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Antiplatelets Reduce Stroke Risk in Diabetics

Diabetes Mellitus is just one of the myriad of diseases prone to formation of blood clots which makes a diabetic in rendezvous with events like heart attack, stroke and blood vessel diseases involving the legs and feet. Uncontrolled blood glucose levels lead to dysfunction of the lining of arteries and veins causing coagulation or blood clotting defects. Platelets play a vital role in this coagulation system thru thickening of the blood resulting in clot formation and consequent impaired blood flow.

What are antiplatelets?
As the name implies, antiplatelets are medications which block aggregation of platelets resulting to better circulation, hence, preventing ischemic (loss of blood supply) episodes such as stroke. When the blood flow to the brain is blocked, it causes nutrient deprivation of nerve cells and cell death ensues leading to irreversible effects. Antiplatelets help prevent this cascade of events.

There are several antiplatelet agents which you may be familiar with. Among these are Aspirin, Clopidogrel, Ticlodipine, Dipyridamole and Warfarin. All of these drugs have their own respective claims in blood-thinning and act via different mechanisms in the body. Studies have shown how these drugs play a role. in the primary (avoiding a first event) or secondary (avoiding a second event) prevention of stroke. A team of investigators, known as the Antithrombotic Trialists’ Collaboration (ATC), found that antiplatelet therapy led to a drop of 25 percent in the risk of non-fatal stroke.

Aspirin is the most studied antiplatelet and has been a part of the daily regimen of many patients for decades. The American Diabetes Association Clinical Practice Recommendations 2006 states that aspirin therapy (75 to 162 mg/day) can be used as a prevention strategy in type 1 and type 2 diabetes patients more than 40 years of age or who have additional risk factors such as family history of cardiovascular diseases, hypertension, smoking, abnormal fat levels or protein in the urine.

Most clinical trials used doses ranging from 75 to 325 mg/day and there is yet no evidence as to the specific dose to be used. In addition, use of aspirin had not been studied in those less than 30 years old. Side effects noted from this medication are skin bruising (especially in older people), allergic reaction, irritation of the stomach lining, bleeding from the digestive system, and rarely, bleeding (hemorrhage) in the brain or other internal organs.

Safety tips for patients prescribed with aspirin are: take aspirin with food to prevent irritation of the stomach; use buffered or enteric-coated aspirin for less gastric upset; inform your doctor of any signs of allergy to the drug; check with your doctor before using other nonprescription drugs that may also contain aspirin; let your doctor know if you are taking aspirin when you are planning to have surgery since you may have to stop the aspirin temporarily.

Another antiplatelet, clopidogrel, has proven to be effective for treatment of stroke survivors who also
have abnormal peripheral circulation. Peripheral circulation refers to the blood flow to the external areas of the body, such as the legs. Claudication (leg pain while walking) results from problems in peripheral circulation.  Clopidogrel has a slight advantage over aspirin for treating leg pain due to poor circulation.

In the CAPRIE trial (randomized, blinded trial of Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events), clopidogrel was superior compared to aspirin in the overall circulation of patients with recent stroke, heart attack or symptomatic peripheral arterial disease.

A more recent trial called the MATCH trial compared the combination of aspirin and clopidogrel with clopidogrel alone in 7,599 high risk patients with recent stroke or transient ischemic attack (mini stroke lasting for minutes or a few hours). Results of the study showed consistent reduction of vascular events with
the combination therapy but it was not statistically significant compared to the clopidogrel monotherapy. The side effect of bleeding was even higher with the two agents combined which offsets any beneficial effect.

Warfarin, also know as coumadin, is another oral drug that-blocks blood clotting and often used for long-term blood thinning therapy. Warfarin is used as stroke prevention for people at high risk for blood clot formation making bleeding easier. However, in all patients, too much of a dose of anticlotting can cause serious bleeding risks so they have to be monitored accordingly for their bleeding and clotting parameters.

Ticlodipine and dypiridamole are two more antiplatelet agents. Ticlodipine has an increased risk of side effects, especially bleeding and induce severe decrease in white blood cells called neutropenia. It is therefore considered to be a second-line therapy due to requirements for monitoring and greater cost. Ticlodipine is most commonly used if aspirin fails.

Dypiridamole which is usually marketed as an extended-release tablet was found to reduce the risk of stroke by 37 percent if combined with aspirin and is considered a more safe and effective alternative compared to aspirin alone. Headache, dizziness, stomach upset, vomiting, and diarrhea are among the adverse effects of this combination.

Precautions!
You have to ask your physician which antiplatelet therapy suits your indication. They may work in seemingly similar ways but treatment is still individualized.

These medications should be avoided or prescribed with caution in the following: pregnancy, alcohol drinking problem, known allergy to aspirin and related drugs, asthma, bleeding problems, history of peptic ulcer disease or any gastrointestinal bleeding, liver and kidney disease.

Side effects of antiplatelet regimen which may be subtle and go unnoticed include cough, diarrhea, dizziness, excessive bleeding anywhere in the body, headache, heart palpitations, rash, ringing in the ears, stomach irritation that ranges from mild heartburn to bleeding ulcers. Make sure that you tell your doctor if you experience any of these so you may be tested during clinic consults.

These drugs can interact with the other medications that you are taking such as those prescribed by other physicians, herbal remedies, multivitamins and over-the-counter drugs. It would be very important to tell your doctor concomitant drugs in your regimen to avoid any unwanted effects because they usually do not work well with other medicines. So make a list of all your medications when you go from one doctor to another for separate consults.

Diabetes patients usually practice polypharmacy. Surveys show a diabetic would have an average of four to five drugs in his list. An antiplatelet should always be a part of this daily regimen which, based on several studies has shown substantial benefits in improving blood flow and preventing clot formation.

So, stop that clot! It’s amazing how this teenie-winnie tablet can do a lot of wonders in the prevention of one of the most dreaded complications of diabetes–stroke.

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