Trip Answers

Question answered:21/05/07 Warning! this question is over two years old.

Page 47 of the JBS2 guideline states:

 

“Aspirin 75 mg daily is recommended for all people with type 2 diabetes who are > 50 years of age, and selectively in younger people with one of the following criteria: (1) who have had the disease for more than 10 years; (2) or who are already receiving treatment for hypertension; (3) or who have evidence of target organ damage in the form of retinopathy or nephropathy, and whose blood pressure is controlled to at least , 150/90 mm Hg, and preferably to the optimal target of , 130/80 mm Hg.”

 

Page 6 explains:

 

“Managing high risk people in clinical practice the biology of atherosclerotic disease and its complications makes the traditional separation of ‘‘secondary’’ from ‘‘primary’’ prevention illogical. People with established CVD and those at high risk of developing CVD are all considered to be high risk people who have some degree of atherosclerosis or vascular dysfunction, whether symptomatic or not; in other words they all have the same underlying disease process.

 

So we now recommend that CVD prevention in clinical practice should focus equally on people with established atherosclerotic CVD, people with diabetes, and asymptomatic individuals at high total risk (CVD risk of > 20% over 10 years) of developing symptomatic atherosclerotic disease, because they are all at high risk. People with diabetes are not only at higher risk of developing atherosclerotic disease but also have a higher case fatality…”

 

Concerning the evidence underpinning the recommendation that all patients with diabetes and over 50 years old should take aspirin, JBS2 cites results from the Steno-2 study (see page 43):

 

“The clinical trial evidence for prevention of CVD in diabetes is largely based on single risk factor interventions. However, the Steno-2 study has provided some evidence for the cardiovascular benefits following a multifactorial intervention programme.
…One hundred and sixty patients with type 2 diabetes and microalbuminuria were randomised to receive conventional treatment, or more intensive treatment, with stepwise implementation of behaviour modification and drugs that targeted glycaemia, blood pressure, dyslipidaemia, microalbuminuria (treated with an ACE inhibitor or an ARB), and prophylactic aspirin over a period of 7.8 years. Eighty five cardiovascular events occurred in 35 of the 80 (44%) people in the conventional group, and 33 events in 19 of the 80 (24%) people in the intensive therapy group. Cardiovascular disease was reduced in the intensive group by 53% (0.47, 95% CI 0.24 to 0.73), stroke by 85%, amputations by 50%, nephropathy by 61% (0.39, 95% CI 0.17 to 0.87), retinopathy by 58% (0.42, 95% CI 0.21 to 0.86), and autonomic neuropathy by 67% (0.37, 95% CI 0.18 to 0.70) compared with conventional care. The multifactorial lifestyle and polypharmacy approach advocated in the Steno-2 study is similar to the approach advised in this guideline for all people with diabetes.” [1]

 

PRODIGY in its guidelines on antiplatelet treatment, cardiovascular risk and hypertension in diabetes all advocate antiplatelet treatment for:

 

“All those with diabetes mellitus (type 1 or 2) and any of the following:
- Age 50 years or over
- Diabetes > 10 years
- Taking treatment for hypertension
- Evidence of target organ damage." [2]

 

A third guideline, the Global Guideline for Type 2 recommends:

 

“Provide aspirin 75-100 mg daily (unless aspirin intolerant or blood pressure uncontrolled) in people with evidence of CVD or at high risk.”

 

Although the guideline does not specifically refer to age, it does state:

 

“The use of anti-platelet agents is also addressed by some of the major guidelines (most extensively by the Australian
macrovascular prevention guideline and the NICE lipid lowering guideline), with a general recommendation
of endorsement for the widespread use of low-dose aspirin, the most specific evidence coming from within the ETDRS and HOT studies [11,12], and the most complete review that of Eccles and colleagues. The Canadian guideline notes a more recent meta-analysis of anti-platelet therapy showing a significant 22±2 % (±SE) reduction in vascular events among all high-risk patients in 195 trials but only a non-significant 7±8 % reduction in people with diabetes (9 trials).

 

Nevertheless, efficacy is accepted, although the risk of bleeding results in advice in the NICE and SIGN guidelines  restricting use to people at calculated risk (which would, however, be most people with Type 2 diabetes) and with some caution over uncontrolled hypertension.” [3]

References
1. Joint British Societies’ Guidelines on the Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; Volume 91 Supplement 5. (http://www.bcs.com/download/651/JBS2final.pdf)
2. PRODIGY guideline on antiplatelet treatment. October 2006. (http://www.cks.library.nhs.uk/antiplatelet_treatment/in_depth/management_issues)
3. PRODIGY guideline on cardiovascular risk. October 2006. (http://www.cks.library.nhs.uk/cardiovascular_risk/in_depth/management_issues  )
4. PRODIGY guideline on diabetes type 1 and 2. October 2006. (http://www.cks.library.nhs.uk/diabetes_hypertension/)
5. WHO. Global guideline for Type 2 diabetes: section 12 on cardiovascular risk protection. 2005. (http://www.idf.org/webdata/docs/GGT2D%2012%20Cardiovascular%20risk.pdf

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