Saturday, August 23, 2014

The Nutrition Debate #238: Type 2 Diabetics: Do you take a low-dose aspirin?

Do you take an antiplatelet medication? If you’re not sure, it’s more commonly referred to as “low-dose aspirin therapy.” The most common regimen in the U. S. is an 81mg, enteric coated aspirin, taken once a day. Here, from American Family Physician, are “Updated Recommendations on Daily Aspirin Use in Patients with Diabetes,” confirming the findings. The report was originally published in Circulation, the journal of The American Heart Association (AHA), here.

The guidelines and the supporting research are for the primary prevention of cardiovascular disease in diabetics. (“Primary” means for those who do not already have CHD; “Secondary” prevention would be to prevent a heart attack in those who already have heart disease.) Is it justified? The lede in the Family Practice piece makes a pretty compelling case:

Persons with diabetes mellitus have two to four times the risk of cardiovascular events compared with persons of the same age and sex who do not have the disease. Coronary heart disease (CHD) is responsible for more than two-thirds of deaths in persons with diabetes who are older than 65 years.”

The recommendations is, however, somewhat nuanced:  “Low-dose aspirin therapy is reasonable in adults with diabetes and no history of vascular disease,” who are at increased risk of CHD events based on an accurate assessment of CHD risk, “and who are not at increased risk of bleeding (i.e., no history of GI bleeding or peptic ulcer disease, and no concurrent use of other medications that increase bleeding risk).” Obviously, you should consult a doctor to make that determination.

“Adults with diabetes who are at increased risk of CHD events include most men older than 50 years and women older than 60 years who have at least one additional major risk factor (i.e., smoking, hypertension, dyslipidemia, albuminuria, or family history of premature cardiovascular disease). Aspirin should not be recommended in adults with diabetes who are at low risk of cardiovascular events (men younger than 50 years and women younger than 60 years with no additional major risk factors). The potential adverse effects from bleeding offset the potential benefits in these patients.”

The American Family Physician’s “Practice Guidelines” go still further: “Low-dose aspirin therapy may be considered for patients with diabetes who are at intermediate risk of CHD events (younger patients with at least one risk factor, older patients with no risk factors, or patients with a 10-year risk of 5 to 10 percent).” Again, ask your doctor.

They note also: “Not all patients with diabetes are at high risk, and the use of a risk prediction tool is essential. There are several Web-based tools available, such as the UK Prospective Diabetes Study Risk Engine (here) and the Atherosclerosis Risk in Communities CHD Risk Calculator (here).” And that: “Risk should be reassessed periodically, because patients may acquire additional risk factors over time.”

After its publication in Circulation, the paper appeared two months later here in Diabetes Care, the journal of the American Diabetes Association. The subtitle of both: “A Position Statement of the American Diabetes Association, a Scientific Statement of the American Heart Association, and an Expert Consensus Document of the American College of Cardiology Foundation.” Family Practice Physician bought in to it and closed ranks with its “Practice Guidelines” four months later.

Oddly enough, the time of day the aspirin is taken may make a difference. A New York Times health blog last year began, “Millions of adults take an aspirin every morning to ward off heart disease. But a new study suggests that the pills might be most effective if taken right before bed.”  

The reason:Cardiovascular events are about three times more likely to occur in the morning, when blood pressure and platelet activity are typically at their highest levels.” “Taking a daily aspirin,” therefore, “helps thin the blood and prevent platelets from clumping, lowering the likelihood of heart attacks and stroke,” the Well blog says.

The study was done at Leiden University Medical Center in the Netherlands. The researchers found “that morning platelet activity was reduced to a much greater degree when the aspirin was taken at night. The timing of the aspirin, however, had no impact on morning blood pressure levels, which was something else the researchers measured.” The findings were presented at an American Heart Association (AHA) conference.
So, the lead author of the study said, “it may make more sense for daily aspirin users to take the medication before turning in each night, rather than first thing in the morning.” I take it with supper, so it can dissolve before I lay me down to sleep.


  1. An amazing number of medical "professionals" recommend aspirin to me, some repeatedly, despite my gentle noting that I would need an Epipen every day as well, as I am strongly allergic to the stuff..
    And when I say "anaphylactic shock" ta least half will say "what do you mean by that" as if I could not possibly know what these Big Words mean..


    1. Hi Helen,
      Interesting. This is not my subject area, and I wrote about it only because of the "recommendations" with respect to type 2 diabetes. I was unaware also that people can be alergic to aspirin. Wow!

      I've been taking one 81mg on my own recommendation for probably 10 years, but until I researched and wrote this post, I was unaware that is was called an "antiplatelet" medication. My own platelet count has been on the moderately low side (just out of range) for the last seven years, along with a few other CBC values. Hmmm...
      My doctors have noted it but attributed it to radiation therapy I had 25 years ago affecting secondarily the bone marrow and have said they are not concerned. I wonder, if I stop taking the daily aspirin, will my platelet count and other CBC values return to normal?

    2. Not only aspirin, but all the related drugs like Ibuprofen.. Also, I can't handle fresh-cut willow without gloves.. I'm told it's quite common. Not convinced by any kind of knee-jerk medication, and I'm having a year off from doctors, as I'm sure that's good for my blood-pressure..

    3. LOL. I'm sure you're right about that. The medical group I visited 3 times in Florida (over 2 years) had the same effect on me. When the endo I saw the first time wanted to prescribe a statin, and cited the NCEP standards, I told him he needed to go back to school. He 'fired' me. (Read #86 & #87; it's a hoot).

      Then the Family Practice guy I met in a bar (from the same group), who told me he was a lipidologist, told me I should be on a statin, and I told him I would not take it if prescribed), he put it in my chart anyway (to be in compliance with 'guidelines' if he should be 'audited'). Then, when next I visited him, and he had a medical school student with him that he was mentoring, he reviewed my prescriptions from the medical record screen on him computer. When asked me to confirm a drug that I never heard of (that ended with statin), I said what was that? He 'corrected' the record and no doubt added "patient non-compliant.'

      My lipid panel then was TC = 207; LDL= 110; HDL 90; TG 34. My lipid panel last month TC 210; LDL 109; HDL 91; TG 51. With blood lipid values like these, what thinking doctor (much less a 'llipidologist,' would prescribe a statin for me?

  2. Low dose aspirin was prescribed to me, along with cholesterol and blood pressure medication 8 years ago when I was diagnosed with T2 diabetes. s it turns out, none of them were necessary, all had bad effects, and I stopped taking them within 2 months when that was evident. I bruise easily and even 81mg of aspirin over a couple days time will help me bruise even worse. Yet I've been at the doctor's with the bruises on my lower arms quite obvious and she has still said, "Diabetic women in your age group should take a low dose aspirin every morning."

    1. Hi Jan,
      Read my response to Helen above. What she and you need is a doctor who is in practice for himself, not associated with a large group or a large group that is owned by a large hospital group. I think those doctor's hands are tied by practice and government guidelines that limit their ability to make informed decisions in the best interest of the patient. The one-size-fits-all approach to medicine is ruining the profession. I wonder: Do you have an opportunity to choose you own doctor? Like a DO or sole practitioner? My solution was to add my doctor's email to my distribution list. That way, he knows where I'm coming from. He also considers me to be 'healthy' compared to his other patients (I think). He once told me (on the first visit actually), that I should only need to see him once a year. I told him I wanted to see him (on another doctor) 3 or 4 times a year. Now that I have given up on my Florida doctors, I have settle in with 3 visits/year with him. I think it's too 'risky' and 'arrogant' to not have some oversight of my overall health condition. Besides, as a self-treated type 2, I want the lab tests to keep me motivated and to try to improve my blood glucose control and inflammation markers. Frankly, I don't see how my blood lipids could be any better. (LOL)

      PS: Starting this week, I am going to stop taking the 81mg aspirin until my next visit in early December to see if my CBC values improve, including platelets.

  3. If you have an allergy to aspirin, would high salicylate foods also be an issue?

    Vitamin K (you need K1 and K2 both) and vitamin D can help with the bruising, supposedly.

    1. Apparently not, but I don't think it's the same thing at all..

  4. interesting. and thank goodness since so many foods have the sals.