What is the optimal treatment for a patient experiencing recurrent cerebrovascular accident (CVA) or stroke while on Aspirin (acetylsalicylic acid) alone, followed by another CVA or stroke after switching to Plavix (clopidogrel) alone?

From the Guidelines

For patients experiencing recurrent strokes while on aspirin alone and then on Plavix (clopidogrel) alone, the recommended treatment is typically dual antiplatelet therapy (DAPT) with both aspirin and Plavix, but given the increased risk of hemorrhage, the combination of aspirin and clopidogrel is not recommended for routine secondary prevention after ischemic stroke or TIA, as stated in the guidelines 1.

Specific Regimen:

• Aspirin 81 mg daily and Plavix (clopidogrel) 75 mg daily may be considered for a short period, but the guidelines suggest that the addition of aspirin to clopidogrel increases the risk of hemorrhage and is not routinely recommended for ischemic stroke or TIA patients 1.

Alternative Approach:

• Considering the patient's history of recurrent strokes on both aspirin and clopidogrel monotherapy, an alternative approach could be to use clopidogrel 75 mg daily long-term, as it is a reasonable option for patients who have had an ischemic stroke while taking aspirin, and there is no evidence that increasing the dose of aspirin provides additional benefit 1.

Additional Considerations:

• Ensure optimal control of other stroke risk factors (e.g., hypertension, diabetes, hyperlipidemia) 1.
• Consider adding an anticoagulant if atrial fibrillation is present.
• Lifestyle modifications: smoking cessation, regular exercise, healthy diet.

Justification:

The guidelines provide evidence that dual antiplatelet therapy with aspirin and clopidogrel may not be the best option for patients with recurrent strokes due to the increased risk of hemorrhage 1. Therefore, a more individualized approach, considering the patient's specific risk profile and response to therapy, is necessary to balance the efficacy and safety of antiplatelet therapy.

From the FDA Drug Label

The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were randomized to receive clopidogrel (300 mg loading dose followed by 75 mg once daily) or placebo, and were treated for up to one year Patients also received aspirin (75 to 325 mg once daily) and other standard therapies such as heparin. The number of patients experiencing the primary outcome (CV death, MI, or stroke) was 582 (9.3%) in the clopidogrel-treated group and 719 (11.4%) in the placebo-treated group, a 20% relative risk reduction (95% CI of 10% to 28%; p <0. 001) for the clopidogrel-treated group

The optimal treatment for a patient experiencing recurrent cerebrovascular accident (CVA) or stroke while on Aspirin (acetylsalicylic acid) alone, followed by another CVA or stroke after switching to Plavix (clopidogrel) alone, cannot be determined from the provided information.

• The provided study does not directly address the specific scenario of a patient experiencing recurrent CVA or stroke while on Aspirin alone, followed by another CVA or stroke after switching to Plavix alone.
• The study does not provide guidance on the optimal treatment for this specific patient population.
• Therefore, no conclusion can be drawn regarding the optimal treatment for this patient. 2

From the Research

Optimal Treatment for Recurrent CVA or Stroke

The optimal treatment for a patient experiencing recurrent cerebrovascular accident (CVA) or stroke while on Aspirin (acetylsalicylic acid) alone, followed by another CVA or stroke after switching to Plavix (clopidogrel) alone, involves considering alternative antiplatelet therapies.

• The combination of aspirin and extended-release dipyridamole has been shown to be more efficacious than aspirin alone in preventing recurrent stroke 3, 4, 5.
• Clopidogrel may be more efficacious than aspirin alone for prevention of recurrent stroke, but its effectiveness can be impacted by certain polymorphisms, such as CYP2C19 4.
• Dual antiplatelet therapy with aspirin and clopidogrel has been shown to be superior to antiplatelet monotherapy in secondary stroke prevention, particularly in patients with mild noncardioembolic stroke or high-risk transient ischemic attack 6, 7.
• However, dual therapy is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days 6, 7.

Considerations for Treatment

When choosing an antiplatelet agent for secondary stroke prevention, clinicians should consider the following factors:

• Stroke subtype and characteristics
• Time from symptom onset
• Patient-specific predisposition to develop hemorrhagic complications
• Cost, side effect profile, medical comorbidity, and patient preference 4, 6
• The presence of genetic polymorphisms that may impact the effectiveness of certain antiplatelet agents, such as clopidogrel 4, 6

Alternative Treatment Options

Alternative treatment options for patients who experience recurrent stroke while on aspirin or clopidogrel alone may include:

• Switching to a combination of aspirin and extended-release dipyridamole
• Adding a second antiplatelet agent, such as clopidogrel or ticagrelor, to aspirin
• Using a different antiplatelet agent, such as prasugrel, although this may be associated with a higher risk of brain hemorrhage 4
• Aggressive medical management, including dual antiplatelet therapy, for patients with symptomatic intracranial stenosis 6