What is the consensus regarding using ASA/Persantin/Coumadin in
diabetic patients on hemodialysis in reference to the progression of their
diabetic retinopathy?
M. Babu, M.D.
Santa Maria, CA
Answer by Eli Friedman, M.D.,
(SUNY Health Sciences Center at Brooklyn, NY)
Dr. Babu raises a pertinent question concerning the value (positive or
negative) of aspirin/Persantin/Coumadin in diabetic patients with retinopathy
treated by hemodialysis.
There are no direct studies that address this
issue. It can be stated that the intermittent heparinization required to
conduct hemodialysis imparts no excess risk of retinal or vitreous hemorrhage
over equivalent patients treated with a kidney transplant.
From multiple publications of the Early Treatment Diabetic Retinopathy Study
(ETDRS) we have learned that the effects of aspirin on diabetic patients with
retinopathy are no different than in nondiabetic patients in terms of
mortality from all causes. Aspirin was effective in reducing the risk of
myocardial infarction in diabetic retinopathy and control groups (1). There
appears to be no advantage in adding coumadin to aspirin in terms of either
risk of excessive bleeding or repeat myocardial infarction (2).
Experience suggests that the most important variable to control in diabetic
retinopathy is normalization of hypertensive blood pressure with reduction of
fluid overload and cessation of smoking the next most vital interventive
steps. By consensus, Persantin has not been found to be of value in delaying
the progress of retinopathy. Well timed panretinal photocoagulation is
probably the single most vital action that can be taken in all ESRD patients
with proliferative diabetic retinopathy.
References
(1) ETDRS Investigators. Aspirin effects on mortality and morbidity in
patients with diabetes mellitus. Early treatment diabetic retinopathy report
14.
JAMA 1992;268:1292-1300.
(2) CARS Investigators. Randomised double-blind trial of fixed low-dose
warfarin with aspirin after myocardial infarction. Coumadin aspirin
reinfarction study.
Lancet 1997;350:389-396.