STROKE (BRAIN ATTACK) - William A. Tosches, MD; Michael Previti, MD12

STROKE (BRAIN ATTACK) - William A. Tosches, MD; Michael Previti, MD

MEDICATION (DRUGS)

First Line

· IV tissue plasminogen activator (tPA) 0.9 mg/kg in highly selected cases within 3 hours of ischemic stroke symptom onset

· Enteric-coated aspirin 50-325 mg/d or

· Dipyridamole-aspirin (Aggrenox): Extended release, 200 mg/25 mg capsule PO b.i.d.; more efficacious than aspirin or dipyridamole alone. (3)[A]

· Clopidogrel (Plavix): 75 mg/d; fewer side effects, but shows only slight advantage over aspirin

· Warfarin: INR adjusted dose 2-4 for patients with atrial fibrillation and cardioembolic stroke has shown decreased risk of recurrent stroke compared to ASA 300 mg/d at 2.3 years. (1)[A]

· Contraindications

  - Enteric-coated aspirin: Active peptic ulcer disease, hypersensitivity to aspirin, patients who had bronchospastic reaction to aspirin or other NSAIDs

  - Warfarin: Intolerance or allergy, dementia, liver disease, active bleeding, pregnancy, recent head injury

· Precautions

  - Enteric-coated aspirin: May aggravate pre-existing peptic ulcer disease, may worsen symptoms in some patients with asthma

  - Clopidogrel and ticlopidine: Thrombotic thrombocytopenic purpura can occur.

  - Warfarin: Poor balance, alcohol/drug abuse, age >80

· Significant possible interactions

  - Enteric-coated aspirin: May potentiate effects of anticoagulants and sulfonylurea, hypoglycemic agents

  - Ticlopidine: Digoxin plasma levels decreased 15%, theophylline half-life increased from 8.6-12.2 hours

  - Warfarin: Aspirin, NSAIDs, antibiotics, tranquilizers

Second Line

Ticlopidine (Ticlid): The treatment of 250 mg PO b.i.d. has fallen out of favor, because of an unfavorable side-effect profile, risk of neutropenia, and need for CBC monitoring.

· Caution: 2.4% of patients develop neutropenia (0.8% severe neutropenia) that is reversible with cessation of drug; monitor blood counts every 2 weeks for the 1st 3 months