Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 17004

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : FC07 - FC11 Full Version

Antiplatelet Efficacy of 75 mg Aspirin Once a Day versus Twice a Day Dosing in Type 2 Diabetes Mellitus Patients- A Longitudinal Open Label Study


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57300.16994
Mayur B Phulpagare, Smita A Tiwari, Rajesh S Hiray

1. Senior Resident, Department of Pharmacology, B.J. Government Medical College and Sassoon Government Hospital, Pune, Maharashtra, India. 2. Associate Professor, Department of Pharmacology, B.J. Government Medical College and Sassoon Government Hospital, Pune, Maharashtra, India. 3. Professor and Head, Department of Pharmacology, B.J. Government Medical College and Sassoon Government Hospital, Pune, Maharashtra, India.

Correspondence Address :
Dr. Smita A Tiwari,
Associate Professor, Department of Pharmacology, B.J. Government Medical College and Sassoon Government Hospital, Pune, Maharashtra, India.
E-mail: drsmitamd@gmail.com

Abstract

Introduction: Patients of Type 2 Diabetes Mellitus (T2DM) characteristically have platelets hyper-reactivity and accelerated turnover rates leading increased adhesion, aggregation and procoagulant activity. Half-life of aspirin is only 20 minutes and it, therefore, irreversibly inactivates limited number of platelets over this short duration, when given as a once-daily dose. Newly generated-active platelets enter circulation, thereafter, and weaken antiplatelet effect of aspirin. Therefore, single daily dose of 75 mg aspirin may be insufficient to provide 24 hours protection against cardiovascular events, in these patients.

Aim: To study and compare antiplatelet efficacy of 75 mg aspirin twice a day (75 mg BD) versus 75 mg aspirin once a day (75 mg OD) in patients of T2DM and to study the effect of variation in glycated haemoglobin (HbA1c) levels on antiplatelet efficacy.

Materials and Methods: This was a longitudinal, open label, comparative trial conducted at tertiary care hospital for a period of nine months. A total of 129 subjects, diagnosed with T2DM according to American Diabetes Association (ADA) criteria 2018 (N=129) were enrolled in the study, of which nine were lost to follow-up and antiplatelet efficacy of aspirin dosing was examined at baseline and three-monthly intervals thereafter, till nine months, using colorimetric method.

Results: Mean age of enrolled patients was 62 years (Interquartile Range (IQR) 57-66). HbA1c levels of both the groups were comparable (p=0.77) at baseline. At the end of nine months, percentage platelet aggregability of the 75 mg B.D. group (29.30±10.39) was significantly lower (p<0.00001) than that of 75 mg OD (38.20±10.36). There was no correlation observed between HbA1c variation and percentage platelet aggregability for entire study population.

Conclusion: Present study concludes that, 75 mg OD aspirin as a strategy for secondary cardiovascular disease prevention is advocated, but not adequate in T2DM patients. Splitting a dose of 150 mg/day aspirin as 75 mg twice is more effective, due to increased platelet turnover in diabetic patients.

Keywords

Aspirin prophylaxis, Non insulin dependent diabetes mellitus, Split dosing

Diabetes is a complex lifestyle disorder characterised by additional long-term effects like-“prothrombotic state” (1). In T2DM patients platelet physiology is modestly different. Platelets in these patients are hyper reactive and have reduced life span and increased turnover rates leading to enhanced regeneration of platelets (2),(3). Hyperglycaemia also increases platelet reactivity by various mechanisms (4). Other factors that contribute abnormal platelet activity is dysregulation of several signaling pathways with intensified adhesion, activation and aggregation (5). Only modest reductions in cardiovascular events and mortality have been observed with once-daily low dose aspirin treatment in patients with diabetes (including patients with a previous cardiovascular event); perhaps because of disparity between aspirin pharmacokinetics and diabetes-related platelet abnormalities (6).

Aspirin irreversibly acetylates and inactivates Cyclooxygenase-1 (COX-1) in circulating platelets and has only a 20 minute half-life. This short duration of action, therefore, does not allow newly generated platelets entering the circulation to be sufficiently exposed to aspirin especially when there is accelerated thrombopoiesis in these T2DM patients. This may lead to a considerable proportion of circulating platelets with uninhibited COX-1 activity that continue to generate high levels of thromboxane and therefore, promote activation of circulating platelets and contributes to their increased risk of adverse cardiovascular events (7). This may be attributed to raise platelet turnover rates resulting in an increased proportion of non aspirin-inhibited platelets during daily dosing interval.

Therefore, there is theoretical possibility that a single daily dose could not be sufficient to exert a full inhibitory effect on the new platelets generated and released by bone marrow during the course of 24 hours after aspirin intake (8).

In this background, the study aimed to compare that increasing the frequency of aspirin administration might be effective in inhibiting the newly generated platelets and thus, improving aspirin-induced pharmacodynamic effects. The secondary outcome measures were to study the effect of variation in HbA1c levels on the antiplatelet efficacy of above mentioned doses of aspirin in the same set of T2DM patients.

Material and Methods

This study was a prospective, open-labelled, parallel group, longitudinal study, conducted at B.J. Government Medical College and Sassoon General Hospital Pune, Maharashtra, India from November 2018 to June 2020. Approval from the Institutional Ethics Committee (IEC) was obtained prior to the commencement of the trial (IEC/Pharmac/D-0918135-135). A total of 129 subjects with T2DM were enrolled in the study, from those that attended the diabetic out-patient and of which nine were lost to follow-up. Written informed consent (in the vernacular language Marathi/ English) was taken from patients prior to inclusion in the study.

Inclusion criteria: Patients in the age group 35 to 70 years with previously diagnosed T2DM according to ADA criteria 2018 (9). Above mentioned patients receiving oral antidiabetic (Metformin 0.5-2g/day sulfonylurea-Glimepiride 1-2 mg/day) and/or Antihypertensive drugs (Amlodipine, Enalapril). Patients receiving aspirin as antiplatelet (75 or 150 mg/day) as single dose.

Exclusion criteria: Patient who were smokers, those with uncontrolled diabetes mellitus (Fasting Plasma Glucose Level >300 mg/dL despite therapy), requiring insulin, uncontrolled hypertension, abnormal liver function tests and/or renal function tests, deranged bleeding and/or clotting time at baseline, patients on-analgesic antiinflammatory dose of aspirin therapy for >7 days and/or other non steroidal antiinflammatory drugs and/or any other antithrombotic or anticoagulant therapy were excluded from study.

Sample size calculation: (10)

n= Z²(1-a/2) V / d² ……………(formula-1)

Where

V=P1(1-P1)+P2(1-P2) ……. (formula-2) (**Calculated as below)
Z(1-a/2)=1.96
d=13%
(Prevalence of high on-treatment platelet reactivity in patients with diabetes).
**60-100 mg {23 Studies (n=1,689)}=23.6%
Platelet inhibition (Aspirin 60-100 mg) Prevalence P1=(100-23.6)=76.4%=0.764
101-162 mg {10 Studies (n=271)}=8.9%
Platelet inhibition (Aspirin 101-162 mg) Prevalence P2=(100-8.9)=91.1%=0.911
Substituting values in formula-2
V=0.764(1-0.764)+0. 911(1-0.911)
=(0.764*0.236)+(0.911*0.089)
=0.1803+0.0811
V=0.2614
Substituting values in formula-1
n= (1.96)2*0.2614 / (0.13)2 = 3.8416*0.2614 / 0.0169 = 1.0042 / 0.0169
=59.42 patients per group

Detail Research Plan

Screening/Visit 1: Total 129 patients were screened for clinical inclusion/exclusion criteria, underwent physical examination and biochemical tests viz fasting plasma glucose level, clotting time, prothrombin time, liver function tests, renal function test and lipid profile and previous data of HbA1c levels were recorded.

Visit 2-Patients were selected as per the inclusion/exclusion criteria and written informed consent was obtained from eligible diabetic patients. Patients taking 75 mg aspirin once a day were assigned to Group A and those taking 150 mg aspirin once a day assigned to Group B.

Baseline platelet aggregability study was done by colorimetric method.

Group A: Patients taking 75 mg aspirin OD. were instructed to take daily dose of drug every day before breakfast (8 am).

Group B: Patients taking 75 mg aspirin B.D. were instructed to take one tablet every day before breakfast (8 am) and second 75 mg aspirin tablet every night before dinner (8 pm). Thus the total 150 mg dose was split in 75 mg twice.

After one month: Every patient was examined for any adverse effects (nausea, vomiting, epigastric pain, increased occult blood loss in stools, dyspepsia, acute gastritis, gastrointestinal bleeding) and enquired about compliance every month, till the completion of study.

After 3,6,9 months: Every patient was examined for adverse effects, if any, and blood sample were collected for determining platelet aggregability, Fasting Plasma Glucose Level (FPGL), Postprandial Glucose level (PPGL) and HbA1c.

Platelet Aggregability Method

Platelet aggregability was estimated by the colorimetric method as given by O’Brien J (11),(12). Blood was centrifuge using Centrifuge Machine of model type P-23 manufactured by REMI Group, Mumbai. Optical density was determined by Photochem-5 Colorimeter manufactured by AIMIL Instrumentation, India. Adenosine-5-diphosphate obtained from Sisco Research Laboratories Pvt. Ltd. Mumbai), Trisodium Citrate (3.8%) obtained from Chem Laboratory, Pune, Maharashtra, India.

Methodology: To avoid diurnal variation in platelet aggregation, time for collection of blood sample was kept constant between 10 am-12 noon. Blood sample was collected from the antecubital vein under all aseptic and antiseptic precautions using disposable syringes with 21-gauge needles.

About 9 mL of blood was collected in plastic centrifuge tubes by syringes already flushed with trisodium citrate (3.8%) (to minimise chances of blood coagulation in syringe) and mixed with 1 mL 3.8% of trisodium citrate. Clear Platelet Rich Plasma (PRP) obtained by centrifuging the blood at 1200 rpm for 15 minutes, 2 mL of which was used for determining platelet aggregability.

About 2 mL of PRP obtained as above, was taken in a plastic tube and kept in a preset colorimeter and absorbance reading was obtained. Colorimeter was adjusted for an operative wavelength of 540 nm in such a way that the absorbance for the dark is infinite and for distilled water, at 0. It was kept constant for each test.

Then, 0.1 mL of 200 μg/mL of Adenosine diphosphate (ADP) solution was added to it and mixed by manual stirring (gently shaking the tube) and absorbance reading was again noted at the end of 15 seconds. Thus, change in the absorbance (optical density-OD) of PRP at the end of 15 seconds was taken as measure of platelet aggregability. Greater the decrease in the absorbance, more is the platelet aggregability.

% Platelet Aggregability (PA)= (OD of PRP at 0 time-OD of PRP at 15 sec after ADP) / (OD of PRP at 0 time-OD of PPP) ×100

Hence, change in % Platelet Aggregability (?PA)=PA (x months)-PA (Baseline)

statistical Analysis

Data was analysed using Microsoft excel 2017 and OpenEpi (www.openepi.com) (13). Repeated measure one-way Analysis of Variance (ANOVA) was used to assess efficacy of 75 mg aspirin once a day vs twice a day dosing. All p-values were two-sided with statistical significance evaluated at 0.05 α level.

Results

A total of 129 subjects with T2DM were enrolled in the study, of which nine were lost to follow-up. Thus, total number of 120 of them completed the study and were included for analysis (Table/Fig 1).

Both the study groups were comparable as regards to demographic characteristics (Table/Fig 2) and laboratory baseline parameters (Table/Fig 3), except for median Serum Glutamic-oxaloacetic Transaminase (SGOT), median serum cholesterol and percentage platelet aggregability that differed significantly in the two groups. The percentage platelet aggregability was higher in group B as compared to that of group A, even at month 3, but not at month 6 of the study (p-value=0.61). Interestingly at month 9, it was significantly lower in group B. Percentage platelet aggregability at three, six and nine months, when compared with that at baseline; was statistically lower (p-value <0.0001), in group B. This was not seen in group A (p-value=0.36) (Table/Fig 4).

The baseline values of “change in percentage platelet” when compared with that of three monthly each, there was significant decrease of the values over three months in group A and group B (p-value <0.0001).

Negative change in percentage platelet aggregability indicated there is increase in inhibition of platelet aggregation from baseline at three monthly visits in Group B (Table/Fig 5), (Table/Fig 6).

Both the groups were comparable as regards to fasting and post-prandial blood glucose levels. These readings had no statistically significant difference at the subsequent three monthly readings, with the respective baseline values within the groups. HbA1c Levels were comparable in two groups and did not show statistically significant difference (Table/Fig 7).

There was no correlation between HbA1c and percentage platelet aggregability for entire the study duration in both the groups (Table/Fig 8), (Table/Fig 9), (Table/Fig 10). Similarly, no correlation between serum cholesterol and percentage platelet aggregability was observed in the individual groups (Table/Fig 11).

Discussion

The aim of the present study was to find the potential benefit of BID dosing of 75 mg aspirin in effectively inhibiting the newly generated platelets and increased platelet turnover in T2DM patients. As per the study observations, total dose of aspirin 150 mg/day at baseline had significantly lower values of platelet aggregability as that compared to 75 mg/day. The main finding of the present study was that splitting a dose of 150 mg/day aspirin as 75 mg twice a day is more effective in inhibiting the platelet aggregability in T2DM patients.

Elevated levels of serum cholesterol in diabetic patients enhance platelet activation and platelet aggregability (14). Although serum cholesterol median values were significantly higher in Group B of the present study, yet they were within standard normal cut-off for cholesterol and therefore, may not influence platelet aggregability at baseline. Further a statistical analysis was done, that, confirmed that there was no correlation between serum cholesterol and platelet aggregation values at baseline in both groups in the present study.

Additionally variability in antiplatelet response to aspirin has been documented in research previously and have attributed it to various patient related factors of which non compliance to aspirin therapy plays an important role (15). The patients treated with aspirin 75 mg twice a day demonstrated a significantly effective and progressive inhibition of platelet aggregation estimated at three monthly intervals starting from the third month till the ninth month, when compared with baseline values. This phenomenon was not seen with 75 mg once a day dosing.

This is supported by fact that thromboxane A2 (TXA2) is the major arachidonic acid product generated by platelets and maximum inhibition of this phenomenon by aspirin occurs in portal circulation. The newly generated platelets are able to synthesise TXA2, and once this TXA2 reaches a certain concentration, it triggers aggregation of all platelets including the older acetylated ones (which remain sensitive to TXA2 even, if they do not produce it) (16).

Percentage of non acetylated platelets necessary to start a significant global response to arachidonic acid is estimated at about 20-30% platelet turnover. This recovery could be reached in 24 hours in patients whose platelet turnover is accelerated as for patients with DM. Therefore, a second dose of aspirin 75 mg may inhibit the newly generated platelets (17). In particular, lower than expected inhibition of platelet-derived TXA2 has been reported in approximately 1/3rd of T2DM patients on a once daily, low-dose aspirin regimen compared to that in non-DM patients (18).

Several studies have concluded that the antiplatelet dose of aspirin (150-200 mg/day) when spilt as twice daily dose as compared to single total dose shows benefit in terms of decreasing the platelet reactivity. These studies were done in patients in the western diabetic population and they had smaller sample size, as compared to present study (19),(20).

A crossover trial by Spectre G et al., but with smaller effect sizes compared aspirin 75 mg once daily, 75 mg twice daily in 25 people with T2DM and macrovascular or microvascular complications, and demonstrated that, aspirin 75 mg twice daily significantly reduced whole blood platelet aggregation compared with once daily (21). Di Minno G et al., first suggested that entry of new platelets into circulation can allow thromboxane formation as early as four hours after aspirin ingestion (22). Plasma level peak is about 30 to 45 minutes after aspirin ingestion, and aspirin half-life in plasma is 15 to 20 minutes (23). The time aspirin is present within plasma to acetlytate platelets in blood is very less, around two hours. In normal conditions, approximately 10-15% of circulating platelets are replaced daily, and near normal aggregation due to non acetylated platelet replacement has been found 48 to 72 hours after last aspirin intake (24).

Studies suggest that patients with suboptimal or ineffective response to aspirin may benefit from this split-dosing regimen (e.g. twice-versus once-daily) as a result of greater platelet inhibition (25). Patients with T2DM have specific abnormalities in platelet function. Thus, this group of patients are suitable population to assess if modified dosing regimens of aspirin may impact pharmacodynamic response (26),(27). Hyperglycaemia, independently enhances platelet activation despite aspirin treatment (28). The present study also explored the blood glucose variation at three monthly intervals from baseline and its effect on platelet aggregability; but no statistical significant variation found. Similarly, there was no correlation between HbA1c levels and percentage platelet aggregability for entire study population as well as individual groups at all time. This may be attributed to sample size effect or control diabetes in the study population. In a similar study by Neergaard-Petersen S et al., found that levels of HbA1c did not correlate with platelet aggregation and platelet turnover in coronary artery disease patients with known T2DM (29).

The ongoing Aspirin Twice a Day in Patients with Diabetes and Acute Coronary Syndrome (ANDAMAN) trial is comparing a standard 100 mg vs BD regimen (100 mg in morning and 100 mg in evening) of low dose aspirin in treatment of DM patients with ACS, and will provide the required clinical evidence for the efficacy and safety of this approach (30).

Limitation(s)

Patients already receiving 150 mg/day were allocated to 75 mg twice a day group and split dosing was done. A third group of 150 mg/day as single daily dose would have added more value in terms of minimising bias due to dose dependent effect on platelet aggregation. Certain baseline parameters were not comparable, but, did not show statistically significant impact on study parameters. Colorimetric method for determination of platelet aggregability has its own limitations.

Conclusion

Despite recent progress, there is still an unmet therapeutic need for primary prevention of serious vascular events in DM. The present study concludes that, 75 mg OD as a strategy for secondary cardiovascular disease prevention is advocated but not adequate in T2DM patients. Addressing to the additional needs of diabetic patients, as regards to platelet turnover, it is advisable to use a higher dose of aspirin i.e.150 mg once a day in these patients. The use of 150 mg/day dose is more effective, if splitted, into 75 mg twice a day. The study showed a statistically significant effect on inhibition of platelet aggregation and appropriate utilisation of the drug by the body. Further, well-planned randomised control trials are needed to assess clinical efficacy in order to validate this approach for prevention of cardiovascular events and cardiovascular mortality in clinical practice.

References

1.
Purushothaman KR, Meerarani P, Moreno PR. Inflammation and neovascularization in diabetic atherosclerosis. Indian J Exp Biol. 2007;1:93-102.
2.
Sharpe PC, Trinick T. Mean platelet volume in diabetes mellitus. Q J Med. 1993;86:739-42.
3.
Winocour PD. Platelet turnover in advanced diabetes. Eur J Clin Invest. 1994;24(suppl 1):34-37. [crossref] [PubMed]
4.
Rollini F, Franchi F, Muniz-Lozano A, Angiolillo DJ. Platelet function profiles in patients with diabetes mellitus. J Cardiovasc Transl Res. 2013;6(3):329-45. [crossref] [PubMed]
5.
Kim JH, Bae HY, Kim SY. Clinical marker of platelet hyperreactivity in diabetes mellitus. Diabetes Metab J. 2013;37(6):423-28. [crossref] [PubMed]
6.
Perneby C, Wallén NH, Rooney C, Fitzgerald D, Hjemdahl P. Dose-and time-dependent antiplatelet effects of aspirin. Thrombosis and Haemostasis. 2006;95(04):652-58. [crossref] [PubMed]
7.
Capodanno D, Patel A, Dharmashankar K, Ferreiro J, Ueno M, Kodali M, et al. Pharmacodynamic effects of different aspirin dosing regimens in type 2 diabetes mellitus patients with coronary artery disease. J Am Coll Cardiol. 2011;57(14):E1910. [crossref]
8.
Vermillet A, Boval B, Guyetand C, Petroni T, Dillinger J, Sideris G, et al. 24-hour time-dependent aspirin efficacy in patients with stable coronary artery disease. Thrombosis and Haemostasis. 2011;105(2):336-44. [crossref] [PubMed]
9.
American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Supplement_1):S13-27. [crossref] [PubMed]
10.
Simpson SH, Abdelmoneim AS, Omran D, Featherstone TR. Prevalence of high on-treatment platelet reactivity in diabetic patients treated with aspirin. Am J Med. 2014;127(1):95-e1-e9. [crossref] [PubMed]
11.
O’Brien J. Platelet aggregation: Part II some results from a new method of study. J Clin Pathol. 1962;15(5):452-55. [crossref] [PubMed]
12.
O’Brien J. A comparison of platelet aggregation produced by seven compounds and a comparison of their inhibitors. J Clin Pathol. 1964;17(3):275-81. [crossref] [PubMed]
13.
OpenEpi Menu. [online] Available at: < http://www.openepi.com/Menu/OE_Menu. htm > [Accessed 23 November 2021].
14.
Ravindran R, Krishnan LK. Increased platelet cholesterol and decreased percentage volume of platelets as a secondary risk factor for coronary artery disease. Pathophysiology of Haemostasis and Thrombosis. 2007;36(1):45-51. [crossref] [PubMed]
15.
Storey RF. Variability of response to antiplatelet therapy. Euro Heart J Supp. 2008;10(suppl_A):A21-27. [crossref]
16.
Patrono C, Rocca B. Drug insight: Aspirin resistance: Fact or fashion? Nat Clin Pract Cardiovasc Med. 2007;4:42-50. [crossref] [PubMed]
17.
Brown AS, Hong Y, de Belder A, Beacon H, Beeso J, Sherwood R, et al. Megakaryocyte ploidy and platelet changes in human diabetes and atherosclerosis. Arterioscler Thromb Vasc Biol. 1997;17:802-07. [crossref] [PubMed]
18.
Rocca B, Patrono C. Aspirin in the primary prevention of cardiovascular disease in diabetes mellitus: A new perspective. Diabet Res Clin Prac. 2020;160:108008. [crossref] [PubMed]
19.
Bethel MA, Harrison P, Sourij H, Sun Y, Tucker L, Kennedy I, et al. Randomised controlled trial comparing impact on platelet reactivity of twice-daily with once-daily aspirin in people with Type 2 diabetes. Diabet Med. 2016;33:224-30. [crossref] [PubMed]
20.
Dillinger JG, Drissa A, Sideris G, Bal ditSollier C, Voicu S, Manzo Silberman S, et al. Biological efficacy of twice daily aspirin in type 2 diabetic patients with coronary artery disease. Am Heart J. 2012;164(4):600-06. [crossref] [PubMed]
21.
Spectre G, Arnetz L, Ostenson CG, Brismar K, Li N, Hjemdahl P. Twice daily dosing of aspirin improves platelet inhibition in whole blood in patients with type 2 diabetes mellitus and micro-or macrovascular complications.Thromb Haemost. 2011;106:491-09. [crossref] [PubMed]
22.
Di Minno G, Silver MJ, Murphy S. Monitoring the entry of new platelets into the circulation after ingestion of aspirin. Blood. 1983;61:1081-85. [crossref] [PubMed]
23.
Patrono C, Garcia Rodriguez LA, Landolfi R, Baigent C. Low-dose aspirin for the prevention of atherothrombosis. N Engl J Med. 2005;353:2373-83. [crossref] [PubMed]
24.
Awtry EH, Loscalzo J. Aspirin. Circulation. 2000;101:1206-18. [crossref] [PubMed]
25.
Bem D, Dretzke J, Stevens S, Lordkipanidzé M, Hodgkinson J, Bayliss S, et al. Investigating the effectiveness of different aspirin dosing regimens and the timing of aspirin intake in primary and secondary prevention of cardiovascular disease: Protocol for a systematic review. Sys Rev. 2015;4(1):01-06. [crossref] [PubMed]
26.
Ferreiro JL, Angiolillo DJ. Diabetes and anti-platelet therapy in acute coronary syndrome. Circulation. 2011;123(7):798-813. [crossref] [PubMed]
27.
Angiolillo DJ. Antiplatelet therapy in diabetes: [Efficacy and limitations of current treatment strategies and future directions. Diabetes Care. 2009;32:531-40. [crossref] [PubMed]
28.
Gresele P, Marzotti S, Guglielmini G, Momi S, Giannini S, Minuz P, et al. Hyperglycemia-induced platelet activation in type 2 diabetes is resistant to aspirin but not to a nitric oxide-donating agent. Diabetes Care. 2010;33:1262-68. [crossref] [PubMed]
29.
Neergaard-Petersen S, Hvas AM, Grove EL, Larsen SB, Gregersen S, Kristensen SD. The influence of haemoglobin A1c levels on platelet aggregation and platelet turnover in patients with coronary artery disease treated with aspirin. PLoS One. 2015;10(7):e0132629. [crossref] [PubMed]
30.
History of Changes for Study: NCT02520921 [Internet]. Clinicaltrials.gov. 2021 [cited 23 March 2021]. Available from: https://clinicaltrials.gov/ct2/history/ NCT02520921?V_3=Viewa.

DOI and Others

DOI: 10.7860/JCDR/2022/57300.16994

Date of Submission: Apr 26, 2022
Date of Peer Review: May 27, 2022
Date of Acceptance: Jul 27, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 03, 2022
• Manual Googling: Jul 18, 2022
• iThenticate Software: Jul 25, 2022 (15%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com