Retrospective #238: Low-dose aspirin, a nuanced approach for Type 2s

Do you take an anti-platelet medication? 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. A 2014 report published in Circulation, the journal of The American Heart Association (AHA), had updated findings. American Family Physician, re-published the findings under, “Updated Recommendations on Daily Aspirin Use in Patients with Diabetes.”

The guidelines and the supporting research are for the primary prevention of cardiovascular disease in diabetics. (“Primary” is medical jargon for those who do not already have CHD; “Secondary” prevention would be to prevent a heart attack in those who already have heart disease.) The lede in the Family Practice piece makes a 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 are, however, very 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).” You should consult your doctor.

“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, 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 (referenced) and the Atherosclerosis Risk in Communities CHD Risk Calculator” (also referenced). And that: “Risk should be reassessed periodically, because patients may acquire additional risk factors over time.”

After publication in Circulation, the paper appeared two months later in Diabetes Care, the journal of the American Diabetes Association, subtitled, “A Position Statement of the American Diabetes Association, a Scientific Statement of the American Heart Association, and an Expert Consensus of the American College of Cardiology Foundation.” Four months later, Family Practice Physician bought into it too and closed ranks with its “Practice Guidelines.”

Oddly enough, the time of day that aspirin is taken may make a difference. In 2013, a New York Times Well blog 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.” Why? “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 helps thin the blood and prevent platelets from clumping, lowering the likelihood of heart attacks and stroke.”

The time-of-day 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.

With my doctor’s approval, now that I’m “non-diabetic,” I discontinued my daily low-dose aspirin about 5 years ago. Up ‘till then, I took a low-dose aspirin with supper, so it could dissolve before I lay me down to sleep.