- GENERIC clopidogrel is now recommended as the first line option, with no restriction on duration of treatment.
- If treatment with clopidogrel is contraindicated or not tolerated, then aspirin may be used in combination with MR dipyridamole, with no restriction on duration of treatment.
- If both clopidogrel and aspirin are contraindicated or not tolerated, then treat with MR dipyridamole alone with no restriction on duration of treatment§.
Transient Ischaemic Attack (TIA)
- Long term clopidogrel is recommended for TIA, although it is not licensed for this indication. Ensure that the patient or carers are informed of off-licence use.
- Treatment with aspirin in combination with MR dipyridamole is recommended as an option where Clopidogrel is either contra-indicated or not tolerated, but now there is no restriction on duration of treatment.
- If treatment with aspirin or clopidogrel is contraindicated or not tolerated, then treat with MR dipyridamole alone with no restriction on duration of treatment§.
Myocardial Infarction (MI)
- Aspirin remains the first line option.
- If treatment with aspirin is contraindicated or not tolerated, then treat with GENERIC clopidogrel.
- This guidance should be considered alongside existing NICE guidance on clopidogrel in combination with aspirin in people with unstable angina or NSTEMI (CG94); and those who have had an MI (CG48).
§ Although not discussed in this guidance, if treatment with clopidogrel and/or dipyridamole is contraindicated or not tolerated, treatment with aspirin alone would be a logical choice.
Ischaemic stroke in AF
|Use aspirin for the following types of stroke: |
|Acute ischaemic stroke (without primary intracerebral haemorrhage): |
| Give aspirin 300mg as soon as possible within 24 hours (see box below). |
| > Give orally if the person is not dysphagic. |
| > Give rectally or by enteral tube if they have dysphagia. |
| > Continue aspirin 300mg for two weeks (or until discharged from hospital if |
| sooner), then start long-term antiplatelets or anticoagulants as indicated. |
| > Give a proton pump inhibitor with aspirin if dyspepsia with aspirin has previously |
| been reported. |
| Transient Ischaemic Attack |
| > Start daily aspirin (300mg) immediately. |
| > Introduce measures for secondary prevention once diagnosis is confirmed. |
| > Assess risk of subsequent stroke. |
| Immediate assessment |
| > Use FAST (Face Arm Speech Test) in primary care to screen for diagnosis of stroke |
| or TIA in people with sudden onset of neurological symptoms. |
| > Admit anyone with suspected stroke to a specialist unit. |
Treatment and management
Dipyridamole is used as an adjunct to oral anticoagulation for prophylaxis of thromboembolism associated with prosthetic heart valves. The combination of modified-release (MR) dipyridamole and aspirin is recommended for people who have had a transient ischaemic attack (TIA). Thereafter, or if MR dipyridamole is not tolerated, preventative therapy should revert to standard care (including long-term treatment with low-dose aspirin).
Clopidogrel is used in acute coronary syndrome in combination with aspirin for up to 12 months, after which clopidogrel is stopped (and aspirin continued) unless otherwise advised by the consultant cardiologist. It is also given following an ST-elevated myocardial infarction with aspirin for 28 days, after which clopidogrel is stopped and aspirin continued long term.
Clopidogrel alone is only recommended for people who are intolerant of low-dose aspirin and either have experienced an occlusive vascular event or have symptomatic peripheral arterial disease. Aspirin intolerance is defined as either of the following: proven hypersensitivity to aspirin-containing medicines, OR a history of severe dyspepsia induced by low dose aspirin.
Clopidogrel should not be used concomitantly with aspirin in the secondary prevention of stroke or TIA due to the increased bleeding risk.
Prasugrel NICE TA317
Prasugrel 10 mg in combination with aspirin is recommended as an option within its marketing authorisation, for preventing atherothrombotic events in adults with acute coronary syndrome (unstable angina [UA], non-ST segment elevation myocardial infarction [NSTEMI] or ST segment elevation myocardial infarction [STEMI]) having primary or delayed percutaneous coronary intervention.
The summary of product characteristics for prasugrel states that it should be started with a single 60 mg loading dose and then continued at 10 mg once a day. People taking prasugrel should also take 75 mg to 325 mg aspirin daily. Treatment for up to 12 months is recommended unless stopping prasugrel is clinically indicated.
According to the summary of product characteristics, the use of prasugrel in people 75 years or older is generally not recommended. However, if treatment is deemed necessary a reduced maintenance dose of 5 mg should be prescribed. For people who weigh less than 60 kg, the summary of product characteristics states that the 10 mg maintenance dose is not recommended and the 5 mg maintenance dose should be used. For people with unstable angina or NSTEMI, if coronary angiography is performed within 48 hours after admission, the summary of product characteristics states that the loading dose should only be given at the time of percutaneous coronary intervention.
Ticagrelor (Brilique®) in combination with aspirin is recommended as an option for preventing atherothrombotic events in people with acute coronary syndromes, covering STEMI (with PCI), NSTEMI and unstable angina (NICE TA236).
Ticagrelor (Brilique®) in combination with aspirin, is recommended as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event. (NICE TA420). Treatment should be stopped when clinically indicated or at a maximum of 3 years.