Management is directed at the primary disease, but if hyperviscosity and bleeding are significant, prompt plasmapheresis may be required to lower the level of abnormal protein and to correct the bleeding disorder. The platelets are irreversibly affected. Aspirin acetylates and irreversibly inhibits the cyclooxygenase that catalyzes the synthesis of the endoperoxides. Some apparently normal subjects display marked sensitivity to the action of aspirin, so that their bleeding times are very much prolonged and they have severe clinical hemorrhage, particularly during or after surgery or trauma. These patients may have a mild form of storage pool disease.
Uremic patients are especially sensitive to bleeding induced by aspirin.
The mechanism by which aspirin prolongs the bleeding time in uremia is unknown, but it appears to depend on a pathway that does not involve cyclooxygenase inhibition. The combination of alcohol and aspirin is also dangerous because of its ability to prolong the bleeding time. Platelets modified by aspirin can aggregate when exposed to ADP but do not undergo the release reaction. The transfused platelets undergo the release reaction, after which the platelets modified by aspirin can aggregate. Because aspirin acetylates platelets irreversibly, the hemostatic compromise might last for four to five days after the aspirin has been discontinued.