MD Conference Express ADA 2011 - (Page 16)

n SELECTED UPD ATES I N ANTI PLATELET THER APY The Role of Antiplatelet Drugs in Diabetes Written by Rita Buckley The role of low-dose aspirin as primary prevention among individuals who are at high risk for cardiovascular disease (CVD) is controversial. Given the greater risk for cardiovascular (CV) events among individuals with diabetes, antiplatelet therapy has appeal as a way to reduce the risk of thrombi and subsequent ischemic events in both the primary and secondary setting. Aspirin for Primary Prevention The great interest—and uncertainty—about the role of aspirin as primary prevention has been demonstrated by the number of recent meta-analyses on aspirin trials, said Nilay Shah, MD, Mayo Clinic, Rochester, Minnesota, USA. In the most recent meta-analysis, aspirin decreased the risk for CV events and nonfatal myocardial infarction (MI), but there were no significant differences in the incidence of stroke, CV or all-cause mortality, or total coronary heart disease [Bartolucci AA et al. Am J Caridiol 2011]. Five other meta-analyses that focused on patients with diabetes demonstrated a nonsignificant reduction in CV events (Table 1). Table 1. Summary of Evidence. Author Bartolucci (2011) Butalia (2011) Stavrakis (2011) Younis (2010) Zhang (2010) Deberardis (2009) ATTC (2009) Number of studies (patients) 9 (~90,000) 7 (~11,000) 5 (~7300) 6 (~7300) 7 (~12,000) 5 (~9600) 6 (~95,000) Relative Risk on CV Events (95% CI) 0.87 (0.80 to 0.93) 0.91 (0.82 to 1.00) 0.89 (0.70 to 1.13) 0.90 (0.78 to 1.05) 0.92 (0.83 to 1.02) 0.90 (0.81 to 1.00) 0.82 (0.75 to 0.90) Effect on Bleeding 0.3 to 4.5% 2.50 (0.77 to 8.10) 3.02 (0.48 to 18.86) 2.49 (0.70 to 8.84) 2.46 (0.70 to 8.61) 2.50 (0.76 to 8.21) 1.54 (1.30 to1.82) All Diabetes Diabetes Diabetes Diabetes Diabetes All Despite the benefits that are associated with aspirin, the benefits must be weighed against the risk of excess bleeding. “Heterogeneity exists in the risk-benefit tradeoff of aspirin,” said Dr. Shah, increasing the challenge of decision-making. Peer-Reviewed Highlights from the Most of the benefit of aspirin for men is derived from a reduction in MIs, whereas the greatest benefit for women is a reduction in strokes [Berger JS et al. JAMA 2006]. This difference in benefit is reflected in the United States Prevention Services Task Force guideline, which recommends aspirin for primary prevention for men aged 45 to 79 years and women aged 55 to 79 years when the CV risk outweighs harm; specific risks are defined for each gender and age group (Table 2) [Wolff T et al. Ann Intern Med 2009]. There is no differentiation in recommendations for individuals with diabetes. The guidelines that were set forth by the American Diabetes Association (ADA)/American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) in 2010 “are quite different than the 2002 guidelines,” said Dr. Shah. The new guideline notes that aspirin therapy for primary prevention may be considered for individuals with type 1 or type 2 diabetes who are at increased CV risk, which is defined as a 10-year risk >10%. The guideline does not recommend aspirin for individuals with diabetes and a low CV risk (10-year risk <5%) and notes that clinical judgment is required for individuals with a 10year CV risk of 5% to 10% [Pignone M et al. Diabetes Care 2010]. There is no differentiation according to gender. 16 August 2011 www.mdconferencexpress.com  http://www.mdconferencexpress.com http://professional.diabetes.org/Congress_Display.aspx?TYP=9&CID=82452 http://www.mdconferencexpress.com

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