Annals of Long Term Care

American Society of Consultant Pharmacists 40th Annual Meeting
Anaheim, CA; November 18-20, 2009

Reducing the Risk of Secondary Stroke

Anaheim, CA—Transient ischemic attack (TIA) and stroke are significant health concerns for the elderly, and TIA often serves as a warning sign of increased risk for future stroke. According to the American Heart Association, nearly 87% of stroke deaths occur in individuals age 65 and older; an estimated 24% of nursing home residents have had a stroke. Dr. Nerses Sanossian, Assistant Professor, Neurocritical Care and Stroke Section, Department of Neurology, Keck School of Medicine, Los Angeles, CA, discussed therapeutic options for prevention of secondary stroke in older persons at the ASCP annual meeting.

New recommendations in 2008 from the American Heart Association and American Stroke Association guidelines recommend antiplatelet therapy over oral anticoagulation for patients with noncardioembolic ischemic stroke of TIA; for class I, level of evidence B, there is a stronger indication for dipyridamole plus aspirin over aspirin alone (Sacco RL et al, Stroke, 2006). The National Stroke Association guidelines recommend daily long-term antiplatelet therapy with combination extended-release dipyridamole and aspirin as first choice for reducing risk of stroke following noncardioembolic TIA (Johnston SG et al, Ann Neurol, 2006). In patients with TIA or thrombotic stroke not due to cardioembolism, the American Medical Directors Association recommends lifelong antiplatelet therapy, including aspirin, aspirin plus extended-release dipyridamole, or clopidogrel, to reduce the risk of thrombotic stroke.

The European Stroke Prevention Study (ESPS 2), a randomized, placebo-controlled, double-blind trial, investigated the safety and efficacy of low-dose acetylsalicylic acid (ASA), extended-release dipyridamole, and the two agents in combination for secondary prevention of ischemic stroke. Patients with prior stroke or TIA were randomized to treatment with ASA alone (50 mg daily), extended-release dipyridamole alone (400 mg daily), the two agents in a combined formulation, or placebo. Primary end points were stroke, death, and stroke or death together. TIA and other vascular events were secondary end points. Patients were followed on treatment for 2 years. Data from 6602 patients were analyzed and found a highly significant effect for ASA and for dipyridamole in reducing the risk of stroke (P ≤ 0.001) and stroke or death combined (P < 0.01). In pairwise comparisons, stroke risk in comparison to placebo was reduced by 18% with ASA alone (P = 0.013); 16% with dipyridamole alone (P = 0.039); and 37% with combination therapy (P < 0.001). Risk of stroke or death was reduced by 13% with ASA alone (P = 0.016); 15% with dipyridamole alone (P = 0.015); and 24% with the combination (P < 0.001). The treatment had no statistically significant effect on the death rate alone. Factorial analysis also demonstrated a highly significant effect of ASA (P < 0.001) and dipyridamole (P < 0.01) for preventing TIA. The risk reduction for the combination was 36% (P < 0.001) in comparison with placebo. Headache was the most common adverse event, occurring more frequently in dipyridamole-treated patients. All-site bleeding and gastrointestinal bleeding were significantly more common in patients who received ASA in comparison to placebo or dipyridamole. Investigators concluded that the combination was significantly more effective than either agent alone.

__________________

Managing Osteoporosis in Senior Care

Anaheim, CA—Many residents of long-term care facilities are at high risk for fracture.