Know new medications for transient ischemic attacks
There are new drugs being used for treatment of transient ischemic attacks (TIAs), as noted in the Dallas-based American Heart Association Stroke Councils’ new guidelines.
"Aspirin was a gold standard and continues to be, but there are now other options," says Susan Unipan Rodriguez, BSN, CNRN, nurse coordinator for the National Institutes of Health/National Institute for Neurological Disorder and Stroke (NINDS), Stroke Branch/Stroke Diagnostics and Therapeutics, based in Bethesda, MD.
Aspirin is not necessarily the best intervention for each patient, notes Rodriguez. "Now you can ask what is the best therapy to optimize TIA and stroke prevention for this patient, because there are other choices."
Here are some medication options that you may encounter with TIA patients in the ED:
• Aggrenox (colpedogrel).
This combination therapy of dipyridamole and aspirin, manufactured by Gaithersburg, MD-based Boehringer Ingleheim Therapeutics, has just been approved by the Food and Drug Administration, says Rodriguez. "This is a very effective antiplatelet agent with very few side effects," she reports. The only common side effect is a transient headache. "It is a very good alternative to aspirin therapy alone."
• Ticlid (ticlopidine).
This antiplatelet drug, manufactured by Nutley, NJ-based Roche Pharmaceuticals, has some side effects including diarrhea and neutropenia, notes Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of emergency medicine at University Hospital, University of Cincinnati Medical Center and consultant for the National Stroke Association, based in Englewood, CO.
The patient needs to have regular labs drawn while they are on this drug, Spilker says. "Because of the need for ongoing testing, it can be difficult to manage," she notes.
• Plavix (clopidogrel).
This antiplatelet drug, manufactured by Princeton, NJ-based Bristol-Myers Squibb, is also recommended for strokes. It also is used in prevention of coronary artery disease, notes Spilker. The safety profile of the drug is at least as good as that of aspirin, according to the guidelines. It does not require chronic laboratory testing like Ticlid and has few side effects, which increases patient compliance.
• Coumadin (warfarin).
For patients with present with a TIA who have atrial fibrillation, Coumadin (warfarin) is the most beneficial prophylaxis and is recommended, says Rodriguez. It is manufactured by DuPont Pharmaceuticals in Wilmington, DE.
There was a great deal of controversy over which patients benefit the most from the use of warfarin, Rodriguez notes. "It can be a difficult drug to regulate. It requires that patients are followed long-term for blood level monitoring, since there is an associated risk of bleeding and its efficacy depends on coagulation levels."
However, the new guidelines recommend the drug for specific groups of patients at risk.
Patients with atrial fibrillation have a 35% higher risk for stroke, Rodriguez says. "Warfarin has been shown in numerous studies to be the most effective stroke prophylaxis for patients with atrial fibrillation. It certainly has been shown to decrease their risk for returning to the ED with a stroke."1-3
References
1. Laupacis A, Albers G, Dalen J, et al. Antithrombotic therapy in atrial fibrillation. Chest 1995; 108:352S-359S.
2. Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation (SPAF) Study: Final results. Circulation 1991; 84:527-539.
3. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin vs. aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation Study. Lancet 1994; 343:687-691.
For more information about the new American Heart Association guidelines for management of transient ischemic attacks (TIAs), contact:
• Susan Unipan Rodriguez, BSN, CNRN, National Institutes of Health/NINDS, Stroke Branch — Stroke Diagnostics and Therapeutics, 10 Center Drive, Building 10, Room 3B10, Bethesda, MD 20892. Telephone: (301) 402-7365. E-mail: [email protected].
• Judith Ann Spilker, RN, Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Bethesda Ave., Cincinnati, OH 45267-0769. Telephone: (513) 558-5430. Fax: (513) 558-6299. E-mail: [email protected].
Single copies of the American Heart Association Stroke Council guidelines, Supplement to the Guidelines for the Management of Transient Ischemic Attacks, are available at no charge. Ask for reprint No. 71-0179. To order, contact:
• American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Telephone: (800) 242-8721 or (202) 785-7900. Fax: (202) 785-7955. Web site: www. americanheart.org.
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