The prevention of diabetic retinopathy requires drugs that leverage the benefits of glycemic control without adding the burden of side effects. Aspirin at dosages of 1-1.5 g/day has prevented manifestations of diabetic retinal microangiopathy in a clinical trial as well as in studies with dogs. Because lower and safer doses of aspirin could be used if its beneficial effects on retinopathy were due to antithrombotic effects, we compared the effects of a selective antiplatelet drug (clopidogrel) to those of aspirin in streptozotocin-induced diabetic rats. Clopidogrel did not prevent neuronal apoptosis, glial reactivity, capillary cell apoptosis, or acellular capillaries in the retina of diabetic rats. Aspirin, at doses yielding serum levels (<0.6 mmol/l) well below the anti-inflammatory range for humans, prevented apoptosis of capillary cells and the development of acellular capillaries but did not prevent neuroglial abnormalities. The aldose reductase inhibitor sorbinil, used as the benchmark for the effect of the other drugs, prevented all abnormalities. The diabetic rat retina showed increased expression of the transcription factor CCAAT/enhancerbinding protein-, one of the known targets of low-intermediate concentrations of aspirin. Thus we found a spectrum of drug efficacy on the prevention of experimental diabetic retinopathy, ranging from the absent effect of a selective antiplatelet drug to the prevention of all abnormalities by an aldose reductase inhibitor. Aspirin at low-intermediate concentrations selectively prevented microangiopathy. The minimal effective dose of aspirin should now be sought. Diabetes 54:3418 -3426, 2005 D iabetic retinopathy remains a sight-threatening complication of diabetes despite decades of efforts to identify drugs that can leverage the prevention afforded by glycemic control. Aspirin has been studied several times in this context, with results that may appear inconsistent but actually are worthy of scrutiny in light of evolving knowledge. The Early Treatment Diabetic Retinopathy Study (ETDRS), the largest of the clinical trials testing aspirin, concluded that aspirin (650 mg/day) has no clinically important beneficial effects on the progression of retinopathy (1). The trial was performed in patients with mild to severe nonproliferative or early proliferative diabetic retinopathy. Having learned from the Diabetes Control and Complications Trial that intervening after retinopathy is clinically evident is much less successful than primary prevention (2), it is safe not to extrapolate the EDTRS results to prevention. The Dipyridamole Aspirin Microangiopathy of Diabetes Study, which enrolled patients with early diabetic retinopathy (a lesssevere degree of retinopathy than that seen in the ETDRS), showed that aspirin (990 mg/day) was able to slow the progression of microaneurysms by Ͼ50% over the 3-year duration of the study (3). Microaneurysms are only a surrogate end point of diabetic retinopathy, but they have high predictive value for worsening retinopathy (4,5). When aspirin ...