Blood thinning medication after stroke

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1 Blood thinning medication after stroke STROKE HELPLINE FACTSHEET 11 Blood thinning medicines are drugs that help to prevent blood clots forming. They are often prescribed after a transient ischaemic attack (TIA) or a stroke caused by a blockage (an ischaemic stroke). This factsheet explains the link between blood clots and stroke and the blood thinners commonly prescribed to reduce this risk. What is a stroke? A stroke can occur in one of two ways. It may arise due to a rupture in a blood vessel in the brain, causing bleeding in or around the brain and damage to the surrounding cells (a haemorrhagic stroke), or it can arise from a blockage in one of the arteries to the brain (an ischaemic stroke). Ischaemic strokes are far more common than haemorrhagic strokes and account for around 80 per cent of cases. They can be caused by: a thrombus (blood clot) forming in a main artery to the brain an embolism (something travelling within the blood stream which should not be present, such as a blood clot, air bubble or fat globule) that travels to the brain causing a blockage a blockage in the tiny blood vessels deep within the brain. As well as stroke, it is estimated that up to 65,000 people in the UK each year have a transient ischaemic attack (TIA), often called a mini-stroke. The symptoms are the same as those of a full-blown stroke, but they do not last as long (usually from a few minutes to 24 hours). As with an ischaemic stroke, TIAs occur when the blood supply to the brain is interrupted. If someone has a TIA or a stroke they are at an increased risk of having another stroke. Both ischaemic stroke and TIA are most often caused by blood clots. How does blood clot? Blood is produced in the bone marrow and consists of red blood cells, platelets, plasma (the fluid part containing salt, proteins and clotting factors) and white blood cells. Blood is released from the bone marrow into the blood stream. Blood clotting is a natural and essential part of life, helping to prevent the loss of too much blood from vital organs and tissues following an injury. To do this, platelets are essential. There are two stages to the blood clotting process. In the first stage, the platelets rush to form a plug in the damaged blood vessel wall by sticking together (a process called The Stroke Association (December 2009) 1

2 aggregation). When platelets group together in this way they release a chemical into the blood that triggers the clotting process. In the second stage, a protein called fibrin is produced. Strands of fibrin join the group of platelets and wrap around them to create the finished thrombus. A thrombus usually forms as a result of injury and should only occur outside of the blood vessel. For some people they can form abnormally inside the vessel and increase the risk of stroke. What are blood thinning medications? Blood thinning medications reduce the bloods ability to clot. There are two types of blood thinners; antiplatelets and anticoagulants, and they work at different stages of the blood clotting process. Blood thinners should not be prescribed after a haemorrhagic stroke as they can make this type of stroke worse. If you have a very high risk of ischaemic stroke, the consultant may decide that blood thinners are necessary despite this risk. Antiplatelets Antiplatelets work at one stage of the blood clotting process by preventing the platelets from sticking together. Commonly prescribed antiplatelets are: Aspirin Dipyridamole Clopidogrel. Aspirin Aspirin (also called acetylsalicylic acid) has been used for more than 100 years for a wide variety of conditions. It belongs to a class of medicines called NSAIDs (nonsteroidal anti inflammatory drugs). It can be used to reduce pain, swelling and fever. It is also an antiplatelet. Aspirin prevents the production of a molecule called thromboxane A 2 a molecule that when released causes the platelets to stick to one another. By blocking this molecule, aspirin makes blood clotting less likely. Research has found that taking aspirin after an ischaemic stroke or TIA reduces the risk of having another one by as much as 22 per cent. After a TIA the risk of stroke is greatest within the first 7 to 14 days. If you have a suspected TIA, you should be diagnosed as quickly as possible and, if a brain scan or other tests show that you could benefit from aspirin, you will be started on a daily dose of 300mg (milligrams) immediately. If you have a stroke and a brain scan confirms it is ischaemic, 300mg of aspirin may be given initially. After fourteen days this medicine will be reviewed and the dosage may be altered for longer-term treatment. It is likely that the dosage will be reduced to between 50 and 300mg daily. Like all drugs, aspirin has unwanted, as well as beneficial, effects. The main one is irritation of, and/or bleeding from, the lining of the stomach. For this reason, aspirin is not suitable for people who have peptic ulcers. Other side effects can include indigestion, nausea and vomiting. Aspirin is also not suitable for people who have an allergy to aspirin or other similar medications, asthma, kidney disease, or bleeding disorders. 2 The Stroke Association (December 2009)

3 Some people develop indigestion when taking aspirin because the protective lining of the stomach is weakened and stomach acid begins to damage it. This can lead to abdominal pain, vomiting and changes in appetite. A Proton Pump Inhibitor (PPI) is an anti-ulcer drug. It is usually given to people who have previously taken aspirin and developed indigestion. The following is a list of PPIs: Esomeprazole Lansoprazole Omeprazole Pantoprazole Rabeprazole If you develop indigestion whilst taking aspirin you may be prescribed a PPI along with two antibiotics: this is known as triple therapy. Relief from symptoms is usually felt within two hours and the course lasts for one to two weeks. Unfortunately, PPIs can have side effects too which can include constipation and diarrhoea. Dipyridamole Dipyridamole (also known by the brand name Persantin) was first used in a trial of anti-platelets in People responded to this drug differently because the rates of absorption by the intestine differed. To overcome this, a modified-release form of the drug was trialled. Dipyridamole is an antiplatelet that increases the levels of a chemical called cyclic AMP. Increased levels of cyclic AMP reduce the likelihood of the platelets clumping together thus achieving the same end result as aspirin. Numerous studies have demonstrated that a combination of modified-release dipyridamole and aspirin produce better results and lower the risk of bleeding, than either one alone. It is now common practice to be prescribed this combination of antiplatelet therapy. A drug which combines both aspirin and dipyridamole is called Asasantin. There are many medical conditions that might mean this drug is unsuitable. It is important to make sure the doctor is aware of your full medical history before starting this treatment. Following a TIA or an ischaemic stroke, long term combination antiplatelet treatment is usually mg aspirin and 200mg dipyridamole. Like aspirin, Asasantin can have unwanted side effects. There are some very common problems such as stomach upset, nausea, dizziness, indigestion and headaches which can affect as many as 1 in 10 people. Headaches can sometimes be alleviated by having the dose of dipyridamole reduced for a period of time (e.g. a month), after which it is then raised back to the full dose. There are other complications that are less common like bleeding, rashes, muscle pain and fainting. It is not a safe drug to be given if pregnant because it can lead to complications. It can also react with anticoagulant, antiplatelet and blood pressure medicines to name just a few (check your medicines information leaflet for a full list). Clopidogrel Clopidogel (brand name Plavix) is a more recent antiplatelet that works in a different way to aspirin and dipyridamole. It blocks a chemical called ADP, another chemical involved in platelet aggregation. The Stroke Association (December 2009) 3

4 There is no evidence to suggest that clopidogrel alone is better than aspirin alone, and clopidogrel is more likely to have an increased risk of bleeding when it is combined with aspirin. Clopidogrel is normally prescribed at 75mg daily after a TIA or ischaemic stroke to people who are intolerant of aspirin. The main side effect is unwanted bleeding. More rarely, nausea, vomiting, headache, dizziness, constipation, itching and sore throat can occur. If you develop a sore throat you should contact your GP immediately. It is not recommended to people who are pregnant or breastfeeding because of a lack of research in this area. It also interacts with NSAIDs, dipyridamole and warfarin. Another important drug interaction occurs between PPIs and clopidogrel reducing the effectiveness of clopidogrel as a blood thinner. For this reason, PPIs should be swapped for an alternative drug. Anticoagulants Anticoagulants are blood thinners that work at a later stage of the blood clotting process by preventing the production of fibrin. Anticoagulants also make existing blood clots more stable and less likely to break away and travel towards the brain. Warfarin Warfarin (sometimes called a coumarin anticoagulant) was first developed in 1944 as a rat poison. Its usefulness as a blood thinner was soon realised and within a few years it became licensed for this purpose. Warfarin is commonly prescribed to people at risk of blood clotting because of specific health conditions like atrial fibrillation, (abnormal heart rhythm) or rheumatic heart disease, or after insertion of artificial heart valves. Warfarin changes the way the liver uses vitamin K a vitamin necessary to the blood clotting process. The less vitamin K available; the longer it takes the blood to clot. The effects of warfarin can be reversed quickly by an injection of vitamin K, or reduced by eating foods containing large quantities of vitamin K. Foods that have high levels of vitamin K are pine nuts, fruit such as kiwi, blueberries and blackberries and green leafy vegetables like green beans, broccoli, spinach, cabbage and kale. As these foods are healthy for us and can help to reduce the risk of stroke and heart attack, warfarin levels are usually adjusted to compensate for the high levels of vitamin K. Cranberry juice is an exception and should not be drunk. Anyone who wishes to change their diet suddenly should consult a doctor and their anticoagulation clinic so that the effects of warfarin can be monitored more closely and changed if needed. Warfarin levels are monitored using blood tests. The test compares how quickly the blood clots at a particular stage in the process and compares it to the International Normalised Ratio (INR). INR is expressed as a value. A normal INR value for blood that is not anticoagulated is around 1. Depending on the health condition, differing INR levels will be sought. For example, for atrial fibrillation the blood should be two to three times thinner, so an INR value of 2 to 3 is aimed for. 4 The Stroke Association (December 2009)

5 Warfarin tablets should be taken at the same time each day and are available in different strengths, colour coded as follows: 0.5mg white tablets 1mg brown tablets 3mg blue tablets 5mg pink tablets When you are first prescribed warfarin you should receive a pack from the GP or hospital which contains a credit-card sized alert card, a yellow patient information booklet titled Oral Anticoagulant Therapy, and a record card. You should carry your alert card at all times in case of a medical emergency. Your dentist will need to see a recent INR result before carrying out any treatment. Warfarin should not be taken by people who have severe hypertension, peptic ulcers or bacterial endocarditis. It should also be avoided if you are pregnant. Minor side effects of this drug include rashes, nausea, vomiting and diarrhoea. The main side effect of warfarin is bleeding. Anyone experiencing bleeding should seek medical attention and have an urgent blood test. The risk of a serious bleed increases with the INR value. One study found that the risk of a bleed in the brain in patients on warfarin was 1.6 per cent and that this risk increased dramatically as INR levels rose above 4. For this reason, INR levels should be checked regularly and maintained. Warfarin also reacts with other medicines to have an enhanced effect. This means that your INR level will increase. Some medicines that have this effect are: Antibiotics Antidepressants Aspirin Clopidogrel Dipyridamole NSAIDs Statins Ulcer medicines There are also medicines, including herbal remedies that reduce the effects of warfarin. Always check the medicines with your GP and pharmacist and read the patient information leaflets. It is also advisable to keep alcohol to a minimum whilst taking warfarin as this will increase the INR value and the risk of a serious bleed. Binge drinking is particularly dangerous and should be avoided. Dabigatran and rivaroxaban There is currently research underway on new generation anticoagulants such as dabigatran and rivaroxaban, for reducing the risk of stroke in people with atrial fibrillation. These medications will not need such careful monitoring as warfarin. What else do I need to know? Please note that we have not provided an exhaustive list of side effects and drug interactions. Always refer to the patient information leaflet for a full list. Never stop taking medicine if you feel unwell. Always contact your GP for advice stopping medication suddenly can be dangerous. In a medical emergency, always call 999. Useful organisations All organisations are UK wide unless otherwise stated. The Stroke Association (December 2009) 5

6 Anticoagulation Europe PO Box 405, Bromley Kent BR2 9WP Tel: Website: Atrial Fibrillation Association (AFA) PO Box 1219, Chew Magna, Bristol BS40 8WB Tel: Website: British Heart Foundation (BHF) Greater London House, 180 Hampstead Road London NW1 7AW Tel: Website: Disclaimer: The Stroke Association provides the details of other organisations for information only. Inclusion in this factsheet does not constitute a recommendation or endorsement. For further information, phone the Stroke Helpline on , or visit our website If you are unhappy about any aspect of The Stroke Association, please make your views known to us immediately. We will happily discuss any issues and how they can best be resolved. Produced by The Stroke Associations Information Service. For sources used, visit information/our_publications Factsheet 11, version 01 published December 2009 (next revision due December 2011). Glossary of terms Aggregation = part of the blood clotting process where platelets stick together Anticoagulant = blood thinner Antiplatelet = blood thinner Embolism = something travelling within the blood stream which should not be present, such as a blood clot, air bubble or fat globule INR = international normalised ratio Ischaemic = interruption to blood flow caused by a blockage NSAIDs = non-steroidal anti inflammatory drugs Plasma = the fluid part of blood containing salt, proteins and clotting factors PPI = proton pump inhibitor (an anti-ulcer drug) Thrombus = blood clot TIA = transient ischaemic attack F11 Blood thinners after stroke The Stroke Association The Stroke Association is registered as a Charity in England and Wales (No ) and in Scotland (SC037789). Also registered in Isle of Man (No 945) Jersey (NPO 369) and in Northern Ireland. 6 The Stroke Association (December 2009)

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