Correct Aspirin Dose May Be Key Helping Diabetic Patients Avoid a Second Cardiovascular Event

Diabetes patients already at-risk can learn about full strength aspirin, a possible future low-cost, widely available way to cut risks of a second heart attack or stroke and also learn about the smaller aspirin doses currently recommend.

A recent study suggests a higher daily dose of aspirin may significantly reduce by 23 percent the risk of death from a second heart attack or stroke by patients with diabetes.

The operative word is “may.” The life-saving potential may be real, but there’s that word “may” again.

Unfortunately, no matter what you read in the tabloids the evidence is not strong enough for most people including adults with diabetes to rush out and start taking daily doses of full strength aspirin even if they have had one heart attack or stroke and want to prevent another.

The operative phrase in the above paragraph is “full strength aspirin.” According to the 2011 Standards of Care from the American Diabetes Association, high risk people with diabetes and any cardiovascular disease (CVD) such as hypertension (high blood pressure) or high cholesterol or triglycerides (hyperlipidemia) and any diabetes patient with previous heart attacks or stroke (who thus are at high risk for second heart attacks or stroke) may want to talk to their physician about doubling the widely recommended daily “baby” aspirin dose of 82 mg.

The ADA’s 2011 Standards of Care put it this way: Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at
increased cardiovascular risk (10-year risk 10%). This includes most men 50 years of age or women 60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria).

This time the operative phrase in the above paragraph is “high risk.” Aspirin is no longer recommended for those at low risk for CVD. Low risk individuals include women under age 60 and men under age 50 with no major CVD risk factors such as family history or a prior heart attack or stroke or with hypertension and/or hyperlipidemia.

Figures from the University of Alberta’s meta-analysis (an analysis of previously published studies) also showed that diabetes patients who took aspirin (at any dose) were less likely to have second heart attacks than diabetes patients who took no aspirin at all. That reinforces that diabetes patient, especially with a family history of cardiovascular problems or any of the above mentioned risk factors should definitely be on an aspirin regimen, but that finding isn’t new, says Todd Marcy, a professor of pharmacy at the University of Oklahoma.

Older studies already indicate that smaller doses of aspirin reduce the chances of a person with diabetes from having a stroke or heart attack in the first place. That is important information because adults with diabetes are at the same risk of heart attack or stroke as someone who already has had a heart attack or stroke. Another way of putting it is that diabetes patients are two to four times more likely to die of a heart attack than people without diabetes.

The new meta-analysis, conducted by the University of Alberta (UA) in Canada, found that daily aspirin doses of 325 milligrams or more reduced by 23 percent the chances of a person with type 2 diabetes dying from a second heart attack or stroke.

However, diabetes patients who have had heart attacks or stroke shouldn’t rush to increase their aspirin doses just yet because there’s a downside to taking aspirin, especially full-strength 325 mg aspirin.

“There was a significant amount of variation amongst the studies, so at this point, the observed associations should be considered hypothesis-generating and not strong evidence to change practice,” says one of the UA’s study’s lead researchers, Scot Simpson, PharmD, an associate professor of pharmacology at UA, Edmonton. (A hypothesis (hi pot thesis) is a proposed explanation for a specific set of facts. Every quantitative study (a study that measures) starts out to examine at least one hypothesis to determine if it really explains what the hypothesis says it does). But there is another factor: Is taking that much aspirin on a daily basis safe for people for people with diabetes?

“In our meta-analysis of previous research there were only two big studies, the Physician’s Health Study and the United Kingdom’s Transient Ischemic Attack (TIA) Trials that looked at people with diabetes taking fairly large doses of aspirin. Unfortunately, there were fewer than 600 people with diabetes taking aspirin in those trials.”

Because of the safety issue, that’s too small of a group on which to make recommendations to patients, “However, we have identified a gap in the literature and it is our hope that some organization will fund a large and long enough, at least five year, prospective study upon which we can recommend the best doses of aspirin to prevent second heart attacks or strokes for people with diabetes without significantly increasing the chances of bleeding in the stomach or elsewhere in the body.”

Aspirin works by making platelets in the blood less likely to stick to one another, lowering the risk of clots that can cause heart attack and stroke. Researchers have suggested that people with diabetes are more resistant to aspirin’s effects than non-diabetic people, leading to the hypothesis that higher doses might be better than lower ones. According to current research, however, the dose of aspirin taken by patients is less important than aspirin’s mere presence in the bloodstream.

“Individuals with diabetes and heart disease should take at least some dose of aspirin,” says Cara East, a cardiovascular doctor and director of the Soltero Cardiovascular Research Center at Baylor University Medical Center in Dallas. “Science has not yet told us that one dose of aspirin is better than the other.”

Current standards of care suggest that aspirin may help prevent a first heart attack or stroke in high-risk individuals including men 50 and older, and women 60 and older, who in addition to diabetes also have other heart disease risk factors such those previously mentioned as well as smoking or diabetes itself. The American Diabetes Association recommends that anyone with diabetes who already has increased cardiovascular disease (CVD) risk or those who already have had a heart attack or stroke take aspirin at doses of 75-162 mg on a daily basis but NOT the large 325 mg aspirin because of the increased risk of bleeding that accompanies aspirin therapy.

See your physician to determine your CVD risk before taking any aspirin on a regular basis.

Diabetes patients also have other ways to lower the risk of heart attack. Patients should aim to lower their blood pressure to 130/80 – less than the general population’s goal of 140/90 – and keep their LDL cholesterol levels to less than 100 milligrams. Hemoglobin A1C tests, which measure the amount of glucose in your blood over time, should also reveal A1C levels of 7 percent or less. These goals can be reached by altering lifestyle habits (such as reducing one’s intake of fats and sugars by being aware of the nutritional content of foods you eat), through taking prescribed medications, or both.

Editor’s Note: Jennifer Acosta Scott contributed to this story
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