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Aspirin Greatly Underutilized Among Patients with Diabetes

Medically Reviewed by Gary D. Vogin, MD
From the WebMD Archives

Feb. 13, 2001 -- A simple aspirin is one of the cheapest and most widely available therapies for preventing life-threatening complications of diabetes, yet few people are taking advantage of it, according to researchers at the CDC in Atlanta.

A national health survey has shown that just a little more than a third of all patients with diabetes who also have cardiovascular disease regularly use aspirin, despite the fact that it is a potent therapy for preventing heart attacks and stroke. And only a little more than a tenth of all diabetes patients who have risk factors for cardiovascular disease are regularly using aspirin, according to Deborah B. Rolka, MS, a statistician in the division of diabetes translation at the CDC.

The use of aspirin among diabetic patients who could benefit from it was especially low among African-Americans, Mexican-Americans, and other non-white ethnic groups, she says.

"Our findings suggest that there is a real opportunity to educate people with diabetes about potential benefits of aspirin therapy," Rolka tells WebMD. "What we see is that nearly every adult with diabetes either has cardiovascular disease or one of the risk factors for cardiovascular disease that make aspirin therapy potentially beneficial. Even though that is the case, quite recently only one in five people took aspirin." Rolka and colleagues reported the findings in the February edition of Diabetes Care.

The Third National Health and Nutrition Examination Survey included more than 1,500 adults with self-reported diabetes from 1988-1994. An estimated 27% had cardiovascular disease, and an additional 71% had one or more risk factors for cardiovascular disease. Those risk factors include family history of heart attack, smoking, obesity, high blood pressure, and high cholesterol.

Yet only 37% of diabetic patients with cardiovascular disease used aspirin regularly -- defined as taking aspirin more than 15 times in the previous month. And only 13% of patients who had one or more risk factors for cardiovascular disease were regularly taking aspirin, according to the report.

Overall, just 20% of all diabetes patients who should be taking aspirin actually were regularly taking the drug. The American Diabetes Association recommends that all diabetics with a history of cardiovascular disease, or those who have at least one risk factor for cardiovascular disease or are age 30 or older, should regularly be taking aspirin.

Rolka says a possible reason for the low use of aspirin is an overestimation of the risks involved in aspirin therapy on the part of both doctors and patients. "We know patients with diabetes may be taking a lot of medications, and it may be that physicians have had some concerns that adding something else to the mix may be dangerous," Rolka says. "But the clinical trials don't suggest that."

There are risks of bleeding from the stomach associated with aspirin use, and regular use in people under age 20 can put them at risk for Reyes Syndrome -- a potentially fatal condition characterized by liver malfunction and bleeding in the brain.

But clinical trials have demonstrated that aspirin is relatively safe and can be effective as "primary" prevention, avoiding heart attack or stroke in patients who have never had one. Studies have also shown it can be useful as "secondary" prevention by avoiding further cardiovascular disease events in people with previous disease, according to Rolka.

How does aspirin work to prevent cardiovascular disease?

K.M. Venkat Narayan, MD, of the CDC, explains that aspirin inhibits the body's production of thromboxane, a substance released by blood platelets that causes them to clump together, leading to blood clotting. By reducing blood clotting, aspirin can diminish the risk of cardiovascular events, he says.

Narayan, who was co-author of the Diabetes Care report, says the recommended dose of aspirin is 81-325 milligrams. "Even with a small dose the protection is there," Narayan tells WebMD.

Rolka and Narayan say increasing awareness of the benefits of aspirin and education of doctors and patients is key to increasing use of the therapy. They also recommend including use of aspirin among diabetic patients as a performance measure on the "report cards" used by the managed care industry to determine how well health plans are performing.

"People with type 2 diabetes don't realize they are at very high risk for heart attack or cardiovascular death," says John Colwell, MD, PhD, who authored an editorial accompanying the report. "That has not been put up front in educating people about the complications of diabetes. The bottom line is that both male and female patients with type 2 diabetes have exactly the same risk for heart attack as someone who is nondiabetic but has already had a heart attack." Colwell is a professor of medicine and director of the Diabetes Center at the Medical University of South Carolina in Charleston.

The fact that aspirin is so commonly available and regularly used for minor aches and pains may lead patients -- especially those who are taking multiple, expensive medications for diabetes -- to underestimate the value of aspirin for a serious illness, Colwell suggests.

"I go around giving talks about prevention of complications of diabetes, and I go through a whole list of expensive medications that are commonly used," Colwell tells WebMD. "But the cheapest, and one of the most effective, is aspirin. It's so mundane that people tend to overlook it."

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