Aspirin Therapy to Prevent CVD in Patients With Diabetes: Recommendations From the ADA

December 31, 2006

Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).

Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).1THE EVIDENCE BEHIND ASPIRINPrimary prevention. Low-dose aspirin therapy(325 mg every other day) reduced the risk of cardiovascularevents in men by 44% in the US Physicians' HealthStudy. A subgroup of patients with diabetes experienced a6% decrease in the incidence of myocardial infarction.1Secondary prevention. In the Anti-Platelet Trialists'(APT) meta-analysis, secondary vascular events were reducedby 25% among patients with diabetes who receivedlow-dose aspirin therapy. The Early Treatment DiabeticRetinopathy Study (ETDRS) demonstrated that aspirin significantlylowered the relative risk of myocardial infarctionto 0.72 (CI, 0.55 to 0.95) in patients with either type 1 ortype 2 diabetes. Myocardial infarction and other cardiovascularevents were reduced by 36% and 15%, respectively, inpatients with hypertension in the Hypertension OptimalTreatment (HOT) Trial; this study includedpersons with diabetes.2SAFETY OF ASPIRINThe major risks of aspirin therapyare gastric mucosal injury and GIhemorrhage. However, these adverseeffects are dose-related. When lowdoses (75 to 325 mg/d) of entericcoatedaspirin are used, the incidenceof these risks is comparable to thatassociated with placebo. Low-doseaspirin may predispose patients tominor bleeding events, such as epistaxisor bruising.The ETDRS showed that aspirintherapy did not increase the risk ofretinal or vitreous hemorrhage; moreover,it had no effect on the progressionof diabetic retinopathy andmaculopathy. Low-dose aspirin doesnot significantly impair renal functionor blood pressure control in patientswith hypertension.
Aspirin reduces the effectiveness of angiotensin-convertingenzyme inhibitors in patients with establishedCVD.3 Consider an alternative antiplatelet agent for thesepatients.RECOMMENDATIONS FOR PRACTICE

  • Use a dosage of 81 to 325 mg/d of enteric-coated aspirin.
  • Avoid aspirin in patients with aspirin allergy, bleedingtendency, anticoagulant therapy, recent GI bleeding, orclinically active hepatic disease and those under the age of21 years (because of increased risk of Reye syndrome).
  • Consider another antiplatelet agent in patients for whomaspirin therapy is contraindicated. Clopidogrel may be analternative for persons with aspirin allergy.4

References:

REFERENCES:1. Colwell JA. Aspirin therapy in diabetes. Diabetes Care. 2003;26(suppl 1):S87-S88.
2. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive bloodpressurelowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet.1998;351:1755-1762.
3. Peterson JG, Topol EJ, Sapp SK, et al. Evaluation of the effects of aspirin combinedwith angiotensin-converting enzyme inhibitors in patients with coronary artery disease. Am J Med. 2000;109:371-377.
4. CAPRIE Steering Committee. A randomised, blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329-1339.