Treating Stroke With Drug Therapies
Michael Faithe, Pharm.D., BCPS
Neurosciences Clinical Pharmacy
Specialist
University of Colorado Hospital
Outline
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Anti-platelet medications
Anticoagulants
Supplement-drug interactions
Drugs used to treat cholesterol, blood
pressure and diabetes
Medications Used to Prevent Stroke
• Anti-platelets
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Aspirin
Plavix® (clopidogrel)
Ticlid® (ticlopidine)
Aggrenox®
(dipyridamole/aspirin)
• Anticoagulants
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Coumadin® (warfarin)
Pradaxa® (dabigatran)
Xarelto® (rivaroxaban)
Eliquis® (apixaban)
Anti-platelet Agents
• Reduce the risk of having another stroke or
cardiovascular (heart-related) events
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Aspirin
Ticlid® (ticlopidine)
Plavix® (clopidogrel)
Aggrenox® (aspirin/dipyridamole)
Aspirin
• Most commonly used anti-platelet medication to prevent
stroke
– Low cost and prevents strokes
• Drug interactions
– Avoid NSAIDS (Motrin®, Advil®, Aleve®, etc.) until at least 30
min. after taking aspirin or wait 8 hours before taking aspirin dose
– Use Tylenol® (acetaminophen) for pain
• Side effects
– Bleeding, bruising, black stools, stomach pain, ringing in the ears
• Aspirin dose
– 81-325 mg
Plavix® (clopidogrel)
• Used in aspirin-allergic patients or patients who have had a
stroke on aspirin
• Dose is 75 mg orally once daily with or without food
• Drug interactions
– Avoid Prilosec® and Nexium® as they may reduce the beneficial
effects of Plavix
• Side effects
– Bleeding, bruising, black stools, rash
• Generic is available
• Notify MD if planning any major surgeries
Aggrenox® (aspirin/dipyridamole)
• Dose is 1 capsule by mouth twice daily
– Swallow capsules whole (do not chew, break or crush)
– Can take with or without food
• Drug interactions
– Look for interaction with both aspirin and dipyridamole components. Check with your
MD or pharmacist
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Side effects
– Headache, stomach pain, nausea, diarrhea, bleeding, bruising, black stools
• Headache up to 39% of patients
• Usually resolves with time ~ 1 week
– If headache is intolerable, can take one capsule at bedtime and a baby aspirin in
the morning until headache resolves then increase back to twice daily
•
Not available as a generic drug
Cost Comparison
Name
Cost
Brand
Generic
Aspirin 81 mg
$1.80
$0.35
Plavix® 75 mg
(clopidogrel)
$232
$208.57
$317.64
Not available
Aggrenox® 25/100 mg
(aspirin/dipyridamole)
Based on 1-month supply from: Medi-Span ®
Prevention of Strokes in Patients With
Abnormal Heart Rhythm (Atrial Fibrillation)
– Aspirin decreases risk by approximately 21%
• Not as effective as warfarin
– Warfarin decreases risk by approximately 68%
• Goal INR 2-3
– New oral anticoagulants (dabigatran, rivaroxaban,
and apixaban) are about as effective as warfarin
• Lower risk of intracranial hemorrhage (brain bleeding)
• Monitoring not required
Coumadin® (warfarin)
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Monitoring
– Coumadin specialist (MD, nurse or pharmacist)
– Labs (INR)
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Diet
– Vitamin K
• Spinach, green leafy vegetables, collard greens
– Be consistent with green leafy vegetable intake
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Drug interactions
– Many: notify MD or pharmacist if starting or stopping any prescription or
nonprescription medications (including herbals)
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Side effects
– Same as other blood thinners
Pradaxa® (dabigatran)
• Approved to prevent stroke in atrial fibrillation
• Dose is 150 mg orally twice daily
– Must be swallowed whole
• No monitoring required
• Most common side effect is stomach pain
• Used with caution in patients with kidney problems
• No reversal agent
• Cost is about $240 month
Xarelto® (rivaroxaban)
• Approved to prevent stroke in atrial fibrillation
• Dose is 20 mg orally once daily with food
– Can be crushed if needed
• No monitoring required
• Side effects: bleeding
• No monitoring required
• No reversal agent
• Cost is about $300/month
Eliquis® (apixaban)
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Approved to prevent stroke in atrial fibrillation
Dose is 5 mg orally twice daily
Side effects: bleeding
No monitoring required
No reversal agent
Used with caution in patients with kidney problems
Cost is about $300/month
Supplement-bleeding Risk Analysis
• Supplements that may
increase bleeding risk:
– Ginkgo biloba
– Ginger
– Garlic
– Ginseng
– Fish oil
– Willow bark (active
ingredient of aspirin)
– Red clover
– Nattokinase
– Vitamin E
• Supplements that may
increase clotting risk:
– St. John’s Wort
(decrease effect of
warfarin)
– CoQ10 (can mimic
vitamin K)
Cholesterol
• LDL (bad cholesterol) can form plaques and clog the
vessels in your brain and heart
• HDL (good cholesterol) can help remove the LDL from
your vessels
• LDL goal for patients with stroke is <100 mg/dl
– Optional goal of <70 mg/dl for “very high risk” patients
• Statins are the most common medications used to lower
LDL cholesterol
Statins
• Lipitor® (atorvastatin), Zocor® (simvastatin),
Pravachol® (pravastatin), Crestor® (rosuvastatin)
• Reduce stroke and heart attacks
• Monitoring
– Liver function tests
• Medication-food interactions
– Many medications, alcohol, grapefruit, red yeast rice
• Side effects
– Generally well-tolerated but muscle pain or weakness can
occur
– Seek medical attention if you notice muscle pain or
weakness along with dark urine
High Blood Pressure Treatment
• Adequately controlling blood pressure can reduce risk of
having another stroke
• Goal blood pressure
– <140/90
– <130/80 if you have diabetes
• Medications
– ACE-inhibitors (lisinopril, etc.) and diuretics (hydrochlorothiazide)
are first line drugs
– Others
• Beta blockers (metoprolol, atenolol, etc.) calcium channel
blockers (amlodipine, felodipine, etc.)
– May need a combination of several medications to reach goal
blood pressure
Diabetes
• Monitoring of hemoglobin A1c to screen for diabetes is
recommended in stroke patients
• A1c measures average blood glucose over a 3-month
period
– Glucose control to near normal levels to prevent complications
(kidney, eye, heart and nerve damage)
– A1c >/= 6.5% means you have diabetes
– A1c is 5.7-6.4% means you are at risk of developing diabetes
• Medications
– Insulin, glyburide, metformin
What Else Can You Do to Lower Your
Risk of Stroke?
• Quit smoking
• Eat a balanced diet
– low in salt and fat and high in fiber
• Get moving!
– Aerobic exercise for 30 min. most days of the
week
• Start with 5-10 min. and work your way up
Summary
• You may be taking multiple medications after you
have a stroke
• Talk to your pharmacist or doctor before starting or
stopping any medications or supplements
• Future strokes can be prevented by controlling
blood pressure, cholesterol and diabetes
• Stop smoking, eat healthier and exercise!
Financial Assistance for Medications
Need Meds
www.NeedyMeds.com
Rx Assist - Patient Assistance Program Center
www.rxassist.org
Questions?