Which antiplatelet agents are used for the treatment of middle cerebral artery (MCA) stroke?

Updated: Feb 20, 2018
  • Author: Daniel I Slater, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Answer

Medication selection is based on the etiology of the MCA stroke, comorbidities, and past medical history. Commonly used antiplatelet agents include aspirin, dipyridamole/aspirin, and clopidogrel. An increased bleeding risk is common to all of the medications within this class. Of note, prasugrel is contraindicated in patients with a history of stroke [70] and ticagrelor is only approved for use in patients with acute coronary syndrome. [71] While warfarin remains a common oral anticoagulant, newer agents include apixaban, dabigatran, and rivaroxaban.

Table 1. Hematologic Agents Mechanisms of Action and Considerations (Open Table in a new window)

Drug

Mechanism of Action

Consideration

Antiplatelets

Aspirin

Inhibits cyclo-oxygenase

May also be used to treat mild to moderate pain and headaches

Dipyridamole/aspirin

Inhibits platelet adenosine uptake and cyclo-oxygenase [72]

Twice daily dosing

Headaches are a common adverse effect, which may limit tolerability of therapy [73]

Clopidogrel

Blocks platelet adenosine diphosphate (ADP) P2Y12 receptor [74]

Avoidance of omeprazole and esomeprazole with clopidogrel was recommended in the 2009 FDA release warning about reduced efficacy [75]

Anticoagulants

Apixaban

Direct factor Xa inhibitor [76]

Not recommended for use in patients with CrCl < 15 mL/min or severe liver impairment

Dabigatran

Direct thrombin inhibitor [77]

Dosage adjustment needed for CrCl 50 mL/min or less

Rivaroxaban

Direct factor Xa inhibitor [78]

Dosage adjustment needed for CrCl 50 mL/min or less

Underweight patients have a slightly increased level/response [78]

Warfarin

Inhibits formation of vitamin-K dependent clotting factors [79]

Dosing based on international normalized ratio

Multiple food and drug interactions [79]


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