Medication management in the secondary prevention of stroke and TIA

Antiplatelet therapy

Antiplatelet therapy reduces the risk of further stroke for those with ischaemic stroke and Transient Ischaemic Attack (TIA), but increase the risk for those with haemorrhagic stroke. Antiplatelet therapy is therefore only indicated in Ischaemic stroke and TIA. 

a)   For patients with ischaemic stroke⁷

• Generic clopidogrel (75mg daily) monotherapy is recommended for first line treatment
• Aspirin 75mg daily plus dipyridamole MR 200mg twice daily (both long term) if clopidogrel is contraindicated or not tolerated
• Dipyridamole MR monotherapy is recommended only if aspirin and clopidogrel are contraindicated or not tolerated
• If patients experience headache on dipyridamole, consider simple analgesia such as paracetamol or dose titration using dipyridamole initially.
• Consider a proton pump inhibitor (PPI) when there is dyspepsia with clopidogrel or aspirin other significant risk of gastrointestinal bleeding associated with clopidogrel or aspirin. If prescribing a PPI with clopidogrel, lansoprazole is the PPI of choice due to the interaction between clopidogrel and omeprazole
• Do not use aspirin / clopidogrel combination unless prescribed for a short time for carotid stenosis with stent insert (see c) below).
• Clopidogrel  tablets may be crushed and mixed with water if difficult to swallow (unlicensed use)
• Consider opening dipyridamole MR capsules if swallowing difficulties, (unlicensed use). Granules may be dispersed in water but not crushed or chewed⁸.Do not use dipyridamole suspension as this has not been shown to be effective⁹.

b)  For patients with TIA⁷

• Long term combination of aspirin 75mg daily plus dipyridamole MR 200mg twice daily
• Use dipyridamole  monotherapy if aspirin is contraindicated or not tolerated
• Alternatively if patients are intolerant of dipyridamole despite simple analgesia, aspirin or clopidogrel (unlicensed indication) may be used

c)   for patients with carotid stenosis with stent insert(unlicensed indication)

• Generic clopidogrel 75mg daily long term plus aspirin 75mg daily for 1 month

d) for carotid endarterectomy patients

• Generic clopidogrel 75mg daily long term
• Any other treatment combinations should be confirmed in writing by the Stroke Specialists or Neurologists.