Prescription of Aspirin for adults with Diabetes

BACKGROUND: To evaluate the prescription of aspirin for primary and secondary prevention of cardiovascular disorders in diabetic patients, in the light of American Diabetes Association guidelines. MATERIALS AND METHODS: In this retrospective analysis, presence of any cardiovascular disease or cardiovascular disease risk factor as deÞ ned in American Diabetes Association guidelines and the use of aspirin and other medication data were extracted from the case Þ les of 100 patients with type 2 diabetes mellitus visiting two teaching hospitals. RESULTS: Of 100 patients studied, 58% were men and 42% women and all were ≥ 40 years of age. 45% had at least one cardiovascular disease and all (100%) were on aspirin for secondary prevention; 45% had one or more risk factors, of which 11% (05/45) had aspirin prescribed for primary prevention; remaining 10% had neither risk factors nor cardiovascular disease (but age ≥ 40 years) and no aspirin documentation. Reasons for not using aspirin/antiplatelet drug were not recorded. CONCLUSIONS: American Diabetes Association recommendations for aspirin use for secondary prevention of cardiovascular diseases were strictly adhered to, in contrast to that for primary prevention. Under-prescription of aspirin could be attributed to the physicians concern about the burden of poly-pharmacy and toxic effects of aspirin on longterm use. Extensive efforts are necessary to enhance aspirin use in this regard.


Introduction
American Diabetes Association (ADA) recommends aspirin therapy for the secondary and primary prevention/prophylaxis (SP and PP) of cardiovascular events in DM patients with established CVD or those with cardiovascular disease risk factors (CVDRFs), respectively. [3]In this retrospective analyses, we evaluated the documentation of aspirin use in diabetic patients attending two teaching hospitals. [3]

Materials and Methods
Case files of 100 patients of type 2 DM, who were inpatients during the year 2005 at the two tertiary care hospitals attached to a teaching institution, were selected (Þ rst 50 names from each hospital data sheet) after obtaining permission from the concerned hospital authorities.Patient demographic details, CVDs, CVDRFs, and medications were recorded.We considered CVD as the presence of one or more of the Þ ve conditions (history of myocardial infarction (MI), vascular bypass procedure, stroke/transient ischemic attack, peripheral vascular disease (PVD), and angina), and CVDRFs as the presence of one or more of the Þ ve conditions (family history of CVD, hypertension, smoking, dyslipidemia, and albuminuria) as deÞ ned in ADA recommendation guidelines. [3]Age ≥ 40 years was considered as a separate CVDRF. [3]We recorded disease diagnoses as it was entered in the case Þ les.Patient compliance was assumed if aspirin prescription was found documented in the case Þ les.We estimated the percentage of diabetic patients with established CVD conditions and of those presenting with CVDRFs alone.The percentage of aspirin users in both the groups was analyzed.

Results
Case Þ les of 100 patients of type 2 DM were studied.The age of the patients ranged between 41 and 75 years, and 58% were men and 42% women.Table 1 gives the risk category and percent of aspirin users.Forty Þ ve percent had at least one of the CVDs, 45% had one or more CVDRFs alone.Remaining 10% had neither CVD nor any of the CVDRFs.Of the total, 50% of patients were prescribed aspirin (75-150 mg/day).Aspirin use was documented as SP measure, in the case Þ les of 100% (45/45) patients with CVD conditions.Among those who had CVDRFS alone, 11% (05/45) were prescribed aspirin as primary prevention measure and these Þ ve patients had two risk factors (hypertension and dyslipidemia).Patients (10%) without CVD/ CVDRFs did not receive aspirin.

Discussion
Aspirin prescription was documented in the case Þ les of 50% of the diabetic patients.The captured data show encouraging results with reference to aspirin usage, which is 100% as secondary prevention strategy in established CVD conditions.The beneficial effects of aspirin in preventing subsequent cardiovascular events are well established. [3]][7][8][9] Forty-Þ ve percent of diabetic patients had CVDRFs alone and were potential candidates for aspirin primary prophylaxis.Among them, only 11% (05/45) who had two risk factors (hypertension and dyslipidemia) were prescribed aspirin and the remaining 89% (40/45) were deprived of this protective measure.According to ADA recommendations, age ≥ 40 years itself is a separate risk factor to be considered for aspirin primary prevention in DM patients, which if considered, even the remaining 10% patients with neither CVD nor CVDRFs ought to have received aspirin. Research shows that low-dose aspirin is effective for primary prevention of CVD events in diabetic patients, who are at high risk. [3][9]10] Our observations(11%) are highly disappointing in this regard.Contraindications [3] for the use of aspirin were neither recorded in case Þ les of patients not receiving aspirin nor were they prescribed any other antiplatelet drug.All those patients who ought to have received aspirin, but did not, were on more than three drugs.In an attempt to reduce the burden of poly pharmacy, physicians may give more preference to antidiabetic and antihypertensive drugs than to aspirin, in the absence of established CVD.Controversy about the cardiovascular beneÞ ts of aspirin in diabetics, [11] and concern about toxicities of aspirin on long-term usage might also have contributed to the under-prescription of aspirin.

Conclusions
We evaluated the case Þ les of a small number (100) of patients, being treated by restricted number of physicians belonging to two hospitals.Hence, the results cannot be generalized to the diabetic population.In the present study, we can only conclude that adherence to ADA Clinical Practice guidelines regarding aspirin use for primary prevention of CVD, is not satisfactory in the two teaching hospitals that we considered for our study.Hospital authorities and medical associations may play a major role in setting guidelines for the medical practitioners to encourage aspirin use for patients with diabetes.

References
1. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and

Table 1 : Risk category and percentage of Aspirin users
11% Aspirin users for primary prophylaxis had two CVDRFs -hypertension and dyslipidemia Sabitha P et al.: Aspirin for diabetic patients [ *