ADA updates recommendations on aspirin use in diabetics

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The American Diabetes Association (ADA) has reviewed and updated its recommendations for the use of aspirin in the primary prevention of cardiovascular disease in people with diabetes, in conjunction with the American Heart Association (AHA) and American College of Cardiology (ACC).

The new position statement is based on the results of two large randomized controlled trials in patients with type 2 diabetes (JPAD* and POPADAD†), neither of which showed a statistically significant reduction in cardiovascular events with aspirin therapy. [JAMA 2008;300(18):2134-41; BMJ 2008;337:a1840. doi: 10.1136/bmj.a1840]

“The [latest] recommendations are more conservative than prior recommendations, in part because there is newer evidence suggesting that the effects of aspirin for primary prevention are more modest than previously believed,” said Dr. M. Sue Kirkman, senior vice president, ADA Medical Affairs and Community Information.

“We still need to know more about subgroups of patients,” she added. ”There is a suggestion that aspirin may have different benefits in men and women, but current studies aren’t large enough to answer this. We also need better tools to help determine a particular patient’s risk of a future event (either a side effect of aspirin or a cardiovascular event).”

As well as reviewing the published literature, the authors of the new report performed a meta-analysis of available data on the effects of aspirin for primary prevention of heart attack and stroke in people with diabetes. This analysis found that aspirin was associated with a modest reduction in myocardial infarction.

“As the relative risk reduction is probably similar across all levels of baseline risk, it is likely that the absolute risk reduction will be greatest in those with the highest baseline risk,” said Kirkman. “The suggestion is therefore to recommend aspirin in those at highest risk for [cardiovascular] events. In those at lower risk, any potential benefits are likely to be offset by bleeding risk (gastrointestinal bleeding or hemorrhagic stroke).”

“I think the current guidelines are logical,” said Dr. Kevin Tan Eng Kiat, a consultant diabetologist and endocrinologist in private practice at Mount Elizabeth and Mount Alvernia Medical Centres, and vice-president of the Diabetic Society of Singapore. “Diabetes has long been considered a cardiovascular risk equivalent, carrying the same cardiovascular risk as a person with a previous myocardial infarction. In such people, anti-thrombotic therapy either as aspirin or clopidogrel is standard therapy.”

Tan pointed out that no two diabetics are the same and that, while the risk of cardiovascular events tends to be elevated in all patients with diabetes, there are different strata of risk spanning the whole diabetic population. “Compounding this issue is the fact that there is increased hemorrhagic stroke and gastrointestinal bleed risk with aspirin. Therefore it is logical that those with diabetes who are to benefit from aspirin therapy should have a greater lowering of cardiovascular risk, out-weighing the increased risks of using aspirin.”

Source: mims.com