The vulnerable blood. Coagulation and clot structure in diabetes mellitus

Association between fatty liver index and blood coagulation markers: a population-based study

BACKGROUND

Population-based studies investigating the association between blood coagulation markers and non-alcoholic fatty liver disease (NAFLD) are rare. Thus, we aimed to investigate the relationship between the Fatty Liver Index (FLI) as a measure of hepatic steatosis and plasma concentrations of antithrombin III, D-dimer, fibrinogen D, protein C, protein S, factor VIII, activated partial thromboplastin time (aPTT), quick value and international thromboplastin time (INR) in the general population.

METHODS

After the exclusion of participants with anticoagulative treatment, 776 participants (420 women and 356 men, aged 54-74 years) of the population-based KORA Fit study with analytic data on hemostatic factors were included in the present analysis. Linear regression models were used to explore the associations between FLI and hemostatic markers, adjusted for sex, age, alcohol consumption, education, smoking status, and physical activity. In a second model, additional adjustments were made for the history of stroke, hypertension, myocardial infarction, serum non-HDL cholesterol levels, and diabetes status. In addition, analyses were stratified by diabetes status.

RESULTS

In the multivariable models (with or without health conditions), significantly positive associations with FLI were obtained for plasma concentrations of D-dimers, factor VIII, fibrinogen D, protein C, protein S, and quick value, while INR and antithrombin III were inversely associated. These associations were weaker in pre-diabetic subjects and largely disappeared in diabetic patients.

CONCLUSION

In this population-based study, an increased FLI is clearly related to changes in the blood coagulation system, possibly increasing the risk of thrombotic events. Due to a generally more pro-coagulative profile of hemostatic factors, such an association is not visible in diabetic subjects.

Analysis of clinical predictors of kidney diseases in type 2 diabetes patients based on machine learning

BACKGROUND

The heterogeneity of Type 2 Diabetes Mellitus (T2DM) complicated with renal diseases has not been fully understood in clinical practice. The purpose of the study was to propose potential predictive factors to identify diabetic kidney disease (DKD), nondiabetic kidney disease (NDKD), and DKD superimposed on NDKD (DKD + NDKD) in T2DM patients noninvasively and accurately.

METHODS

Two hundred forty-one eligible patients confirmed by renal biopsy were enrolled in this retrospective, analytical study. The features composed of clinical and biochemical data prior to renal biopsy were extracted from patients' electronic medical records. Machine learning algorithms were used to distinguish among different kidney diseases pairwise. Feature variables selected in the developed model were evaluated.

RESULTS

Logistic regression model achieved an accuracy of 0.8306 ± 0.0057 for DKD and NDKD classification. Hematocrit, diabetic retinopathy (DR), hematuria, platelet distribution width and history of hypertension were identified as important risk factors. Then SVM model allowed us to differentiate NDKD from DKD + NDKD with accuracy 0.8686 ± 0.052 where hematuria, diabetes duration, international normalized ratio (INR), D-Dimer, high-density lipoprotein cholesterol were the top risk factors. Finally, the logistic regression model indicated that DD-dimer, hematuria, INR, systolic pressure, DR were likely to be predictive factors to identify DKD with DKD + NDKD.

CONCLUSION

Predictive factors were successfully identified among different renal diseases in type 2 diabetes patients via machine learning methods. More attention should be paid on the coagulation factors in the DKD + NDKD patients, which might indicate a hypercoagulable state and an increased risk of thrombosis.

A Multifactorial Risk Score System for the Prediction of Diabetic Kidney Disease in Patients with Type 2 Diabetes Mellitus

PURPOSE

In-depth investigations of risk factors for the identification of diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM) are rare. We aimed to investigate the risk factors for developing DKD from multiple types of clinical data and conduct a comprehensive risk assessment for individuals with diabetes.

METHODS

We carried out a case-control study, enrolling 958 patients to identify the risk factors for developing DKD in T2DM patients from a database established from inpatient electronic medical records. Multivariable logistic regression was applied to develop a prediction model and the performance of the model was evaluated using the area under the curve (AUC) and calibration curve. A multifactorial risk score system was established according to the Framingham Study risk score.

RESULTS

DKD accounted for 34.03% of eligible patients in total. Twelve risk factors were selected in the final prediction model, including age, duration of diabetes, duration of hypertension, fasting blood glucose, fasting C-peptide, insulin use, systolic blood pressure, low-density lipoprotein, γ-glutamyl transpeptidase, platelet, uric acid, and thyroid stimulating hormone; and one protective factor, serum albumin. The prediction model showed an AUC of 0.862 (95% Confidence Interval (CI) 0.834-0.890) with an accuracy of 81.5% in the derivation dataset and an AUC of 0.876 (95% CI 0.825-0.928) in the validation dataset. The calibration curves were excellent and the estimated probability of DKD was more than 80% when the cumulative score for risk factors reached 17 points.

CONCLUSION

Newly recognized risk factors were applied to assess the development of DKD in T2DM patients and the established risk score system was a reliable and feasible tool for assisting clinicians to identify patients at high risk of DKD.

α1-Adrenergic Stimulation Increases Platelet Adhesion to Endothelial Cells Mediated by TRPC6

Stimulation of a1-adrenergic nervous system is increased during systemic inflammation and other pathological conditions with the consequent adrenergic receptors (ARs) activation. It has been reported that a1-stimulation contributes to coagulation since a1-AR blockers inhibit coagulation and its organic consequences. Also, coagulation induced by a1-AR stimulation can be greatly decreased using a1-AR blockers. In health, endothelial cells (ECs) perform anticoagulant actions at cellular and molecular level. However, during inflammation, ECs turn dysfunctional promoting a procoagulant state. Endothelium-dependent coagulation progresses at cellular and molecular levels, promoting endothelial acquisition of procoagulant properties to potentiate coagulation by means of prothrombotic and antifibrinolytic proteins expression increase in ECs releasing them to circulation, the thrombus formation is strengthened. Calcium signaling is a main feature of coagulation. Inhibition of ion channels involved in Ca²⁺ entry severely decreases coagulation. The transient receptor potential canonical 6 (TRPC6) is a non-selective Ca²⁺-permeable ion channel. TRPC6 activity is induced by diacylglycerol, suggesting that is regulated by a1-ARs. Furthermore, a1-ARs stimulation elicits a TRPC-like current in rat mesenteric artery smooth muscle and mesangial cells. However, whether TRPC6 could promote an ECs-mediated platelet adhesion induced by a1-adrenergic stimulation is currently not known. Therefore, the aim of this study was to examine if the TRPC6 calcium channel mediates platelet adhesion induced by a1-adrenergic stimulation. Our results suggest that platelet adhesion to ECs is enhanced by the a1-adrenergic stimulation evoked by phenylephrine mediated by TRPC6 activity. We conclude that TRPC6 is a molecular determinant in platelet adhesion to ECs with implications in systemic inflammatory diseases treatment.

Changes of plasma nitric oxide, endothelin-1, and blood coagulation following intravitreal conbercept

Intravitreal anti-VEGF (anti-vascular endothelial growth factor) biologics have revolutionized the pharmacological management of chorioretinal diseases. However, the systemic adverse events such as stroke or bleeding are the concerns for many patients and physicians. The mechanism to develop these side effects are poorly understood. Consecutive 95 patients with retinal diseases were studied for their blood activated partial thromboplastin time (APTT), prothrombin time (PT), international normalized ratio (INR), and concentration of fibrinogen before and after intravitreal conbercept. Additionally, plasma nitric oxide (NO) and endothelin-1 (ET-1) were investigated on 38 of the 95 patients. Compared with the pre-injection, 4-week post-injection values of APTT and PT were increased by 0.582 s (p = 0.038, paired t test) and by 0.086 s (p = 0.080, paired t test; p = 0.0475, Sign test), respectively. At the same time, fibrinogen decreased by 0.048 g/L. Plasma levels of NO or ET-1 or VEGF did not significantly change from pre-injection levels. Our findings advanced the understanding of mechanism for systemic side effects associated with intravitreal anti-VEGF and emphasized paying more attention to higher risk of possible bleedings for patients following intravitreal conbercept.

Glycemia and venous thromboembolism in patients with primary brain tumors - A speculative review

Venous thromboembolism (VTE) is a significant public health issue causing severe morbidity and mortality. One of the most vulnerable populations for VTE development are cancer patients. And among them, patients with brain tumors have arguably the highest risk of developing this often fatal complication. Hyperglycemia is a well-known factor which leads to a wide variety of pro-thrombotic changes. In this article, we review the current literature on the topic of VTE in brain tumor patients. We also discuss the known correlation between VTE and glycemia, as well as the importance and frequency of glycemia dysregulation in brain tumor patients. Based on the already well-known importance of glucose metabolism in cancer patients, as well as the previous research of our group, we hypothesize that there is a significant number of brain tumor patients who have chronically elevated glycemia, a fact that so-far hasn't been reported. We argue that these patients carry a significantly higher risk of VTE development and would benefit greatly from strict glycemic control. We present our hypothesis, the ways in which to test it, as well as the possible counter-arguments against it. Our hope is that other investigators will be inspired by our article to continue this type of research, since we consider the topic of VTE in brain tumor patients highly important and urgent, primarily due to its prevalence and severity.

High cardiovascular risk of patients with type 2 diabetes is only partially attributed to angiographic burden of atherosclerosis

BACKGROUND

Patients with type 2 diabetes (T2DM) are at high risk for cardiovascular events and present more severe coronary artery disease (CAD). The Gensini and COURAGE scores are established angiographic instruments to assess CAD severity, which may also predict future cardiovascular risk. However, it is unclear if these scores are able to depict the increased risk of patients with T2DM and stable CAD (T2DM-SAP).

METHODS

We performed quantitative coronary angiography and assessed the Gensini and COURAGE scores in 124 patients with T2DM-SAP. Angiographic data were compared to patients with stable angina without T2DM (Non-DM-SAP, n = 74), and to patients with acute coronary syndrome and T2DM (T2DM-ACS, n = 53).

RESULTS

T2DM-SAP patients had similar Gensini and COURAGE-scores compared to Non-DM-SAP-patients (Gensini: 14.44 ± 27.34 vs 11.49 ± 26.99, p = 0.465; COURAGE: 3.48 ± 4.49 vs 3.60 ± 4.72, p = 0.854). In contrast, T2DM-SAP patients had significantly lower Gensini (14.44 ± 27.34 vs 30.94 ± 48.74, p = 0.003) and lower COURAGE (3.48 ± 4.49 vs 5.30 ± 4.63, p = 0.016) scores compared to T2DM-ACS-patients.

CONCLUSION

Both the Gensini and the COURAGE score fail to predict the high cardiovascular risk of patients with T2DM-SAP. Therefore, these scores should be used with caution in the assessment of future risk of patients with T2DM. However, among T2DM-ACS patients, both scores are increased, reflecting the high cardiovascular risk in this patient population.

Influence of diagnosis of venous thromboembolism on immature platelets, absolute platelet count and platelet aggregation over time

The extent of the involvement of platelets in venous thromboembolisms (VTE) is still not fully understood. Immature platelets are large, RNA-rich, prothrombotic platelets. They are involved in arterial thromboembolisms and are associated with adverse cardiovascular events. Their role in VTE has not been investigated before. The aim of this study was to assess different platelet parameters including immature platelet fraction (IPF), immature platelet count (IPC), absolute platelet count and platelet aggregation (PA) over time in patients with VTE at time of diagnosis, as well as at 3-10 days and at 90-110 days after diagnosis. 50 healthy volunteers similar in age and sex to patients served as controls at diagnosis. IPF was measured by the Sysmex XE-5000 analyzer, PA was assessed using the Multiplate analyzer. Diagnosis of VTE had no relevant effect on IPF and IPC whereas absolute platelet count and PA were significantly decreased compared to controls. In the course of VTE, IPF decreased significantly, whereas IPC, absolute platelet count and PA increased. In conclusion, VTE was associated with relevant changes of the absolute platelet count and PA at diagnosis, as well as changes in IPF and IPC over time reflecting a relevant and measurable platelet consumption in VTEs.

Impact of diabetes mellitus on coagulation function before and after off-pump coronary artery bypass grafting

Background

This study aims to explore the influence of off-pump coronary artery bypass grafting (OPCABG) on coagulation function and the effects of diabetes on coagulation function during OPCABG.

Methods

Patients who met the inclusion and exclusion criteria were divided into two groups: diabetes mellitus (DM) and non-diabetes mellitus (NDM) groups. Thromboelastography (TEG) was tested at the following time points: T0, five days after aspirin and clopidogrel therapy, and before OPCABG; T1, returning to care unit after OPCABG; T2, 5 days after aspirin and clopidogrel therapy, and after OPCABG.

Results

A total of 56 patients were involved. There were no deaths, or no early postoperative thrombotic events and abnormal bleeding after OPCABG. Intra-group comparison: Compared with T0, the R and K value decreased, while the α angle and MA value increased at T1 and T2, in both groups (P<0.05). A significantly statistical difference was found in the multiple comparison at T0, T1 and T2 (P<0.05). The results are as follows: the R value decreased at T1 and increased at T2, but the value remained less than that at T0. After the OPCABG, the K value gradually decreased, while the MA value and α angle gradually increased. Comparison between groups: T1: the R values were lower in the DM group, when compared to the NDM group (t=3.611, P=0.001). The differences in the MA, K and α angle were not statistically significant. T0 and T2: there were no statistically difference in the R, MA, K, α angle and LY30 between the two groups (P>0.05).

Conclusions

The coagulation function of patients was at a hypercoagulable state at the early stage after OPCABG. The coagulation function was affected by diabetes at the day of OPCABG. However, there was no statistical difference after 5 days of aspirin and clopidogrel therapy following OPCABG.

The GLP-1 receptor agonist liraglutide protects against oxidized LDL-induced endothelial inflammation and dysfunction via KLF2

Cardiovascular complications are the major causes of the mortality and morbidities in diabetic patients. The diabetic patients have an increased risk of developing atherosclerosis, which could lead to heart attack and stroke. Glucagon-like peptide 1 (GLP-1) receptor agonists are a class of potent anti-glycemic agents to treat diabetes. Recently, several GLP-1 receptor agonists have been found to have cardiovascular benefit independent of their glucose lowing ability. Liraglutide is one of clinically approved effective GLP-1 receptor agonists. In this study, we explored the molecular mechanism of Liraglutide against oxidized low-density lipoprotein (ox-LDL) in cultured endothelial cells. Our data show that Liraglutide treatment ameliorates ox-LDL caused reduction of the transcriptional factor KLF2. In the same experiment, Liraglutide also rescues ox-LDL induced reduction of mitogen-activated protein kinase (MAPK) kinase extracellular signal regulated kinase 5 (ERK5) phosphorylation, and blockage of ERK5 activity by its inhibitor XMD8-92 abolishes the protection of Liraglutide on KLF2 expression. These facts suggest that the action of Liraglutide on endothelial KLF2 is dependent on ERK5. Liraglutide also recovers ox-LDL caused reduction of endothelial tight junctions protein Occludin and ameliorates ox-LDL induced endothelial monolayer permeability increase. On the other hand, Liraglutide inhibits ox-LDL induced expression of vascular adhesion molecules (E-selectin and vascular cell adhesion molecule 1), and prevents ox-LDL induced attachment of monocytes adhesion to endothelial cells. Moreover, Liraglutide mitigates ox-LDL triggered reduction of endothelial nitric oxide synthase (eNOS) expression and NO release. Collectively, our study provides multiple facets of the mechanisms that Liraglutide is a protective agent in endothelial cells and has the potential implication in therapeutic usage of vascular complication in diabetes patients. © 2019 IUBMB Life, 71(9):1347-1354, 2019.

Prothrombotic State in Atrial Fibrillation Patients With One Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex)

BACKGROUND

It is unclear whether a prothrombotic state occurs in atrial fibrillation (AF) with low stroke risk.

METHODS

We studied 118 patients with AF with the Congestive Heart Failure, Hypertension, Age (≥ 75 years), Diabetes, Stroke/Transient Ischemic Attack/Systemic Embolism, Vascular Disease, Age (65-74 years), Sex (Female) (CHA₂DS₂-VASc) score of 1 in men or 2 in women vs 52 patients with AF with the CHA₂DS₂-VASc score of 0 in men or 1 in women. Plasma clot permeability (K_s), a measure of fibrin clot density, and clot lysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor antigen, and plasminogen activator inhibitor-1 were evaluated in nonanticoagulated subjects.

RESULTS

Patients with the CHA₂DS₂-VASc score of 1 (beyond sex), compared with those with 0, had lower K_s, prolonged CLT, increased ETP, von Willebrand factor antigen, and plasminogen activator inhibitor-1 (all P < 0.001), without any sex-dependent differences. Heart failure (odds ratio [OR]: 10.28; 95% confidence interval [CI]: 2.32-45.41), age 65-74 years (OR: 4.37; 95% CI: 1.76-10.83), and hypertension (OR: 5.03; 95% CI: 1.81-13.94) were independently associated with low K_s (the lowest quartile, ≤ 6.4 × 10^-9 cm²), whereas only age 65-74 years (OR: 3.33; 95% CI: 1.59-6.96) significantly predicted prolonged CLT (the top quartile, ≥ 108 minutes). Age 65-74 years (OR: 5.21; 95% CI: 2.12-12.80), heart failure (OR: 6.58; 95% CI: 1.49-29.06), and hypertension (OR: 4.33; 95% CI: 1.54-12.15) were independently associated with high ETP (the top quartile, ≥ 1681.3 nM × minutes).

CONCLUSIONS

A prothrombotic state (increased thrombin generation, denser fibrin clots, impaired fibrinolysis, and endothelial injury) characterizes patients with AF with 1 additional clinical stroke risk factor (beyond sex), with age 65-74 years being particularly associated with prothrombotic indices.

Clopidogrel Reduces Fibronectin Accumulation and Improves Diabetes-Induced Renal Fibrosis

Hyperglycemia-induced renal fibrosis causes end-stage renal disease. Clopidogrel, a platelet inhibitor, is often administered to decrease cardiovascular events in diabetic patients. We investigated whether clopidogrel can reduce diabetes-induced renal fibrosis in a streptozotocin-induced type 1 diabetes murine model and fibronectin involvement in this protective response. Diabetic and age-matched controls were sacrificed three months after the onset of diabetes, and additional controls and diabetic animals were further treated with clopidogrel or vehicle for three months. Diabetes induced renal morphological changes and fibrosis after three months. Clopidogrel, administered during the last three months, significantly decreased blood glucose, collagen and fibronectin expression compared to vehicle-treated diabetic mice. Diabetes increased TGF-β expression, inducing fibrosis via Smad-independent pathways, MAP kinases, and Akt activation at three months but returned to baseline at six months, whereas the expression of fibronectin and collagen remained elevated. Our results suggest that activation of TGF-β, CTGF, and MAP kinases are early profibrotic signaling events, resulting in significant fibronectin accumulation at the early time point and returning to baseline at a later time point. Akt activation at the three-month time point may serve as an adaptive response in T1D. Mechanisms of clopidogrel therapeutic effect on the diabetic kidney remain to be investigated as this clinically approved compound could provide novel approaches to prevent diabetes-induced renal disease, therefore improving patients' survival.

Clinical Significance of Hemostatic Parameters in the Prediction for Type 2 Diabetes Mellitus and Diabetic Nephropathy

It would be important to predict type 2 diabetes mellitus (T2DM) and diabetic nephropathy (DN). This study was aimed at evaluating the predicting significance of hemostatic parameters for T2DM and DN. Plasma coagulation and hematologic parameters before treatment were measured in 297 T2DM patients. The risk factors and their predicting power were evaluated. T2DM patients without complications exhibited significantly different activated partial thromboplastin time (aPTT), platelet (PLT), and D-dimer (D-D) levels compared with controls (P < 0.01). Fibrinogen (FIB), PLT, and D-D increased in DN patients compared with those without complications (P < 0.001). Both aPTT and PLT were the independent risk factors for T2DM (OR: 1.320 and 1.211, P < 0.01, resp.), and FIB and PLT were the independent risk factors for DN (OR: 1.611 and 1.194, P < 0.01, resp.). The area under ROC curve (AUC) of aPTT and PLT was 0.592 and 0.647, respectively, with low sensitivity in predicting T2DM. AUC of FIB was 0.874 with high sensitivity (85%) and specificity (76%) for DN, and that of PLT was 0.564, with sensitivity (60%) and specificity (89%) based on the cutoff values of 3.15 g/L and 245 × 10⁹/L, respectively. This study suggests that hemostatic parameters have a low predicting value for T2DM, whereas fibrinogen is a powerful predictor for DN.

Hypofibrinolysis in diabetes: a therapeutic target for the reduction of cardiovascular risk

An enhanced thrombotic environment and premature atherosclerosis are key factors for the increased cardiovascular risk in diabetes. The occlusive vascular thrombus, formed secondary to interactions between platelets and coagulation proteins, is composed of a skeleton of fibrin fibres with cellular elements embedded in this network. Diabetes is characterised by quantitative and qualitative changes in coagulation proteins, which collectively increase resistance to fibrinolysis, consequently augmenting thrombosis risk. Current long-term therapies to prevent arterial occlusion in diabetes are focussed on anti-platelet agents, a strategy that fails to address the contribution of coagulation proteins to the enhanced thrombotic milieu. Moreover, antiplatelet treatment is associated with bleeding complications, particularly with newer agents and more aggressive combination therapies, questioning the safety of this approach. Therefore, to safely control thrombosis risk in diabetes, an alternative approach is required with the fibrin network representing a credible therapeutic target. In the current review, we address diabetes-specific mechanistic pathways responsible for hypofibrinolysis including the role of clot structure, defects in the fibrinolytic system and increased incorporation of anti-fibrinolytic proteins into the clot. Future anti-thrombotic therapeutic options are discussed with special emphasis on the potential advantages of modulating incorporation of the anti-fibrinolytic proteins into fibrin networks. This latter approach carries theoretical advantages, including specificity for diabetes, ability to target a particular protein with a possible favourable risk of bleeding. The development of alternative treatment strategies to better control residual thrombosis risk in diabetes will help to reduce vascular events, which remain the main cause of mortality in this condition.

The Protective Effect of Antioxidants Consumption on Diabetes and Vascular Complications

Obesity and diabetes is generally accompanied by a chronic state of oxidative stress, disequilibrium in the redox balance, implicated in the development and progression of complications such as micro- and macro-angiopathies. Disorders in the inner layer of blood vessels, the endothelium, play an early and critical role in the development of these complications. Blunted endothelium-dependent relaxation and/or contractions are quietly associated to oxidative stress. Thus, preserving endothelial function and oxidative stress seems to be an optimization strategy in the prevention of vascular complications associated with diabetes. Diet is a major lifestyle factor that can greatly influence the incidence and the progression of type 2 diabetes and cardiovascular complications. The notion that foods not only provide basic nutrition but can also prevent diseases and ensure good health and longevity is now attained greater prominence. Some dietary and lifestyle modifications associated to antioxidative supply could be an effective prophylactic means to fight against oxidative stress in diabesity and complications. A significant benefit of phytochemicals (polyphenols in wine, grape, teas), vitamins (ascorbate, tocopherol), minerals (selenium, magnesium), and fruits and vegetables in foods is thought to be capable of scavenging free radicals, lowering the incidence of chronic diseases. In this review, we discuss the role of oxidative stress in diabetes and complications, highlight the endothelial dysfunction, and examine the impact of antioxidant foods, plants, fruits, and vegetables, currently used medication with antioxidant properties, in relation to the development and progression of diabetes and cardiovascular complications.

Aspirin in the prevention of cardiovascular events in patients with diabetes

Diabetes imparts a substantial increased risk for cardiovascular disease-related mortality and morbidity. Because of this, current medical guidelines recommend prophylactic treatment with once-daily, low-dose aspirin (acetylsalicylic acid) for primary and secondary prevention of cardiovascular (CV) events in high-risk patients. However, only modest reductions in CV events and mortality have been observed with once-daily aspirin treatment in patients with diabetes, including patients with a previous CV event, perhaps because of disparity between aspirin pharmacokinetics and diabetes-related platelet abnormalities. Once-daily aspirin irreversibly inactivates platelets for only a short duration (acetylsalicylic acid half-life, approximately 15-20 minutes), after which time newly generated, active platelets enter the circulation and weaken aspirin's effect. Platelets from patients with diabetes are more reactive and are turned over more rapidly than platelets from normal individuals; the short inhibitory window provided by once-daily aspirin may therefore be insufficient to provide 24-h protection against CV events. Alternative conventional aspirin regimens (e.g. higher daily dose, twice-daily dosing, combination with clopidogrel) and newer formulations (e.g. 24-h, extended-release) have been proposed to overcome the apparent limited efficacy of conventional aspirin in patients with diabetes; however, tolerability concerns and limited clinical efficacy data need to be taken into account when considering the use of such regimens.