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Aspirin Prescribing Guidelines for Diabetes

Aspirin Prescribing Guidelines for Diabetes

Written by By Donna Itzstein, Diabetes Queensland Pharmacist

Did you know aspirin prescribing guidelines regarding low-dose aspirin in diabetes have changed over time? Previously, it was thought aspirin was appropriate for anyone at risk of cardiovascular disease (CVD). However, after the results of a landmark randomised clinical control trial3, changes were made to Australian and European Aspirin prescribing guidelines. This article discusses the current guidelines around diabetes and aspirin, as well as some surprising prescribing points for you to consider.

Aspirin prescribing guidelines in primary prevention

Currently, the Australian Therapeutic guidelines and General Practice Management of Type 2 Diabetes guidelines state:

Aspirin and other antiplatelet drugs are not routinely recommended for the primary prevention of cardiovascular disease.1,2

The results for aspirin in primary prevention of CVD remain mixed. The change in Australian and European guidelines reflect the results of the ASCEND study.3 This is because, while aspirin prevented serious vascular events in people living with diabetes and with no previous CVD, it was concluded the benefits were offset by the risk of major bleeding.

nSubjectsTreatmentDuration Outcomes
15,480 >40 years of age with
diabetes mellitus
without evident CVD
randomized to
100 mg of aspirin
vs placebo daily
mean follow-up of 7.4 years– serious vascular events: 9.6% placebo v 8.5% aspirin

– major bleeding events: 4.1% placebo v 3.2% aspirin

American guidelines recommend the use of low-dose aspirin for people with diabetes who are:

  • at an increased risk of CVD but have no previous history and
  • not at an increased risk for bleeding and are,
  • men >50 years or women >60 years.

Aspirin prescribing guidelines for diabetes and CVD management

Established atherosclerotic cardiovascular disease

Australian Therapeutic guidelines

Regardless of the initial antiplatelet regimen, most patients with atherosclerotic CVD benefit from long-term therapy with aspirin or clopidogrel. The recommended dose is 100 to 150 mg aspirin or 75 mg clopidogrel, taken orally, and daily. Dual antiplatelet therapy, such as aspirin plus clopidogrel, is not recommended in patients with stable peripheral arterial disease. This is because it has no advantage over aspirin alone. Furthermore, it is associated with increased bleeding.1

During the 12 months following an acute coronary syndrome, dual therapy is recommended. And usually once an anticoagulant therapy starts, antiplatelet therapy stops until the anticoagulant is withdrawn. This is because dual therapy with an anticoagulant and antiplatelet significantly increases the risk of major bleeding. Furthermore, in certain high-risk patients, such as those with recent coronary stenting, it may be beneficial to continue the antiplatelet drug. This is in addition to an anticoagulant drug, with specialist advice.

Intermittent claudication (leg cramps) such as found in peripheral vascular disease

In this patient group, recommendations include 100 to 150 mg aspirin or 75 mg clopidogrel orally, daily.4 Not to mention, Rivaroxaban is also another option. Although, at time of publication it is not currently available in Australia under the Pharmaceutical Benefit Scheme.

Key Prescribing points:
  • When using enteric-coated (EC) aspirin preparations it is important to note the quick and almost complete release of aspirin when the PH is higher. For this reason, it is best to take EC aspirin before a meal or going to bed, as it will reduce the frequency of adverse gastric reactions.5
  • Immediate release aspirin has good evidence in the treatment of cardiovascular disease.6
  • Studies show:
    • Twice daily administration of low dose aspirin is superior to once daily dosing.
    • Increased body weight is associated with lower aspirin responsiveness regardless of diabetes.7
  • Taking aspirin with non-steroidal anti-inflammatory medications, such as Ibuprofen, reduce antiplatelet action. It may also increase adverse gastrointestinal reactions. Occasional use is acceptable due to the long-lasting effects of aspirin on platelets. Paracetamol and Celecoxib do not interfere.
  • Food does not affect the amount absorbed with low dose aspirin. However food does delay the absorption of aspirin.8
  • Any alcohol intake will increase rates of gastrointestinal bleeding.
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  1. Therapeutic Guidelines Ltd. eTG January 2019 edition. s.l. : Therapeutic Guidelines Ltd, January 2019.
  2. The Royal College of General Practitioners and Diabetes Australia. General Practice Management of type 2 diabetes 2016-18. [Online] April 2019.
  3. Effects of aspirin for primary prevention in persons with diabetes mellitus: the ASCEND Study Collaborative Group. Bowman, L, et al. 2018, New England Journal of Medicine. 18;379(16):1529-1539.
  4. Antiplatelet agents for intermittent claudication. Cochrane Database of Systematic Reviews.Wong PF, Chong LY, Mikhailidis DP, Robless P, Stansby G. 11, 2011.
  5. Relationship between adverse gastric reactions and the timing of enteric-coated aspirin administration. Wejun, G, et al. 2, Auckland : s.n., February 2017, Clinical Drug Investigation, Vol. 37.
  6. Enteric-coated aspirin in cardiac patients: Is it less effective than aspirin. R, Jirmar and P, Widimsy. 2, 2018, Vol. 60.
  7. Type 2 diabetes, Obesity and aspirin responsiveness. C, Patrono and B, Rocca. 6, 2017, Journal of American College of Cardiology, Vol. 69.
  8. Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDS- a systemic review. A, Moore R, et al. 3, 2015, British Journal of Clinical Pharmacology, Vol. 80.