Aspirin

• Dispersible tablets 75mg, 300mg (£0.77 = 75mg daily)

Indications

• Secondary prevention of thrombotic cerebrovascular or cardiovascular disease
• Following coronary by-pass surgery
• Acute migraine

Dose

• Usual dosage, for long term use, is 75-150mg once daily
• Dose for pain: By mouth, 300–900mg every 4–6 hours when necessary; maximum 4g daily

Notes

1. Offer antiplatelet drugs to people with CKD for the secondary prevention of cardiovascular disease, but be aware of the increased risk of bleeding that increases with severity of CKD.
2. Low-dose aspirin is generally well tolerated, but it can cause gastrointestinal (GI) adverse effects. Gastroprotection using a proton pump inhibitor may be considered in people taking low dose aspirin in the following situations:
   1. People with prior history of a GI bleed
   2. People without symptoms but at high risk of GI adverse effects (e.g. co-morbidities or other medications associated with increased GI risk)
   3. anyone with current dyspepsia
3. Taking aspirin with a PPI is more effective at preventing recurrent ulcer bleeding in people with previous aspirin-induced bleeding ulceration, than switching from aspirin to clopidogrel.
4. Stop concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) if possible: the risk of serious GI complications increases significantly in people who regularly take an antiplatelet drug and an NSAID.
5. Owing to an association with Reye's syndrome, aspirin-containing preparations should not be given to children under 16 years, unless specifically indicated, e.g. for Kawasaki disease.

Clopidogrel

• Tablets 75mg (£1.11)

Notes

1. NICE TA210: Evidence-based recommendations on clopidogrel and modified-release dipyridamole for preventing occlusive vascular events in adults (December 2010):
   1. Clopidogrel is recommended as an option to prevent occlusive vascular events:
      1. for people who have had an ischaemic stroke or who have peripheral arterial disease or multivascular disease or
      2. for people who have had a myocardial infarction only if aspirin is contraindicated or not tolerated.
   2. Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation.

Dipyridamole

• Modified-release capsules 200mg (£13.15 = 60 capsules)

Dose

• Modified-release: one capsule twice daily

Notes

1. NICE TA210: Evidence-based recommendations on clopidogrel and modified-release dipyridamole for preventing occlusive vascular events in adults (December 2010):
   1. Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events:
      1. for people who have had a transient ischaemic attack or
      2. for people who have had an ischaemic stroke only if clopidogrel is contraindicated or not tolerated.
   2. Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events:
      1. for people who have had an ischaemic stroke only if aspirin and clopidogrel are contraindicated or not tolerated or
      2. for people who have had a transient ischaemic attack only if aspirin is contraindicated or not tolerated.

Prasugrel

• Tablets 5mg, 10mg (£35.57 = 28 tablets x 5mg, £4.94 = 28 tablets x 10mg)

Indications

• In combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Dose

• Initially 60mg as a single dose then, body-weight over 60kg 10mg once daily or body-weight under 60kg, or over 75 years of age, 5mg once daily
• The treatment period for prasugrel should not exceed 12 months

Notes

1. NICE TA317 Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention (July 2014)
2. To be initiated only by a Consultant Cardiologist in line with NICE guidance and also for patients who otherwise would be treated with clopidogrel but who are intolerant / allergic to clopidogrel. The use of prasugrel in this patient group is only within the licensed indications for prasugrel. Allergy/intolerance is defined as a skin reaction such as rash or puritis
3. MHRA Drug Safety Update (May 2011): Prescribers should be aware of the potential risk of rare but serious hypersensitivity reactions with prasugrel and should monitor for signs in all patients, including those with a previous known history of hypersensitivity reactions to thienopyridines. When prescribing prasugrel, inform patients of the potential risk of hypersensitivity reactions, including angioedema.

Ticagrelor

• Tablets 60mg, 90mg (£54.60)

Indications and dose

• In combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome (ACS):
  • initially 180mg as a single dose, then 90mg twice daily for a maximum of 12 months
• In combination with aspirin for the prevention of atherothrombotic events after myocardial infarction (MI) in those at high risk of a further event:
  • 60mg twice daily for a maximum of 3 years as continuation therapy after the initial 12 months treatment with ticagrelor 90mg twice daily (or other adenosine diphosphate (ADP) receptor inhibitor therapy in patients with ACS). Treatment can also be started up to 2 years from the MI, or within 1 year after stopping previous ADP receptor inhibitor treatment

Notes

1. High risk of a further atherothrombotic event, the presence of at least 1 of the following 5 risk factors:
   1. Age 65 years or over or
   2. Diabetes mellitus requiring medication or
   3. A 2nd prior MI or
   4. Evidence of multi-vessel coronary artery disease or
   5. Chronic non-end stage renal dysfunction (creatinine clearance <60ml/min)
2. Please refer to: NICE TA236 Ticagrelor for the treatment of acute coronary syndromes (October 2012). To be initiated only by a Consultant Cardiologist in line with NICE guidance.
3. Please refer to: NICE TA420 Ticagrelor for preventing atherothrombotic events after myocardial infarction- guidance (December 2016)

Abciximab

• Injection 10mg in 5ml

Notes

1. Please refer to:
   1. NICE TA47 Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors (September 2002)
   2. NICE CG94 Unstable angina and NSTEMI (March 2010)

Eptifibatide

• Solution for injection 2mg/1ml
• Solution for infusion 750micrograms/1ml

Notes

1. NICE TA47: Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors (September 2002)
2. NICE TA230: Myocardial infarction (persistent ST-segment elevation) – bivalirudin (July 2011)
3. NICE CG94: Unstable angina and NSTEMI (March 2010)