Therapeutic Handbook - GGC Prescribing

Secondary prevention of stroke and TransientIschaemic Attack (TIA)IntroductionSecondary prevention of stroke should be considered in all patients as soon as possible after theirstroke or TIA. Initiation of secondary prevention investigations and treatment should be guided bythe stroke team, therefore, ensure that all new stroke or TIA patients are referred to the local strokeservice.Drug therapyCardiovascular SystemAntithromboticsPatients in sinus rhythm:First choice is:Clopidogrel oral 75 mg each day (N.B. In TIA it would be an unlicensed indication).If the patient is allergic or intolerant to clopidogrel then prescribe combination therapy:Aspirin oral 300 mg each day for 14 days or until hospital discharge, then reduce toaspirin oral 75 mg each day andDipyridamole MR oral 200 mg, starting with 200 mg each night and increasing to 200 mgtwice daily if tolerated (severe ischaemic heart disease is one possible contraindication).Patients in atrial fibrillation (AF):• Patients will usually start oral anticoagulants 10 to 14 days after the acute stroke but advice from astroke consultant should be sought about this. Where patients are already on anticoagulation andhave an ischaemic stroke, seek advice from a stroke consultant before resuming anticoagulation.Ensure stroke team advise before prescribing warfarin (see page 107 for information on AFmanagement and page 78 for warfarin initiation information). If discharging patient home onwarfarin ensure follow up arrangements are in place (see page 83 for referral to anticoagulationclinic).• If contraindications to warfarin, seek advice from the stroke consultant.Patients with haemorrhagic stroke:• Antiplatelet drugs are contraindicated unless cause of intracerebral bleed resolves and patientsalso have concomitant ischaemic heart or stroke disease. This is a risk / benefit balance andadvice should be sought from the stroke team.Continues on next pagePage 124