From the Guidelines
Yes, it is possible to be on dual antiplatelet therapy (DAPT) and cilostazol simultaneously, which is sometimes called "triple antiplatelet therapy." This combination is occasionally used in specific high-risk patients with peripheral artery disease or after certain cardiovascular procedures. DAPT typically consists of aspirin (81-325 mg daily) plus a P2Y12 inhibitor such as clopidogrel (75 mg daily), while cilostazol (100 mg twice daily) works through a different mechanism as a phosphodiesterase inhibitor. However, this combination significantly increases bleeding risk and should only be used under careful medical supervision, as noted in studies such as 1.
The rationale for this combination in select cases is that cilostazol provides additional benefits for claudication symptoms and may have different antiplatelet effects than traditional DAPT medications. Patients on this combination should be monitored closely for bleeding complications, and the duration of triple therapy is typically limited to the shortest necessary period. Guidelines such as those from the American College of Chest Physicians suggest the use of cilostazol in addition to aspirin or clopidogrel for patients with refractory claudication despite exercise therapy and smoking cessation 1.
It's also worth noting that more recent guidelines, such as the 2024 ESC guidelines for the management of chronic coronary syndromes, discuss the importance of balancing the risk of bleeding with the need for antithrombotic therapy in patients with coronary syndromes, although they do not specifically address the combination of DAPT and cilostazol 1. Anyone considering this combination should discuss the specific risks and benefits with their healthcare provider, as individual patient factors greatly influence the appropriateness of this approach. Key considerations include:
- The patient's specific cardiovascular risk factors and history
- The potential benefits of cilostazol for claudication symptoms or other indications
- The increased risk of bleeding associated with triple antiplatelet therapy
- The need for close monitoring and regular follow-up to minimize risks.
From the Research
Dual Antiplatelet Therapy (DAPT) and Cilostazol
- DAPT combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases 2.
- Cilostazol, a phosphodiesterase III inhibitor, has been shown to significantly improve high on-treatment platelet reactivity in patients receiving both aspirin and clopidogrel 3.
- The use of cilostazol in addition to aspirin and clopidogrel (triple antiplatelet therapy) has been associated with a significantly greater platelet inhibition, reduced major adverse cardiovascular events, target lesion revascularization, and target vessel revascularization with no increased risk for a hemorrhagic event 3.
Benefits and Risks of Combining DAPT and Cilostazol
- Adding cilostazol to DAPT may benefit secondary prevention and claudication 2.
- The combination of DAPT and cilostazol may provide added benefits, but should be weighed against the risk of bleeding 2.
- In patients with stable ischemic heart disease, the use of long-duration DAPT is being investigated, and cilostazol may be a potential addition to DAPT in certain cases 4.
Specific Patient Populations
- In patients with extracranial arterial stenosis, the benefit of DAPT with cilostazol is uncertain, while in patients without arterial stenosis, DAPT with cilostazol may be beneficial for prevention of recurrent stroke and vascular events 5.
- In patients undergoing percutaneous coronary intervention, the addition of cilostazol to DAPT has been shown to reduce major adverse cardiovascular events and restenosis 3.