Treating Stroke With Drug Therapies Michael Faithe, Pharm.D., BCPS Neurosciences Clinical Pharmacy...
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Transcript of Treating Stroke With Drug Therapies Michael Faithe, Pharm.D., BCPS Neurosciences Clinical Pharmacy...
Treating Stroke With Drug Therapies
Michael Faithe, Pharm.D., BCPSNeurosciences Clinical Pharmacy Specialist University of Colorado Hospital
Outline
• Anti-platelet medications• Anticoagulants• Supplement-drug interactions• Drugs used to treat cholesterol, blood
pressure and diabetes
Medications Used to Prevent Stroke
• Anti-platelets– Aspirin– Plavix® (clopidogrel)– Ticlid® (ticlopidine)– Aggrenox® (dipyridamole/aspirin)
• Anticoagulants– Coumadin® (warfarin)– Pradaxa® (dabigatran)– Xarelto® (rivaroxaban)– Eliquis® (apixaban)
Anti-platelet Agents
• Reduce the risk of having another stroke or cardiovascular (heart-related) events– Aspirin– Ticlid® (ticlopidine) – Plavix® (clopidogrel)– Aggrenox® (aspirin/dipyridamole)
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
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
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
Cost Comparison
NameCost
Brand Generic
Aspirin 81 mg $1.80 $0.35
Plavix® 75 mg (clopidogrel) $232 $208.57
Aggrenox® 25/100 mg(aspirin/dipyridamole) $317.64 Not available
Based on 1-month supply from: Medi-Span ®
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
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
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
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
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
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)
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
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
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
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
What Else Can You Do to Lower YourRisk 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
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
Need Meds
www.NeedyMeds.com
Rx Assist - Patient Assistance Program Center
www.rxassist.org
Questions?