Transcript Treating Stroke With Drug Therapies

Medications for Treating Stroke
Adapted by
Anne Morgan, PharmD
Neurosciences Clinical Pharmacy Specialist
University of Colorado Hospital
With permission from
Michael Faithe, PharmD, BCPS and Megan Wong, PharmD
Outline
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Anti-platelet medications
Anticoagulants
Supplement-drug interactions
Drugs used to treat cholesterol, blood
pressure and diabetes
Types of Stroke
Medications Used to Prevent Stroke
• Anti-platelets
– Aspirin
– Plavix® (clopidogrel)
– Aggrenox®
(dipyridamole/aspirin)
• Anticoagulants
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Coumadin® (warfarin)
Pradaxa® (dabigatran)
Xarelto® (rivaroxaban)
Eliquis® (apixaban)
Savaysa® (edoxaban)
Anti-platelet Agents
• Reduce the risk of having another stroke or
cardiovascular (heart-related) event
– Aspirin
– Plavix® (clopidogrel)
– Aggrenox® (aspirin/dipyridamole)
Aspirin
• Most commonly used anti-platelet medication to
prevent stroke
• Dose: 81-325mg by mouth daily
• 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
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 MD or pharmacist
• Side effects
– Headache, stomach pain, nausea, diarrhea, bleeding, bruising, black
stools
– Headache up to 39% of patients, usually resolves with time
– If headache is intolerable speak with your physician or pharmacist
• Generic available, but still pricey
Prevention of Strokes in Patients With
Abnormal Heart Rhythm (Atrial Fibrillation)
• Aspirin decreases risk by approximately 21%
– Not as effective as warfarin
• Anticoagulants
– Warfarin decreases risk by approximately 68%
• Goal INR 2-3
– New oral anticoagulants (dabigatran, rivaroxaban,
apixaban, edoxaban) are about as effective as
warfarin
• Lower risk of intracranial hemorrhage (brain bleeding)
• Monitoring not required, no dietary restrictions
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 MD or pharmacist if starting or stopping any
prescription/nonprescription medications
Pradaxa® (dabigatran)
• Approved to prevent stroke in atrial fibrillation
• Dose: 150 mg orally twice daily
– Must be swallowed whole
– Not monitored through an lNR test
– Dose may be reduced with kidney problems
• Side effects
– Stomach pain, bleeding/bruising, diarrhea
• Reversal agent: Praxbind® (idarucizumad)
– FDA approved: October 16, 2015
Xarelto® (rivaroxaban)
• Approved to prevent stroke in atrial fibrillation
• Dose: 20 mg orally once daily with evening meal
– Can be crushed if needed
– Not monitored through an lNR test
– 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 atrial fibrillation
• Dose: 5 mg orally twice daily
– Can be crushed if needed
– Not monitored through an INR test
– Dose may be reduced for kidney problems, age >80 years old,
and/or body weight < 60 kg
• Side effects
– Bleeding/bruising, nausea
• No reversal agent
– Andexanet alfa currently being studied in clinical trials
Savaysa® (edoxaban)
• Approved to prevent stroke in atrial fibrillation
• Dose: 60 mg orally once daily
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Unknown if crushing tablets is safe/effective
Not monitored through an INR test
Not recommended with highly functional kidneys
Dose may be reduced for kidney problems
• Side effects
– Bleeding/bruising, abnormal liver function tests, rash
• No reversal agent
– Andexanet alfa currently being studied in clinical trials
Caution with
Anti-platelets & Anticoagulants
• Watch for unusual bleeding/bruising
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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
Caution with
Anti-platelets & Anticoagulants
• 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
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Prescriptions
Over the counter (OTC)
Vitamins
Supplements
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)
Other Risk Factors for Stroke
• High cholesterol
• High blood pressure (hypertension)
• Diabetes
Cholesterol
• LDL = “Lousy” Cholesterol
– Forms plaques and clogs the vessels in your brain and heart
• HDL = 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
• Medications
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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
What Else Can You Do to Lower Your
Risk 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
Needy Meds
www.NeedyMeds.com
Rx Assist - Patient Assistance Program Center
www.rxassist.org
Questions?