College of Cardiology 60th Annual Scientific Sessions
NEW ORLEANS — Aspirin has been proven to be effective in reducing
the risk for cardiovascular events; however, patients with diabetes are a
unique population that requires special considerations before treatment. While
aspirin therapy is recommended, further exploration into dosing strategies,
stronger antiplatelet therapy and the clinical interaction between aspirin and
patients with diabetes is essential, a speaker said here.
“A landmark study published in 1990 really set the stage as to why
diabetics are different and why antiplatelet therapy may be effective in this
population,” Jeffrey S. Berger, MD, of the NYU Cardiac and Vascular
Institute at the NYU Langone Medical Center in New York, said during a
presentation. “Compared with nondiabetics, diabetics had greater platelet
Berger noted that one study currently being conducted at NYU suggests
that markers of platelet activity correspond well with an increasing prevalence
of diabetes, even in patients without CV disease. Data from other trials
support this association, and these results raised an important question: Can
measuring platelet activity prevent a future event? At present, this question
remains unanswered but warrants further investigation, he said.
In addition, physicians must consider dosing when treating with aspirin.
Berger explained that aspirin inhibits COX-1 and, thus, reduces amounts of
platelet activation and vascular constriction. However, aspirin at higher doses
also reportedly inhibits prostacyclin, which causes an effect opposite of
thromboxane. Therefore, Berger emphasized that physicians be careful not to
prescribe too much aspirin, even among patients with diabetes.
Many physicians believe that patients with diabetes have a different
clinical response to aspirin than those without the disease. Berger pointed out
that this is a misconception, however, and cited data from a large
meta-analysis that indicated no significant differences in aspirin's effect on
decreasing myocardial infarctions, stroke or all-cause mortality in patients
with diabetes compared with those without the disease. Most importantly, he
said, research showed no significant interaction in how aspirin prevents CV
events between patients with diabetes and those without.
Despite aspirin’s efficacy in decreasing CV benefits, the
medication has been linked with serious adverse events, such as major bleeding,
with research showing a low number needed to treat and a low number needed to
“Thinking about it this way, for every 1,000 patients treated for 5
years, three ischemic events are avoided, but three major bleeds are
caused,” Berger said. “So when you’re thinking about who should
get aspirin, you should think about the absolute benefit and the absolute
Because patients with diabetes are a special population, researchers and
physicians should consider whether stronger antiplatelet therapies are
required. Berger said future studies must take other medications into account.
Statins, fish oil and ACE inhibitors, for example, have antiplatelet activity
and this effect may attenuate some of aspirin's effect. He also noted that
dosing strategies may have to be altered, such as administering aspirin twice a
day instead of once daily. Additionally, improved tools for monitoring
aspirin’s effect on preventing CV events would also be extremely valuable,
according to Berger.
“There is no significant clinical interaction between diabetics and
nondiabetics regarding the effect of aspirin. It remains uncertain if diabetics may need a
different strategy of dosing or a stronger antiplatelet therapy, and I think
future clinical trials should address these issues,” Berger said. –
by Melissa Foster
Disclosure: Dr. Berger reports receiving fees from Astra Zeneca.
For more information:
- Berger JS. ACC Symposium 0622-7. Presented at: ACC 60th Annual
Scientific Sessions; April 2-5, 2011; New Orleans.
Dr. Berger raised some very provocative points, particularly about what
dose of aspirin should be used. The fact that he showed data that suggest that
a lower dose of 81 mg may not be as effective as we think in patients with
diabetes is an important take-home message. I don’t think that message is
really out there. The other very provocative point he raised is that we need
better tools to monitor the effect of aspirin like we have to monitor the
effect of cholesterol-lowering and blood pressure-lowering drugs. We are really
missing that with aspirin. Some of the focus for future trials that he
discussed would be incredibly useful to the overall care for the patient with
– Rhonda Cooper-DeHoff, PharmD
Associate Professor, Department of Pharmacotherapy and
Colleges of Pharmacy and Medicine, University of
Disclosure: Dr. Cooper-DeHoff reports no relevant financial