Prof. Steen Dalby Kristensen,
Diabetic patients have a higher incidence of cardiovascular events than non-diabetics. Agneta Siegbahn (Uppsala, Sweden) elegantly presented convincing data showing that patients with diabetes have increased platelet reactivity due to changes in several important pathways. The reason for these changes is unknown, but might involve hyperglycaemia, hyperinsulinism or the presence of glycosylated molecules. Furthermore, in diabetes, the number of circulating microparticles derived from platelets and other cells is increased. High levels of circulating microparticles have previously been shown to be associated with an increase in cardiovascular complications. Carlo Patrono (Rome, Italy) emphasized that the platelet response to low-dose aspirin in the individual patient varies from day to day. Thus, repetitive measurements are necessary to identify low-responders. Poor compliance or the use of NSAID’s such as ibuprofen and naproxen are common causes of a low response. However, Patrono and colleagues have shown specifically in diabetics, that some patients respond inadequately at the end of the dosing interval when given a single low-dose of aspirin. Therefore, it should be investigated whether patients with diabetes might benefit from twice-daily dosing of aspirin. Diabetic patients have a lower response to clopidogrel than non-diabetics. Dominick Angiolillo (Jacksonville, US) reported that this, at least in part, is due to a poor metabolism of clopidogrel to its active metabolite. To some extent, the low response to clopidogrel can be partially overcome by intake of another antiplatelet drug; cilastazol. Other new P2Y12 inhibitors such as prasugrel and ticagrelor have been shown to provide stronger platelet inhibition and better clinical outcomes than clopidogrel in diabetics suffering acute coronary syndromes. Lars Wallentin (Uppsala, Sweden) presented interesting data from large Swedish registries. Patients with diabetes have a high risk of acute coronary syndromes; a condition which is often undertreated in these patients. Subgroup analyses suggest that diabetics may benefit from stronger antiplatelet therapy, but further evidence from well-designed clinical trials is warranted. At present, diabetic patients with acute coronary syndrome should be treated in the same way as non-diabetics.
Is there a need to tailor antiplatelet therapy in diabetes?
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