Two recently published trials explored the value of early dual-antiplatelet therapy with aspirin and clopidogrel in the early period after minor stroke and TIA. It is worth noting that the therapy was started early within 24 hours of presentation and dual therapy was only continued for 21 days. In light of these findings, the AHA suggests that the combination of clopidogrel and aspirin might be considered within 24 hours of a minor ischemic stroke or TIA and continued for up to 21 days Class IIb recommendation, level of evidence B.
Three randomized, controlled trials have evaluated the use of combined clopidogrel and aspirin therapy outside of the immediate stroke period. In the MATCH trial, this dual therapy led to no significant reductions in secondary stroke rates, but it did increase the rate of life-threatening bleeding by 1. Finally, the SPS3 trial of more than patients with MRI-confirmed lacunar stroke within the previous days found that while rates of ischemic stroke were slightly reduced with dual-antiplatelet therapy, the rates of hemorrhagic stroke and mortality were increased.
Two randomized trials explored the benefit of the combination product of aspirin and extended-release dipyridamole with aspirin alone. In the ESPS-2 trial, this combination therapy significantly reduced the risk of stroke and death, but it was limited by problems in data quality reporting.
Both of these trials noted significantly more adverse drug events with the combination primarily headache and gastrointestinal symptoms , and the product is significantly more expensive than aspirin monotherapy.
Because of these limitations, this combination cannot be considered superior to aspirin monotherapy. Rather, the AHA guidelines recommend that the combination of aspirin 25 mg and dipyridamole mg twice daily can be considered as an alternative initial therapy after a stroke or TIA for prevention of future stroke Class I recommendation, level of evidence B.
In patients who experience a recurrent stroke or TIA while taking aspirin therapy, the initial impulse to increase the dose of aspirin must be resisted. There is no evidence to suggest that increasing the dose of aspirin provides any further benefit.
Unfortunately, there are no clinical trials to indicate that switching antiplatelet agents reduces the risk of subsequent events in patients who experience a stroke while taking aspirin. Alternatively, clopidogrel monotherapy could be considered, as this regimen was proven effective in reducing the risk of recurrent stroke in the PRoFESS trial.
The selection of the appropriate antiplatelet agent for secondary stroke prevention should be based on relative effectiveness, safety, and cost, in addition to patient characteristics and preference. Aspirin monotherapy is a reasonable first-line choice for most patients, but a short-term combination of aspirin with clopidogrel can be considered if initiated early after diagnosis.
Aspirin with dipyridamole is also an acceptable first-line choice if the patient can afford it. For those with intolerance to aspirin or aspirin-dipyridamole, clopidogrel is a good alternative. Mozaffarian D, et al. Kernan WN, et al.
Johnson ES, et al. A meta-regression analysis of the dose-response effect of aspirin on stroke. Arch Intern Med. Namely, they decrease the clumping of blood cells called platelets. This lowers the risk that potentially harmful blood clots will form. Some people might be prone to the formation of such clots. In people whose arteries have narrowed from atherosclerosis—the "hardening of the arteries" that is the basis of coronary artery disease and peripheral artery disease in the legs and neck, for example —blood clumping and clotting can become dangerous.
This report evaluates the use of antiplatelet drugs in preventing heart attacks, strokes, and premature death in people who have acute coronary syndrome unstable angina or had a heart attack , peripheral vascular disease, a stent, or previously had a stroke. Five of these medications are evaluated in this report: aspirin, a fixed combination of aspirin plus extended-release dipyridamole Aggrenox , clopidogrel Plavix , prasugrel Effient , and ticlopidine Ticlid and generic.
Taking effectiveness, safety, side effects, and cost into account, we have chosen the following as Consumer Reports Best Buy Drugs if you have any of these conditions:. Be sure to ask your doctor about generic clopidogrel, which should become available in the spring of These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin gabapentin.
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