2. Treating Stroke With Drug Therapies Michael Faithe, Pharm.D., BCPS Neurosciences Clinical Pharmacy Specialist University of Colorado Hospital

3. Outline Anti-platelet medications Anticoagulants Supplement-drug interactions Drugs used to treat cholesterol, blood pressure and diabetes

4. Medications Used to Prevent Stroke Anti-platelets –Aspirin –Plavix ® (clopidogrel) –Ticlid ® (ticlopidine) –Aggrenox ® (dipyridamole/aspirin) Anticoagulants –Coumadin ® (warfarin) –Pradaxa ® (dabigatran) –Xarelto ® (rivaroxaban) –Eliquis ® (apixaban)

5. Anti-platelet Agents Reduce the risk of having another stroke or cardiovascular (heart-related) events –Aspirin –Ticlid ® (ticlopidine) –Plavix ® (clopidogrel) –Aggrenox ® (aspirin/dipyridamole)

6. 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

7. 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

8. 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

9. Cost Comparison Name Cost BrandGeneric Aspirin 81 mg$1.80$0.35 Plavix® 75 mg (clopidogrel) $232$208.57 Aggrenox® 25/100 mg (aspirin/dipyridamole) $317.64Not available Based on 1-month supply from: Medi-Span ®Medi-Span

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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!

22. Financial Assistance for Medications Need Meds www.NeedyMeds.com Rx Assist - Patient Assistance Program Center www.rxassist.org

23. Questions?