By Donna Itzstein
Diabetes Queensland Pharmacist
The 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). This article discusses
the current guidelines around diabetes and aspirin. Studies also
reveal some surprising prescribing points for you to consider.
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.
The ASCEND study 2005-2011 (3)
>40 years of age with diabetes mellitus without evident
randomized to 100 mg of aspirin vs placebo daily
mean follow-up of 7.4 years
serious vascular events
major bleeding events
The conclusion was although aspirin prevented serious vascular
events in people living with diabetes and with no previous CVD, the
benefits were offset by the risk of major bleeding.
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
- not at an increased risk for bleeding and are,
- men >50 years or women >60 years.
Established atherosclerotic cardiovascular
Australian Therapeutic guidelines
Regardless of the initial antiplatelet regimen, most
patients with atherosclerotic CVD benefit from long-term therapy
with aspirin 100 to 150 mg or clopidogrel 75 mg orally, daily. Do
not use dual antiplatelet therapy (i.e. aspirin plus clopidogrel)
in patients with stable peripheral arterial disease. It has no
advantage over aspirin alone and is associated with increased
During the 12 months following an acute coronary syndrome, dual
therapy is recommended. Generally once an anticoagulant therapy is
commenced, antiplatelet therapy is ceased until the anticoagulant
is withdrawn. Dual therapy with an anticoagulant and antiplatelet
increases the risk of major bleeding significantly. In certain
high-risk patients (e.g. recent coronary stenting), it may be
appropriate to continue the antiplatelet drug (in addition to an
anticoagulant drug) with specialist advice.
Intermittent claudication (leg cramps) such
as found in peripheral vascular disease
The recommendation is aspirin 100 to 150 mg or
clopidogrel 75 mg orally, daily. (4) Rivaroxaban is
another option, which may soon become available in Australia under
the Pharmaceutical Benefit Scheme.
- If using enteric-coated (EC) aspirin preparations aspirin is
released quickly and almost completely when the PH is
higher. For this reason, optimal dosing of EC aspirin
is best taken before a meal or before sleep. This dosing
reduced the frequency of adverse gastric reactions. (5)
- It is debatable whether EC aspirin decreases the
frequency of adverse gastric reactions, and may in fact lead to
suboptimal results compared to aspirin immediate release.
In fact, the cause of gastric reactions such as bleeding is thought
to be mainly as a result of platelet inhibition rather than local
irritation. Immediate release aspirin has a sufficient body of
evidence supporting its role in the treatment of cardiovascular
- Studies show:
- Twice daily administration of low dose aspirin was
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 will reduce antiplatelet action and
may increase gastrointestinal adverse reactions.
Occasional use is acceptable due to the long-lasting effects of
aspirin on platelets. Paracetamol and Celecoxib do not
- Food does not affect the amount absorbed with low dose
aspirin. The absorption of aspirin is delayed by food.
- Any alcohol intake will increase rates of
- Therapeutic Guidelines Ltd. eTG
January 2019 edition. s.l. : Therapeutic Guidelines Ltd,
- The Royal College of General Practioners and Diabetes
Australia. General Practice Management of type 2 diabetes
2016-18. [Online] April 2019. [Cited: 2019.]
- Effects of aspirin for primary prevention in persons with
diabetes mellitus: the ASCEND Study Collaborative Group.
Bowman, L, et al. 1, January 1st, 2019, Journal of
Vascular Surgery, Vol. 69, p. 305.
- Antiplatelet agents for intermittent claudication. Cochrane
Database of Systematic Reviews. Wong PF, Chong LY,
Mikhailidis DP, Robless P, Stansby G. 11, 2011.
- 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.
- Enteric-coated aspirin in cardiac patients: Is it less
effective than aspirin. R, Jirmar and P,
Widimsy. 2, 2018, Vol. 60.
- Type 2 diabetes, Obesity and aspirin responsiveness.
C, Patrono and B, Rocca. 6, 2017, Journal of
American College of Cardiology, Vol. 69.
- 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.