1. Educational Solutions for Workforce Development Pharmacy STROKE Anne Kinnear Lead Pharmacist NHS Lothian

2. Educational Solutions for Workforce Development Pharmacy Aim To update pharmacists on Stroke: the disease and its management and explore ways to implement pharmaceutical care for this patient group as part of normal working practice.

3. Educational Solutions for Workforce Development Pharmacy Objectives Describe the disease, identify risk factors and signs and symptoms associated with Stroke. Define the current therapeutic management of acute Stroke and secondary prevention measures. Identify pharmaceutical care issues and respond to symptoms in patient scenarios and identify appropriate management solutions. Explore how to implement the principles of a pharmaceutical care needs assessment tool in practice.

4. Educational Solutions for Workforce Development Pharmacy Stroke Third commonest cause of death in Scotland 15,000 stroke patients in Scotland annually One of leading causes of disability in adults

5. Educational Solutions for Workforce Development Pharmacy “Time is Brain”

6. Educational Solutions for Workforce Development Pharmacy Stroke 2 million neurones per minute

7. Educational Solutions for Workforce Development Pharmacy How do you know if someone is having a stroke?

8. Educational Solutions for Workforce Development Pharmacy What is FAST? F acial weakness - can the person smile? Has their mouth or eye drooped? A rm weakness - can the person raise both arms? S peech problems - can the person speak clearly and understand what you say? T est – all 3

9. Educational Solutions for Workforce Development Pharmacy Stroke WHO Definition A neurological deficit (usually loss of function) caused by reduction in blood supply to the brain. This is usually because a blood vessel bursts or is blocked by a clot. This affects the supply of oxygen and nutrients, causing damage to the brain tissue.

10. Educational Solutions for Workforce Development Pharmacy Chest Heart and Stroke Definition A stroke is a brain attack. It happens when the blood supply to the brain is disrupted. Most strokes occur when a blood clot blocks the flow of blood to the brain. Some strokes are caused by bleeding in or around the brain from a burst blood vessel.

11. Educational Solutions for Workforce Development Pharmacy Stroke Transient Ischaemic Attack (TIA) – a stroke which resolves within 24 hours (10% risk of stroke within 7 days) Minor Stroke – a stroke resulting in persisting symptoms but not causing significant disability Major Stroke – a stroke resulting in persistent deficit

12. Educational Solutions for Workforce Development Pharmacy Diagnosis Computed Tomography scan (CT scan) `Immediate`

13. Cerebral infarct Cerebral haemorrhage Diagnosis – stroke type STROKE CT scan

14. Educational Solutions for Workforce Development Pharmacy Stroke

15. Educational Solutions for Workforce Development Pharmacy Atherosclerotic thrombosis

16. Educational Solutions for Workforce Development Pharmacy Stroke 1 - Anterior cerebral artery 2 - Anterior communicating artery 3 - Internal carotid artery 4 - Posterior communicating artery 5 - Middle cerebral artery 6 - Posterior cerebral artery 7 - Superior cerebellar artery 8 - Basilar artery 9 - Anterior inferior cerebellar artery

17. Educational Solutions for Workforce Development Pharmacy

18. Educational Solutions for Workforce Development Pharmacy Cerebrum – intellect, speech, emotion, sensory, movement Cerebellum – balance, co-ordination Brain stem – respiration, heart rate, blood pressure, wakefulness Cerebrum - left hemisphere – speech and language

19. Educational Solutions for Workforce Development Pharmacy Risk factors Risk Factors For Stroke: Treatable Major Diabetes Hypertension Smoking Lifestyle Diet Cholesterol Heart disease, esp. atrial fibrillation Transient ischaemic attacks Less Well Documented Excessive alcohol intake / drug abuse Acute infection

20. Educational Solutions for Workforce Development Pharmacy Risk factors Risk Factors for Stroke That Cannot Be Changed Increased age Being male Race (e.g., African- Americans) Family history of stroke

21. Educational Solutions for Workforce Development Pharmacy Evidence Base for Treatment ACTIVE PROGRESS CHARISMA SPARCL ESPRIT MATCH PROFESS RE-LY

22. Educational Solutions for Workforce Development Pharmacy Acute Secondary Prevention

23. Educational Solutions for Workforce Development Pharmacy Acute treatment Thrombolysis Antiplatelets Blood pressure Hydration Oxygen Blood glucose Temperature

24. Educational Solutions for Workforce Development Pharmacy Thrombolysis Lyses clot by digesting fibrinogen Intravenous recombinant tissue plasminogen activator (tPA - Alteplase) 0.9mg/kg after test dose Within 4.5 hours (6hrs if IST-3 clinical trial) Reduces death and disability at 90 days 2% incidence of symptomatic haemorrhage at 24 hrs 8% incidence of symptomatic haemorrhage at 7 days

25. Educational Solutions for Workforce Development Pharmacy Antiplatelets Aspirin 300mg within 48 hours continued for 14 days reduces 14 day mortality and morbidity No evidence for: Anticoagulants Combinations of antiplatelets or antiplatelets with anticoagulants Neuroprotectants

26. Educational Solutions for Workforce Development Pharmacy Blood pressure - not actively managed in acute phase Hydration – IV Sodium Chloride 0.9% is preferred to glucose 5% Blood glucose - treat if blood glucose is >11mmol/L Oxygen - supplemental Oxygen if saturation <95% Temperature – prescribe antipyretics

27. Educational Solutions for Workforce Development Pharmacy Secondary Prevention Treatment

28. Educational Solutions for Workforce Development Pharmacy Antiplatelets

29. Educational Solutions for Workforce Development Pharmacy Antiplatelets Evidence Cochrane Reviews Dipyridamole MR Clopidogrel vs Aspirin Randomised Clinical Trials MATCH Aspirin + Clopidogrel vs Clopidogrel CHARISMA Aspirin + Clopidogrel vs Aspirin ESPRIT Aspirin + Dipyridamole MR vs either alone PROFESS Aspirin + Dipyridamole MR vs Clopidogrel

30. Educational Solutions for Workforce Development Pharmacy Antiplatelets Aspirin and Dipyridamole MR in combination significantly reduces risk of vascular events compared to aspirin alone (approx 25% risk reduction) without an increase in bleeding The combination of Aspirin and Clopidogrel is no more effective than either alone is associated with an increase in moderate/life threatening bleeding only 25% patients in studies had a history of previous stroke used in acute coronary syndrome (NSTEMI) or carotid stenosis

31. Educational Solutions for Workforce Development Pharmacy Antiplatelets The combination of Aspirin and Dipyridamole MR vs Clopidogrel showed no difference in efficacy

32. Educational Solutions for Workforce Development Pharmacy Antiplatelets Recommendations Clopidogrel 75mg daily OR Aspirin 75mg daily and Dipyridamole 200mg MR twice daily should be prescribed after ischaemic stroke for secondary prevention of vascular events Aspirin alone – if dipyridamole intolerance (headache 26% withdrawal ESPRIT trial) - or if carotid stenosis 70% or unstable angina The combination of aspirin and clopidogrel is not recommended for prevention of ischaemic stroke or TIA

33. Educational Solutions for Workforce Development Pharmacy Statins Evidence 2 x Systematic reviews (170000 pts) Randomised Clinical Trial – SPARCL (4700 pts) Statins significantly reduce relative risk of ischaemic stroke by 21% but stroke death is not reduced Effect occurs without an increase in haemorrhagic stroke Statins reduce coronary events and all cause mortality Effect occurs irrespective of baseline cholesterol level (proportional to LDL lowering)

34. Educational Solutions for Workforce Development Pharmacy Statins Recommendations A statin should be prescribed to patients who have had an ischaemic stroke irrespective of cholesterol level Which statin? Simvastatin 40mg – high risk coronary event Atorvastatin 80mg – TIA / ischaemic stroke Should not be used in patients with a prior history of intracerebral haemorrhage

35. Educational Solutions for Workforce Development Pharmacy Anticoagulants Non-cardioembolic ischaemic stroke Evidence Systematic review Anticoagulant vs antiplatelet Randomised clinical trial – ESPRIT Anticoagulants no more effective than aspirin No difference in all cause mortality between antiplatelets and low or medium anticoagulation Higher mortality and major bleeding at intensive anticoagulation Recommendation Anticoagulation not recommended

36. Educational Solutions for Workforce Development Pharmacy Anticoagulants Atrial fibrillation and ischaemic stroke Evidence RE-LY trial Warfarin MORE effective for prevention of all vascular events and recurrent stroke No significant increase in intracranial bleed Not within 2 weeks Recommendation Warfarin should be offered with target INR of 2.0-3.0 OR Dabigatran (direct thrombin inhibitor) 110mg or 150mg twice a day may become an alternative to warfarin

37. Educational Solutions for Workforce Development Pharmacy Anticoagulants Atrial fibrillation and ischaemic stroke Evidence RE –LY trial (NEJM 2009) Warfarin versus Dabigatran in AF with primary outcome of stroke Recommendation Equal efficacy for warfarin and dabigatran with no worse safety profile for the dabigatran

38. Educational Solutions for Workforce Development Pharmacy Antihypertensives Evidence Well established link between BP reduction and stroke primary prevention Systematic review (7 trials) Randomised Clinical Trial - PROGRESS Perindopril/Indapamide Lowering BP reduced recurrent stroke and major vascular events No effect on vascular or all cause mortality Reduction in stroke related to difference in systolic BP between groups

39. Educational Solutions for Workforce Development Pharmacy Antihypertensives Recommendation BP should be assessed in all patients and therapy with an ACE inhibitor and thiazide diuretic should be considered regardless of BP Target blood pressure is <140/85 – diabetics <130/80 mmHg

40. Educational Solutions for Workforce Development Pharmacy Summary Secondary Prevention of Ischaemic Stroke Aspirin 75mg + Dipyridamole 200mg twice daily (or Clopidogrel 75mg if ACS) Simvastatin 40mg / Atorvastatin 80mg Thiazide diuretic ACE inhibitor Warfarin or dabigatran if AF

41. Educational Solutions for Workforce Development Pharmacy Pharmacist Role Public health, education and information Pharmaceutical care Research Multidisciplinary team membership

42. Educational Solutions for Workforce Development Pharmacy Public Health, education and information Awareness and promotion of: Public Health campaigns CHSS campaigns and resources Risk factors – action to take Stroke Identification – FAST test Lifestyle advice – smoking, weight loss/diet, vitamins

43. Educational Solutions for Workforce Development Pharmacy Pharmacist Role Public health, education and information Pharmaceutical care Research Multidisciplinary team membership

44. Educational Solutions for Workforce Development Pharmacy Pharmaceutical Care Transfer of patient information primary/secondary care interface -continuity of care - reduction of medication errors/discrepancies Identification and resolution of pharmaceutical care issues - level and type of resultant disability

45. Educational Solutions for Workforce Development Pharmacy Modified Rankin Score (mRS) Disability Score ScoreSymptoms 0No symptoms 1No significant disabling symptoms 2Slight disability 3Moderate disability 4Moderate/severe disability 5Severe disability 6Dead

46. Educational Solutions for Workforce Development Pharmacy Disability Dysphasia Aphasia Dysphagia Aphagia Hemiparesis Hemiplegic Hemianopia Speech Swallow Weakness Paralysis Visual difficulties

47. Educational Solutions for Workforce Development Pharmacy Pharmaceutical Care Issues Speech Comprehension Swallow Communication/counselling carers Ability to take medicines aspiration risk and liquids formulations bioavailability eg phenytoin NG and PEG tube feeding

48. Educational Solutions for Workforce Development Pharmacy Stroke Weakness or paralysis Visual problems Ability to operate devices inhalers, insulin Ability to open containers Ability to read instructions labels, leaflets, charts

49. Educational Solutions for Workforce Development Pharmacy Pharmacist Role Public health, education and information Pharmaceutical care Research Multidisciplinary team membership

50. Educational Solutions for Workforce Development Pharmacy Research Practice development project – MSc Strathclyde University Standardised pharmaceutical care plan validation Validation of care issues for transfer – needs assessment tool Pharmacist Research Fellow Design and validate transfer document for stroke

51. Educational Solutions for Workforce Development Pharmacy Research Audit of prescribing adherence to stroke guidelines and design and evaluation of a pharmaceutical care model Prospective evaluation of prescribing in acute stroke unit patients against guidelines and development of a pharmaceutical care plan Retrospective evaluation of prescribing in the same patients following discharge to primary care and design of documentation to facilitate information transfer between secondary and primary care

52. Educational Solutions for Workforce Development Pharmacy Research Primary Care - Results adherence 75% (hospital 79% 94%) lower for quality indicators not included in GMS contract lower for communication criteria Primary Care - Conclusions Improvement areas for prescribing use of warfarin in atrial fibrillation achievement of clinical target blood pressure and glycaemic control to audit and clinical standards

53. Educational Solutions for Workforce Development Pharmacy Pharmacist Role Public health, education and information Pharmaceutical care Research Multidisciplinary team membership

54. Educational Solutions for Workforce Development Pharmacy Multidisciplinary team membership SIGN – Scottish Intercollegiate Network Managed Clinical Network for Stroke (MCN) National Advisory Group for Stroke Stroke Unit Multidisciplinary Team

55. Educational Solutions for Workforce Development Pharmacy Stroke Key Messages Time is brain Think FAST Brain attack – dial 999

56. Educational Solutions for Workforce Development Pharmacy Useful Contacts