Aspirin And Diabetes
June 3, 2010 (Chapel Hill, North Carolina) A new scientific statement on the use of aspirin for the primary prevention of cardiovascular disease in patients with diabetes recommends that low-dose aspirin is "reasonable" in those with no history of vascular disease but who are at an increased 10-year risk of cardiovascular events [1]. The new recommendations, from a joint statement of the American Diabetes Association (ADA), the American Heart Association (AHA), and the American College of Cardiology (ACC), essentially call for tighter criteria for aspirin use in the diabetic population. The organizations state that only men older than 50 and women older than 60 who have one or more additional major risk factors should be treated with aspirin for primary prevention of cardiovascular events. "The guidelines are more conservative, or there is less of a general recommendation for aspirin than there used to be, and this is based on some of the newer studies that have come out," Dr Sue Kirkman (ADA, Alexandria, VA), a member of the writing committee, told heartwire . "The previous recommendations had been that pretty much anybody with diabetes over the age of 40 should be on aspirin." The group recommends low-dose aspirin, 75 mg/d to 162 mg/d, for adults with diabetes and no history of cardiovascular disease but who are at an increased risk based on age and at least one additional cardiovascular disease risk factor, such as smoking, dyslipidemia, hypertension, family history of disease, and albuminuria. It is a class IIa recommendation with a level of evidence B. Aspirin is not recommended for high-risk diabetic patients who are also at risk for bleeding and is not recommended for individuals at low risk of cardiovascular events. For those at intermediate risk, the use of as Continue reading >>
Low-dose Aspirin For Primary Prevention Of Cardiovascular Events In Patients With Type 2 Diabetes: 10-year Follow-up Of A Randomized Controlled Trial
Journal of the American Heart Association Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Patients with Type 2 Diabetes: 10-year Follow-up of a Randomized Controlled Trial Yoshihiko Saito, Sadanori Okada, Hisao Ogawa, Hirofumi Soejima, Mio Sakuma, Masafumi Nakayama, Naofumi Doi, Hideaki Jinnouchi, Masako Waki, Izuru Masuda, Takeshi Morimoto For correspondence: [email protected] First Department of Internal Medicine, Nara Medical University Kashihara, Nara, Japan & Department of Diabetology, Nara Medical University, Kashihara, Nara, Japan BackgroundThe long-term efficacy and safety of low-dose aspirin for primary prevention of cardiovascular events in patients with type 2 diabetes are still inconclusive. MethodsThe Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial was a randomized, open-label, standard-care controlled trial examining whether low-dose aspirin affected cardiovascular events in 2539 Japanese patients with type 2 diabetes and without pre-existing cardiovascular disease. Patients were randomly allocated to receive aspirin (81 mg or 100 mg daily, aspirin group) or no aspirin (no-aspirin group) in the JPAD trial. After that the trial ended in 2008, we followed the patients until 2015, with no attempt to change the previously assigned therapy. Primary end points were cardiovascular events, including sudden death, fatal or nonfatal coronary artery disease, fatal or nonfatal stroke, and peripheral vascular disease. For the safety analysis, hemorrhagic events, consisting of gastrointestinal bleeding, hemorrhagic stroke, and bleeding from any other sites, were also analyzed. The primary analysis was conducted for cardiovascular events among patients who retained their original allocation (a per-protocol c Continue reading >>
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Aspirin For Primary Cardiovascular Risk Prevention And Beyond In Diabetes Mellitus
Aspirin for Primary Cardiovascular Risk Prevention and Beyond in Diabetes Mellitus Davide Capodanno, Dominick J. Angiolillo Daily administration of low-dose of aspirin has proven to be beneficial in preventing recurrent cardiovascular events. However, the role of aspirin for primary prevention in patients with no overt cardiovascular disease is more controversial. In fact, in lower risk patients, the modest benefit in reducing serious vascular events can be offset by the increased risk of bleeding, including intracranial and gastrointestinal hemorrhage. Diabetes mellitus (DM) has been associated with a substantially increased risk of both first and recurrent atherothrombotic events, which makes aspirin therapy of potential value in these subjects. Moving from general aspects of aspirin pharmacology and specific issues in DM, this article reviews the literature on the topic of aspirin for primary prevention in general, and in subjects with DM in particular, to end up with arguments pro and con, and a practical risk-based algorithm for aspirin initiation in daily practice. Aspirin for Primary Cardiovascular Risk Prevention and Beyond in Diabetes Mellitus Davide Capodanno and Dominick J. Angiolillo Circulation. 2016;CIRCULATIONAHA.116.023164, originally published October 11, 2016 Log in to Email Alerts with your email address. Continue reading >>
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Practice Guidelines: Updated Recommendations On Daily Aspirin Use In Patients With Diabetes - American Family Physician
Updated Recommendations on Daily Aspirin Use in Patients with Diabetes Am Fam Physician.2010Dec15;82(12):1559-1563. Guideline source: American Diabetes Association, American Heart Association, and American College of Cardiology Foundation Published source: Circulation, June 22, 2010 Available at: Persons with diabetes mellitus have two to four times the risk of cardiovascular events compared with persons of the same age and sex who do not have the disease. Coronary heart disease (CHD) is responsible for more than two-thirds of deaths in persons with diabetes who are older than 65 years. Although aspirin has been proven to reduce cardiovascular morbidity and mortality rates in high-risk patients with myocardial infarction or stroke, its benefit is unclear in patients without a history of cardiovascular events. In 2007, the American Diabetes Association and American Heart Association recommended aspirin therapy (75 to 162 mg daily) for primary prevention in patients with diabetes who had increased CHD risk (e.g., older than 40 years, smoking, family history of cardiovascular disease). Since these recommendations were published, new evidence has raised questions about the effectiveness of this strategy. The U.S. Preventive Services Task Force recently recommended that physicians encourage aspirin use in men 45 to 79 years of age and in women 55 to 79 years of age, regardless of whether they have diabetes. To address the uncertainties about aspirin use in persons with diabetes, experts from the American Diabetes Association, American Heart Association, and American College of Cardiology Foundation reviewed the current evidence and updated the 2007 recommendations. The group organized its recommendations around the following questions: What is the evidence for aspirin in pr Continue reading >>
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Aspirin Therapy In Diabetes
These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. Originally approved 1997. The recommendations in this article are based on the evidence reviewed in the following publication: Standards of Care for Diabetes (Technical Review). Diabetes Care 17:767-71, 1997. Reprinted with permission from Diabetes Care (Suppl. 1): 21:S45-46, 1998. eople with diabetes have a two- to fourfold increase in the risk of dying from the complications of cardiovascular disease. Both men and women are at increased risk. Atherosclerosis and vascular thrombosis are major contributors, and it is generally accepted that platelets are contributory. Platelets from men and women with diabetes are often hypersensitive in vitro to platelet aggregating agents. A major mechanism is increased production of thromboxane, a potent vasoconstrictor and platelet aggregant. Investigators have found evidence in vivo of excess thromboxane release in type 2 diabetic patients with cardiovascular disease. Aspirin blocks thromboxane synthesis by acetylating platelet cyclo-oxygenase and has been used as a primary and secondary strategy to prevent cardiovascular events in nondiabetic and diabetic individuals. Meta-analyses of these studies and large-scale collaborative trials in men and women with diabetes support the view that low-dose aspirin therapy should be prescribed as a secondary prevention strategy, if no contraindications exist. Substantial evidence suggests that low-dose aspirin therapy should also be used as a primary prevention strategy in men and women with diabetes who are at high risk for cardiovascular events.1 A meta-analysis of 145 prospective controlled Continue reading >>
Should Patients With Type 2 Diabetes Take Aspirin To Prevent Stroke And Coronary Events?
What is the role of aspirin in primary prevention — preventing the first cardiovascular event in our patients? This has been an area of changing recommendations leading to considerable uncertainty among practitioners. Aspirin is an effective antiplatelet agent that acts by inhibiting cyclooxygenase-1 (COX-1) which leads to reduced levels of thromboxane A2, a potent promoter of platelet aggregation. It is therefore widely used in high-risk individuals to prevent myocardial infarction and stroke. It may also reduce the risk of colorectal cancer. However, aspirin use is not without risks — the reduced platelet action increases the risk of gastrointestinal bleeding and hemorrhagic strokes. When aspirin is used for secondary prevention — to reduce the risk of recurrent myocardial infarction or ischemic stroke in patients with established cardiovascular disease — the risk of a recurrent cardiovascular event is so high that the benefits of aspirin greatly outweigh the risks. But what about aspirin in primary prevention? Many patients who present with myocardial infarction or ischemic stroke have no previous history of cardiovascular disease but may have been at high risk for such disease due to risk factors such as type 2 diabetes. NEJM Knowledge+ Internal Medicine Board Review includes the following question on this very topic; we have heard from many learners that they are uncertain about the current recommendations. The Case & Question A 44-year-old man with hypertension, hyperlipidemia, obesity, type 2 diabetes, and paroxysmal atrial fibrillation presents for a new-patient visit. He feels well and has no complaints. His current medications include metformin 1000 mg twice daily, metoprolol extended-release 75 mg once daily, lisinopril 20 mg once daily, simvastatin 2 Continue reading >>
Aspirin For Primary Prevention In Diabetic Patients
Aspirin for Primary Prevention in Diabetic Patients Aspirin for Primary Cardiovascular Risk Prevention and Beyond in Diabetes Mellitus. Circulation 2016;Oct 11:[Epub ahead of print]. The following are key points to remember about aspirin for primary cardiovascular disease (CVD) risk prevention in diabetes mellitus (DM): Among patients with documented CVD, strong evidence exists for the benefits of aspirin. However, its benefit for primary prevention is less clear. A modest benefit has been observed, but at an increased risk for intracranial and gastrointestinal bleeding. Patients with DM are at increased risk for CVD; however, the sole presence of DM does not appear to be sufficient to recommend aspirin to all DM patients. Given the projected increase in DM (an estimated 366 million adults by 2030), research on the riskbenefit of aspirin among diabetes is warranted. If prescribed for primary prevention, aspirin should be at the lowest dose possible (such as 75-100 mg). The authors recommend uncoated aspirin with higher bioavailability but with concurrent use of a proton-pump inhibitor for patients at high risk for bleeding. Among those who are prescribed aspirin, concurrent administration of nonsteroidal anti-inflammatory drugs should be avoided. Ongoing clinical trials will add clinically meaningful information regarding who will receive the greatest benefit with the least risk from aspirin. Continue reading >>
No Primary Prevention Gains From Low-dose Aspirin In Diabetes
No primary prevention gains from low-dose aspirin in diabetes Key clinical point: Low-dose aspirin does not lower the risk of cardiovascular events in individuals with type 2 diabetes but without preexisting cardiovascular disease. Major finding: Patients with type 2 diabetes taking daily low-dose aspirin showed no significant reductions in cardiovascular events, compared with a control group not taking aspirin. Data source: Long-term follow-up in a randomized controlled trial in 2,539 patients with type 2 diabetes in the absence of preexisting cardiovascular disease. Disclosures: The study was supported by the Ministry of Health, Labour, and Welfare of Japan and the Japan Heart Foundation. Eight authors declared funding, grants, honoraria, and other support from the pharmaceutical industry. No other conflicts of interest were declared. Low-dose aspirin does not appear to reduce the risk of cardiovascular events in individuals with type 2 diabetes but without preexisting cardiovascular disease, according to a study presented at the American Heart Association scientific sessions and published simultaneously in the Nov. 15 edition of Circulation. In the long-term follow-up of participants in an open-label controlled trial, Japanese researchers followed 2,539 patients with type 2 diabetes who were randomized to daily aspirin (81 mg or 100 mg) or no aspirin, for a median of 10.3 years to see the impact on the incidence of cardiovascular events. Yoshihiko Saito, MD, of Nara Medical University, Kashihara, Japan, and coauthors noted that while results from randomized clinical trials support the benefits of low-dose aspirin for secondary prevention - and guidelines advocate their use for primary prevention in people with diabetes over a certain age or with cardiovascular risk Continue reading >>
Aspirin For Primary Prevention In Patients With Diabetes Mellitus.
Aspirin for primary prevention in patients with diabetes mellitus. Kansas City University of Medicine and Biosciences, USA. Evidence supports the routine use of low-dose aspirin (ASA) in the prevention of cardiovascular (CV) events in patients with diabetes mellitus (DM). In 1997, the American Diabetes Association (ADA) recommended ASA prophylaxis for all diabetic patients over the age of 30 with one additional risk factor for cardiovascular disease (CVD). Our objective was to determine the adherence to the ADA guidelines for ASA therapy in DM using a national database. Data from the 1997-2000 National Ambulatory Medical Care Survey (NAMCS) was used to determine the usage rates of ASA in patients with DM over age 30 years with one or more CV risk factors. Multiple logistic regression methods were used to determine what factors were related to ASA prophylaxis. During 1997-2000, more than one third of all diabetic patients should have been considered for ASA prophylaxis because they had one or more CV risk factors. Yet, from 1997-2000, the percentage of these patients given ASA for primary prevention was 2.8% in 1997, 2.9% in 1998, 2.1% in 1999, and 5.7% in 2000. Factors associated with increased ASA prophylaxis were non-white ethnicity, male gender, older age (more than 44 years old), rural clinic setting, preventative counseling given during visit, being prescribed more than two medications, having cardiovascular risk factors, and being seen by a cardiologist. Adherence rates to the ADA standard of care guideline regarding routine ASA prophylaxis in adults with DM and at least one CV risk factor are extremely low. National efforts directed at increasing these rates of ASA prophylaxis are indicated to meet the Healthy People 2010 goal of 30%. Continue reading >>
Enteric Coating And Aspirinnonresponsiveness In Patientswith Type2diabetes Mellitus - Sciencedirect
Volume 69, Issue 6 , 14 February 2017, Pages 603-612 A limitation of aspirin is that some patients, particularly those with diabetes, may not have an optimal antiplatelet effect. The goal of this study was to determine if oral bioavailability mediates nonresponsiveness. The rate and extent of serum thromboxane generation and aspirin pharmacokinetics were measured in 40patients with diabetes in a randomized, single-blind, triple-crossover study. Patients were exposed to three 325-mg aspirin formulations: plain aspirin, PL2200 (a modified-release lipid-based aspirin), and a delayed-release enteric-coated (EC) aspirin. Onset of antiplatelet activity was determined by the rate and extent of inhibition of serum thromboxane B2 (TXB2) generation. Aspirin nonresponsiveness was defined as a level of residual serum TXB2 associated with elevated thrombotic risk (<99.0% inhibition or TXB2 >3.1 ng/ml) within 72 h after 3 daily aspirin doses. The rate of aspirin nonresponsiveness was 15.8%, 8.1%, and 52.8% for plain aspirin, PL2200, and EC aspirin, respectively (p< 0.001 for both comparisons vs. EC aspirin; p= 0.30 for comparison between plain aspirin and PL2200). Similarly, 56% of EC aspirintreated subjects had serum TXB2 levels >3.1 ng/ml, compared with 18% and 11% of subjects after administration of plain aspirin and PL2200 (p< 0.0001). Compared with findings for plain aspirin and PL2200, thishigh rate of nonresponsiveness with EC aspirin was associated with lower exposure to acetylsalicylic acid (63% and 70% lower geometric mean maximum plasma concentration [Cmax] and 77% and 82% lower AUC0t [area under the curve from time 0 to the last time measured]) and 66% and 72% lower maximum decrease of TXB2, with marked interindividual variability. A high proportion of patients treated w Continue reading >>
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New Aspirin Guidelines For Diabetes Patients
June 2, 2010 -- Women under 60 and men under 50 who have diabetes but no other major risk factors for heart disease probably should not be on low-dose aspirin therapy, new research suggests. The new recommendations are based on close examination of nine studies that found the risks of some aspirin side effects, such as stomach bleeding, should be better balanced against the possible benefits of using aspirin. The new guidelines suggest low-dose aspirin therapy be used by men over 50 and women over 60 with diabetes who have other risk factors for heart attack and stroke. The U.S. Preventive Services Task Force still recommends low-dose aspirin for prevention of heart attacks and stroke in men aged 45 to 79 and women aged 55 to 79. The new guidelines have been endorsed by a panel of experts from the American Diabetes Association, the American Heart Association, and the American College of Cardiology Foundation. "The larger theme here is that use of low-dose aspirin to prevent heart attacks in people who have not already experienced one is probably not as efficacious as we used to believe it was," Craig Williams, PharmD, an associate professor in the College of Pharmacy at Oregon State University, says in a news release. Williams, one of those on the recent review panel, says doctors need to balance the benefits of any medication against possible side effects, and that even low-dose baby aspirin has some degree of risk, even though it is very low. "[We] have to be able to show clear benefits that outweigh that risk," he says. "In the case of young adults with diabetes but no other significant risk factors, it's not quite clear that the benefits are adequate to merit use of aspirin." People with diabetes face a higher risk of heart disease as they age, and many doctors have Continue reading >>
Diabetes And Aspirin
Tweet In the past, aspirin was often prescribed to people with diabetes, with the aim of reducing the risk of cardiovascular disease as a diabetes complication. However, concerns over an increased risk of bleeding associated with aspirin have led to recent new guidelines for aspirin for diabetics in the UK. Aspirin: revised recommendations In late 2009, Diabetes UK revised their recommendations regarding aspirin. They stated that people without known cardiovascular disease need to discuss their individual cases with their healthcare team, rather than taking aspirin as a preventative. Those people that are already taking aspirin were advised to continue until they have talked with their healthcare team. Diabetes UK recommends that people with diabetes who have a history of cardiovascular disease should take aspirin - including those with heart disease, stroke, transient ischemic attack and peripheral vascular disease. Effectively, the consensus is that aspirin should not be used routinely to prevent heart attacks amongst people with diabetes. Previous guidelines that suggested aspirin should be used by diabetics to counter the risk of heart attack and stroke are now invalid. That said, some high-risk groups should still use aspirin to lower their risk. Patients with diabetes should discuss their aspirin use with their healthcare professional. The fact remains that amongst people who have had a heart attack or stroke, aspirin has been shown to reduce the risk of future cardiovascular events by a significant amount. The risk of stomach bleeding needs to be carefully considered and discussed with your healthcare team. What the community are saying about hypos? Foreman: I have stopped taking low dose aspirin following advice from a consultant. Now my GP wants to restart me o Continue reading >>
Updated Recommendations On Aspirin Therapy In Diabetic Patients
An overview on aspirin use in the prevention of cardiovascular events…. Aspirin is a pharmaceutical drug that has been commercially available since 1899. Although originally used as a pain reliever and fever reducer, significant studies show aspirin can play a role in reducing the risk of cardiovascular disease. Patients with diabetes are at two to four fold greater risk of cardiovascular disease than those without diabetes. The updated recommendations are in response to a previous published article on aspirin therapy released in 2011. The current 2013 guideline recommendations by the American Diabetes Association (ADA) suggest aspirin therapy for primary prevention in patients with either type 1 or 2 diabetes who have an increased risk of cardiovascular disease. They do not recommend aspirin therapy in men under 50 years of age or most women under 60 years of age that have a low risk of cardiovascular disease because the risk of bleeding outweighs the potential benefits of aspirin treatment. A joint statement between the ADA, the American Heart Association, and the American College of Cardiology Foundation have provided additional recommendations for the use of aspirin in diabetics. They state that low dose aspirin is reasonable for diabetic adults who are at increased risk of cardiovascular disease (with no previous history of vascular disease) and not at an increased risk for bleeding. This includes men > 50 years old and most women > 60 years old. Aspirin is not recommended for diabetic patients who have a low risk of cardiovascular disease, such as men < 50 years old and women < 60 years old with no major risk factors. Additionally, aspirin might be recommended in those with an intermediate risk of cardiovascular disease. They also recommend an aspirin dose range Continue reading >>
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Aspirin Therapy In Diabetes
EFFICACY Secondary prevention trials A meta-analysis of 145 prospective controlled trials of antiplatelet therapy in men and women after myocardial infarction, stroke or transient ischemic attack, or positive cardiovascular history (vascular surgery, angioplasty, angina, etc.) has been reported by the Anti-Platelet Trialists (APT) (4). Reductions in vascular events were about one-quarter in each of these categories, and diabetic subjects had risk reductions that were comparable to nondiabetic individuals. There was a trend toward increased risk reductions with doses of aspirin between 75 and 162 mg/day. It was estimated that 38 ± 12 vascular events per 1,000 diabetic patients would be prevented if they were treated with aspirin as a secondary prevention strategy. Comparable results were seen in males and females. Primary prevention trials Two studies have examined the effect of aspirin in primary prevention and have included patients with diabetes. The U.S. Physicians’ Health Study (5) was a primary prevention trial in which a low-dose aspirin regimen (325 mg every other day) was compared with placebo in male physicians. There was a 44% risk reduction in the treated group, and subgroup analyses in the diabetic physicians revealed a reduction in myocardial infarction from 10.1% (placebo) to 4.0% (aspirin), yielding a relative risk of 0.39 for the diabetic men on aspirin therapy. These results are supported by the Early Treatment Diabetic Retinopathy Study (ETDRS), a mixed primary and secondary prevention trial (6). This population consisted of type 1 and type 2 diabetic men and women, about 48% of whom had a history of cardiovascular disease. The study, therefore, may be viewed as a mixed primary and secondary prevention trial. The relative risk for myocardial infarct Continue reading >>
Recommending Aspirin For Primary Prevention In Diabetic Patients: What May We Conclude From The Data?
Recommending Aspirin for Primary Prevention in Diabetic Patients: What May We Conclude from the Data? Author information Copyright and License information Disclaimer Cardiovascular (CV) disease is the leading cause of morbidity and is responsible for premature mortality in patients with diabetes [ King et al. 1998 ]. In addition to its association with multiple classical CV risk factors, diabetes is associated with accelerated atherosclerosis and inflammation that contribute to the pathogenesis and progression of vascular complications [ Evangelista et al. 2005 ]. For this reason, antiplatelet therapy is considered an essential component of diabetes care to reduce ischemic risk [ Angiolillo, 2009 ]. Aspirin has been on the market since 1899, and is still one of the most widely used medications for the treatment and prevention of CV disease. Despite such a long history of use, the role of aspirin for the primary prevention of CV events in individuals with diabetes is still a matter of debate. The new evidence made available in the last few years seems to have increased, rather than resolved, all the doubts regarding the risk-benefit profile of antiplatelet therapy. The uncertainty surrounding this topic is clearly demonstrated by the extreme heterogeneity in the recommendations issued by different scientific societies. As an example, until 2008, the American Diabetes Association recommended the use of aspirin for primary prevention of CV events in all individuals aged over 40 years or with additional risk factors [ American Diabetes Association, 2008 ]. This recommendation was graded as A, that is, supported by evidence of the highest quality. In 2009, while maintaining the same recommendation, grading was changed to C (evidence from poorly controlled studies) [ America Continue reading >>
