The Pennine Acute Hospitals
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2 Cardiovascular system
02-09 Antiplatelet drugs

GMMMG Recommendations on prevention of occlusive vascular events

Ischaemic stroke

First-line - give Clopidogrel monotherapy.

Give dipyridamole MR + Aspirin ONLY if:

�� Clopidogrel is contraindicated (CI) or not tolerated, OR

�� to continue treatment in patients already receiving this combination.

Give dipyridamole MR monotherapy ONLY if Aspirin AND Clopidogrel are CI or not tolerated.

TIA

First-line - give dipyridamole MR + Aspirin.

Give dipyridamole MR monotherapy ONLY if Aspirin is CI or not tolerated.

Clopidogrel is not recommended for people who have had a TIA as it does not have UK marketing authorisation for this indication.

PAD or multivascular disease

First-line - give Clopidogrel monotherapy.

MI

Following initial acute management according to NICE CG94: Unstable angina and NSTEMI or NICE CG48: MI, Secondary Prevention :

First-line - give Aspirin monotherapy.

Give Clopidogrel monotherapy ONLY if Aspirin is CI or not tolerated.

Although not discussed in this NICE guideline, Aspirin monotherapy would only be used if dipyridamole and/or Clopidogrel are contraindicated or not tolerated.

Dual anti-platelet therapy (Aspirin plus Clopidogrel or Ticagrelor or Prasugrel) should be prescribed for up to 12 months after an acute MI (Usually 12 months will be recommended). Occasionally, consultant cardiologists may recommend a longer period of therapy (possibly lifelong/indefinitely) having taken account the risks and benefits at an individual patient level. This will usually be after a complex coronary stenting procedure of after recurrent events despite optimal therapy.

A course length for clopidogrel, ticagrelor or prasugrel must be indicated on any communication with primary care.

Early discontinuation of anti-platelets must be avoided especially in patients who have had intra-coronary stents, without prior discussion with cardiologists.

In severe dyspepsia, low dose Aspirin should be initiated with gastro-protection (Omeprazole). Should the severe dyspepsia continue despite gastroprotection, substitute with Clopidogrel 75mg daily.

Concomitant use of Clopidogrel and Omeprazole or Esomeprazole is discouraged unless considered essential. Consider Lansoprazole in patients who are taking Clopidogrel. Other gastrointestinal therapy such as H2 blockers (except cimetidine) or antacids may be suitable in some patients


Aspirin (antiplatelet)
Formulary
Dispersible tablets
Gastro-resistant (enteric coated) tablets (only for patients established on this product)
Tablets

See information above.

Low dose aspirin prophylaxis should not routinely be initiated for primary prevention.

Enteric-coated aspirin tablets are not recommended. There is no convincing evidence that at a daily dose of 75mg using enteric coated rather than soluble aspirin reduces the risk of gastrointestinal bleeding. (Ref: Drug Ter Bull. Jan 1997, p7-8).

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Clopidogrel
Formulary
Tablets

See information above.
Link  NICE TA210: Clopidogrel/dipyridamole MR prevention of occlusive vascular events.
 

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Dipyridamole
Formulary
Tablets
Modified Release Capsules
Oral suspension

See information above.
Link  NICE TA 210: Clopidogrel/dipyridamole MR for prevention of occlusive vascular events
 

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Dipyridamole and Aspirin Asasantin® Retard
Formulary
Modified release capsules.

See information above.
Link  NICE TA210: Clopidogrel/dipyridamole MR for prevention of occlusive vascular events.
 

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Ticagrelor Brilique®
Formulary
Tablets

See information above.

Restricted Item Only to be prescribed on advice of cardiology
Link  NICE TA236: Ticagrelor for the treatment of acute coronary syndromes
 

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Prasugrel Efient®
Formulary
Tablets

See information above, and GMMMG algorithms below.
Link  NICE TA317: Acute coronary syndrome - prasugrel
 

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Abciximab
Formulary
Injection
Link  Adult Loading Doses Policy
 

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Eptifibatide Integrilin®
Formulary
Injection
Infusion

Link  Adult Loading Doses Policy
 

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Tirofiban Aggrastat®
Formulary
Concentrate for infusion
Link  Adult Loading Doses Policy
 

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