Is it indicated to start a 50-year-old patient with type 1 diabetes mellitus (T1DM) on Aspirin (acetylsalicylic acid)?

From the Guidelines

Aspirin therapy may be considered for a 50-year-old patient with type 1 diabetes mellitus (T1DM) if they have additional cardiovascular risk factors, after a comprehensive discussion on the benefits versus the comparable increased risk of bleeding.

Key Considerations

• The patient's age and presence of diabetes alone do not necessarily warrant aspirin therapy; additional risk factors such as hypertension, dyslipidemia, smoking, family history of premature cardiovascular disease, or chronic kidney disease/albuminuria should be considered 1.
• The decision to start aspirin should be based on a shared decision-making process, weighing the cardiovascular benefits against the increased risk of bleeding, particularly in patients with a high risk of bleeding or those over 70 years old 1.
• Aspirin therapy for primary prevention may be considered in patients with diabetes who are at increased cardiovascular risk, with a recommended dose of 75-162 mg/day 1.

Important Factors

• The patient should be assessed for contraindications such as aspirin allergy, active bleeding, recent gastrointestinal bleeding, or other bleeding disorders before starting aspirin therapy.
• Non-invasive imaging techniques such as coronary calcium scoring may help further tailor aspirin therapy, particularly in those at low risk 1.
• The cardiovascular benefit of aspirin works through inhibition of platelet aggregation, reducing the risk of arterial thrombosis, while the main risk is increased bleeding, particularly gastrointestinal 1.

Recommendation

Aspirin therapy should be individualized based on the balance between cardiovascular benefit and bleeding risk, and a discussion with the patient about the benefits and risks is essential before initiating therapy.

From the Research

Aspirin Therapy for Primary Prevention in Type 1 Diabetes Mellitus (T1DM)

• The use of aspirin for primary prevention of cardiovascular disease in patients with diabetes mellitus, including those with T1DM, has been a topic of debate 2, 3, 4, 5, 6.
• Studies have shown that aspirin can reduce the relative risk of myocardial infarction and stroke by about 10% in patients with diabetes mellitus, but it also increases the risk of gastrointestinal bleeding 2.
• A meta-analysis of 6 studies found no difference between aspirin and placebo with respect to the risk of all-cause mortality or individual atherosclerotic events in patients with diabetes, but the risk of bleeding was increased 3.
• The ASCEND trial found that aspirin use prevented serious vascular events in persons with diabetes and no evident cardiovascular disease, but it also caused major bleeding events, and the absolute benefits were largely counterbalanced by the bleeding hazard 5.

Considerations for Aspirin Therapy in a 50-year-old Patient with T1DM

• The decision to start a 50-year-old patient with T1DM on aspirin therapy should be based on an individual assessment of their cardiovascular risk and bleeding risk 4, 6.
• Current guidelines recommend aspirin therapy for primary prevention in people with diabetes under specific circumstances, such as those with a high cardiovascular risk and no risk of gastrointestinal bleeding 6.
• The patient's age, duration of diabetes, presence of other cardiovascular risk factors, and history of bleeding events should be taken into account when making this decision 2, 5.