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Tighter Criteria Introduced for Aspirin Use in Diabetes
 
 
  MedPage Today
Published: May 27, 2010
 
A more conservative approach to aspirin for primary prevention in adults with diabetes is called for in a joint statement issued today by diabetes and cardiovascular associations.
 
Action Point Note that the U.S. Preventive Services Task Force recommends aspirin for primary prevention in men ages 45 to 79 and women ages 55 to 79 regardless of diabetes status.
 
Low-dose aspirin can be considered reasonable for diabetes patients with a cardiovascular disease risk above 10% over 10 years and no excess bleeding risk, according to the statement released by the American Heart Association, the American Diabetes Association, and American College of Cardiology.
 
That group of patients will include most men older than 50 and women over 60 with at least one major risk factor in addition to diabetes -- smoking, hypertension, dyslipidemia, family history of premature cardiovascular disease, or albuminuria.
 
This represents an update from the 2007 joint recommendation for low-dose aspirin (75 to 162 mg per day) as primary prevention in diabetes patients over 40 years of age or who have additional risk factors.
 
Patients currently on aspirin who no longer fit into one of the recommended categories should discuss with their physician whether this is the right choice, noted statement co-author Mark J. Alberts, MD, of Northwestern University in Chicago and a spokesperson for the American Stroke Association.
 
The prior recommendation had been based on several older trials that included relatively few diabetes patients, noted writing committee member M. Sue Kirkman, MD, of the ADA in Alexandria, Va., and colleagues.
 
The organizations decided to refine the guidelines after two recent randomized controlled trials performed specifically in diabetes patients "raised questions about the efficacy of aspirin for primary prevention in diabetes," they wrote online in Circulation: Journal of the American Heart Association.
 
The Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes trial showed only a trend overall (hazard ratio 0.80, 95% CI 0.58 to 1.10) for reduction of atherosclerotic events -- ischemic heart disease, stroke, and peripheral arterial disease -- in patients with type 2 diabetes.
 
However, there was a significant 32% reduction in the risk of all atherosclerotic events in patients 65 and older.
 
The Prevention of Progression of Arterial Disease and Diabetes (POPADAD) trial, which looked at diabetes patients with asymptomatic peripheral arterial disease, also found no benefit for primary prevention of fatal and nonfatal cardiovascular events (HR 0.98, 95% CI 0.76 to 1.26).
 
Adding this evidence to prior trials, a meta-analysis suggested a modest and nonsignificant 9% relative reduction in risk of fatal or nonfatal MI and a nonsignificant 15% relative stroke risk reduction with aspirin, with greater absolute benefits among those with higher underlying baseline risk.
 
Counterbalancing this is the increased risk of gastrointestinal bleeding, which may be as high as one to five excess events per 1,000 patients per year in real-world settings.
 
For adults with a cardiovascular disease risk greater than 1% per year, "the number of cardiovascular disease events will be similar to or greater than the number of bleeding events induced, although the events considered (MI, stroke, and gastrointestinal bleeding) do not have equal effects on long-term health," Kirkman's group wrote.
 
Thus, the cardiovascular and diabetes societies recommended against prophylactic aspirin use in those at low cardiovascular risk, which they said included men under age 50 and women younger than 60 with no major additional cardiovascular disease risk factors or a 10-year cardiovascular disease risk less than 5%.
 
For those with an intermediate level of risk -- younger patients with one or more risk factors, older patients with no risk factors, or patients with a 10-year cardiovascular disease risk of 5% to 10% -- low-dose aspirin might be considered pending further research.
 
"All patients with diabetes do not have high cardiovascular risk, despite the assumptions of some previous guidelines," Kirkman's group emphasized in the statement.
 
 
 
 
 
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