Ischemic Stroke Medication

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Medication

Medication Summary

While only 1 drug, recombinant tissue-type plasminogen activator (alteplase or generically referred to as rt-PA), has demonstrated efficacy and effectiveness in treating acute ischemic stroke and is approved by the FDA, other medications are equally important. National consensus panels have included the use of antihypertensives, anticonvulsants, and osmotic agents in their recommendations. Additional agents may be required for comorbid illnesses in many patients with stroke.

Medications for the management of ischemic stroke can be distributed into the following categories:

  • Anticoagulation

  • Reperfusion

  • Antiplatelet

  • Neuroprotective

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Thrombolytics

Class Summary

Thrombolytic—more accurately, fibrinolytic—agents convert entrapped plasminogen to plasmin and initiate local fibrinolysis by binding to fibrin in a clot.

Alteplase (Activase)

Alteplase is a t-PA used in management of acute myocardial infarction (MI), acute ischemic stroke, and pulmonary embolism. Safety and efficacy with concomitant administration of heparin or aspirin during the first 24 hours after symptom onset have not been investigated.

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Anticonvulsants, Other

Class Summary

While seizures associated with stroke are relatively uncommon, recurrent seizures may be life threatening. Generally, agents used for treating recurrent convulsive seizures are also used in patients with seizures after stroke. Benzodiazepines, typically diazepam and lorazepam, are the first-line drugs for ongoing seizures.

Diazepam (Valium)

Diazepam acts on the gamma-aminobutyric acid (GABA) receptor complex in the limbic system and thalamus, producing a calming effect. The drug is useful in controlling active seizures and should be augmented by longer-acting anticonvulsants, such as phenytoin or phenobarbital.

Lorazepam (Ativan)

Lorazepam is a short-acting benzodiazepine with a moderately long half-life. It has become the drug of choice in many centers for treating active seizures.

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Antiplatelet Agents

Class Summary

Although antiplatelet agents have proved useful for preventing recurrent stroke or stroke after transient ischemic attacks (TIAs), efficacy in the treatment of acute ischemic stroke has not been demonstrated. Early aspirin therapy is recommended within 48 hours of the onset of symptoms but should be delayed for at least 24 hours after rt-PA administration. Aspirin should not be considered as an alternative to intravenous fibrinolysis or other therapies aimed at improving outcomes after stroke.

Aspirin (ASA)

Aspirin blocks prostaglandin synthetase action, which in turn inhibits prostaglandin synthesis and prevents the formation of platelet-aggregating thromboxane A2. It also acts on the hypothalamic heat-regulating center to reduce fever.

Dipyridamole and aspirin (Aggrenox)

The combination of extended-release dipyridamole and aspirin reduces the relative risk of stroke, death, and myocardial infarction (MI). It is used for the secondary prevention of ischemic stroke and TIAs.

Clopidogrel (Plavix)

Clopidogrel inhibits platelet aggregation and is used for secondary stroke prevention. It is indicated for the reduction of atherothrombotic events following a recent stroke.

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Anticoagulants, Hematologic

Class Summary

Anticoagulants such as warfarin are used for secondary stroke prevention.

Warfarin (Coumadin, Jantoven)

Warfarin is an anticoagulant used to reduce the risk of death, recurrent MI, and thromboembolic events such as stroke or systemic embolization after MI.

Dabigatran (Pradaxa)

Dabigatran is a competitive, direct inhibitor of thrombin that can prevent thrombus development. This agent inhibits free and clot-bound thrombin and thrombin-induced platelet aggregation. It may be used as an alternative to warfarin for the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent atrial fibrillation and risk factors for stroke or systemic embolization.

Rivaroxaban (Xarelto)

Rivaroxaban is a Factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. The dose is adjusted according to estimated creatinine clearance.

Apixaban (Eliquis)

Apixaban is a factor Xa inhibitor that inhibits platelet activation by selectively and reversibly blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It inhibits free and clot-bound factor Xa and prothrombinase activity. Although this agent has no direct effect on platelet aggregation, it does indirectly inhibit platelet aggregation induced by thrombin. Apixaban is indicated to reduce risk of stroke and systemic embolism associated with nonvalvular atrial fibrillation.

Edoxaban (Savaysa)

Edoxaban is a Factor Xa inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. A lower dose is needed with CrCl < 50 mL/min. Do not use with CrCL >95 mL/min. In the ENGAGE AF-TIMI 48 study, patients with NVAF with CrCL >95 mL/min had an increased rate of ischemic stroke with edoxaban 60 mg/day compared with patients treated with warfarin.

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Analgesics, Other

Class Summary

Hyperthermia in acute stroke is potentially harmful and should be treated. Agents with potential bleeding risk should be avoided, if possible.

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

Acetaminophen reduces fever by acting directly on hypothalamic heat-regulating centers, which increases the dissipation of body heat via vasodilation and sweating.

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Beta Blockers, Alpha Activity

Class Summary

Optimal blood pressure management in acute stroke remains subject to some debate. Treatment parameters depend largely on whether the patient is a candidate for fibrinolytic therapy. While the target blood pressures may differ, the therapeutic agents are primarily the same.

Labetalol (Normodyne, Trandate)

Labetalol is an adrenergic receptor-blocking agent with nonselective beta-adrenergic and selective alpha1 competitive receptor-blocking actions. It produces dose-related decreases in blood pressure without inducing reflex tachycardia.

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ACE Inhibitors

Class Summary

Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Enalapril (Vasotec)

An ACE inhibitor, enalapril decreases circulating angiotensin II levels and suppresses the renin-angiotensin-aldosterone system, lowering overall blood pressure.

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Calcium Channel Blockers

Class Summary

Optimal blood pressure management in acute stroke remains subject to some debate. Treatment parameters depend largely on whether the patient is a candidate for fibrinolytic therapy. While the target blood pressures may differ, the therapeutic agents are largely the same.

Nicardipine (Cardene)

A calcium channel blocker, nicardipine inhibits calcium ion influx into vascular smooth muscle and myocardium. [92]

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Vasodilators

Class Summary

Vasodilators lower blood pressure through direct vasodilation and relaxation of the vascular smooth muscle. They are used more for blood pressure lowering in severe or refractory situations and should be used with caution.

Nitroprusside sodium (Nipride, Nitropress, Sodium Nitroprusside)

Nitroprusside sodium is a vasodilator that decreases peripheral vascular resistance by relaxing arteriolar smooth muscle. It also decreases venous return through venous dilation.

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