Note: Gastroprotection

Antiplatelet monotherapy (low dose aspirin or clopidogrel):

  • patients with low gastrointestinal (GI) bleeding risk: if patients develop dyspepsia whilst on antiplatelet monotherapy consider co-prescription of ranitidine150mg twice daily initially; if ineffective change to lansoprazole (start on treatment dose but aim to reduce to maintenance dose to minimise Clostridioides difficile (CDI) risk*).
  • patients with higher GI bleeding risk**: co-prescribe lansoprazole on initiation of antiplatelet monotherapy. Consider the risk of CDI when prescribing antibiotics in the future.

Antiplatelet dual therapy (low dose aspirin and clopidogrel/ticagrelor/prasugrel):

  • lansoprazole is indicated in dual therapy if age and co-morbidity confer a significant risk in the event of GI bleeding. Consider the risk of CDI when prescribing antibiotics in the future.

*Patients at high risk of infection with CDI are those with any of the following risk factors:

  • a history of previous CDI or known colonisation with CDI (eg glutamate dehydrogenase (GDH) positive)
  • age over 65 years
  • co-prescription of high risk antibiotics namely clindamycin, cephalosporins, co-amoxiclav and fluoroquinolones (eg ciprofloxacin)
  • immunocompromised or severe co-morbidity.

** Patients at high risk of GI adverse effects are those with any of the following risk factors:

  • a history of gastroduodenal ulcer, GI bleeding or gastroduodenal perforation
  • concomitant use of medications known to increase the risk of GI bleeds (see BNF)
  • older age especially if frail, with serious co-morbidities, eg cardiovascular disease, hepatic or renal impairment, diabetes, hypertension.

ASPIRIN - (First line)

Therapy notes

For patients with swallowing difficulties, consider rectal aspirin administration. There is no proven additional benefit of using aspirin enteric-coated tablets over the dispersible formulation.

Formulation and dosage details

Formulation:

Dispersible tablets 75mg, 300mg

Dosage:

75mg daily for secondary prevention of thrombotic cerebrovascular or cardiovascular disease, and following coronary stenting. 

Following bypass surgery, aspirin 300mg daily is given initially reducing at a variable interval to 75mg to 150mg daily as defined by the surgeon; if clopidogrel is given concomitantly, only aspirin 75mg daily is given.

Aspirin, used in combination with rivaroxaban (specialist initiation only), as per CAD/PAD guideline.

Formulation and dosage details

Formulation:

Suppositories 150mg, 300mg unlicensed

CLOPIDOGREL

Therapy notes

  • Clopidogrel 75mg daily is a suitable alternative to aspirin if the patient has a further event while on aspirin or where aspirin is contra-indicated or genuinely not tolerated (ie proven hypersensitivity to aspirin-containing medicines or history of severe dyspepsia induced by low-dose aspirin which is unresponsive to PPI co-prescription).
  • See gastroprotection advice above. The risk of gastro-intestinal complications with clopidogrel is as high as with aspirin. Most of the benefit is seen early after starting treatment, however the increased risk of bleeding remains throughout the course; liaise with Cardiologist if appropriate. Combination of aspirin and clopidogrel further increases the risk of GI bleeding.
  • Clopidogrel is contra-indicated in active bleeding.
  • Discontinue 7 days before elective surgery; if in doubt discuss with Consultant Surgeon (if a person with a stent requires clopidogrel this must be discussed with Cardiologist).

Formulation and dosage details

Formulation:

Tablets 75mg

Dosage:

Secondary prevention of myocardial infarction, cerebrovascular disease or atherosclerotic events in peripheral arterial disease, 75mg daily. See: Secondary prevention post myocardial infarction and Lipid lowering therapy in the prevention/treatment of atherosclerosis.

Acute coronary syndromes (unstable angina (if new ECG changes), ST elevation MI, non-ST elevation MI), initial loading dose of 300mg then 75mg daily.

Dual antiplatelet therapy with aspirin and clopidogrel (or ticagrelor or prasugrel) is more usually prescribed on the advice of the specialist following acute coronary syndrome. Duration of therapy is decided on an individual basis.

Formulation and dosage details

Formulation:

Tablets 300mg (s)

Dosage:

Acute coronary syndromes (unstable angina (if new ECG changes), ST elevation MI, non-ST elevation MI), initial loading dose of 300mg then 75mg daily.

PRASUGREL

Therapy notes

Formulation and dosage details

Formulation:

Tablets 5mg, 10mg (Specialist initiation only)

Dosage:

By mouth, initially 60mg as a single dose then, body weight over 60kg, 10mg once daily or body weight under 60kg or over 75 years, 5mg once daily.  For cardiologist initiation in combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome.

TICAGRELOR

Therapy notes

There is a small risk of episodic breathlessness with ticagrelor which is usually self-limiting.

Formulation and dosage details

Formulation:

Tablets 90mg (specialist initiation or recommendation only)

Dosage:

By mouth, initially 180mg as a single dose, then 90mg twice daily. For cardiologist initiation in combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome.

Formulation and dosage details

Formulation:

Orodispersible tablets 90mg (specialist initiation or recommendation only)

Dosage:

By mouth, initially 180mg as a single dose, then 90mg twice daily. For cardiologist initiation in combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome.

TIROFIBAN

Therapy notes

Formulation and dosage details

Formulation:

Concentrate for intravenous infusion 12·5mg/250mL (Hospital use only)

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