Should a patient with diabetes and low ASCVD risk be started on aspirin?

• A. No ASA
• B. Initiate ASA
• C. Initiate ASA only if LDL > 100
• D. Initiate ASA with PPI

Answer: (A)

Balancing the potential benefit of aspirin for reducing ASCVD events against its bleeding risks is the key idea. In a patient with diabetes but low ASCVD risk, the absolute benefit of low-dose aspirin is small, while the harms—especially gastrointestinal bleeding and hemorrhagic stroke—are not negligible. Because the bleeding risk outweighs the minimal expected ASCVD reduction, starting aspirin is not recommended. LDL level or adding a PPI doesn’t change this fundamental risk-benefit balance in someone with low ASCVD risk. The best approach is not to initiate aspirin in this scenario.