We believe that the currently available evidence is insufficient to determine whether aspirin is more, equally, or less effective in people with diabetes as compared to those without diabetes. In their letter, Nicolucci et al. (1) correctly point out that the recommendation statement was not the product of a new systematic review but an effort to align previously published recommendations of the American Diabetes Association and the American Heart Association by consensus of those at the table. As we mention in the section entitled “Comprehensive Risk Assessment” (2), patients with diabetes can have a range of cardiovascular risk levels, although most men over 40 and women over 50 years of age with diabetes have a sufficient level of risk to benefit from aspirin if it is effective for cardiovascular risk reduction. In contrast, some people with diabetes will not benefit from aspirin therapy over age 40 years—e.g., a physically active thin woman with type 1 diabetes of recent onset and no other cardiovascular risk factors. The clinical trials that Nicolucci et al. cite will certainly expand the evidence base on aspirin's efficacy and thus help support or refute the recommendations.
Until then, we stand by the recommendations to routinely employ low-dose aspirin therapy in patients with diabetes over age 40 years or with other cardiovascular risk factors in the absence of contraindications or recognized adverse events. These recommendations are designed to provide easily translated advice for primary care providers and community health workers about the likely beneficial and cost-effective strategies to reduce cardiovascular disease–related morbidity and mortality.
