Toward Precision Aspirin Prophylaxis: Optimal Aspirin Dosing For Prevention of Preeclampsia

To review contemporary evidence regarding optimal aspirin dosing for prevention of preeclampsia, focusing on dose-response relationships, timing of initiation, and phenotype-specific prophylaxis.

Recent trials and meta-analyses have produced conflicting findings regarding whether higher-dose aspirin (100-162 mg daily) provides greater protection against preeclampsia than conventional 75-81 mg regimens. Benefit appears greatest in placental-risk phenotypes and select high-risk populations, including patients with obesity, multifetal gestation, chronic hypertension, diabetes, and multiple concurrent risk factors. Pharmacokinetic studies indicate altered aspirin metabolism and reduced platelet inhibition during pregnancy, supporting biologic plausibility for higher-dose strategies. However, pragmatic real-world studies remain mixed, and definitive recommendations are lacking. Aspirin efficacy is phenotype-dependent, and optimal dosing likely varies according to placental biology, pharmacokinetics, and baseline risk. Emerging evidence supports individualized prophylaxis emphasizing early initiation and consideration of higher-dose aspirin in select high-risk populations.