Don’t use ticagrelor PLUS aspirin after stroke

Stick with clopidogrel (Plavix, Clopex) plus aspirin when using short-term dual antiplatelet therapy after a minor stroke or high-risk TIA....

As a hospital pharmacist, you will hear ticagrelor (Brilique, Brilinta) plus aspirin promoted after a MINOR ischemic stroke or high-risk TIA. New evidence shows that taking this combo for 30 days after a minor stroke or high-risk TIA decreases the composite of death or stroke in 1 in 91 patients, compared to aspirin monotherapy.

But the benefit is mostly from reducing stroke risk, the combo doesn’t seem to reduce mortality alone OR improve disability scores. And it leads to severe bleeding, usually intracranial hemorrhage, in 1 in 263 patients. Put this new evidence into perspective. A short course of up to 21 days of CLOPIDOGREL (Plavix) plus aspirin also decreases stroke risk in these patients. There aren’t head-to-head comparisons of these combos, but major bleeding risk seems similar. And clopidogrel (Plavix) plus aspirin isn’t shown to increase risk of intracranial hemorrhage. Plus ticagrelor (Brilique) must be taken BID, and can cause dyspnea.

Stick with clopidogrel (Plavix, Clopex) plus aspirin when using short-term dual antiplatelet therapy after a minor stroke or high-risk TIA. Keep in mind, these patients generally have an NIH stroke scale score of 3 or less, or an ABCD2 score of 4 or more for TIA, and haven’t received thrombolytics.
Start clopidogrel plus aspirin within 24 hours of symptom onset, it’s too soon to say if there’s benefit when started later.
Follow up post discharge to ensure patients switch to monotherapy after no more than 21 days of the combo, generally to aspirin.
Get our note, "Antiplatelets options for recurrent ischemic stroke" for more updated information about antiplatelets therapy for stroke.

References

Johnston SC, Amarenco P, et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med. 2020 Jul 16;383(3):207-217.
Johnston SC, Easton JD, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018 Jul 19;379(3):215-225.
Prasad K, Siemieniuk R, Hao Q, Guyatt G, et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ. 2018 Dec 18;363:k5130.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.