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Guideline 708FM Antiplatelets and Rivaroxaban 2.5 Mg Tablets For

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Guideline 708FM Antiplatelets and Rivaroxaban 2.5 Mg Tablets For 708FM.5.1 ANTIPLATELETS AND RIVAROXABAN 2.5 mg TABLETS FOR SECONDARY PREVENTION OF OCCLUSIVE VASCULAR EVENTS Purpose/Scope • This guideline covers the use of antiplatelets and rivaroxaban 2.5 mg tablets following an occlusive vascular event. • It does NOT cover the use of these agents following an occlusive vascular event if the patient is anticoagulated for another indication. Duration of dual antiplatelet therapy (DAPT) or single antiplatelet plus rivaroxaban 2.5 mg tablets When these medicines are started in secondary care, VERY clear information about duration of treatment needs to be communicated to primary care so that a stop date can be put on EMIS for all repeat prescriptions. To achieve this: • The discharging clinician will clearly document the DURATION of treatment and STOP DATE on discharge letters and discharge prescriptions. • The validating pharmacist will check that the DURATION and STOP DATE are recorded on discharge prescriptions and pharmacy staff will document this on hospital pharmacy medicine labels. It will be reinforced via counselling of patients. Gastrointestinal (GI) bleeding risk assessment for DAPT: Use appendix 1 to decide whether gastro protective medicine is needed. Antiplatelet intolerance: See algorithms 1 and 2 and their footnotes. CONTENTS ALGORITHM 1. Transient ischaemic attack (TIA), ischaemic stroke, intracranial stenosis: Immediate and long term management ........................................................................................... 2 ALGORITHM 2. Acute coronary syndrome (ACS), stable angina, stent thrombosis, vascular disease: Long term management ................................................................................................... 3 TABLE 1. Doses for immediate and long term management of ACS, stable angina, stent thrombosis, and vascular disease (based upon first choice treatment) ............................................ 4 EXTENDED PROPHYLAXIS WITH MORE THAN ONE AGENT FOR HIGH RISK ISCHAEMIC PATIENTS ...................................................................................................................................... 4 ADDITIONAL PRESCRIBING INFORMATION IN ACS ................................................................... 5 Ticagrelor ................................................................................................................................. 5 Prasugrel ................................................................................................................................. 6 Clopidogrel .............................................................................................................................. 6 Rivaroxaban............................................................................................................................. 6 General Points ......................................................................................................................... 7 BACK-UP INFORMATION/ADVICE ................................................................................................ 8 REFERENCES ............................................................................................................................... 8 APPENDIX 1: Assessment of Gastrointestinal (GI) bleeding risk in patients prescribed dual antiplatelet therapy (DAPT) ........................................................................................................... 10 Guideline 708FM.5.1 1 of 10 Uncontrolled if printed ALGORITHM 1. Transient ischaemic attack (TIA), ischaemic stroke, intracranial stenosis: Immediate and long term management Suspected TIA Minor ischaemic Definite/probable Possible TIA Cardioembolic Severe Intracranial (awaiting scan stroke (non- TIA (uncertain ischaemic ischaemic stenosis and stroke cardioembolic) with diagnosis) stroke stroke consultant NIHSS score <=3 review) (After clinical assessment from stroke team) Aspirin 300 mg daily up to Aspirin 300 mg FOURTEEN STAT Aspirin 300 mg AND DAYS (until clopidogrel 300 mg Aspirin 300 mg daily for 14 Aspirin 300 mg anticoagulant STAT days STAT Aspirin 300 mg STAT AND STAT (if not started) AND refer clopidogrel 300 mg STAT given already) to Trust NOAC† team for review (stroke physicians can prescribe Aspirin 75 mg NOAC but to be daily AND Aspirin 75 mg daily AND referred to NOAC clopidogrel 75 mg Aspirin 300 mg clopidogrel 75 mg daily* for team to follow up) daily* for THREE daily for 14 days THREE weeks** Clopidogrel months** (patient should be seen in TIA clinic 75 mg daily LONG within this time Clopidogrel 75 mg Direct oral TERM frame. If not, then daily LONG TERM anticoagulant/ aspirin continue aspirin Clopidogrel 75 mg OR aspirin 75 mg warfarin as per OR Clopidogrel 75 mg 75 mg daily 75 mg daily)* daily LONG daily LONG NOAC team or stroke daily LONG TERM* TERM* physician*** if intolerant* TERM* Note: Refer to Appendix 1 for assessment of gastrointestinal (GI) bleeding risk in patients prescribed dual antiplatelet therapy * For true aspirin and/or clopidogrel intolerance, dipyridamole M/R can be continued in existing patients. For new patients, contact stroke physician on-call (SPOC) ** The discharge summary/letters and hospital Pharmacy medicine labels will record the stop date for DAPT and this will be reinforced via counselling of patients. *** For those patients who require both anticoagulation and antiplatelet treatment (e.g. patients who have carotid stenosis/concomitant large artery disease and Atrial fibrillation related stroke), the duration of the antiplatelet will be determined by the treating stroke physician. Hospital to supply full course of aspirin (3 weeks for minor ischaemic stroke/TIA and 3 months for intracranial stenosis). † NOAC = Novel oral anticoagulant Guideline 708FM.5.1 2 of 10 Uncontrolled if printed ALGORITHM 2. ACS, stable angina, stent thrombosis, vascular disease: Long term management (see Table 1 for doses) Established After ACS After stable angina After stent PAD or thrombosis on multivascular clopidogrel disease or No STEMI + primary PCI*, All other ACS DES stent Diabetes + acute PCI*, or +/- PCI* Prasugrel ACS + CABG Clopidogrel + aspirin‡ Clopidogrel + LONG TERM LONG TERM aspirin‡ FOR Ticagrelor + aspirin‡ SIX or TWELVE FOR TWELVE MONTHS^ MONTHS^^^ Prasugrel CI or Clopidogrel CI Clopidogrel CI not tolerated or not tolerated Ticagrelor CI or or not tolerated not tolerated Ticagrelor Aspirin‡ ‡ Prasugrel + aspirin FOR + aspirin‡ LONG Clopidogrel + aspirin‡ SIX or TWELVE LONG TERM TERM FOR TWELVE MONTHS^ MONTHS^^^ Prasugrel CI or Abbreviations Clopidogrel CI not tolerated ACS Acute coronary syndrome or not tolerated * Drug eluting stent CABG Coronary artery bypass graft ‡ Ticagrelor + aspirin CI Contraindicated Prasugrel + aspirin‡ FOR FOR SIX or TWELVE DES Drug eluting stent TWELVE MONTHS^ MONTHS^^^ MI Myocardial infarction PAD Peripheral arterial disease PCI Percutaneous coronary intervention Aspirin‡ LONG TERM^^ STEMI ST elevation myocardial infarction ‡ ^^ Aspirin LONG TERM TIA Transient ischaemic attack ^Some high risk MI patients may require ticagrelor 60 mg twice daily + aspirin 75 mg daily as extended prophylaxis for up to 3 years (NICE TA 420) ^^Some high risk MI patients may require rivaroxaban 2.5 mg twice daily + aspirin 75 mg daily as extended prophylaxis long term (NICE TA 607 and TA 335) ^^^Duration of antiplatelet therapy will be guided by the cardiologist based upon the ischaemic and bleeding risk. ‡ For true aspirin intolerance in stable angina with no stent, switch to clopidogrel 75 mg daily. For true aspirin intolerance in all other patients, seek specialist advice using e-Referral Service (ERS) Advice and Guidance or by contacting the cardiologist on-call via switchboard. Guideline 708FM.5.1 3 of 10 Uncontrolled if printed TABLE 1. Doses for immediate and long term management of ACS, stable angina, stent thrombosis, and vascular disease (based upon first choice treatment). See also extended prophylaxis below. After an occlusive vascular Immediate treatment in hospital Followed by event STEMI + primary PCI Ticagrelor 180 mg STAT (even if Ticagrelor 90 mg twice daily and OR clopidogrel has been given in the aspirin 75 mg daily FOR TWELVE ACS + diabetes + acute PCI ambulance or if the patient is taking MONTHS. clopidogrel regularly) and aspirin The duration of dual therapy is not 300 mg STAT affected by the type of stent used. ACS + CABG Awaiting CABG Then: (not suitable for PCI) Ticagrelor 90 mg twice daily and Aspirin 75 mg daily LONG TERM aspirin 75 mg daily Loading dose for CABG Ticagrelor 180 mg STAT and aspirin 300 mg STAT ACS +/- PCI (drug eluting Non-STEMI (NSTEMI)/Unstable Clopidogrel 75 mg daily and aspirin stent) angina (UA) 75 mg daily FOR TWELVE Clopidogrel* 300 mg STAT and MONTHS. aspirin 300 mg STAT The duration of dual therapy is not affected by the type of stent used. Then: Aspirin 75 mg daily LONG TERM Stable angina + stent (drug Clopidogrel* 300 mg STAT and Clopidogrel 75 mg daily and aspirin eluting stent) aspirin 300 mg STAT 75 mg daily FOR SIX or TWELVE MONTHS followed by aspirin 75 mg daily LONG TERM Stable angina – no stent Aspirin 75 mg daily Aspirin 75 mg daily LONG TERM Stent thrombosis whilst taking Prasugrel 60 mg STAT and Prasugrel 10 mg daily** and clopidogrel aspirin 300 mg STAT aspirin 75 mg daily LONG TERM Stent thrombosis whilst taking Ticagrelor 180 mg STAT and aspirin Ticagrelor 90 mg twice daily and clopidogrel where prasugrel is 300 mg STAT aspirin 75 mg daily LONG TERM CI or not tolerated * Clopidogrel loading dose should be administered
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