Summary of diabetes guidelines
2019 ESC Guidelines on diabetes, pre-diabetes and cardiovascular diseases developed in collaboration with the EASD.
These are the third set of collaborative guidelines produced jointly by the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD).
The guidelines explain that patients with DM and symptomatic CVD should be treated the same as people without DM when it comes to antiplatelet therapy. Low-dose aspirin [75-100 mg per day] maybe considered for people with diabetes mellitus [DM] who also have a high risk of cardiovascular disease [CVD] and no clear contraindications to aspirin. Aspirin is not recommended for lower risk groups.
Low dose aspirin is recommended for secondary CVD prevention in people with diabetes and acute or chronic coronary syndromes. An additional antithrombotic drug can be used with aspirin for long term secondary prevention in those who are not considered to be at high risk of a bleeding event.
The concomitant use of a protein pump inhibitor is recommended for patients on aspirin monotherapy, dual antiplatelet therapy [DAPT] or oral anticoagulant monotherapy if they are considered to be at high risk of gastrointestinal bleeding.
DAPT can be prolonged beyond 12 months for people with DM who have a very high risk of CVD and have tolerated DAPT without encountering any major bleeding complications.
The combination of low dose rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily may be considered for people with DM and symptomatic lower extremity artery disease [LEAD].
Lifestyle changes are seen as key to prevent DM and CVD complications.
Further research is recommended in order to understand the effect of body mass [e.g. moderate to severe obesity] on antiplatelet drug responsiveness and effectiveness in people with DM. Higher dosing strategies with aspirin in obesity need to be investigated.
The guidelines point out that overall ‘studies comparing different antithrombotic strategies in patients with DM and CAD are lacking.’
Overall the guidelines recommend a patient-centred approach with a sharing of control and decision making taking place within the context of the patients own priorities and goals.
For further information please see:
Cosentino F, Grant PJ and Aboyans V et al 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with EASD. European Heart Journal 2019 )), 1-69 DOI:10.1093/eurheartj/ehz486
Ticagrelor in Patients with Stable Coronary Disease and Diabetes.
This randomised, double-blind trial looks at people with type 2 diabetes who are 50 years or older in age, with stable coronary artery disease to see if adding ticagrelor to aspirin reduces their risk of a CVD event and the effect of this intervention on additional bleeding risk .
The study included 19,220 patients without prior MI or stroke, over a mean follow-up period of just under 40 months. The primary efficacy measure was a composite of CVD death, MI or stroke. The primary safety outcome was a major bleeding events using the TIMI criteria.
The results showed that whilst ischemic CVD events were lower in the ticagrelor plus aspirin group there was a higher incidence of major bleeding events in this population when compared with placebo plus aspirin. The authors conclude:
“There was no significantly lower incidence of the exploratory composite outcome of efficacy and safety with ticagreglor than with placebo.”
For further information please see:
Steg PG, Bhatt T, Simon K et al. Ticagrelor in patinets with satble coronary disease and diabetes. N Engl J Med 2019: DOI: 10.1056/NEJM0a908077.
Diabetes UK states: “Diabetes UK recommends that people with diabetes without known cardiovascular disease should discuss their individual risk with their healthcare team.”
JBS 3 2014 “There is no role for aspirin in primary prevention of CVD in type 1 diabetes.”
“Low dose aspirin is not recommended for primary prevention of CVD in patients with type 2 diabetes.”
NICE NG17 2015 (updated July 2016) “Do not offer aspirin for the primary prevention of cardiovascular disease to adults with type 1 diabetes.”
NICE NG28 2015 (updated May 2017) Type 2 diabetes in adults- management “Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.”
SIGN 116 2010 (last revised Nov 2017) Management of Diabetes “Low-dose aspirin is not recommended for primary prevention of vascular disease in patients with diabetes.”
PREVENTION OF CARDIOVASCULAR EVENTS IN DIABETICS
The American Diabetes Association 2014 does advocate the use of aspirin for primary prevention of CVD for some people (Usually men over 50 and women over 60 years with other risk factors e.g. high BP and/or cholesterol) http://professional.diabetes.org/pel/taking-aspirin-protect-your-heart-english