Medications for Treating Stroke

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

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

Types of Stroke 4

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

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

Aspirin Most commonly used antiplatelet medication to prevent stroke Dose: 81-325 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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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 5.7-6.4% 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

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

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 Needy Meds www.NeedyMeds.com Rx Assist - Patient Assistance Program Center www.rxassist.org

Questions? 28

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