Pharmacological management of post stroke patients

1. Pharmacological management of post stroke patients By Khalid Khan Pharmacist HASU

2. Plan • Stroke- definition, classification-covered elsewhere • Drug history and medicines reconciliation • Secondary prevention • Antiplatelets • Lipid regulating drugs- statins • Antihypertensives • Drug fomulations and dose adjustments • Summary

3. Drug history and medicines reconciliation • Sources of drug history • Role of pharmacists and pharmacy technicians • Medicines reconciliation -establish drug history -identify discrepancies -make interventions

4. Secondary prevention • Risk of recurrent stroke -10% within the first week -20% within the first month -30-43% over the next five years -23% people die within 30 days of having a stroke -60-70% who survives die within 3 years -about 900,000 people in England are living with the effects of stoke with about half of them dependent on others with everyday life

5. Antiplatelets • Aspirin, clopidogrel, dipyridamole • Prevents aggregation of platelets by inhibiting the production of thromboxane • The aim of treatment is to prevent occlusive event and its recurrence by using one or two antiplatelet agents

6. Antiplatelets • Clopidogrel is recommended as 1st line in patients with ischemic stroke • Dipyridamole MR plus aspirin- • 1st line in TIA • 2nd line in ischemic stroke where clopidogrel is contraindicated or not tolerated • Dipyridamole MR alone- • 2nd line in TIA where aspirin is contraindicated or not tolerated • 3rd line in ischemic stroke where clopidogrel and aspirin is contraindicated or not tolerated (NICE TA Dec 2010)

7. Antiplatelets • Side effects -Aspirin: GI bleed/dyspesia- use PPI to prevent GI symptoms -Clopidogrel: less likely to cause dyspepsia -Dipyridamole: headache (for other less common side effects refer to BNF) • Contraindication -Aspirin: under 16 years, hypersensitivity (asthma, angiodema, urticaria) -Clopidogrel: active bleeding, severe liver impairment, pregnancy -Dipyridamole: Hypersenitivity

8. Lipid lowering drugs • Statins- simvastatin, atorvastatin, pravastatin • Contraindication: Active liver disease (use with caution in history of liver disease), pregnancy, renal impairment (CrCl <30ml/min) use atorvastatin or simvastatin 10mg od. Avoid grapefruit juice • Interactions: Increased risk of muscle effects with with enzyme inducers (macrolides, rifampicin, itraconazole,etc- avoid concomitant use with macrolides and antifungals, HIV protease inhibitors simvastatin needs dose reduction with diltiazem, verapramil, ciclosporin, • Side effects: muscles effects- counselling

9. Antihypertensives • NICE hypertension guidelines • ACE inhibitors (ramipril, lisinopril, perindopril) -Action: inhibits angiotensin converting enzyme -Contraindication: Hypersensivity (angioedema), bilateral renal artery stenosis, caution in acute renal and hepatic impairment. -Side effects: Hyperkalemia, persistent dry cough, rash

10. Antihypertensives • Thiazides (bendroflumethiazide) • Ca channel blockers (amlodipine, felodipine, nifedipine; diltiazepm and verapramil) • Alpha blockers: (doxazocin, indoramin) • Nitrates: (Isosorbide mononitrate, GTN) • Beta blockers: (atenolol, bisoprolol, metoprolol) • A2RBs (angiotensin converting enzyme blockers)- candesartan, valsartan, losartan

11. High blood pressure in acute stroke • Target 180/110mmHg • IV labetolol: 50-200mg in 5% dextrose or 0.9% normal saline (nor more than 1mg per ml) to be infused over 2-4 hours (2mg/minute) -monitor ECG • GTN: 10-200 microgram per minute (maximum 400microgram per minute) in 100ml 5 %dextrose or 0.9% normal saline.

12. Drug formulation and dose adjustment • Swallowing difficulties • Change tablets capsules to liquid formulation or use alternative routes • Digoxin 62.5mcg tablets to 50mcg liquid • Do not use dipyridamole liquid (not licensed for stroke) • Some tablets can be crushed such as simvastatin, amlodipine, ramipril • Do not crush modified release and enteric coated tablets e.g. Dipyridamole MR caps, ISMN MR, diclofenac EC

13. Summary