1. Medications for Treating Stroke

2. Subject Expert Sonny Kupniewski, PharmD, BCPS Swedish Medical Center
Englewood, CO

3. Objectives Medications used to prevent stroke
Prevention of strokes in patients with Atrial Fibrillation (AFib)
Risk avoidance when using antiplatelets and anticoagulants
Supplement-drug interactions
Drugs used to treat cholesterol, blood pressure and diabetes

4. Types of Stroke 4

5. 5

6. Medications to Prevent Stroke
Antiplatelets
Aspirin
Plavix® (clopidogrel)
Aggrenox® (dipyridamole/aspirin)
Anticoagulants
Coumadin® (warfarin)
Pradaxa® (dabigatran)
Xarelto® (rivaroxaban)
Eliquis® (apixaban)

7. Antiplatelet Agents
Reduce the risk of having another stroke or cardiovascular (heart-related) event
Aspirin
Plavix® (clopidogrel)
Aggrenox® (aspirin/dipyridamole)

8. Aspirin Most commonly used antiplatelet medication to prevent stroke
Dose: mg by mouth daily
Drug interactions
Avoid NSAIDS (Motrin®, Advil®, Aleve®, etc.) until at least 30 minutes 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

9. Plavix® (clopidogrel)
Used in aspirin-allergic patients or patients who have had a stroke on aspirin
Sometimes used in combination with aspirin for the first 90 days following a stroke
Dose is 75 mg orally once daily with or without food
Side effects
Bleeding, bruising, black stools, rash
Generic is available

10. 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 physician or pharmacist

11. Aggrenox® Cont. Side effects
Headache, stomach pain, nausea, diarrhea, bleeding, bruising, black stool
The most common side effect is headache, which can occur in up to 39% of patients but usually resolves with time
If the headache is intolerable, please contact your physician or pharmacist
Generic available, but still pricey

12. Prevention of Strokes in Patients With Atrial Fibrillation
Aspirin decreases risk by approximately 22%
Not as effective as oral anticoagulation
Anticoagulants
Warfarin decreases risk by approximately 64%
Goal INR 2-3
Direct acting oral anticoagulants (dabigatran, rivaroxaban, apixaban) are as effective as warfarin
Lower risk of intracranial hemorrhage (brain bleeding)
Monitoring not required, no dietary restrictions
Medications can be cost prohibitive because there are no generic forms available yet

13. Coumadin® (warfarin) Dose is patient-specific Monitoring
Coumadin specialist (MD, DO, PA, nurse or pharmacist)
Labs (INR)
Diet should be consistent
Vitamin K
Spinach, kale, leafy green vegetables, collard greens
Drug interactions
Many! Notify physician or pharmacist if starting or stopping any prescription/nonprescription medications

14. Pradaxa® (dabigatran)
Approved to prevent stroke in nonvalvular atrial fibrillation
Dose: 150 mg orally twice daily
Must be swallowed whole
Dose may be reduced with kidney problems
Keep in original pill bottle or blister package
Side effects
Stomach pain (dyspepsia), bleeding/bruising, diarrhea
Reversal agent: Praxbind® (idarucizumad)
FDA approved: October 16, 2015

15. Xarelto® (rivaroxaban)
Approved to prevent stroke in nonvalvular atrial fibrillation
Dose: 20 mg orally once daily with evening meal
Xarelto® must be taken with largest meal of the day (i.e. dinner)
Dose may be reduced with kidney problems
Side effects
Bleeding/bruising
No reversal agent
Andexanet alfa being studied in clinical trials

16. Eliquis® (apixaban)
Approved to prevent stroke in nonvalvular atrial fibrillation
Dose: 5 mg orally twice daily
Can be crushed if needed
Dose may be reduced for kidney problems, older age, and low body weight
Side effects
Bleeding/bruising, nausea
No reversal agent
Andexanet alfa currently being studied in clinical trials

17. Caution with Antiplatelets and Anticoagulants
Watch for unusual bleeding/bruising
Bruises that are getting larger
Black, tar-like stools
Blood in the urine
Vomit that looks like coffee grounds
“Worst headache of your life”
Any bleeding that will not stop
If you experience any of these symptoms, you must seek medical attention immediately

18. Caution with Antiplatelets and Anticoagulants Cont.
Avoid NSAIDs
Ibuprofen (Advil®, Motrin®), Naproxen (Aleve®)
May need to stop before surgery, dental procedures
Inform your doctor, pharmacist, and nurse about ALL medicines you take
Prescriptions
Over the counter (OTC)
Vitamins
Supplements

19. Supplements and Risk of Bleeding
Supplements that may increase bleeding risk:
Ginkgo biloba
Ginger
Garlic
Ginseng
Fish oil
Red clover
Nattokinase
Vitamin E
Willow bark (active ingredient in aspirin)
Supplements that may increase clotting risk:
St. John’s Wort (decreases the effect of warfarin)
CoQ10 (can mimic vitamin K)

20. Other Risk Factors for Stroke
High cholesterol
High blood pressure (hypertension)
Diabetes

21. Cholesterol LDL = “bad” Cholesterol
Forms plaques and clogs the vessels in your brain and heart
HDL = “good”, healthy Cholesterol
Can remove the LDL from your vessels
“Statins” are the drug of choice
High intensity statin should be recommended
Atorvastatin 40mg-80mg or rosuvastatin 20mg-40mg
Moderate intensity statin if high intensity is not tolerated

22. Statins
Lipitor® (atorvastatin), Zocor® (simvastatin), Pravachol® (pravastatin), Crestor® (rosuvastatin), Mevacor ® (lovastatin), Lescol® (fluvastatin)
Monitoring
Liver function tests will be checked before starting therapy
Medication-food interactions
Many medications, alcohol, grapefruit, red yeast rice
Side effects
Generally well tolerated
Seek medical attention if you notice muscle pain or weakness and/or dark urine

23. High Blood Pressure Treatment
Adequately controlling blood pressure can reduce risk of having another stroke
Goal blood pressure
<140/90 mmHg
Medications
ACE-inhibitors and ARBs (lisinopril, losartan)
Diuretics (hydrochlorothiazide, chlorthalidone)
Calcium channel blockers (amlodipine)
Beta blockers if other heart issues are present (metoprolol)
May need a combination of several medications to reach goal blood pressure

24. Diabetes
Monitoring hemoglobin A1c is recommended in stroke patients to evaluate for diabetes
A1c measures average blood sugar over a 3-month period
A1c > 6.5% means you have diabetes
A1c is % means you are at risk of developing diabetes
Proper blood sugar control can prevent damage to your kidneys, eyes, heart, and nerves
With a diagnosis of diabetes, Goal A1c < 7.0 %
Treatments include lifestyle modifications, oral agents and/or insulin

25. Other Ways to Lower Your Risk of Stroke?
Quit smoking
Eat a balanced diet
Low in salt and fat
High in fiber
Get moving!
Aerobic exercise for 30 minutes most days of the week
Start with 5-10 minutes and work your way up

26. 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!

27. Financial Assistance for Medications
Needy Meds Rx Assist - Patient Assistance Program Center

28. Questions? 28

29. Learn more at stroke.org
THANK YOU!
Learn more at stroke.org
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©2017 National Stroke Association