Aspirin decreases hepatocellular carcinoma risk in hepatitis C virus carriers: a nationwide cohort study

Statin Monotherapy Not Inferior to Aspirin or Combined Aspirin and Statins Reducing the Incidences of Cirrhosis, HCC, and Mortality in MAFLD/MASH Patients: A Population Cohort Study

Purpose

Metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatohepatitis (MASH) pose significant risks for liver cirrhosis and hepatocellular carcinoma (HCC). Daily aspirin and statins could reduce HCC in patients with MAFLD/MASH. We aimed to clarify whether combined aspirin and statins exert a synergistic effect on prevention of cirrhosis and HCC in patients with MAFLD/MASH.

Patients and Methods

Patients and their clinical data were collected from the National Health Insurance Research Database (NHIRD), encompassing about 20 million population. A total of 735,574 MAFLD/MASH patients between January 1, 2009, and December 31, 2020 were identified. After applying exclusion criteria, 662,004 cases were enrolled, with a follow-up period of 3 years. Propensity score matching was employed for comparative analysis.

Results

Our findings indicate that combined statin and aspirin use significantly reduced the incidence of liver cirrhosis (p < 0.001) compared to statin or aspirin alone, or non-use of both drugs. However, the combined therapy did not confer additional benefits in reducing mortality rates and HCC. Furthermore, statin monotherapy exhibited a more pronounced effect in reducing mortality and HCC compared to aspirin alone or combined therapy.

Conclusion

Our study underscores that statin monotherapy was not inferior to aspirin or aspirin-statin combined therapies in terms of chemoprevention of cirrhosis, HCC, and overall mortality in MAFLD/MASH patients.

Association between antithrombotic agents use and hepatocellular carcinoma risk: a two-sample mendelian randomization analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary liver cancer worldwide. Multiple observational studies demonstrated a negative association between the use of antithrombotic agents and the risk of HCC. However, the precise causal relationship between these factors remains uncertain. Therefore, our study used a two-sample Mendelian randomization (MR) analysis to assess the causal link between these two factors.

METHOD

The summary statistics of single nucleotide polymorphisms (SNPs) associated with the use of antithrombotic agents were acquired from a genome-wide association study (GWAS) performed on individuals of European descent. A two-sample MR analysis was performed using the inverse variance weighting (IVW), the weighted median estimate, the MR-Egger regression, and the weighted-mode estimate. Sensitivity analysis of the primary findings was performed using MR-PRESSO, MR-Egger regression, Cochran's Q test, and Leave-one-out analysis.

RESULTS

Ten SNPs associated with the use of antithrombotic agents were selected as instrumental variables. The MR analysis performed using the four methods mentioned above revealed a negative causal association between the use of antithrombotic agents and HCC. Univariate MR estimates based on the inverse variance weighting (IVW) method suggested a negative causal association between the use of antithrombotic agents and HCC [odds ratio (OR) 0.444, 95% confidence interval (CI) 0.279 to 0.707, P = 0.001]. The other methods also produced similar results. No heterogeneity and horizontal pleiotropy were found.

CONCLUSION

Our findings suggested an inverse causal association of antithrombotic agents with the risk of HCC.

Aspirin in Patients with Viral Hepatitis: Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Hepatocellular carcinoma (HCC) is a disease demonstrating increasing morbidity and mortality, especially in patients with chronic viral hepatitis. Studies have shown that aspirin can reduce the incidence of liver cancer; however, the degree of benefit in patients with viral hepatitis is unclear. This study focused on the association between aspirin use and HCC risk in patients with chronic viral hepatitis.

METHODS

A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to December 16, 2023. The primary outcome was HCC incidence, and the secondary outcome was gastrointestinal bleeding. The results were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs). Meta-analyses were performed by using random or fixed-effects models based on the heterogeneity assessed via the I2 statistic.

RESULTS

A total of 13 articles (303,414 participants and 14,423 HCC patients) were included in the analysis. The incidence of HCC in aspirin users was lower than that in non-aspirin users (HR 0.75; 95% CI, 0.68-0.83; P < 0.001; I2 = 90.0%). Subgroup analysis further showed that this effect may be more obvious in HCV patients, non-cirrhotic patients, patients with statins, and long-term aspirin users, but it may have the risk of gastrointestinal bleeding (HR 1.13; 95% CI, 1.07-1.20; P = 0.906; I2 = 0.0%).

CONCLUSIONS

Our meta-analysis shows that in patients with chronic viral hepatitis, aspirin use is associated with a significantly reduced risk of liver cancer, but attention should be paid to the possible risk of gastrointestinal bleeding, and this conclusion needs further validation in the future.

Effect of aspirin use on survival in patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the seventh most prevalent cancer globally and is the third leading cause of cancer-related mortality.

AIM

The aim of this study was to evaluate the effect of aspirin use on the survival rates of individuals diagnosed with HCC.

METHODS

The patients were divided into two groups: those who used aspirin and those who did not. Aspirin use was defined as individuals who had used aspirin either before or after the diagnosis of HCC. Aspirin usage was determined based on prescription records. The criteria for aspirin use were defined as a minimum of 3 months and a minimum daily dose of 100 mg. Survival time; The time elapsed after the diagnosis of HCC was calculated as 'months'.

RESULT

Of the 300 cohorts studied in our study, 104 (34.6%) were using aspirin, while 196 (65.4%) were not. It was observed that bleeding occurred only in the patient group taking aspirin ( P  = 0.002). When evaluated in terms of survival time, it was observed that it was significantly higher in the patient group using aspirin ( P  = 0.001). Aspirin use was identified as factors that significantly impact survival ( P  < 0.05). Aspirin use was identified as independent risk factors that significantly impact of survival ( P  < 0.05).

CONCLUSION

The aspirin group had a similar metabolic and liver reserve as the other group and had a longer survival despite being older and more comorbid diseases.

Postoperative adjuvant aspirin for patients with hepatitis B virus-related hepatocellular carcinoma and portal vein tumor thrombus: An open-label, randomized controlled trial

Purpose

To compare the survival outcomes of postoperative adjuvant aspirin with surgery alone in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

Methods

From June 2013 to July 2015, an open-label, randomized controlled study was conducted in patients with resectable HBV-related HCC and PVTT. Patients were randomly assigned to undergo surgical resection and postoperative adjuvant aspirin (n = 40) or hepatectomy alone (n = 40). The primary end point was overall survival (OS). The secondary end points were time to recurrence of primary tumor (t-TTR) and time to recurrence of PVTT (p-TTR). The expression levels of COX1 and COX2 in surgical specimens of the aspirin group were correlated with patients' survival.

Results

The median OS were 16.2 and 13.4 months for the adjuvant aspirin and surgery alone groups, respectively. The median t-TTR were 5.3 and 3.2 months for the adjuvant aspirin and surgery alone groups, respectively. There was no significant difference in the OS and t-TTR between the two groups of patients (P = 0.078 and 0.336, respectively). The median p-TTR were 12.0 months and 5.4 months for the adjuvant aspirin group and the surgery alone group, respectively. Patients in the adjuvant aspirin group had markedly longer p-TTR (P = 0.001). Increased expressions of COX1 or COX2 in tumor tissues denoted better prognosis for patients receiving adjuvant aspirin.

Conclusion

For patients with resectable HBV-related HCC and PVTT, postoperative adjuvant aspirin significantly prolonged time to recurrence of PVTT than surgery alone. Expression of COX1 or COX2 may predict survival in these patients.

The relationship between aspirin consumption and hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Recent studies have shown that aspirin consumption may reduce the risk of hepatocellular carcinoma (HCC), but their correlation is still not fully understood. This meta-analysis aimed to investigate the correlation between aspirin consumption and HCC.

METHODS

A systematic literature search was conducted on PubMed, Scopus, Cochrane Library, EMBASE, and Web of Science databases. The search period was from the establishment of the database to July 1, 2022 with no language restrictions.

RESULTS

A total of 19 studies including three prospective studies and 16 retrospective ones with 2,217,712 patients were included. Compared with those who did not take aspirin, those who took aspirin had a 30% lower risk of HCC (hazard ratio [HR] = 0.70, 95% confidence interval [CI] 0.63-0.76, I² = 84.7%, P < 0.001). Subgroup analysis showed that aspirin significantly reduced the risk of HCC by 19% in Asia (HR = 0.81, 95% CI 0.80-0.82, I² = 85.2%, P < 0.001) and by 33% (HR = 0.67, 95% CI 0.61-0.73, I² = 43.6%, P = 0.150) in Europe and the U.S with no significant difference. Moreover, in patients with HBV or HCV infection, aspirin reduced 19% and 24% of the risk of HCC, respectively. However, aspirin administration might increase risks of gastrointestinal bleeding in patients with chronic liver disease (HR = 1.14, 95% CI 0.99-1.31, I² = 0.0%, P = 0.712). Sensitivity analysis showed no significant difference of results after excluding individual studies, suggesting that the results were robust.

CONCLUSION

Aspirin may reduce the risk of HCC in both healthy population and patients with chronic liver disease. However, attention should be paid to adverse events such as gastrointestinal bleeding in patients with chronic liver disease.

The Effect of Aspirin Use on Incident Hepatocellular Carcinoma-An Updated Systematic Review and Meta-Analysis

An increasing number of observational studies have described an association between aspirin use and a reduced risk of incident hepatocellular carcinoma. We performed this meta-analysis to provide a comprehensive and updated aggregate assessment of the effect of aspirin on HCC incidence. Two independent authors performed a systematic search of the literature, utilising the Medline, Embase, Scopus, and PubMed databases. A total of 16 studies (12 cohort studies, and 4 case-control studies) were selected for inclusion, with a large number of studies excluded, due to an overlapping study population. The pooled analysis of cohort studies involving a total population of approximately 2.5 million subjects, 822,680 aspirin users, and 20,626 HCC cases demonstrated a 30% reduced risk of HCC associated with aspirin use (adjusted HR 0.70, 95%CI 0.60-0.81). There was a similar but non-significant association observed across the case-control studies (adjusted OR 0.60, 95%CI 0.32-1.15, p = 0.13), which involved a total of 1961 HCC cases. In a subgroup meta-analysis of patients with cirrhosis, the relationship between aspirin use and incident HCC diminished to non-significance (adjusted HR 0.96, 95%CI 0.84-1.09). Aspirin use was associated with a statistically significant increase in bleeding events when all relevant studies were pooled together (adjusted HR 1.11, 95%CI 1.02-1.22). Prospectively collected data should be sought, to define the optimal patient group in which aspirin is safe and effective for the chemoprophylaxis of HCC.

Impact of Aspirin Use on Outcomes in Patients With Hepatocellular Cancer: A Nationwide Analysis

Background

Despite the use of new immunotherapies, hepatocellular carcinoma (HCC) has a poor survival rate. Through multiple molecular mechanisms, aspirin (ASA) has demonstrated a reduced incidence of HCC, however, the impact of long-term ASA use on in-hospital outcomes has not been studied.

Methods

We queried the National Inpatient Sample (NIS) database from 2016 to 2020 to identify patients with HCC. Patients were stratified into two groups, based on long-term ASA use. Information was collected regarding patient demographics, Elixhauser comorbidities, interventions, etiology, and decompensations of liver disease. Outcomes studied included sepsis, shock, acute kidney injury (AKI), intensive care unit (ICU) admission, and in-hospital mortality. The association between long-term ASA use and outcomes was studied using multivariate analysis.

Results

A total of 224,735 patients were included in the study. Of them, 18,835 (8.4%) patients were on long-term ASA. The majority of the patients with ASA use were White (61.3%), men (78.2%), and aged > 65 years old (68.8%). Patients in the ASA group had a higher incidence of non-alcoholic steatohepatitis (NASH) and decreased rates of hepatic decompensation than those not on ASA. Patients with ASA use had lower incidence of sepsis (2.76% vs. 3.54%), shock (4.86% vs. 8.23%), AKI (30.9% vs. 33.4%), ICU admission (3.88% vs. 7.4%) and in-hospital mortality (5.18% vs. 9.87%). After adjusting for confounding factors, ASA use was associated with a 30% lower risk of in-hospital mortality (adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.60 - 0.82, P < 0.001). ASA users also had 21% lower odds of developing shock (aOR: 0.79, 95% CI: 0.67 - 0.94, P = 0.007) and 31% lower odds of requiring ICU admission (aOR: 0.69, 95% CI: 0.54 - 0.78, P < 0.001).

Conclusions

Our study noted that patients on long-term ASA use had better in-hospital outcomes such as mortality, shock, and ICU admissions compared to non-ASA users. These findings are of interest, and further randomized clinical trials confirming the benefits of ASA in improving outcomes in HCC patients need to be conducted.

Meta-analysis: Chemoprevention of hepatocellular carcinoma with statins, aspirin and metformin

BACKGROUND

Emerging data suggest that statins, aspirin and metformin may protect against hepatocellular carcinoma (HCC) development. However, prior meta-analyses were limited by heterogeneity and inclusion of studies without adequate adjustment for baseline risks.

AIM

To examine by an updated meta-analysis the association between these medications and HCC risk.

METHODS

Medline and Embase databases were searched from inception to March 2022 for studies that balanced baseline risks between study groups via propensity score matching or inverse probability of treatment weighting, that reported the impact of statins, aspirin or metformin on HCC risk. Multivariable-adjusted hazard ratios (HRs) for HCC were pooled using a random effects model.

RESULTS

Statin use was associated with reduced HCC risk overall (HR: 0.52; 95% CI: 0.37-0.72) (10 studies, 1,774,476), and in subgroup analyses for cirrhosis, hepatitis B/C, non-alcoholic fatty liver disease, studies accounting for concurrent aspirin and metformin consumption and lipophilic statins. Aspirin use was associated with reduced HCC risk overall (HR: 0.48; 95% CI: 0.27-0.87) (11 studies, 2,190,285 patients) but not in studies accounting for concurrent statin and metformin use. Metformin use was not associated with reduced HCC risk overall (HR: 0.57; 95% CI: 0.31-1.06) (3 studies, 125,458 patients). Most analyses had moderate/substantial heterogeneity, except in follow-up <60 months for aspirin (I2  = 0%).

CONCLUSION

Although statin and aspirin use were associated with reduced HCC risk, only statin use was significant in subgroup analyses accounting for concurrent medications. Metformin use was not associated with reduced HCC risk. These data have implications for future clinical trial design.

Biochemical and pathophysiological improvements in rats with thioacetamide induced-hepatocellular carcinoma using aspirin plus vitamin C

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death, so we should be concerned and look for effective/less-harmful treatments than chemotherapeutics already clinically in application. Aspirin works well ''in conjunction'' with other therapies for HCC since aspirin can boost the sensitivity of anti-cancer activity. Vitamin C also was shown to have antitumor effects. In this study, we examined the anti-HCC activities of synergistic combination (aspirin and vitamin C) vs. doxorubicin on HCC-bearing rats and hepatocellular carcinoma (HepG-2) cells.

METHODS

In vitro, we evaluated IC₅₀ and selectivity index (SI) using HepG-2 and human lung fibroblast (WI-38) cell lines. In vivo, four rat groups were used: Normal, HCC (intraperitoneally (i.p.) administered 200 mg thioacetamide/kg/twice a week), HCC + DOXO (HCC-bearing rats i.p. administered 0.72 mg doxorubicin (DOXO)/rat/once a week), and HCC + Aspirin + Vit. C (i.p. administered vitamin C (Vit. C) 4 g/kg/day after day concomitant with aspirin 60 mg/kg/orally day after day). We evaluated biochemical factors [aminotransferases (ALT and AST), albumin, and bilirubin (TBIL) spectrophotometrically, caspase 8 (CASP8), p53, Bcl2 associated X protein (BAX), caspase 3 (CASP3), alpha-fetoprotein (AFP), cancer antigen 19.9 (CA19.9), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6) using ELISA], and liver histopathologically.

RESULTS

HCC induction was accompanied by significant time-dependent elevations in all measured biochemical parameters except the p53 level significantly declined. Liver tissue architecture organization appeared disturbed with cellular infiltration, trabeculae, fibrosis, and neovascularization. Following drug medication, all biochemical levels significantly reversed toward normal, with fewer signs of carcinogenicity in liver tissues. Compared to doxorubicin, aspirin & vitamin C therapy ameliorations were more appreciated. In vitro, combination therapy (aspirin & vitamin C) exhibited potent cytotoxicity (HepG-2 IC₅₀ of 17.41 ± 1.4 µg/mL) and more excellent safety with a SI of 3.663.

CONCLUSIONS

Based on our results, aspirin plus vitamin C can be considered reliable, accessible, and efficient synergistic anti-HCC medication.

Metformin reduces hepatocellular carcinoma incidence after successful antiviral therapy in patients with diabetes and chronic hepatitis C in Taiwan

BACKGROUND & AIMS

Diabetes mellitus (DM) is known to increase the risk of hepatocellular carcinoma (HCC) among individuals with chronic hepatitis C (CHC). We aimed to evaluate whether metformin reduces HCC risk among individuals with DM and CHC after successful antiviral therapy.

METHODS

Individuals with CHC who achieved a sustained virological response (SVR) after interferon-based therapy were enrolled in a large-scale, multicenter cohort in Taiwan (T-COACH). Cases of HCC at least 1 year after SVR were identified through linkage to the catastrophic illness and cancer registry databases.

RESULTS

Of 7,249 individuals with CHC enrolled in the study, 781 (10.8%) had diabetes and 647 (82.8%) were metformin users. During a median follow-up of 4.4 years, 227 patients developed new-onset HCC. The 5-year cumulative HCC incidence was 10.9% in non-metformin users and 2.6% in metformin users, compared to 3.0% in individuals without DM (adjusted hazard ratio [aHR] 2.83; 95% CI 1.57-5.08 and aHR 1.46; 95% CI 0.98-2.19, respectively). Cirrhosis was the most important factor significantly associated with higher HCC risk in Cox regression analysis, followed by DM non-metformin use, older age, male sex, and obesity; whereas hyperlipidemia with statin use was associated with a lower HCC risk. Using the two most crucial risk factors, cirrhosis and DM non-metformin use, we constructed a simple risk model that could predict HCC risk among individuals with CHC after SVR. Metformin use was shown to reduce the risk of all liver-related complications.

CONCLUSIONS

Metformin use greatly reduced HCC risk after successful antiviral therapy in individuals with diabetes and CHC. A simple risk stratification model comprising cirrhosis and DM non-metformin use could predict long-term outcomes in individuals with CHC after SVR.

IMPACT AND IMPLICATIONS

The current study provides evidence that metformin could reduce hepatocellular carcinoma (HCC) incidence after successful antiviral therapy among those with diabetes and chronic hepatitis C in a large-scale nationwide cohort study. Although successful antiviral therapy greatly reduces HCC risk in individuals with chronic hepatitis C, those with cirrhosis, diabetes, obesity, and the elderly remain at high risk of HCC development. We demonstrated that a simple risk model composed of two crucial unfavorable factors, cirrhosis and diabetes without metformin use, predicts the risk of HCC and major liver-related complications after successful antiviral therapy in individuals with chronic hepatitis C. Metformin use is highly recommended for individuals with diabetes and chronic hepatitis C after viral eradication to reduce the risk of HCC.

Improving Management of Portal Hypertension: The Potential Benefit of Non-Etiological Therapies in Cirrhosis

Portal hypertension is the consequence of cirrhosis and results from increased sinusoidal vascular resistance and hepatic blood inflow. Etiological therapies represent the first intervention to prevent a significant increase in portal pressure due to chronic liver damage. However, other superimposed pathophysiological drivers may worsen liver disease, including inflammation, bacterial translocation, endothelial dysfunction, and hyperactivation of hemostasis. These mechanisms can be targeted by a specific class of drugs already used in clinical practice. Albumin, rifaximin, statins, aspirin, and anticoagulants have been tested in cirrhosis and were a topic of discussion in the last Baveno consensus as non-etiological therapies. Based on the pathogenesis of portal hypertension in cirrhosis, our review summarizes the main mechanisms targeted by these drugs as well as the clinical evidence that considers them a valid complementary option to manage patients with cirrhosis and portal hypertension.

The role of antiplatelet therapies on incidence and mortality of hepatocellular carcinoma

AIM

To evaluate the impact of antiplatelet therapy (APT)on the incidence of hepatocellular carcinoma (HCC) and mortality following its treatment.

METHODS

A systematic literature search was performed using PubMed and Cochrane Central Register of Controlled Trials Databases. Two HCC clinical settings were explored: (i) incidence, and (ii) death after any HCC treatment. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated to compare the pooled data between patients who received or did not receive APT.

RESULTS

A total of 20 studies were identified, of whom 15 focused on HCC incidence, including 2,685,009 patients, and five on post-treatment death, including 3281 patients. APT was associated with an overall reduced risk of HCC incidence (OR: 0.63; 95%CI = 0.51-0.79; p < 0.001) as well as of post-treatment mortality (OR: 0.54; 95%CI = 0.35-0.83; p = 0.006).

CONCLUSIONS

Current data suggest that APT correlated with higher HCC incidence and poor overall survival following tumour treatment.

Does aspirin reduce the incidence, recurrence, and mortality of hepatocellular carcinoma? A GRADE-assessed systematic review and dose-response meta-analysis

PURPOSE

Aspirin has been suggested to reduce the risk of cancer. However, previous studies have been inconsistent regarding the relationship between aspirin use and the risk of occurrence of hepatocellular carcinoma (HCC). The purpose of this study was to assess the effect of aspirin on clinical outcomes in patients with HCC in a meta-analysis and to explore the possible dose-response relationship.

METHODS

A systematic literature search was conducted in 10 electronic databases and 4 registries. The combined hazard ratios (HRs) were calculated using a random-effects model with 95% confidence interval (CIs) to assess the effect of aspirin on the risk of HCC. Relevant subgroup analyses and sensitivity analyses were performed.

RESULTS

The results show that aspirin use correlated with lower incidence of HCC (HR: 0.75, 95% CI: 0.71-0.80), decreased risk of HCC recurrence (HR: 0.79, 95% CI: 0.65-0.96), and reduced mortality (HR: 0.72, 95% CI: 0.60-0.87). The results of the subgroup analysis showed that aspirin use was consistently associated with reduced incidence of HCC across different regions, study designs, and populations. A linear relationship was found for both dosage and duration of aspirin use. An increased of bleeding with aspirin use among patients was also observed (HR 1.10, 95% CI: 1.02-1.20).

CONCLUSIONS

This meta-analysis found that aspirin use was independently associated with a reduced risk of HCC incidence, recurrence, and death. Furthermore, aspirin use influenced HCC occurrence in a dose-dependent and duration-dependent manner. However, an increased risk of bleeding with aspirin use was noted.

Aspirin and Primary Cancer Risk Reduction in Ischemic Cardiac or Cerebrovascular Disease Survivors: A Nationwide Population-Based Propensity-Matched Cohort Study

Ischemic cardiac or cerebrovascular disease (ICCD) survivors represent a subpopulation with a high cancer risk. Antiplatelet medications, such as aspirin, remain a fundamental therapy for the secondary prevention of ischemic attack in these patients. We conducted a population-based cohort study to investigate the association of long-term low-dose aspirin use with the risk of primary cancer in ICCD survivors. Patients aged ≥20 years with newly diagnosed ICCD (n = 98,519) between January 2000 and December 2013 were identified from the Taiwan National Health Insurance Research Database. The aspirin user and nonuser groups (each n = 24,030) were propensity-matched (1:1) for age, sex, comorbidities, prior medications, ICCD diagnosis year, and year of index dates. The incidence rate of primary cancer was significantly lower in the user group (6.49/1000 person-years) than in the nonuser group (14.04/1000 person-years). Multivariate Cox regression analysis indicated that aspirin use was an independent factor associated with a reduced risk of primary cancer (aHR (95% confidence interval) = 0.42 (0.38−0.45)) after adjustment. Kaplan−Meier curve analysis revealed that the cumulative incidence rate of primary cancer was significantly lower (p < 0.0001) in the user group than in the nonuser group over the 14-year follow-up period. Subgroup analyses demonstrated that this anticancer effect increased with duration of treatment and with similar estimates in women and men. In addition, aspirin use was associated with a reduced risk for seven out of the ten most common cancers in Taiwan. These findings suggest the anticancer effect of aspirin in ICCD survivors and provide information for assessing the benefit-to-risk profile of aspirin as an antiplatelet medication in these patients.

Aspirin Use and the Risk of Hepatocellular Carcinoma: A Meta-analysis

INTRODUCTION AND AIM

The use of aspirin is a potential protective factor against the development of hepatocellular carcinoma (HCC). Therefore, we conducted a meta-analysis to evaluate the contribution of aspirin to the risk of HCC.

METHODS

We searched for PubMed and EMBASE through September 2021.

RESULTS

Eighteen studies (16 cohort, 2 case-control) were included. Aspirin users were less likely to develop HCC than nonusers [adjusted odds ratio (OR), 0.54; 95% confidence interval (CI): 0.44-0.66]. Stratified analysis showed that aspirin reduced the risk of HCC in Asian and Western populations (OR, 0.59 vs. 0.67). Besides, aspirin has protective effects against HCC after hepatitis B virus (OR, 0.70; 95% CI: 0.52-0.93) and hepatitis C virus infections (OR, 0.41; 95% CI: 0.23-0.73). Aspirin has protective effects on people with chronic liver disease (OR, 0.46; 95% CI: 0.31-0.67) and on the general population (OR, 0.65; 95% CI: 0.54-0.79). In addition, confounding factors have an important impact on the results of aspirin prevention of liver cancer before (OR, 0.28; 95% CI: 0.06-1.27) and after (OR, 0.58; 95% CI: 0.47-0.71) adjustment. Further studies have shown that those in the long duration group do not experience better effects in preventing HCC (OR, 0.62 vs. 0.63). A further meta-analysis of 3 articles showed that the use of aspirin did not increase the risk of bleeding in patients with HCC (OR, 1.19; 95% CI: 0.87-1.64).

CONCLUSION

Our meta-analysis shows that the use of aspirin is associated with a lower risk of liver cancer.

Therapeutic mechanisms and beneficial effects of non-antidiabetic drugs in chronic liver diseases

The global burden of chronic liver disease (CLD) is substantial. Due to the limited indication of and accessibility to antiviral therapy in viral hepatitis and lack of effective pharmacological treatment in nonalcoholic fatty liver disease, the beneficial effects of antidiabetics and non-antidiabetics in clinical practice have been continuously investigated in patients with CLD. In this narrative review, we focused on non-antidiabetic drugs, including ursodeoxycholic acid, silymarin, dimethyl4,4'-dimethoxy-5,6,5',6'-dimethylenedixoybiphenyl-2,2'-dicarboxylate, L-ornithine L-aspartate, branched chain amino acids, statin, probiotics, vitamin E, and aspirin, and summarized their beneficial effects in CLD. Based on the antioxidant, anti-inflammatory properties, and regulatory functions in glucose or lipid metabolism, several non-antidiabetic drugs have shown beneficial effects in improving liver histology, aminotransferase level, and metabolic parameters and reducing risks of hepatocellular carcinoma and mortality, without significant safety concerns, in patients with CLD. Although the effect as the centerpiece management in patients with CLD is not robust, the use of these non-antidiabetic drugs might be potentially beneficial as an adjuvant or combined treatment strategy.

Systematic Review and Meta-analysis: Association of Aspirin With Incidence of Hepatocellular Carcinoma

Aim: To explore the relationship between the use of aspirin and the incidence of hepatocellular carcinoma (HCC). Methods: MEDLINE, EMBASE, Web of Science and Cochrane CENTRAL databases were searched systematically from the earliest available date to 13 March 2020. The primary outcome was incidence of HCC, and the secondary outcomes were recurrence and mortality of HCC. The results were expressed as the Hazard Ratio (HR) and 95% confidence interval (CI). Based on the heterogeneity evaluated with the I 2 statistic, a meta-analysis was performed using either a random- or fixed-effects model. Results: A total of sixteen articles (2781100 participants) were included. There was lower incidence of HCC in aspirin users than those in non-aspirin users (HR, 0.56; 95% CI, 0.46-0.69; p < 0.001). Subgroup analysis further showed that the incidence of liver cancer in patients with alcoholic cirrhosis (HR, 0.14; 95% CI, 0.09-0.22; p < 0.001) and virus hepatitis (HR, 0.68; 95% CI, 0.62-0.74; p < 0.001) who use aspirin was lower than that of patients who do not use aspirin. In addition, aspirin was found to associate with decreased risk of HCC mortality (HR, 0.71; 95% CI, 0.65-0.78; p < 0.001), not HCC recurrence (HR, 0.52; 95% CI, 0.15-1.76; p = 0.291). Conclusions: Aspirin use is significantly associated with the low incidence rate of liver cancer.

Aspirin and Infection: A Narrative Review

Acetylsalicylic acid (ASA) is one of the most commonly used drugs in the world. It derives from the extract of white willow bark, whose therapeutic potential was known in Egypt since 1534 BC. ASA’s pharmacological effects are historically considered secondary to its anti-inflammatory, platelet-inhibiting properties; however, human studies demonstrating a pro-inflammatory effect of ASA exist. It is likely that we are aware of only part of ASA’s mechanisms of action; moreover, the clinical effect is largely dependent on dosages. During the past few decades, evidence of the anti-infective properties of ASA has emerged. We performed a review of such research in order to provide a comprehensive overview of ASA and viral, bacterial, fungal and parasitic infections, as well as ASA’s antibiofilm properties.

Aspirin for the prevention of hepatocellular carcinoma: an updated meta-analysis with particular focus on patients with chronic liver disease

BACKGROUND

Previous studies have suggested a chemoprotective effect of aspirin in hepatocellular carcinoma (HCC), but evidence is limited for patients with chronic liver disease (CLD). Thus, we performed a meta-analysis of all observational studies, and aimed to provide a comprehensive and quantitative understanding of this topic.

METHODS

The PubMed/MEDLINE, Scopus, Cochrane, and Web of Science databases were systematically searched until September 2021. We pooled the hazard ratio (HR) of HCC for aspirin use versus non-use and investigated the possible dose-risk and duration-risk associations.

RESULTS

Ten studies involving 202,567 CLD patients were enrolled in this study. The pooled results showed a significant reduction in HCC risk in aspirin users than in non-users (HR = 0.64; 95% CI = 0.54-0.77; p_{heterogeneity} < 0.001; I² = 84.9%). In subgroup analyses, an aspirin dose of 100 mg/day (0.56, 0.44-0.72) showed a significant protective effect against HCC than 160 mg/day. The linear model showed a significant inverse association between the duration of aspirin use and HCC risk (exb(b) = 0.92; 95% CI = 0.90-0.94); also, a non-linear model revealed a comparable association (coef₁ = 0.80, p₁ < 0.001; coef₂ = 1.13, p₂ = 0.001). No significantly higher risk of gastrointestinal bleeding of the aspirin-treated group was detected.

CONCLUSIONS

The present meta-analysis suggested a significant and duration-related association between reduced HCC risk and aspirin use in a broad at-risk population. Nevertheless, aspirin therapy applied to CLD patients should be carefully monitored, although there was no significantly higher risk of gastrointestinal bleeding.

REGISTRATION

PROSPERO, CRD42021229892.

Statin and aspirin for chemoprevention of hepatocellular carcinoma: Time to use or wait further?

Preclinical studies highlighted potential therapeutic applications of aspirin and statins as anticancer agents based on their pleiotropic effects. Epidemiologic studies suggested the role of aspirin and statins in the chemoprevention of hepatocellular carcinoma (HCC). However, observational data is prone to bias, and no prospective randomized trials are currently available to assess the risks and benefits of statin or aspirin therapy for chemoprevention of HCC. It is therefore important for clinicians and researchers to be aware of the quality of current evidence regarding this issue. In this review, we summarize currently available evidence to assist clinicians with their decision to use statin or aspirin and provide information for further clinical investigations.

Association of aspirin and nonaspirin NSAIDs therapy with the incidence risk of hepatocellular carcinoma: a systematic review and meta-analysis on cohort studies

According to the current research evidence, the therapy of nonsteroidal anti-inflammatory drugs (NSAIDs) might effectively decrease the risk of hepatocellular carcinoma (HCC) incidence. Investigations have been conducted on the relationship between NSAIDs (aspirin and nonaspirin NSAIDs) and the risk of HCC incidence. We searched the PubMed, Web of Science, Embase and Cochrane Library databases for cohort studies published prior to 15 March 2020 and screened eligible studies. There were a total of 12 eligible studies (published between 2012 and 2020). We observed a lower risk of HCC among aspirin users [hazard ratio 0.53; 95% confidence interval (CI), 0.43-0.65]. However, there were no statistically significant associations discovered between nonaspirin NSAID use and the risk of HCC incidence (hazard ratio 0.95; 95% CI, 0.79-1.15). Furthermore, aspirin use has also been found to reduce the risk of HCC in patients with cirrhosis or viral hepatitis compared to that in the general population (hazard ratio 0.15; 95% CI, 0.10-0.23; hazard ratio 0.65; 95% CI, 0.56-0.76, respectively). Moreover, no statistical associations were found between aspirin use and a higher risk of bleeding risk, with a hazard ratio value of 0.76 (95% CI, 0.51-1.13). In summary, the conducted meta-analysis reveals that aspirin, rather than nonaspirin NSAIDs, can significantly decrease the risk of HCC, particularly in patients with cirrhosis or viral hepatitis.

Immunobiology and pathogenesis of hepatitis B virus infection

Hepatitis B virus (HBV) is a non-cytopathic, hepatotropic virus with the potential to cause a persistent infection, ultimately leading to cirrhosis and hepatocellular carcinoma. Over the past four decades, the basic principles of HBV gene expression and replication as well as the viral and host determinants governing infection outcome have been largely uncovered. Whereas HBV appears to induce little or no innate immune activation, the adaptive immune response mediates both viral clearance as well as liver disease. Here, we review our current knowledge on the immunobiology and pathogenesis of HBV infection, focusing in particular on the role of CD8⁺ T cells and on several recent breakthroughs that challenge current dogmas. For example, we now trust that HBV integration into the host genome often serves as a relevant source of hepatitis B surface antigen (HBsAg) expression during chronic infection, possibly triggering dysfunctional T cell responses and favouring detrimental immunopathology. Further, the unique haemodynamics and anatomy of the liver - and the changes they frequently endure during disease progression to liver fibrosis and cirrhosis - profoundly influence T cell priming, differentiation and function. We also discuss why therapeutic approaches that limit the intrahepatic inflammatory processes triggered by HBV-specific T cells might be surprisingly beneficial for patients with chronic infection.

Systematic review with meta-analysis: The effects of non-steroidal anti-inflammatory drugs and anti-platelet therapy on the incidence and recurrence of hepatocellular carcinoma

BACKGROUND

Chemoprevention with NSAIDs, including aspirin, and anti-platelet therapy (APT), has been suggested to reduce the incidence and recurrence of hepatocellular carcinoma (HCC).

AIM

To determine by meta-analysis whether NSAIDs and APT use affected HCC incidence, HCC recurrence and liver-related mortality in at-risk populations with chronic liver disease.

METHOD

Electronic databases including Pubmed, Scopus, Medline, Embase and Cochrane Library were searched (from inception to 31 May 2021) for eligible studies evaluating the impacts of NSAID or APT use on HCC incidence, recurrence and mortality. Data on HCC incidence, recurrence, liver-related mortality or bleeding complications had to be available. Studies were included if they evaluated adults with hepatitis B virus (HBV), hepatitis C virus (HCV), alcohol-related liver disease (ALD) or nonalcoholic steatohepatitis that were administered at least one NSAID or APT for a defined period of time and were followed for at least 6 months. The primary outcome was HCC incidence. Secondary outcomes included: HCC recurrence, liver-related mortality and bleeding complications. Data were pooled using a random effects model with hazard ratios (HRs) or odds ratio (OR), and 95% confidence intervals (CIs) presented.

RESULTS

Of 3773 articles screened, 19 studies were included, with a total of 147 283 participants. Aspirin use reduced the risk of HCC incidence (HR: 0.51, 95% CI: 0.36-0.72); and improved liver-related mortality (OR: 0.32, 95% CI: 0.15-0.70), with a small increased risk of gastrointestinal bleeding events (OR: 1.32, 95% CI: 1.08-1.94). With respect to HCC recurrence following treatment, analysis of all aspirin and NSAID treatment (including; aspirin only; non-aspirin NSAIDs only; and combination NSAIDs groups) was associated with a decreased risk of HCC recurrence (HR: 0.80, 95% CI: 0.75-0.86). By stratified analysis, only the non-aspirin NSAID group showed significant risk reduction (HR: 0.73, 95% CI: 0.63-0.84).

CONCLUSION

The study supports the use of aspirin in at-risk individuals to reduce the incidence of HCC and liver-related mortality. HCC recurrence following treatment was lower with NSAID treatment.

Aspirin in Hepatocellular Carcinoma

Preclinical and clinical studies provide evidence for aspirin as a preventative agent for cancer. Compelling direct evidence supports a chemopreventive effect of aspirin in individuals at high risk of developing colorectal cancer due to Lynch syndrome, while indirect evidence indicates that aspirin may reduce the risk of and mortality from sporadic colorectal cancer. There is weaker evidence for a protective effect of aspirin against all cancers taken as a group. Nevertheless, the results of recent retrospective cohort studies consistently indicate a beneficial effect of aspirin as a chemopreventive or adjuvant chemotherapeutic agent in hepatocellular carcinoma (HCC). Epidemiologic studies conducted in the general population or in selected populations at higher risk for HCC reveal that regular aspirin use is associated with reduced HCC incidence. In addition, aspirin may act as an adjuvant to other therapies in reducing HCC recurrence. According to studies in animal models, the cancer-preventative effect of aspirin may be related to its antiplatelet and anti-inflammatory activities. Prospective studies are warranted to determine whether aspirin should be recommended to diverse populations of patients at risk for HCC.

Blockade of AMPK-Mediated cAMP-PKA-CREB/ATF1 Signaling Synergizes with Aspirin to Inhibit Hepatocellular Carcinoma

Simple Summary

Epidemiological and experimental studies have demonstrated that aspirin (acetylsalicylic acid) may prevent the incidence of some types of human cancer, including colorectal cancer and hepatocellular carcinoma (HCC). In addition, preclinical studies indicate that aspirin in combination with other treatments may achieve a more significant anti-cancer effect for established tumors. This study aims to improve the anti-cancer effect of aspirin by targeting signaling pathways related to aspirin and its targets. We find that aspirin may induce cAMP–PKA–CREB/ATF1 signaling in HCC via AMPK and its downstream target carbamoyl-phosphate synthase 1 (CPS1). Blockade of PKA–CREB/ATF1 signaling by the natural agent berbamine could sensitize HCC to aspirin. This research indicates that the combination of two inexpensive drugs, aspirin and berbamine, holds promise in preventing and treating HCC.

Abstract

Aspirin can prevent or inhibit inflammation-related cancers, such as colorectal cancer and hepatocellular carcinoma (HCC). However, the effectiveness of chemotherapy may be compromised by activating oncogenic pathways in cancer cells. Elucidation of such chemoresistance mechanisms is crucial to developing novel strategies to maximize the anti-cancer effects of aspirin. Here, we report that aspirin markedly induces CREB/ATF1 phosphorylation in HCC cells, which compromises aspirin’s anti-HCC effect. Inhibition of AMP-activated protein kinase (AMPK) abrogates the induction of CREB/ATF1 phosphorylation by aspirin. Mechanistically, activation of AMPK by aspirin results in decreased expression of the urea cycle enzyme carbamoyl-phosphate synthase 1 (CPS1) in HCC cells and xenografts. Treatment with aspirin or CPS1 knockdown stimulates soluble adenylyl cyclase expression, thereby increasing cyclic AMP (cAMP) synthesis and stimulating PKA–CREB/ATF1 signaling. Importantly, abrogation of aspirin-induced CREB/ATF1 phosphorylation could sensitize HCC to aspirin. The bis-benzylisoquinoline alkaloid berbamine suppresses the expression of cancerous inhibitor of protein phosphatase 2A (CIP2A), leading to protein phosphatase 2A-mediated downregulation of CREB/ATF1 phosphorylation. The combination of berbamine and aspirin significantly inhibits HCC in vitro and in vivo. These data demonstrate that the regulation of cAMP-PKA-CREB/ATF1 signaling represents a noncanonical function of CPS1. Targeting the PKA–CREB/ATF1 axis may be a strategy to improve the therapeutic effects of aspirin on HCC.

Functional Role of Novel Indomethacin Derivatives for the Treatment of Hepatocellular Carcinoma Through Inhibition of Platelet-Derived Growth Factor

BACKGROUND

Several studies suggested anticancer potential of NSAIDs. Therefore, we aimed to evaluate novel indomethacin derivatives for the treatment of hepatocellular carcinoma.

METHODS

The molecular docking of derivatives was carried out for prediction of inhibitory effect on PDGFR-α using pass online software, followed by cytotoxicity study by performing MTT assay. The disease was induced with N-Nitrosodiethylamine (200 mg/kg, i.p.) followed by 2-acetylaminofluorene orally for two weeks. After 12 weeks of induction, treatment was given for one week and blood was collected for determination of biochemical parameters and tumor markers. Liver samples were isolated for immunohistochemistry, histopathology, and gene expression study for VEGF.

RESULTS

JI-MT has shown maximum inhibitory activity for PDGFRα in docking study also showed good cytotoxic effect in the HepG2 cell line and based on the IC₅₀ values, JI-MT was selected for in-vivo study. We have found statistically significant reduction in body weight gain, number of nodules and liver weight to body weight ratio with treatment with JI-MT. Hepatoprotective role of JI-MT has been observed in tumor-specific markers like α-fetoprotein levels, carcinoembryonic antigen and PDGF-α levels. Liver markers like ALT, ALP, AST, LDH and total bilirubin levels were found to be reduced with treatments. Also, on histopathological examination, the protective effect of JI-MT was observed. Treatment also showed increased expression of P53 in immunohistochemical analysis and up-regulation of VEGF gene by JI-MT.

CONCLUSION

From the present study, we can conclude that JI-MT has potential in treatment of HCC by the virtue of PDGFRα inhibitory activity.

Aspirin Use and the Incidence of Hepatocellular Carcinoma in Patients With Hepatitis B Virus or Hepatitis C Virus Infection: A Meta-Analysis of Cohort Studies

Background: The association between aspirin use and the incidence of hepatocellular carcinoma (HCC) in patients with hepatitis B virus (HBV) or hepatitis C (HCV) virus infection remains not fully determined. A meta-analysis was performed to summarize the findings of cohort studies. Methods: Relevant cohort studies were retrieved via a search of PubMed Cochrane's Library and Embase databases. A random-effect model was used to pool the results. Subgroup analyses were performed to evaluate the influence of study characteristics on the association. Results: Seven cohort studies with 120,945 adult patients with HBV or HCV infection were included. Pooled results showed that aspirin use was independently associated with a reduced risk of HCC in these patients (risk ratio: 0.73, 95% confidence interval: 0.64 to 0.83, p < 0.001; I² = 86%). Subgroup analyses showed that aspirin use was associated with a reduced HCC risk regardless of the viral type, age, sex, the diabetic, and cirrhotic status of the patients, and the follow-up durations. Moreover, consistent results were obtained in studies with and without adjustment of antiviral treatment and statin use. Pooled results of four studies showed that aspirin use was associated with an increased risk of gastrointestinal bleeding in these patients (risk ratio: 1.15, 95% confidence interval: 1.02 to 1.28, p = 0.02; I² = 0%). Conclusions: Aspirin use was independently associated with a reduced risk of HCC in patients with HBV or HCV infection, whereas the risk of gastrointestinal bleeding may be increased. These results should be validated in clinical trials.