Current literature suggests that dual antiplatelet therapy is indicated for at least a year after an acute coronary syndrome event in all patients, but it appears to be particularly important in diabetes patients, according to one of the presenters in a Friday afternoon symposium at the Scientific Sessions.
The session, Antiplatelet and Antithrombotic Therapies in Diabetes, featured three experts discussing the utility of combination antiplatelet therapies and novel anticoagulants, as well as the current evidence of aspirin use for primary cardiovascular risk intervention in diabetes patients.
“While there’s still some controversy regarding the role of aspirin in primary prevention, in the secondary prevention world, patients with diabetes are known to have very high rates of ischemic events and clearly benefit from antiplatelet therapy,” said Deepak L. Bhatt, MD, MPH, Executive Director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital Heart & Vascular Center and Professor of Medicine at Harvard Medical School. “And it seems in many cases, patients with diabetes with prior myocardial infarction (MI) benefit more from intense and longer durations of dual antiplatelet therapy—the combination of aspirin with an oral adenosine diphosphate (ADP) receptor antagonist.”
Dr. Bhatt said results from forthcoming studies will hopefully shed light on the benefits, if any, of dual antiplatelet therapy in diabetes patients with atherosclerosis but without documented prior ischemic events.
“The ongoing THEMIS trial (Effect of Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study), for example, with more than 19,000 patients in it, has randomized them to placebo or the oral ADP receptor antagonist ticagrelor with everyone also getting aspirin,” Dr. Bhatt said. “When that trial is done, we’ll see whether dual antiplatelet therapy does or does not have a role in diabetes patients with atherosclerosis but without prior MI.”
To date, there have been no dedicated trials analyzing anticoagulant therapy and direct-acting oral anticoagulants (DOAC) in diabetes patients, but subgroup analyses from large cardiovascular outcomes trials provide some insight, according to Jacob A. Udell, MD, MPH, FRCPC, a cardiologist and clinician-scientist at Women’s College Hospital, Women’s College Research Institute, and the Peter Munk Cardiac Centre, University Health Network, and Assistant Professor of Medicine at the University of Toronto.
Dr. Udell said there’s no reason to distinguish diabetes patients from the general population when considering DOACs.
“You shouldn’t shy away from using them either,” he said. “They are just as safe in terms of the balance of benefits and risks as they are for the general population. So whatever is currently recommended as standard of care for patients regarding the use of DOACs should be followed and there shouldn’t be any particular preference for one over the other for patients with diabetes.”
Dr. Udell said there’s a less evidence when deciding how to manage atrial fibrillation and lone diabetes when it’s the sole risk factor for stroke or systemic embolism.
“Although this is an infrequent scenario, incidence will likely rise with the advent of more pervasive rhythm monitoring,” he said.
Rita Rastogi Kalyani, MD, MHS, Associate Professor of Medicine at Johns Hopkins School of Medicine, Core Faculty at the Johns Hopkins Center on Aging and Health, and Associate Faculty at the Welch Center for Prevention, Epidemiology, and Clinical Research, discussed the role of aspirin in primary cardiovascular risk intervention for diabetes patients.
“In studies that have been done among people with diabetes, we don’t necessarily see the clear benefit of aspirin in reducing cardiovascular events,” Dr. Kalyani said. “However, in studies that have been done in the general population, which included people both with and without diabetes, there does seem to be good evidence for the benefit of aspirin in reducing cardiovascular events, with a similar effect in both groups.”
Evidence shows a clearer benefit for aspirin therapy in diabetes patients who have a history of clinical atherosclerotic cardiovascular disease, but the benefit is less clear for widespread aspirin use in the primary prevention of cardiovascular disease. Current clinical practice recommendations from the ADA suggest that aspirin may be considered as a primary prevention strategy in patients with type 1 or type 2 diabetes who are at increased cardiovascular risk and are not at increased risk of bleeding.
“The current studies we have offer a bit of a mixed picture regarding aspirin’s benefit in lowering incident cardiovascular events, so we are left interpreting the data we have to see how we might use it to inform diabetes care,” Dr. Kalyani said. “We and others are performing studies looking at the physiology of aspirin’s effect in people with diabetes and, hopefully, these studies will inform future use of aspirin in the prevention of cardiovascular events for people with diabetes.”