Dual antiplatelet therapy in patients with diabetes and acute coronary syndromes managed without revascularization

A Rare Case of Clopidogrel-Induced Migratory Polyarthritis in a Patient With Recent Myocardial Infarction

Clopidogrel is an antiplatelet drug used for secondary prevention of myocardial infarction, and it is also used in patients with cerebrovascular ischemia. Patients with acute myocardial infarction tend to be on dual antiplatelet therapy for 12 months followed by aspirin lifelong to prevent the risk of stent thrombosis. The most common side effects of clopidogrel are bleeding, neutropenia, and rash; however, arthritis is also one of the rare side effects. We present a case of a 53-year-old patient who had a recent myocardial infarction and was commenced on dual antiplatelet therapy in the form of aspirin and clopidogrel. He started to have severe joint pain, particularly in his knees and shoulders, and was not able to mobilize anymore only three weeks after starting the medications. His clopidogrel was stopped and the patient showed dramatic improvement within three to four days after discontinuation with complete resolution one week later.

Antiplatelet and Antithrombotic Therapy in Type I Diabetes Mellitus: Update on Current Data

Diabetes mellitus type 1 (T1DM) is an autoimmune disease characterized by a markedly elevated cardiovascular (CV) risk due to premature atherosclerosis. Previous studies have shown that intense glycemic control reduces the incidence of CV disease. Antiplatelet therapy is considered to be a very important therapy for secondary prevention of recurrent atherothrombotic events in patients with DM, while it may be considered for primary prevention in individuals with T1DM with additional CV risk factors. The aim of the present review is to summarize existing literature data regarding the thrombotic risk in T1DM patients and discuss current treatment strategies.

Efficacy and Safety of Ticagrelor in Diabetes Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Dual antiplatelet treatment, consisting of aspirin and P2Y12 inhibitors, is essential for diabetes mellitus (DM) patients who have undergone percutaneous coronary intervention (PCI). This meta-analysis investigated whether ticagrelor, a novel P2Y12 inhibitor, was superior to clopidogrel and prasugrel in efficacy and safety for DM patients undergoing PCI. PubMed, the Cochrane Library and Google Scholar were searched for randomized controlled trials in which ticagrelor was administered. Eligible studies were independently scrutinized to extract data and assess the trials' quality. Statistical analysis was performed by calculating odds ratios (OR) and 95% confidence intervals (CI). A total of 8 studies consisting of 1056 patients were included. Results showed that ticagrelor reduced the major adverse cardiac events incidence compared with clopidogrel and prasugrel in the overall (OR = 0.40; 95% CI, 0.20-0.79; P = 0.008) and subgroup analyses compared with clopidogrel (OR = 0.39; 95% CI, 0.19-0.80; P = 0.01). No difference was observed in mortality rates (OR = 0.58; 95% CI, 0.23-1.45; P = 0.25), myocardial infarction (OR = 0.67; 95% CI, 0.28-1.60; P = 0.37), stroke (OR = 0.54; 95% CI, 0.10-3.01; P = 0.49), and total bleeding (OR = 1.70; 95% CI, 0.91-3.17; P = 0.10) between the ticagrelor and control groups. In DM patients undergoing PCI, ticagrelor significantly reduced major adverse cardiac events compared with clopidogrel and prasugrel in the overall and in the subgroup of clopidogrel. There was no difference regarding mortality, myocardial infarction, stroke, and bleeding. More randomized controlled trials are required to further validate these results.

Long-term effect of clopidogrel in patients with and without diabetes: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Previous studies have shown that patients with diabetes mellitus (DM) respond poorly to clopidogrel treatment.

AIM

To systematically evaluate the efficacy of clopidogrel for the treatment of acute coronary syndromes or ischemic stroke in patients with or without DM.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE were searched from 1980 on 27 June 2019 to identify relevant randomized controlled trials that compared the effect of a combination of clopidogrel and aspirin with aspirin alone. A random-effects meta-analysis was used to estimate the hazard ratio (HR) and its 95% confidence interval (CI). Sensitivity analysis was performed using a fixed-effect model. The I² statistic was used to evaluate the heterogeneity of the study data.

RESULTS

Six randomized controlled trials, comprising 43352 participants (13491 with and 29861 without DM) who had received antiplatelet therapy for ≥ 3 mo, were included in the meta-analysis. Compared with aspirin alone, a combination of clopidogrel and aspirin significantly reduced the risk of any cardiovascular event in patients without DM (HR = 0.78, 95%CI: 0.71–0.86, P < 0.001; I² = 23%, P = 0.26). Clopidogrel plus aspirin also significantly reduced cardiovascular risk in patients with DM, although the effect was smaller (HR = 0.89, 95%CI: 0.81–0.99, P = 0.030; I² = 0%, P = 0.74). Nevertheless, there was no significant difference in the efficacy of clopidogrel at reducing the risk of cardiovascular events in patients with DM vs those without (P for interaction = 0.062).

CONCLUSION

Thus, the present study shows that the addition of clopidogrel to aspirin significantly lowers cardiovascular risk in patients with or without DM who have experienced ischemic cardiovascular disease. The beneficial effect of the addition of clopidogrel to aspirin for patients with DM was lower than that in patients without DM, although the modifying effect of DM did not reach significance.

Role of Combination Antiplatelet and Anticoagulation Therapy in Diabetes Mellitus and Cardiovascular Disease: Insights From the COMPASS Trial

Supplemental Digital Content is available in the text.

Background:

Patients with established coronary artery disease or peripheral artery disease often have diabetes mellitus. These patients are at high risk of future vascular events.

Methods:

In a prespecified analysis of the COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies), we compared the effects of rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) versus placebo plus aspirin in patients with diabetes mellitus versus without diabetes mellitus in preventing major vascular events. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included all-cause mortality and all major vascular events (cardiovascular death, myocardial infarction, stroke, or major adverse limb events, including amputation). The primary safety end point was a modification of the International Society on Thrombosis and Haemostasis criteria for major bleeding.

Results:

There were 10 341 patients with diabetes mellitus and 17 054 without diabetes mellitus in the overall trial. A consistent and similar relative risk reduction was seen for benefit of rivaroxaban plus aspirin (n=9152) versus placebo plus aspirin (n=9126) in patients both with (n=6922) and without (n=11 356) diabetes mellitus for the primary efficacy end point (hazard ratio, 0.74, P=0.002; and hazard ratio, 0.77, P=0.005, respectively, P_interaction=0.77) and all-cause mortality (hazard ratio, 0.81, P=0.05; and hazard ratio, 0.84, P=0.09, respectively; P_interaction=0.82). However, although the absolute risk reductions appeared numerically larger in patients with versus without diabetes mellitus, both subgroups derived similar benefit (2.3% versus 1.4% for the primary efficacy end point at 3 years, Gail-Simon qualitative P_interaction<0.0001; 1.9% versus 0.6% for all-cause mortality, P_interaction=0.02; 2.7% versus 1.7% for major vascular events, P_interaction<0.0001). Because the bleeding hazards were similar among patients with and without diabetes mellitus, the prespecified net benefit for rivaroxaban appeared particularly favorable in the patients with diabetes mellitus (2.7% versus 1.0%; Gail-Simon qualitative P_interaction=0.001).

Conclusions:

In stable atherosclerosis, the combination of aspirin plus rivaroxaban 2.5 mg twice daily provided a similar relative degree of benefit on coronary, cerebrovascular, and peripheral end points in patients with and without diabetes mellitus. Given their higher baseline risk, the absolute benefits appeared larger in those with diabetes mellitus, including a 3-fold greater reduction in all-cause mortality.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01776424.

Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs

Diabetes mellitus is an important risk factor for a first cardiovascular event and for worse outcomes after a cardiovascular event has occurred. This situation might be caused, at least in part, by the prothrombotic status observed in patients with diabetes. Therefore, contemporary antithrombotic strategies, including more potent agents or drug combinations, might provide greater clinical benefit in patients with diabetes than in those without diabetes. In this Consensus Statement, our Working Group explores the mechanisms of platelet and coagulation activity, the current debate on antiplatelet therapy in primary cardiovascular disease prevention, and the benefit of various antithrombotic approaches in secondary prevention of cardiovascular disease in patients with diabetes. While acknowledging that current data are often derived from underpowered, observational studies or subgroup analyses of larger trials, we propose antithrombotic strategies for patients with diabetes in various cardiovascular settings (primary prevention, stable coronary artery disease, acute coronary syndromes, ischaemic stroke and transient ischaemic attack, peripheral artery disease, atrial fibrillation, and venous thromboembolism). Finally, we summarize the improvements in cardiovascular outcomes observed with the latest glucose-lowering drugs, and on the basis of the available evidence, we expand and integrate current guideline recommendations on antithrombotic strategies in patients with diabetes for both primary and secondary prevention of cardiovascular disease.

Oral Antiplatelet Therapy for Secondary Prevention of Acute Coronary Syndrome

Patients surviving an acute coronary syndrome (ACS) remain at increased risk of ischemic events long term. This paper reviews current evidence and guidelines for oral antiplatelet therapy for secondary prevention following ACS, with respect to decreased risk of ischemic events versus bleeding risk according to individual patient characteristics and risk factors. Specifically, data are reviewed from clinical studies of clopidogrel, prasugrel, ticagrelor and vorapaxar, as well as the results of systematic reviews and meta-analyses looking at the benefits and risks of oral antiplatelet therapy, and the relative merits of shorter versus longer duration of dual antiplatelet therapy, in different patient groups.