Alfredo Michán Doña, Pedro Casado Escribano and Dolores García de Lucas.
The diabetes patients have a higher cardiovascular risk (CVR) than the general population, so in theory the aspirin prescription (acetylsalicylic acid) as a therapeutic option. However, it is rarely used in clinical practice due to a lack of medical consensus on whether the risk outweighs the benefit. In this sense, the scientific community has tried to elucidate in what types of diabetic patients is its use suitable for the great benefits granted and in which ones not because it supposes a bleeding risk. A stratification that leads the clinician to have to assess with the patient who is likely to use it if he wants the drug to be prescribed.
“We must not forget the assessment of the use of aspirin in consensus with the patient. We must walk towards personalized medicine and what needs to be done is arisk-benefit ratio. We have to find out the risk of developing thrombotic events, where aspirin may have better options, and counterbalance it with the hemorrhagic risk”, he details. Alfredo Michan Donaattached to the Internal Medicine Service of the Jerez Hospital (Cádiz) in his speech at the XVI meeting of the Diabetes, Obesity and Nutrition working group of the Spanish Society of Internal Medicine (SEMI).
Michán Doña’s vindication arises after the exchange of opinions that she has carried out with Dolores Garcia Lucasattached to the Internal Medicine Service of the Costa del Sol Hospital (Marbella), during the ‘Controversy table, Universal antiplatelet therapy in type 2 diabetes?’, which was moderated by Pedro Married Clerkincoming coordinator of the GT and internists at the Hospital Universitario de la Princesa (Madrid).
For García de Lucas, the decision to use aspirin or not goes through “personalize” medicine. “We have to discuss it with the patient and focus on other risk factors to delay its use. We have to control blood pressure and sugarand maybe if we have all that under control, we won’t have so many doubts about whether to apply aspirin or not,” he says.
In which patients should its use be assessed?
As the internist points out, the risk of bleeding is the “real” nightmare of aspirin use: “Efficacy is proven, but it is always accompanied by a high risk of gastrointestinal and intracranial bleeding. Between 40 and 59 years of age with a risk greater than 10 percent, it would be fine, but in those over 70 years of age, I would not recommend it due to the high risk of interintestinal bleeding.
A point of view that Michán Doña generally shares, but to which she adds several risk factors to identify diabetics who are likely to take aspirin: “Diabetes who have been evolving for a long time, who have kidney involvement with expression of microalbumin or who require insulin. These evolutionary diabetics are the ones in whom the use of insulin should be assessed and on many occasions in these cases we forget to do so”.
In addition, according to the specialist, there is recent evidence showing that the vast majority of diabetics are at high risk. “93 percent of diabetic patients we serve are high risk and half very high risk. So half, who have a damaged target organ, are likely to apply aspirin.”
A recommendation shared by García de Lucas and to which he adds that “in people with type 2 diabetes primary prevention with aspirin would be indicated when there is also another cardiovascular risk factor and the risk of bleeding is not increased”. In addition, the specialist adds that if the indication is fulfilled, then an “extensive discussion” should be given with the patient about the benefits versus the increased risk of bleeding.
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