Antithrombotic therapy in diabetes: which, when, and for how long?

Abstract

Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.

Berberine: A Review of its Pharmacokinetics Properties and Therapeutic Potentials in Diverse Vascular Diseases

“…Oral berberine (50 mg/kg/day) markedly improved insulin resistance, reduced the inflammation and JNK, IKK-β, and NF-κB p65 phosphorylation by inhibiting M1 macrophage activation in adipose tissue ( Ye et al, 2016 ). Owing to increased aldose reductase (AR) and NADPH oxidase (NOX) activities, platelet hyperreactivity and apoptosis during DM accounts for the accumulation of ROS ( Vara et al, 2019 ; Ajjan et al, 2021 ). It was demonstrated that 50 mM glucose induced platelet aggregation, apoptosis and superoxide production, which was neutralized by 25 and 50 μM berberine via inhibiting of AR, NOX and GSH reductase activities ( Paul et al, 2019 ).…”

Role of diabetes in stroke: Recent advances in pathophysiology and clinical management

“…Diabetes patients have a prothrombotic condition and are at a greater risk of cardiovascular events than individuals who do not have diabetes 149 . Antithrombotic or antiplatelet treatments may be linked with a greater absolute decrease in recurrent episodes in diabetes in comparison to those without diabetes 105,106 . For primary prevention of CVD in diabetes, antiplatelet therapy (aspirin; 75–100 mg daily) is indicated in patients with 10‐year cardiovascular risk greater than 10% in those aged ≥50 years without a high risk of bleeding.…”

“…149 Antithrombotic or antiplatelet treatments may be linked with a greater absolute decrease in recurrent episodes in diabetes in comparison to those without diabetes. 105,106 For primary prevention of CVD in diabetes, antiplatelet therapy (aspirin; 75-100 mg daily) is indicated in patients with 10-year cardiovascular risk greater than 10% in those aged ≥50 years without a high risk of bleeding. A 2019 meta-analysis by Seidu et al demonstrated a significant reduction in stroke with a low-dosage (≤100 mg/day) of aspirin dosage in diabetes patients (RR 0.75, 95% CI 0.59-0.95).…”

Extensive thrombosis with amputation of digit I pedis dextra: A case report in Indonesian adult with type 2 diabetes mellitus

“…Second, the elderly are often accompanied by various comorbidities so that receiving large amounts of drugs will increase the risk of interactions with the antithrombotic drugs given. Therefore, therapy monitoring must be carried out more carefully on the dose, drug effects, or side effects of drugs [17] , [18] .…”