Diabetes guidelines

Summary of diabetes guidelines

May 2021

The purpose of this document is to keep a working list of international guidelines with information on aspirin and diabetes care.  The guidelines themselves should be read for further information.

UK GUIDELINES

Prevention of cardiovascular events in diabeticsNICE NG17 2015 (updated December 2020) states “Do not offer aspirin for the primary prevention of cardiovascular disease to adults with type 1 diabetes.”https://www.nice.org.uk/guidance/ng17/resources/type-1-diabetes-in-adults-diagnosis-and-management-pdf-1837276469701NICE NG28 2015 (updated December 2020) Type 2 diabetes in adults- management state “Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.”https://www.nice.org.uk/guidance/ng151/resources/user-guide-and-data-sources-pdf-8834927870

USA GUIDELINES

Primary prevention of cardiovascular disease in people with diabetes

The American Diabetes Association (ADA) (Cardiovascular disease and risk management: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43(suppl.1): S111-S134) state that for the case of primary CVD prevention;

‘Aspirin therapy (75-162mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding.’

The ADA review clinical trial work including the Antithrombotic trialists’ collaboration, ASCEND, ARRIVE and ASPREE and conclude that aspirin appears to have a modest impact on decreasing ischemic vascular events especially where atherosclerotic cardio vascular disease (ASCVD) risk is higher. This however is tempered by its main side effect of increased gastrointestinal (GI) bleeding which may be as high as 5 per 1,000 per year in the real-world setting. Where ASCVD risk is more than 1% per year the number of ASCVD events that are averted are comparable to the number of GI bleeding events caused. The ADA however recognise that CVD events and GI bleeding events ‘do not have equal effects on long-term health’. The ADA explain that men and women age 50 years or older with diabetes and one additional CVD risk factor such as family history of ASCVD, high blood pressure, high cholesterol, smoking, chronic kidney disease and who are not at increase bleeding risk e.g. older age, anaemia, renal disease, are most likely to benefit from using low-dose aspirin for the primary prevention of ASCVD. They also suggest that non-invasive imagining techniques could potentially help identify people for aspirin primary prevention therapy. For more information see:https://care.diabetesjournals.org/content/44/Supplement_1/S125Secondary prevention of cardiovascular disease in people with diabetesThe American Diabetes Association (ADA) (Cardiovascular disease and risk management: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43(suppl.1): S111-S134) recommends low-dose aspirin (75-162 mg/day) for secondary prevention in people with a history of cardiovascular disease (CVD). For those unable to take aspirin, clopidogrel (75mg/day) can be used. Dual antiplatelet therapy with low-dose aspirin and a P2Y12 inhibitor is recommended for at least a year after acute coronary syndrome therapy (ACS). For more information see:https://care.diabetesjournals.org/content/44/Supplement_1/S125
European guidelinesPrevention of cardiovascular disease in people with diabetesThe ESC 2019 guidelines on diabetes (DM), pre-diabetes, and cardiovascular disease state:
  • Patients with DM and symptomatic CVD should be treated no differently to patients without DM
  •  In patients with DM at moderate CV risk, aspirin for primary prevention is not recommended
  • In patients with DM at high/very high risk, aspirin may be considered in primary prevention
For more information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Diabetes-Pre-Diabetes-and-Cardiovascular-Diseases-developed-with-the-EASDIn addition, the ESC 2019 diabetes guidelines identify the following gaps in the evidence relating to platelet use in people with diabetes:
  • Type 1 diabetes and CVD prevention [in vivo platelet activation has been reported]
  • Body mass and antiplatelet responsiveness especially in those with diabetes and obesity where higher dose strategies need investigation
  • Are antithrombotic effects similar in pre-DM and DM?
In a press release following the ASCEND trial the ESC state that the bleeds and benefits are balanced in people with diabetes using aspirin for primary CVD prevention and that no cancer benefit was found in this study.https://www.escardio.org/The-ESC/Press-Office/Press-releases/bleeds-and-benefit-with-aspirin-balanced-in-patients-with-diabetes-and-no-effect-on-cancer

May 2021

The purpose of this document is to keep a working list of international guidelines with information on aspirin and diabetes care.  The guidelines themselves should be read for further information.

UK GUIDELINES

Prevention of cardiovascular events in diabeticsNICE NG17 2015 (updated December 2020) states “Do not offer aspirin for the primary prevention of cardiovascular disease to adults with type 1 diabetes.”https://www.nice.org.uk/guidance/ng17/resources/type-1-diabetes-in-adults-diagnosis-and-management-pdf-1837276469701NICE NG28 2015 (updated December 2020) Type 2 diabetes in adults- management state “Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.”https://www.nice.org.uk/guidance/ng151/resources/user-guide-and-data-sources-pdf-8834927870

USA GUIDELINES

Primary prevention of cardiovascular disease in people with diabetes

The American Diabetes Association (ADA) (Cardiovascular disease and risk management: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43(suppl.1): S111-S134) state that for the case of primary CVD prevention;

‘Aspirin therapy (75-162mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a comprehensive discussion with the patient on the benefits versus the comparable increased risk of bleeding.’

The ADA review clinical trial work including the Antithrombotic trialists’ collaboration, ASCEND, ARRIVE and ASPREE and conclude that aspirin appears to have a modest impact on decreasing ischemic vascular events especially where atherosclerotic cardio vascular disease (ASCVD) risk is higher. This however is tempered by its main side effect of increased gastrointestinal (GI) bleeding which may be as high as 5 per 1,000 per year in the real-world setting. Where ASCVD risk is more than 1% per year the number of ASCVD events that are averted are comparable to the number of GI bleeding events caused. The ADA however recognise that CVD events and GI bleeding events ‘do not have equal effects on long-term health’. The ADA explain that men and women age 50 years or older with diabetes and one additional CVD risk factor such as family history of ASCVD, high blood pressure, high cholesterol, smoking, chronic kidney disease and who are not at increase bleeding risk e.g. older age, anaemia, renal disease, are most likely to benefit from using low-dose aspirin for the primary prevention of ASCVD. They also suggest that non-invasive imagining techniques could potentially help identify people for aspirin primary prevention therapy. For more information see:https://care.diabetesjournals.org/content/44/Supplement_1/S125Secondary prevention of cardiovascular disease in people with diabetesThe American Diabetes Association (ADA) (Cardiovascular disease and risk management: Standards of Medical Care in Diabetes-2020. Diabetes Care 2020; 43(suppl.1): S111-S134) recommends low-dose aspirin (75-162 mg/day) for secondary prevention in people with a history of cardiovascular disease (CVD). For those unable to take aspirin, clopidogrel (75mg/day) can be used. Dual antiplatelet therapy with low-dose aspirin and a P2Y12 inhibitor is recommended for at least a year after acute coronary syndrome therapy (ACS). For more information see:https://care.diabetesjournals.org/content/44/Supplement_1/S125
European guidelinesPrevention of cardiovascular disease in people with diabetesThe ESC 2019 guidelines on diabetes (DM), pre-diabetes, and cardiovascular disease state:
  • Patients with DM and symptomatic CVD should be treated no differently to patients without DM
  •  In patients with DM at moderate CV risk, aspirin for primary prevention is not recommended
  • In patients with DM at high/very high risk, aspirin may be considered in primary prevention
For more information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Diabetes-Pre-Diabetes-and-Cardiovascular-Diseases-developed-with-the-EASDIn addition, the ESC 2019 diabetes guidelines identify the following gaps in the evidence relating to platelet use in people with diabetes:
  • Type 1 diabetes and CVD prevention [in vivo platelet activation has been reported]
  • Body mass and antiplatelet responsiveness especially in those with diabetes and obesity where higher dose strategies need investigation
  • Are antithrombotic effects similar in pre-DM and DM?
In a press release following the ASCEND trial the ESC state that the bleeds and benefits are balanced in people with diabetes using aspirin for primary CVD prevention and that no cancer benefit was found in this study.https://www.escardio.org/The-ESC/Press-Office/Press-releases/bleeds-and-benefit-with-aspirin-balanced-in-patients-with-diabetes-and-no-effect-on-cancer