Since the 1980s, aspirin has been hailed as the superman of over-the-counter drugs for the secondary prevention of heart attacks. Now the ADA is recommending that people with diabetes who are at high risk of cardiovascular problems take aspirin once daily.
“Statements on aspirin therapy have traditionally downplayed its importance for healthy individuals or emphasized its importance for people at risk for a second heart attack,” says Mayer Davidson, MD, president of the ADA. “These new recommendations close that gap, making aspirin an important preventative for people with diabetes who are at an increased risk for heart disease solely because of their diabetes,” he adds.
Who Should Take Aspirin?
Considering that cardiovascular disease accounts for 65 percent of all diabetic deaths, any person with diabetes who is at high risk for cardiovascular problems, or has already had cardiovascular problems, should consider aspirin therapy. The ADA divides potential candidates into two categories depending on the type of prevention they need: primary or secondary.
Those who use aspirin as primary prevention therapy have type 1 or type 2 diabetes and show a high risk for developing cardiovascular problems. Factors which put someone in this category include: a family history of coronary heart disease, cigarette smoking, hypertension, obesity, albuminuria (protein in the urine) and high cholesterol levels.
The U.S. Physicians’ Health Study, a double blind study of primary prevention subjects, showed that only four percent of those who underwent aspirin therapy suffered a heart attack, compared to over 10 percent in the placebo group.
Candidates for secondary prevention therapy already have evidence of large vessel disease. These include patients with a history of heart attacks, a vascular bypass procedure, stroke or transient ischemic attack, peripheral cardiovascular disease claudication and/or angina.
Aspirin can have significant benefits for these people as well. “Analysis of large randomized trials of aspirin therapy as a secondary prevention strategy showed a reduction in the risk for another event of about 25 percent in people with diabetes,” notes John A. Colwell, MD, PhD, author of the ADA’s position statement on aspirin.
Who Shouldn’t Take Aspirin?
The ADA recommends that those with aspirin allergy, bleeding tendency or recent gastrointestinal bleeding should not be considered for aspirin therapy. It also recommends that those on anticoagulant therapy and people with clinically active hepatic (liver) disease shouldn’t be considered either.
Also, there are no studies on the effectiveness or safety of aspirin therapy in patients under the age of 30. However, “Before puberty, there are no risks for cardiovascular disease,” says Steven Leichter, MD, FACP, FACE, “so taking aspirin before that is not really a factor.” If someone under 30 does have cardiovascular disease risk factors, a physician should be consulted to see if aspirin therapy is needed.
How Aspirin Helps
While aspirin is helpful in preventing heart problems, “Aspirin has no effect on the heart. It affects the blood flowing through the vessels that feeds the heart,” says Margaret Wilkman, RN, MPH, CDE. “Aspirin prevents the spontaneous clumping of platelets in the blood,” she explains.
Platelets are irregularly shaped components of the blood that are responsible for clotting. They naturally clump in all people, but persons with diabetes have additional worries.
When blood sugars run high, red blood cells change shape and flow slower – like sugary maple syrup. In this environment, platelets gum up and clump together more easily.
“Clumping can occur within a few days,” Wilkman says. Aspirin helps prevent clotting in this sticky environment.
When a blood vessel is injured, adhesive blood proteins and platelets are “recruited” to the damaged area.
“These platelets become activated and release thromboxane, which causes further platelet aggregation, constricting the blood vessel. This is where aspirin works,” he adds. “By slowing down this process aspirin helps to prevent the creation of damaging blood vessel blockage.”
After unloading major bucks on diabetic supplies, people with diabetes will be relieved to note the cost of aspirin – it’s cheap. Beyond its inherent low cost, Keith Campbell, RPh, CDE, notes that you can save even more money buying generic aspirin. “Generic or name-brand, they do the same thing,” he says.
The ADA officially recommends taking from 81 mg to 325 mg of enteric coated aspirin once daily. (The enteric coating helps the aspirin pass through the stomach and get absorbed in the intestines, thereby lessening the chances of stomach upset.)
There is some controversy as to the ideal dosage, however. Zachary T. Bloomgarden, MD, noted in the October 1997 issue of Diabetes Care that because persons with diabetes are resistant to the action of aspirin, an 81 mg baby aspirin is probably insufficient. Stephen Weisman MD, medical director for Bayer Consumer Care, recommends taking the highest dosage (adult aspirin) tolerated.
On the other hand, Campbell recommends taking one baby aspirin (81 mg) a day and says that taking more will not provide any additional benefit. Jack VanGrow, MD, a private practice cardiologist from Orange County, Calif., agrees that anything more than 81 mg a day is unnecessary.
Because aspirin doesn’t stay in the blood system a long time, it’s necessary to take it daily. However, if you already use aspirin regularly (e.g., for headaches or arthritis) it’s not necessary to add more in order to receive its beneficial effects on cardiovascular disease.
Every year more aspirin is taken than any other over-the-counter pain reliever, but consumers often worry about stomach upset. Campbell recommends taking aspirin in the morning with a meal to prevent stomach upset.
Bayer states that less than six percent of the population cannot tolerate aspirin due to stomach upset. For many people, taking it with food alleviates the problem.
Aspirin’s potential to upset the stomach does have a positive side, however. It makes it very difficult to overdose on aspirin. In addition, if stomach irritation doesn’t alert a person to an overdose, he or she may notice a ringing in the ears explains VanGrow.
In any event, these are the most extreme side effects adults are likely to experience from an aspirin overdose. “Death from aspirin overdose is very rare,” Weisman says, “because a lot of aspirin is going to make the stomach burn and cause the person to throw up.”
If someone is allergic to aspirin, what alternatives to aspirin exist for cardiovascular therapy?
“Aspirin and ibuprofen probably work the same, but the scientific data is on aspirin and that’s what I would choose personally,” adds Wilkman.
Nearly one trillion aspirin have been consumed since Bayer chemist Felix Hoffman discovered aspirin’s active ingredient in 1897 while searching for a pain relieving medication for his father’s debilitating rheumatism. The drug eased his father’s pain and was marketed by Bayer two years later. It went on to become the world’s most popular pain reliever.
Aspirin derives its active ingredient from willow tree bark. Its pain relieving powers were actually noticed as far back as 200 BC, when Hippocrates (the Greek physician known as the father of medicine) discovered that chewing on the bark could relieve pain and fever.
Although aspirin’s active ingredient was a proven pain reliever, no one really knew how it worked until a British pharmacologist, John Vane, discovered that aspirin inhibited the body’s ability to promote the inflammation that causes pain. Vane won a Nobel Prize for Medicine in 1982 for this medical research breakthrough.
The Wonder Drug
It seems ironic that Bayer’s first aspirin advertisements said that aspirin did “not affect the heart,” as was alleged of other popular medications of the time. Little did Bayer know that it affected the heart in a good way.
It appears that aspirin’s reputation as a “wonder drug” may not be far from the truth. It’s a proven pain killer, has few side-effects and can help prevent heart attacks. And now it is recommended by the ADA for people with diabetes.