Can cilostazol be stopped abruptly and should it be crushed for administration through a gastrostomy tube (gtube)?

Management of Cilostazol Discontinuation and Administration via G-tube

Cilostazol can be stopped abruptly without risk of rebound platelet hyperaggregability, and it should not be crushed for administration through a gastrostomy tube due to potential absorption issues and tube clogging risks.

Discontinuation of Cilostazol

Safety of Abrupt Discontinuation

• Cilostazol can be discontinued without rebound platelet hyperaggregability according to FDA labeling 1
• Unlike thienopyridines (e.g., clopidogrel), cilostazol has reversible effects on platelet function, making abrupt discontinuation safer 2
• The elimination half-life of cilostazol is approximately 10 hours, with complete clearance occurring within 3 days 2, 3

Timing of Discontinuation for Procedures

• If discontinuation is needed for a procedure with bleeding risk, cilostazol should be stopped approximately 3 days before the procedure 2
• This 3-day window corresponds to approximately 5 elimination half-lives, ensuring adequate clearance of the medication 2
• Unlike aspirin or clopidogrel, which require 7-10 days for full platelet function recovery, cilostazol's effects resolve more quickly due to its reversible mechanism 2, 4

Indications for Permanent Discontinuation

• Discontinue cilostazol immediately if a patient develops congestive heart failure of any severity 5
• Consider discontinuation if severe side effects persist, such as headache (occurring in up to 25% of patients), despite dose reduction attempts 5, 6
• Reassess continuation after 3-6 months if no improvement in claudication symptoms is observed 5

Administration via Gastrostomy Tube

Risks of Crushing Cilostazol

• Crushing cilostazol tablets for g-tube administration is not recommended due to several concerns:
  • Cilostazol has dose-dependent pharmacokinetics that may be altered when the tablet form is disrupted 3
  • The medication may cause tube clogging, which is a significant problem with gastrojejunostomy tubes (reported rates of 3.5%-35%) 2
  • Crushed medications increase the risk of tube occlusion, particularly with smaller diameter tubes 2

Alternative Administration Approaches

• For patients requiring enteral feeding who cannot take oral medications:
  • Consider medication administration through the gastrostomy port rather than the jejunostomy port when possible, as it has a larger diameter and reduces clogging risk 2
  • Evaluate the necessity of continuing cilostazol versus the risks of improper administration 5
  • If a patient has a feeding tube and requires antiplatelet therapy, alternative medications with established safety profiles for enteral administration might be more appropriate 2

Monitoring After Discontinuation or During Administration

• Monitor for potential cardiovascular events after discontinuation, particularly in patients with high cardiovascular risk 5, 7
• If cilostazol must be administered via g-tube despite recommendations against it, monitor for:
  • Tube patency and function 2
  • Effectiveness of the medication by assessing claudication symptoms 5
  • Adverse effects including headache, diarrhea, and palpitations, which are the most common side effects 8, 6

Common Pitfalls and Caveats

• Do not confuse cilostazol's discontinuation timeline with that of irreversible antiplatelet agents like aspirin or clopidogrel, which require longer periods to restore platelet function 2
• Unlike some medications, there is no need for "bridging therapy" during cilostazol discontinuation 4
• Fungal colonization of g-tubes is common and may lead to tube degradation; polyurethane tubes may be more resistant than silicone ones if medication administration through the tube is necessary 2
• Be aware that cilostazol has significant drug interactions with inhibitors of CYP3A4 (e.g., ketoconazole, erythromycin) and CYP2C19 (e.g., omeprazole), which may require dose adjustments 1, 8