Treating Stroke With Drug Therapies

Michael Faithe, Pharm.D., BCPSNeurosciences Clinical Pharmacy Specialist University of Colorado Hospital

Outline

• Anti-platelet medications• Anticoagulants• Supplement-drug interactions• Drugs used to treat cholesterol, blood

pressure and diabetes

Medications Used to Prevent Stroke

• Anti-platelets– Aspirin– Plavix® (clopidogrel)– Ticlid® (ticlopidine)– Aggrenox® (dipyridamole/aspirin)

• Anticoagulants– Coumadin® (warfarin)– Pradaxa® (dabigatran)– Xarelto® (rivaroxaban)– Eliquis® (apixaban)

Anti-platelet Agents

• Reduce the risk of having another stroke or cardiovascular (heart-related) events– 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

• 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

NameCost

Brand Generic

Aspirin 81 mg $1.80 $0.35

Plavix® 75 mg (clopidogrel) $232 $208.57

Aggrenox® 25/100 mg(aspirin/dipyridamole) $317.64 Not available

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)• Monitoring

– Coumadin specialist (MD, nurse or pharmacist)

– Labs (INR)

• Diet

– Vitamin K

• Spinach, green leafy vegetables, collard greens

– Be consistent with green leafy vegetable intake

• Drug interactions

– Many: notify MD or pharmacist if starting or stopping any prescription or

nonprescription medications (including herbals)

• 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)

• 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 YourRisk 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?