What are the antithrombotic (anti-clotting) medications used in Acute Ischemic Stroke (AIS)?

From the Guidelines

Antithrombotic therapy with aspirin, clopidogrel, or the combination of aspirin and extended-release dipyridamole is recommended for patients with acute ischemic stroke (AIS). The choice of antithrombotic medication should be individualized based on patient risk factor profiles, cost, tolerance, and other clinical characteristics 1.

Key Considerations

• Aspirin 50-325 mg/d, the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily, and clopidogrel 75 mg monotherapy are all acceptable options for initial therapy 1.
• Dual antiplatelet therapy with aspirin and clopidogrel may be beneficial for patients with minor stroke or high-risk TIA if initiated within 24 hours, but the addition of aspirin to clopidogrel increases the risk of hemorrhage 1.
• For patients receiving IV thrombolysis, antiplatelets should be delayed for 24 hours.
• Anticoagulation with heparin is not recommended for most AIS patients but may be considered in specific cases like cerebral venous thrombosis or stroke with arterial dissection.

Specific Recommendations

• Aspirin is recommended over oral anticoagulants for patients with noncardioembolic ischemic stroke or TIA 1.
• Clopidogrel may be considered instead of aspirin alone for patients hypersensitive to aspirin 1.
• The combination of aspirin and extended-release dipyridamole is recommended over aspirin alone for initial treatment 1.

Recent Guidelines

• The 2018 guidelines for the early management of patients with acute ischemic stroke recommend dual antiplatelet therapy with aspirin and clopidogrel for 21 days in patients with minor stroke or high-risk TIA if initiated within 24 hours 1.
• The guidelines also recommend against the use of glycoprotein IIb/IIIa receptor antagonists, such as abciximab, in the treatment of AIS due to the potential for harm 1.

From the FDA Drug Label

1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 2.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 14.2 Recent Myocardial Infarction, Recent Stroke, or Established Peripheral Arterial Disease

The antithrombotic (anti-clotting) medication used in Acute Ischemic Stroke (AIS) is clopidogrel.

• Key points:
  • Indication: Recent stroke
  • Dosage and administration: specified for recent stroke
  • Clinical studies: include recent myocardial infarction, recent stroke, or established peripheral arterial disease 2

From the Research

Antithrombotic Medications for Acute Ischemic Stroke (AIS)

The following antithrombotic medications are used in the treatment and secondary prevention of Acute Ischemic Stroke (AIS):

• Antiplatelet agents:
  • Aspirin: remains the most commonly used first-line antiplatelet agent for preventing noncardioembolic stroke recurrence 3
  • Clopidogrel: a feasible alternative to aspirin 3
  • Cilostazol: a feasible alternative to aspirin 3, 4
  • Ticagrelor: a feasible alternative to aspirin and clopidogrel 3, 5, 4
• Dual antiplatelet therapies:
  • Aspirin and clopidogrel: reduces the risk of recurrent ischemic events in patients with minor noncardioembolic stroke or high-risk transient ischemic attack 5, 4
  • Aspirin and ticagrelor: superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, but associated with a higher risk of hemorrhagic complications 5
• Anticoagulants:
  • Alteplase: the mainstay treatment of arterial acute ischemic stroke 6
  • Vitamin K antagonists: provides prognostic benefit in patients with atrial fibrillation and additional stroke risk factors 7
  • New oral anticoagulants: demonstrated at least similar efficacy with vitamin K antagonists in preventing stroke in patients with atrial fibrillation 7

Considerations for Antithrombotic Therapy

The selection of antithrombotic therapy should be based on:

• Stroke characteristics 5
• Time from symptom onset 5
• Patient-specific predisposition to develop hemorrhagic complications 5
• Compliance, drug tolerance, or resistance 4