Pharmacological management of post stroke patients

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Pharmacological management of post stroke patients

• By
• Khalid Khan
• Pharmacist HASU

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Plan

• Stroke- definition, classification-covered
  elsewhere
• Drug history and medicines reconciliation
• Secondary prevention
• Antiplatelets
• Lipid regulating drugs- statins
• Antihypertensives
• Drug fomulations and dose adjustments
• Summary

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Drug history and medicines reconciliation

• Sources of drug history
• Role of pharmacists and pharmacy technicians
• Medicines reconciliation
• -establish drug history
• -identify discrepancies
• -make interventions

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Secondary prevention

• Risk of recurrent stroke
• -10 within the first week
• -20 within the first month
• -30-43 over the next five years
• -23 people die within 30 days of having
• a stroke
• -60-70 who survives die within 3 years
• -about 900,000 people in England are living
  with the effects of stoke with about half of them
  dependent on others with everyday life

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Antiplatelets

• Aspirin, clopidogrel, dipyridamole
• Prevents aggregation of platelets by inhibiting
  the production of thromboxane
• The aim of treatment is to prevent occlusive
  event and its recurrence by using one or two
  antiplatelet agents

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Antiplatelets

• Clopidogrel is recommended as 1st line in
  patients with ischemic stroke
• Dipyridamole MR plus aspirin-
• 1st line in TIA
• 2nd line in ischemic stroke where
  clopidogrel is
• contraindicated or not tolerated
• Dipyridamole MR alone-
• 2nd line in TIA where aspirin is contraindicated
  or not tolerated
• 3rd line in ischemic stroke where clopidogrel and
  aspirin is contraindicated or not tolerated
• (NICE TA Dec 2010)

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Antiplatelets

• Side effects
• -Aspirin GI bleed/dyspesia- use PPI to prevent
  GI symptoms
• -Clopidogrel less likely to cause dyspepsia
• -Dipyridamole headache
• (for other less common side effects refer to BNF)
• Contraindication
• -Aspirin under 16 years, hypersensitivity
  (asthma, angiodema, urticaria)
• -Clopidogrel active bleeding, severe liver
  impairment, pregnancy
• -Dipyridamole Hypersenitivity

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Lipid lowering drugs

• Statins- simvastatin, atorvastatin, pravastatin
• Contraindication
• Active liver disease (use with caution in
  history of liver disease), pregnancy, renal
  impairment (CrCl lt30ml/min) use atorvastatin or
  simvastatin 10mg od.
• Avoid grapefruit juice
• Interactions
• Increased risk of muscle effects with with
  enzyme inducers (macrolides, rifampicin,
  itraconazole,etc- avoid concomitant use with
  macrolides and antifungals, HIV protease
  inhibitors
• simvastatin needs dose reduction with
  diltiazem, verapramil, ciclosporin,
• Side effects muscles effects- counselling

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Antihypertensives

• NICE hypertension guidelines
• ACE inhibitors
• (ramipril, lisinopril, perindopril)
• -Action inhibits angiotensin converting
  enzyme
• -Contraindication Hypersensivity
  (angioedema), bilateral renal artery stenosis,
  caution in acute renal and hepatic impairment.
• -Side effects Hyperkalemia, persistent dry
  cough, rash

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Antihypertensives

• Thiazides (bendroflumethiazide)
• Ca channel blockers (amlodipine, felodipine,
  nifedipine diltiazepm and verapramil)
• Alpha blockers (doxazocin, indoramin)
• Nitrates (Isosorbide mononitrate, GTN)
• Beta blockers (atenolol, bisoprolol, metoprolol)
• A2RBs (angiotensin converting enzyme blockers)-
  candesartan, valsartan, losartan

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High blood pressure in acute stroke

• Target 180/110mmHg
• IV labetolol 50-200mg in 5 dextrose or 0.9
  normal saline (nor more than 1mg per ml) to be
  infused over 2-4 hours (2mg/minute)
• -monitor ECG
• GTN 10-200 microgram per minute (maximum
  400microgram per minute) in 100ml 5 dextrose or
  0.9 normal saline.

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Drug formulation and dose adjustment

• Swallowing difficulties
• Change tablets capsules to liquid formulation or
  use alternative routes
• Digoxin 62.5mcg tablets to 50mcg liquid
• Do not use dipyridamole liquid (not licensed for
  stroke)
• Some tablets can be crushed such as simvastatin,
  amlodipine, ramipril
• Do not crush modified release and enteric coated
  tablets e.g. Dipyridamole MR caps, ISMN MR,
  diclofenac EC

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Summary