SlideShare a Scribd company logo
Exeter Drugs Update



Aspirin in the primary prevention of cardiovascular disease in people

with diabetes




Richard Haynes1

Louise Bowman1

Kenneth Macleod2



1
    Clinical Research Fellow, Clinical Trial Service Unit, University of Oxford
2
    Associate Dean & Reader in Medicine, Peninsula College of Medicine &

Dentistry and Consultant Physician (Diabetes & Endocrinology)

Royal Devon & Exeter NHS Foundation Trust
The prevalence of diabetes mellitus is increasing and it affects over two

million people in the UK alone. Patients with diabetes (either type 1 or type 2)

are at increased risk of mortality compared to age- and gender-matched

patients without diabetes and about two-thirds of deaths can be attributed to

vascular causes.1, 2 However, surveys of people with diabetes show that the

large majority do not yet have manifest vascular disease3, 4 and it is therefore

logical to focus on strategies that could prevent the development of

symptomatic vascular disease in these people.



Aspirin has well-proven benefits in the secondary prevention of cardiovascular

disease. Meta-analyses of antiplatelet trials (mostly involving aspirin) showed

a reduction in subsequent vascular events of around one-quarter and the

benefits appear to be similar whether or not such patients also had diabetes.5,
6
    These meta-analyses also found an approximately 60% increase in the risk

of major bleeding (defined as bleeding which was fatal or required

transfusion) with antiplatelet therapy, but this risk is far outweighed by the

benefits in patients at high risk of vascular disease i.e. those with known

vascular disease. Consequently most people with diabetes and known

vascular disease receive antiplatelet therapy.



It remains unclear, however, whether patients with diabetes without a history

of vascular disease are at sufficient risk of vascular disease for the benefits of

aspirin to outweigh the risks. Until recently, the main randomised evidence on

the effects of aspirin in such patients came from a meta-analysis of 9 trials

involving almost 5000 patients which indicates a much smaller proportional
reduction in cardiovascular events than has been found in the secondary

prevention setting (just 7% compared with about 20-25%).6 Even in aggregate

these studies involved relatively few events and the confidence interval for the

estimated effect is wide, ranging from a 23% risk reduction to an 8% hazard.

Guidelines are inconsistent on the recommendation to use aspirin because of

the lack of clear evidence.7 This uncertainty has been reinforced by two recent

trials.



The Prevention of Progression of Arterial Disease And Diabetes (POPADAD)

study randomised 1276 people with diabetes to receive aspirin 100 mg daily

or placebo.8 All participants had an ankle-brachial pressure index <1.0 but

were asymptomatic and the primary outcome was death from coronary

disease or stroke, non-fatal myocardial infarction or stroke, or amputation

above the ankle for critical limb ischaemia. Participants were followed for a

median of 6.7 years but only 233 primary events were reported (annual event

rate 2.7% per annum, well below the 8% the sample size was predicated on).

The study was therefore underpowered to detect a plausible treatment effect

which was reflected in the wide confidence interval of the main result: hazard

ratio 0.98 (95% CI 0.76 – 1.26). The results of POPADAD are consistent with

anything from a 24% risk reduction with aspirin to a 26% increased risk.



More recently the Japanese Primary prevention of atherosclerosis with Aspirin

for Diabetes (JPAD) study reported its results.9 JPAD randomised 2539

patients with type 2 diabetes to receive aspirin 100 mg daily or open control

(placebo arms are not allowed in Japan). There were only 154 atherosclerotic
events in this study: 68 (5.4%) in the aspirin group and 86 (6.7%) in the

control group with a hazard ratio of 0.80 (95% CI 0.58 – 1.10). Again, JPAD

was not large enough to be definitive and, as the accompanying editorial

states, the use of aspirin in the primary prevention of vascular disease in

people with diabetes remains on open question.10



Currently less than half of people with diabetes are taking aspirin: if it is

effective then reliable trial data will help increase this and help prevent

thousands of vascular events in the UK alone each year. Conversely if it is not

safe then hundreds of bleeding episodes could be prevented. GPs deciding

whether or not to treat with aspirin can consider a third option: help to resolve

the current uncertainty by inviting their patients into a large ongoing trial.

ASCEND (A Study of Cardiovascular Events iN Diabetes) is a randomised

placebo-controlled trial of aspirin (and omega-3 fatty acids in a 2x2 factorial

design) in this setting which plans to randomise 10,000 patients with diabetes.

By more than doubling the available data, ASCEND should help to clarify this

important question. It has already recruited nearly 5000 patients and

interested GPs can help identify and invite patients (with the support of the

local Diabetes and Primary Care Research Networks). Further details can be

found on the study website (www.ctsu.ox.ac.uk/ascend), by e-mailing

ascend@ctsu.ox.ac.uk or calling (Freefone) 0800 585323.
1.      Panzram G. Mortality and survival in type 2 (non-insulin-dependent)
diabetes mellitus. Diabetologia 1987;30:123-31.
2.      Pyorala K, Laakso M, Uusitupa M. Diabetes and atherosclerosis: an
epidemiologic view. Diabetes Metab Rev 1987;3:463-524.
3.      Rolka DB, Fagot-Campagna A, Narayan KM. Aspirin use among adults
with diabetes: estimates from the Third National Health and Nutrition
Examination Survey. Diabetes Care 2001;24:197-201.
4.      UK Prospective Diabetes Study 6. Complications in newly diagnosed
type 2 diabetic patients and their association with different clinical and
biochemical risk factors. Diabetes Res 1990;13:1-11.
5.      Collaborative overview of randomised trials of antiplatelet therapy--I:
Prevention of death, myocardial infarction, and stroke by prolonged
antiplatelet therapy in various categories of patients. Antiplatelet Trialists'
Collaboration. BMJ 1994;308:81-106.
6.      Collaborative meta-analysis of randomised trials of antiplatelet therapy
for prevention of death, myocardial infarction, and stroke in high risk patients.
BMJ 2002;324:71-86.
7.      Nicolucci A, De Berardis G, Sacco M, Tognoni G. AHA/ADA vs.
ESC/EASD recommendations on aspirin as a primary prevention strategy in
people with diabetes: how the same data generate divergent conclusions. Eur
Heart J 2007;28:1925-7.
8.      Belch J, MacCuish A, Campbell I, et al. The prevention of progression
of arterial disease and diabetes (POPADAD) trial: factorial randomised
placebo controlled trial of aspirin and antioxidants in patients with diabetes
and asymptomatic peripheral arterial disease. BMJ 2008;337:a1840-.
9.      Ogawa H, Nakayama M, Morimoto T, et al. Low-Dose Aspirin for
Primary Prevention of Atherosclerotic Events in Patients With Type 2
Diabetes: A Randomized Controlled Trial. JAMA 2008.
10.     Nicolucci A. Aspirin for primary prevention of cardiovascular events in
diabetes: still an open question. JAMA 2008;300:2180-1.

More Related Content

What's hot

The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
asclepiuspdfs
 
Drug induced diabetes
Drug induced diabetesDrug induced diabetes
Drug induced diabetes
Zeeshan Naseer
 
Risc cardiovascular i dislipèmies
Risc cardiovascular i dislipèmiesRisc cardiovascular i dislipèmies
Risc cardiovascular i dislipèmies
CAMFiC
 
Chest Pain Scores
Chest Pain ScoresChest Pain Scores
Chest Pain Scores
Kristopher Maday
 
SALT-E 3
SALT-E 3SALT-E 3
Journal club: CheckMate025 trial
Journal club: CheckMate025 trialJournal club: CheckMate025 trial
Journal club: CheckMate025 trial
Ahmed A. Karar Ali
 
SALT-E 2
SALT-E 2SALT-E 2
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
Texas Children's Hospital
 
Nejm199807233390404
Nejm199807233390404Nejm199807233390404
Nejm199807233390404
lolilopez93
 
Cardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysisCardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysis
Fuad Farooq
 
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis PatientsErectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
asclepiuspdfs
 
Bello presentation[2]
Bello presentation[2]Bello presentation[2]
Bello presentation[2]
Samantha Haas
 
SALT-E 5
SALT-E 5SALT-E 5
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
CrimsonGastroenterology
 
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
ahvc0858
 
Hope 3 trial acc 2016 (4) (1)
Hope 3 trial acc 2016 (4) (1)Hope 3 trial acc 2016 (4) (1)
Hope 3 trial acc 2016 (4) (1)
Hirdesh Chawla
 

What's hot (20)

The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...
 
Drug induced diabetes
Drug induced diabetesDrug induced diabetes
Drug induced diabetes
 
Statins and diabetes risk
Statins and diabetes riskStatins and diabetes risk
Statins and diabetes risk
 
Risc cardiovascular i dislipèmies
Risc cardiovascular i dislipèmiesRisc cardiovascular i dislipèmies
Risc cardiovascular i dislipèmies
 
Chest Pain Scores
Chest Pain ScoresChest Pain Scores
Chest Pain Scores
 
SALT-E 3
SALT-E 3SALT-E 3
SALT-E 3
 
Journal club: CheckMate025 trial
Journal club: CheckMate025 trialJournal club: CheckMate025 trial
Journal club: CheckMate025 trial
 
SALT-E 2
SALT-E 2SALT-E 2
SALT-E 2
 
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
Relative Hyperoxia in cyanotic congenital heart disease on veno-arterial ECMO...
 
Nejm199807233390404
Nejm199807233390404Nejm199807233390404
Nejm199807233390404
 
Cardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysisCardiology 2019 trial and meta analysis
Cardiology 2019 trial and meta analysis
 
CV journal Club
CV journal ClubCV journal Club
CV journal Club
 
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis PatientsErectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
Erectile Dysfunction and Risk Factors in Male Peruvian Hemodialysis Patients
 
Bello presentation[2]
Bello presentation[2]Bello presentation[2]
Bello presentation[2]
 
SALT-E 5
SALT-E 5SALT-E 5
SALT-E 5
 
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
Crimson Publishers: Insulin Therapy and Cardiovascular Outcome Trials (CVOTs)...
 
Nrcardio.2014.104
Nrcardio.2014.104Nrcardio.2014.104
Nrcardio.2014.104
 
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...
 
Hope 3 trial acc 2016 (4) (1)
Hope 3 trial acc 2016 (4) (1)Hope 3 trial acc 2016 (4) (1)
Hope 3 trial acc 2016 (4) (1)
 
Dr. Agrawal
Dr. AgrawalDr. Agrawal
Dr. Agrawal
 

Similar to Exeter Drugs Update

Aspirin for primary prevention of CVD
Aspirin for primary prevention of CVDAspirin for primary prevention of CVD
Aspirin for primary prevention of CVD
Pinkesh Parmar
 
A Tab from GOD: Aspirins for CVS Dr.AKS.pptx
A Tab from GOD: Aspirins for CVS Dr.AKS.pptxA Tab from GOD: Aspirins for CVS Dr.AKS.pptx
A Tab from GOD: Aspirins for CVS Dr.AKS.pptx
KyawMyoHtet10
 
Statin Use and Diabetes Risk
Statin Use and Diabetes RiskStatin Use and Diabetes Risk
Statin Use and Diabetes Risk
Linh Huynh, PharmD
 
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptxAspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
KyawMyoHtet10
 
Aspirin for primary prevention in cad in T2DM
Aspirin for primary prevention in cad in T2DMAspirin for primary prevention in cad in T2DM
Aspirin for primary prevention in cad in T2DM
Pijush Kanti Mandal
 
Aspirin for primary prevention in cad in type II DM
Aspirin for primary prevention in cad in type II DMAspirin for primary prevention in cad in type II DM
Aspirin for primary prevention in cad in type II DM
Pijush Kanti Mandal
 
Iatrogenic diabetes
Iatrogenic diabetesIatrogenic diabetes
Iatrogenic diabetes
Veerendra Singh
 
American Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care MedicineAmerican Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care Medicine
SciRes Literature LLC. | Open Access Journals
 
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
Alejandro Mateo
 
Dual antiplatelet therapy
Dual antiplatelet therapyDual antiplatelet therapy
Dual antiplatelet therapy
Ramachandra Barik
 
Ueda2016 diabetes &amp; peripheral arterial diseases -mamdouh el nahas
Ueda2016 diabetes &amp; peripheral arterial diseases  -mamdouh el nahasUeda2016 diabetes &amp; peripheral arterial diseases  -mamdouh el nahas
Ueda2016 diabetes &amp; peripheral arterial diseases -mamdouh el nahas
ueda2015
 
Screening for asymptomatic cad in diabetes
Screening for asymptomatic cad in diabetesScreening for asymptomatic cad in diabetes
Screening for asymptomatic cad in diabetesShyam Jadhav
 
There is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
There is a Primary Prevent Indication in Diabetes | Mubashar A ChoudryThere is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
There is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
Mubashar A Choudry MD
 
JOURNAL CLUB (2) (1) (3) (5) (1).pptx
JOURNAL CLUB (2) (1) (3) (5) (1).pptxJOURNAL CLUB (2) (1) (3) (5) (1).pptx
JOURNAL CLUB (2) (1) (3) (5) (1).pptx
DrGhulamRasool1
 
Stable angina
Stable anginaStable angina
Stable angina
Ramachandra Barik
 
Pablo avanzas novedades farmacologia en intervencionismo
Pablo avanzas   novedades farmacologia en intervencionismoPablo avanzas   novedades farmacologia en intervencionismo
Pablo avanzas novedades farmacologia en intervencionismo
SHCI - Sección de Hemodinámica y Cardiología Intervencionista
 
Hope 3 FUTURE HOPES
Hope 3  FUTURE HOPESHope 3  FUTURE HOPES
Hope 3 FUTURE HOPES
Ramanathan Papanasam
 
B3SC proceedings of November 2016,Singapore
B3SC proceedings of November 2016,SingaporeB3SC proceedings of November 2016,Singapore
B3SC proceedings of November 2016,Singapore
Global R & D Services
 
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
Ks doctor
 
Trials and errors in cardiovascular medicine 2013
Trials and errors in cardiovascular medicine  2013Trials and errors in cardiovascular medicine  2013
Trials and errors in cardiovascular medicine 2013Ramachandra Barik
 

Similar to Exeter Drugs Update (20)

Aspirin for primary prevention of CVD
Aspirin for primary prevention of CVDAspirin for primary prevention of CVD
Aspirin for primary prevention of CVD
 
A Tab from GOD: Aspirins for CVS Dr.AKS.pptx
A Tab from GOD: Aspirins for CVS Dr.AKS.pptxA Tab from GOD: Aspirins for CVS Dr.AKS.pptx
A Tab from GOD: Aspirins for CVS Dr.AKS.pptx
 
Statin Use and Diabetes Risk
Statin Use and Diabetes RiskStatin Use and Diabetes Risk
Statin Use and Diabetes Risk
 
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptxAspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
Aspirin in the primary and secondary prevention of vascular diseases. ppt.pptx
 
Aspirin for primary prevention in cad in T2DM
Aspirin for primary prevention in cad in T2DMAspirin for primary prevention in cad in T2DM
Aspirin for primary prevention in cad in T2DM
 
Aspirin for primary prevention in cad in type II DM
Aspirin for primary prevention in cad in type II DMAspirin for primary prevention in cad in type II DM
Aspirin for primary prevention in cad in type II DM
 
Iatrogenic diabetes
Iatrogenic diabetesIatrogenic diabetes
Iatrogenic diabetes
 
American Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care MedicineAmerican Journal of Emergency & Critical Care Medicine
American Journal of Emergency & Critical Care Medicine
 
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
Sackett bmj 1994 what measures of efficacy should journal articles provide bu...
 
Dual antiplatelet therapy
Dual antiplatelet therapyDual antiplatelet therapy
Dual antiplatelet therapy
 
Ueda2016 diabetes &amp; peripheral arterial diseases -mamdouh el nahas
Ueda2016 diabetes &amp; peripheral arterial diseases  -mamdouh el nahasUeda2016 diabetes &amp; peripheral arterial diseases  -mamdouh el nahas
Ueda2016 diabetes &amp; peripheral arterial diseases -mamdouh el nahas
 
Screening for asymptomatic cad in diabetes
Screening for asymptomatic cad in diabetesScreening for asymptomatic cad in diabetes
Screening for asymptomatic cad in diabetes
 
There is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
There is a Primary Prevent Indication in Diabetes | Mubashar A ChoudryThere is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
There is a Primary Prevent Indication in Diabetes | Mubashar A Choudry
 
JOURNAL CLUB (2) (1) (3) (5) (1).pptx
JOURNAL CLUB (2) (1) (3) (5) (1).pptxJOURNAL CLUB (2) (1) (3) (5) (1).pptx
JOURNAL CLUB (2) (1) (3) (5) (1).pptx
 
Stable angina
Stable anginaStable angina
Stable angina
 
Pablo avanzas novedades farmacologia en intervencionismo
Pablo avanzas   novedades farmacologia en intervencionismoPablo avanzas   novedades farmacologia en intervencionismo
Pablo avanzas novedades farmacologia en intervencionismo
 
Hope 3 FUTURE HOPES
Hope 3  FUTURE HOPESHope 3  FUTURE HOPES
Hope 3 FUTURE HOPES
 
B3SC proceedings of November 2016,Singapore
B3SC proceedings of November 2016,SingaporeB3SC proceedings of November 2016,Singapore
B3SC proceedings of November 2016,Singapore
 
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
1110414-降低糖尿病患者罹患心腎疾病的風險跟血糖達標一樣重要.pdf
 
Trials and errors in cardiovascular medicine 2013
Trials and errors in cardiovascular medicine  2013Trials and errors in cardiovascular medicine  2013
Trials and errors in cardiovascular medicine 2013
 

More from PeninsulaEndocrine

Gestational diabetes
Gestational diabetesGestational diabetes
Gestational diabetes
PeninsulaEndocrine
 
Endocrine disease in pregnancy
Endocrine disease in pregnancyEndocrine disease in pregnancy
Endocrine disease in pregnancy
PeninsulaEndocrine
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
PeninsulaEndocrine
 
Hypoglycaemia in older people
Hypoglycaemia in older peopleHypoglycaemia in older people
Hypoglycaemia in older people
PeninsulaEndocrine
 
Diabetes in the elderly
Diabetes in the elderlyDiabetes in the elderly
Diabetes in the elderly
PeninsulaEndocrine
 
Primary hyperaldosteronism - arterial venous sampling cases
Primary hyperaldosteronism - arterial venous sampling casesPrimary hyperaldosteronism - arterial venous sampling cases
Primary hyperaldosteronism - arterial venous sampling cases
PeninsulaEndocrine
 
Hypogonadism and testosterone replacement part 2
Hypogonadism and testosterone replacement part 2Hypogonadism and testosterone replacement part 2
Hypogonadism and testosterone replacement part 2PeninsulaEndocrine
 
Hypogonadism and testosterone replacement
Hypogonadism and testosterone replacementHypogonadism and testosterone replacement
Hypogonadism and testosterone replacementPeninsulaEndocrine
 
Erectile dysfunction in diabetes
Erectile dysfunction in diabetesErectile dysfunction in diabetes
Erectile dysfunction in diabetesPeninsulaEndocrine
 
ADVANCE - Type 2 diabetes - vascular risk with intervention
ADVANCE - Type 2 diabetes - vascular risk with interventionADVANCE - Type 2 diabetes - vascular risk with intervention
ADVANCE - Type 2 diabetes - vascular risk with interventionPeninsulaEndocrine
 
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with intervention
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with interventionDCCT/EDIC - Type 1 diabetes - cardiovascular risk with intervention
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with interventionPeninsulaEndocrine
 
DCCT – intensive diabetes therapy and glomerular filtration
DCCT – intensive diabetes therapy and glomerular filtrationDCCT – intensive diabetes therapy and glomerular filtration
DCCT – intensive diabetes therapy and glomerular filtrationPeninsulaEndocrine
 

More from PeninsulaEndocrine (20)

Gestational diabetes
Gestational diabetesGestational diabetes
Gestational diabetes
 
Endocrine disease in pregnancy
Endocrine disease in pregnancyEndocrine disease in pregnancy
Endocrine disease in pregnancy
 
Diabetes in pregnancy
Diabetes in pregnancyDiabetes in pregnancy
Diabetes in pregnancy
 
Hypoglycaemia in older people
Hypoglycaemia in older peopleHypoglycaemia in older people
Hypoglycaemia in older people
 
Diabetes in the elderly
Diabetes in the elderlyDiabetes in the elderly
Diabetes in the elderly
 
Primary hyperaldosteronism - arterial venous sampling cases
Primary hyperaldosteronism - arterial venous sampling casesPrimary hyperaldosteronism - arterial venous sampling cases
Primary hyperaldosteronism - arterial venous sampling cases
 
Calcium metabolism handout
Calcium metabolism handoutCalcium metabolism handout
Calcium metabolism handout
 
Calcium metabolism handout
Calcium metabolism handoutCalcium metabolism handout
Calcium metabolism handout
 
Kallmann syndrome
Kallmann syndromeKallmann syndrome
Kallmann syndrome
 
Kallmann syndrome
Kallmann syndromeKallmann syndrome
Kallmann syndrome
 
Hypogonadism and testosterone replacement part 2
Hypogonadism and testosterone replacement part 2Hypogonadism and testosterone replacement part 2
Hypogonadism and testosterone replacement part 2
 
Hypogonadism and testosterone replacement
Hypogonadism and testosterone replacementHypogonadism and testosterone replacement
Hypogonadism and testosterone replacement
 
Erectile dysfunction in diabetes
Erectile dysfunction in diabetesErectile dysfunction in diabetes
Erectile dysfunction in diabetes
 
The role of the podiatrist
The role of the podiatristThe role of the podiatrist
The role of the podiatrist
 
The diabetic foot
The diabetic footThe diabetic foot
The diabetic foot
 
ADVANCE - Type 2 diabetes - vascular risk with intervention
ADVANCE - Type 2 diabetes - vascular risk with interventionADVANCE - Type 2 diabetes - vascular risk with intervention
ADVANCE - Type 2 diabetes - vascular risk with intervention
 
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with intervention
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with interventionDCCT/EDIC - Type 1 diabetes - cardiovascular risk with intervention
DCCT/EDIC - Type 1 diabetes - cardiovascular risk with intervention
 
DCCT - Hypoglycemia
DCCT - HypoglycemiaDCCT - Hypoglycemia
DCCT - Hypoglycemia
 
DCCT overview
DCCT overviewDCCT overview
DCCT overview
 
DCCT – intensive diabetes therapy and glomerular filtration
DCCT – intensive diabetes therapy and glomerular filtrationDCCT – intensive diabetes therapy and glomerular filtration
DCCT – intensive diabetes therapy and glomerular filtration
 

Recently uploaded

Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
VarunMahajani
 
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.GawadHemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
NephroTube - Dr.Gawad
 
POST OPERATIVE OLIGURIA and its management
POST OPERATIVE OLIGURIA and its managementPOST OPERATIVE OLIGURIA and its management
POST OPERATIVE OLIGURIA and its management
touseefaziz1
 
Physiology of Chemical Sensation of smell.pdf
Physiology of Chemical Sensation of smell.pdfPhysiology of Chemical Sensation of smell.pdf
Physiology of Chemical Sensation of smell.pdf
MedicoseAcademics
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
MedicoseAcademics
 
Knee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdfKnee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdf
vimalpl1234
 
Charaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
Charaka Samhita Sutra sthana Chapter 15 UpakalpaniyaadhyayaCharaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
Charaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
Dr KHALID B.M
 
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidadeNovas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Prof. Marcus Renato de Carvalho
 
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIONDACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
DR SETH JOTHAM
 
The Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of IIThe Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of II
MedicoseAcademics
 
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
bkling
 
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdfBENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
DR SETH JOTHAM
 
24 Upakrama.pptx class ppt useful in all
24 Upakrama.pptx class ppt useful in all24 Upakrama.pptx class ppt useful in all
24 Upakrama.pptx class ppt useful in all
DrSathishMS1
 
Prix Galien International 2024 Forum Program
Prix Galien International 2024 Forum ProgramPrix Galien International 2024 Forum Program
Prix Galien International 2024 Forum Program
Levi Shapiro
 
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Oleg Kshivets
 
Non-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdfNon-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdf
MedicoseAcademics
 
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptxTriangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Dr. Rabia Inam Gandapore
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
SumeraAhmad5
 
Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...
Sujoy Dasgupta
 
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #GirlsFor Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
Savita Shen $i11
 

Recently uploaded (20)

Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
 
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.GawadHemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
 
POST OPERATIVE OLIGURIA and its management
POST OPERATIVE OLIGURIA and its managementPOST OPERATIVE OLIGURIA and its management
POST OPERATIVE OLIGURIA and its management
 
Physiology of Chemical Sensation of smell.pdf
Physiology of Chemical Sensation of smell.pdfPhysiology of Chemical Sensation of smell.pdf
Physiology of Chemical Sensation of smell.pdf
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
 
Knee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdfKnee anatomy and clinical tests 2024.pdf
Knee anatomy and clinical tests 2024.pdf
 
Charaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
Charaka Samhita Sutra sthana Chapter 15 UpakalpaniyaadhyayaCharaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
Charaka Samhita Sutra sthana Chapter 15 Upakalpaniyaadhyaya
 
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidadeNovas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
 
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIONDACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
ACUTE SCROTUM.....pdf. ACUTE SCROTAL CONDITIOND
 
The Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of IIThe Normal Electrocardiogram - Part I of II
The Normal Electrocardiogram - Part I of II
 
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
 
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdfBENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
BENIGN PROSTATIC HYPERPLASIA.BPH. BPHpdf
 
24 Upakrama.pptx class ppt useful in all
24 Upakrama.pptx class ppt useful in all24 Upakrama.pptx class ppt useful in all
24 Upakrama.pptx class ppt useful in all
 
Prix Galien International 2024 Forum Program
Prix Galien International 2024 Forum ProgramPrix Galien International 2024 Forum Program
Prix Galien International 2024 Forum Program
 
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
 
Non-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdfNon-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdf
 
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptxTriangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
 
Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...Couples presenting to the infertility clinic- Do they really have infertility...
Couples presenting to the infertility clinic- Do they really have infertility...
 
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #GirlsFor Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
 

Exeter Drugs Update

  • 1. Exeter Drugs Update Aspirin in the primary prevention of cardiovascular disease in people with diabetes Richard Haynes1 Louise Bowman1 Kenneth Macleod2 1 Clinical Research Fellow, Clinical Trial Service Unit, University of Oxford 2 Associate Dean & Reader in Medicine, Peninsula College of Medicine & Dentistry and Consultant Physician (Diabetes & Endocrinology) Royal Devon & Exeter NHS Foundation Trust
  • 2. The prevalence of diabetes mellitus is increasing and it affects over two million people in the UK alone. Patients with diabetes (either type 1 or type 2) are at increased risk of mortality compared to age- and gender-matched patients without diabetes and about two-thirds of deaths can be attributed to vascular causes.1, 2 However, surveys of people with diabetes show that the large majority do not yet have manifest vascular disease3, 4 and it is therefore logical to focus on strategies that could prevent the development of symptomatic vascular disease in these people. Aspirin has well-proven benefits in the secondary prevention of cardiovascular disease. Meta-analyses of antiplatelet trials (mostly involving aspirin) showed a reduction in subsequent vascular events of around one-quarter and the benefits appear to be similar whether or not such patients also had diabetes.5, 6 These meta-analyses also found an approximately 60% increase in the risk of major bleeding (defined as bleeding which was fatal or required transfusion) with antiplatelet therapy, but this risk is far outweighed by the benefits in patients at high risk of vascular disease i.e. those with known vascular disease. Consequently most people with diabetes and known vascular disease receive antiplatelet therapy. It remains unclear, however, whether patients with diabetes without a history of vascular disease are at sufficient risk of vascular disease for the benefits of aspirin to outweigh the risks. Until recently, the main randomised evidence on the effects of aspirin in such patients came from a meta-analysis of 9 trials involving almost 5000 patients which indicates a much smaller proportional
  • 3. reduction in cardiovascular events than has been found in the secondary prevention setting (just 7% compared with about 20-25%).6 Even in aggregate these studies involved relatively few events and the confidence interval for the estimated effect is wide, ranging from a 23% risk reduction to an 8% hazard. Guidelines are inconsistent on the recommendation to use aspirin because of the lack of clear evidence.7 This uncertainty has been reinforced by two recent trials. The Prevention of Progression of Arterial Disease And Diabetes (POPADAD) study randomised 1276 people with diabetes to receive aspirin 100 mg daily or placebo.8 All participants had an ankle-brachial pressure index <1.0 but were asymptomatic and the primary outcome was death from coronary disease or stroke, non-fatal myocardial infarction or stroke, or amputation above the ankle for critical limb ischaemia. Participants were followed for a median of 6.7 years but only 233 primary events were reported (annual event rate 2.7% per annum, well below the 8% the sample size was predicated on). The study was therefore underpowered to detect a plausible treatment effect which was reflected in the wide confidence interval of the main result: hazard ratio 0.98 (95% CI 0.76 – 1.26). The results of POPADAD are consistent with anything from a 24% risk reduction with aspirin to a 26% increased risk. More recently the Japanese Primary prevention of atherosclerosis with Aspirin for Diabetes (JPAD) study reported its results.9 JPAD randomised 2539 patients with type 2 diabetes to receive aspirin 100 mg daily or open control (placebo arms are not allowed in Japan). There were only 154 atherosclerotic
  • 4. events in this study: 68 (5.4%) in the aspirin group and 86 (6.7%) in the control group with a hazard ratio of 0.80 (95% CI 0.58 – 1.10). Again, JPAD was not large enough to be definitive and, as the accompanying editorial states, the use of aspirin in the primary prevention of vascular disease in people with diabetes remains on open question.10 Currently less than half of people with diabetes are taking aspirin: if it is effective then reliable trial data will help increase this and help prevent thousands of vascular events in the UK alone each year. Conversely if it is not safe then hundreds of bleeding episodes could be prevented. GPs deciding whether or not to treat with aspirin can consider a third option: help to resolve the current uncertainty by inviting their patients into a large ongoing trial. ASCEND (A Study of Cardiovascular Events iN Diabetes) is a randomised placebo-controlled trial of aspirin (and omega-3 fatty acids in a 2x2 factorial design) in this setting which plans to randomise 10,000 patients with diabetes. By more than doubling the available data, ASCEND should help to clarify this important question. It has already recruited nearly 5000 patients and interested GPs can help identify and invite patients (with the support of the local Diabetes and Primary Care Research Networks). Further details can be found on the study website (www.ctsu.ox.ac.uk/ascend), by e-mailing ascend@ctsu.ox.ac.uk or calling (Freefone) 0800 585323.
  • 5. 1. Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 1987;30:123-31. 2. Pyorala K, Laakso M, Uusitupa M. Diabetes and atherosclerosis: an epidemiologic view. Diabetes Metab Rev 1987;3:463-524. 3. Rolka DB, Fagot-Campagna A, Narayan KM. Aspirin use among adults with diabetes: estimates from the Third National Health and Nutrition Examination Survey. Diabetes Care 2001;24:197-201. 4. UK Prospective Diabetes Study 6. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. Diabetes Res 1990;13:1-11. 5. Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 1994;308:81-106. 6. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71-86. 7. Nicolucci A, De Berardis G, Sacco M, Tognoni G. AHA/ADA vs. ESC/EASD recommendations on aspirin as a primary prevention strategy in people with diabetes: how the same data generate divergent conclusions. Eur Heart J 2007;28:1925-7. 8. Belch J, MacCuish A, Campbell I, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008;337:a1840-. 9. Ogawa H, Nakayama M, Morimoto T, et al. Low-Dose Aspirin for Primary Prevention of Atherosclerotic Events in Patients With Type 2 Diabetes: A Randomized Controlled Trial. JAMA 2008. 10. Nicolucci A. Aspirin for primary prevention of cardiovascular events in diabetes: still an open question. JAMA 2008;300:2180-1.