting at 30 weeks of gestation (third trimester)
  • Lactation: Breastfeeding not recommended
READ MORE