From the Guidelines
Aspirin is not generally recommended for primary prevention of cardiovascular events in most diabetic patients, due to the modest cardiovascular benefits being outweighed by bleeding risks, as shown in the most recent study 1. The use of aspirin for primary prevention in diabetic patients has been a topic of debate, with recent guidelines shifting away from routine aspirin use due to the potential risks outweighing the benefits. According to the 2023 standards of care in diabetes 1, aspirin may be considered for select diabetic patients at high cardiovascular risk but low bleeding risk, particularly those aged 40-70 with additional risk factors such as hypertension, dyslipidemia, smoking, or family history of premature cardiovascular disease.
Some key points to consider when deciding whether to prescribe aspirin for primary prevention in diabetic patients include:
- The patient's cardiovascular risk profile, including factors such as age, blood pressure, lipid levels, and family history of cardiovascular disease
- The patient's bleeding risk profile, including factors such as age, renal function, and history of bleeding disorders
- The potential benefits of aspirin in reducing cardiovascular events, as shown in studies such as the ASCEND trial 1
- The potential risks of aspirin, including gastrointestinal bleeding and other bleeding complications
When prescribed, the typical dose of aspirin is 75-100 mg daily. Before starting aspirin, patients should undergo comprehensive cardiovascular risk assessment and bleeding risk evaluation. The decision to prescribe aspirin should be individualized through shared decision-making between patient and provider, taking into account the patient's unique risk profile and medical history. Aspirin works by inhibiting platelet aggregation through irreversible inhibition of cyclooxygenase-1, reducing thromboxane A2 production and preventing clot formation. For diabetic patients with established cardiovascular disease (secondary prevention), aspirin remains strongly recommended unless contraindicated, as shown in studies such as the Antithrombotic Trialists’ Collaboration 1.
From the Research
Aspirin Use in Diabetic Patients
- Aspirin has been recommended for the prevention of major adverse cardiovascular events (MACE) in diabetic patients without previous cardiovascular disease 2.
- However, recent meta-analyses have prompted re-evaluation of this practice, suggesting that the benefits of aspirin in primary prevention may be modest and outweighed by the risks of bleeding and gastrointestinal complications 3, 4.
Benefits and Risks of Aspirin
- The use of aspirin in diabetic patients has been shown to reduce the risk of MACE, including myocardial infarction, stroke, and cardiovascular death 2.
- However, aspirin also increases the risk of hemorrhagic and gastrointestinal events, which may outweigh the benefits in some patients 2, 5.
- The absolute benefits and risks of aspirin in diabetic patients depend on individual risk factors, including the presence of other cardiovascular risk factors and the risk of bleeding 2, 5.
Aspirin Dosing and Formulation
- The traditional once-daily, low-dose aspirin regimen may not be sufficient to provide 24-hour protection against cardiovascular events in diabetic patients, due to the rapid turnover of platelets and altered pharmacokinetics 3, 4.
- Alternative dosing regimens, such as twice-daily dosing or non-enteric coated formulations, may be more effective in preventing cardiovascular events in diabetic patients, but require further study 4.
Clinical Decision Making
- The decision to prescribe aspirin to diabetic patients for primary prevention of cardiovascular events should be individualized, taking into account the patient's risk factors, bleeding risk, and other preventive strategies 5, 6.
- Patient-provider discussion is recommended before prescribing aspirin therapy, to weigh the potential benefits and risks and determine the best course of treatment 5.