What is the dosage of Daptomycin (Dapt) for a patient with a stroke, according to the National Institutes of Health Stroke Scale (NIHSS)?

DAPT According to NIHSS

For patients with minor non-cardioembolic ischemic stroke (NIHSS ≤3), initiate dual antiplatelet therapy (DAPT) with aspirin 160-325 mg plus clopidogrel 300-600 mg loading doses within 12-24 hours after excluding intracranial hemorrhage, then continue aspirin 81 mg plus clopidogrel 75 mg daily for 21-90 days. 1, 2

NIHSS-Based Patient Selection for DAPT

Minor Stroke (NIHSS ≤3)

• Patients with NIHSS score ≤3 are eligible for DAPT and should receive this therapy to reduce recurrent ischemic stroke risk 1
• The American Heart Association specifically recommends DAPT for this population when stroke is non-cardioembolic in origin 1

Minor to Moderate Stroke (NIHSS ≤5)

• The American College of Cardiology extends DAPT eligibility to patients with NIHSS ≤5 when stroke occurred within the past 24 hours 1
• This represents a slightly broader indication than the more conservative NIHSS ≤3 threshold, though the evidence strength is moderate 1

Moderate to Severe Stroke (NIHSS >5)

• DAPT is NOT recommended for patients with NIHSS >5 due to lack of evidence and increased bleeding risk in this population
• The ECASS-3 trial specifically excluded patients with baseline NIHSS >25 from thrombolytic therapy, highlighting concerns about severe strokes 3

DAPT Loading Dose Protocol

Initial Administration

• Administer aspirin 160-325 mg PLUS clopidogrel 300-600 mg as loading doses after neuroimaging excludes intracranial hemorrhage 1, 2
• Timing is critical: initiate within 12-24 hours of symptom onset and no later than 7 days after onset 1
• The loading dose of clopidogrel is essential because standard 75 mg daily dosing takes approximately 5 days to achieve maximal platelet inhibition 2

Maintenance Therapy

• Continue with aspirin 81 mg daily plus clopidogrel 75 mg daily for the maintenance phase 2
• Avoid enteric-coated aspirin for the loading dose as it has slower onset of action 2

Duration of DAPT by NIHSS Category

Standard Duration (21-90 Days)

• Continue DAPT for 21 to 90 days after the initial event for patients with NIHSS ≤3-5 1
• The maximal benefit in stroke reduction occurs within the first 21 days, so this represents the minimum effective duration 1
• After 21-90 days, transition to single antiplatelet therapy (SAPT) to avoid excess bleeding risk 1

Alternative Ticagrelor-Based Regimen

• For patients with NIHSS ≤5, ticagrelor 180 mg loading dose plus aspirin 160-325 mg may be considered as an alternative 2
• Continue with ticagrelor 90 mg twice daily plus aspirin 75-100 mg daily for 30 days 2
• Note: Ticagrelor-based DAPT carries increased risk of serious bleeding events including intracranial hemorrhage compared to clopidogrel-based regimens 1

Critical Safety Considerations

Absolute Requirements Before Initiating DAPT

• DAPT must ONLY be initiated after intracranial hemorrhage is ruled out on neuroimaging 1, 2
• This is a high-strength evidence recommendation that cannot be violated 1

Bleeding Risk Management

• Do NOT continue DAPT beyond 90 days as this is associated with excess hemorrhage risk without additional stroke reduction benefit 1
• Never use triple antiplatelet therapy due to increased bleeding risk without additional benefit 1

High-Risk TIA Patients

• Patients with high-risk TIA (ABCD2 score ≥4 or ≥6 depending on guideline) also qualify for DAPT using the same loading dose and duration protocols 1
• These patients follow identical DAPT protocols as minor stroke patients with NIHSS ≤3-5 1

Common Pitfalls to Avoid

• Do not delay DAPT initiation beyond 24 hours when possible, as early treatment maximizes benefit 1
• Do not confuse daptomycin (an antibiotic) with DAPT (dual antiplatelet therapy) - these are completely different interventions 4, 5
• Do not use DAPT in patients with cardioembolic stroke as these patients require anticoagulation, not antiplatelet therapy 1
• Do not skip the loading doses of antiplatelet agents, as standard maintenance dosing takes too long to achieve therapeutic effect in acute stroke 2