The settings in which clopidogrel and modified-release dipyridamole can be prescribed on the NHS to prevent occlusive vascular events have been revised.
In an update of its 2005 guidance, NICE has recommended clopidogrel as an option in patients who have had a myocardial infarction and cannot take aspirin. The antiplatelet agent can also now be prescribed, regardless of aspirin tolerance, for patients with peripheral arterial disease or multivascular disease, and those who have had an ischaemic stroke.
Modified-release dipyridamole can now be given on its own to patients who have had an ischaemic stroke (if aspirin and clopidogrel are contraindicated or not tolerated) or a transient ischaemic attack (TIA, if aspirin is contraindicated or not tolerated).
Use of modified-release dipyridamole plus aspirin in patients who have had an ischaemic stroke or a TIA is no longer limited to a maximum duration of 2 years. However, use of the combination for secondary prevention after ischaemic stroke is now restricted to individuals in whom clopidogrel is contraindicated or not tolerated.
Patients currently receiving clopidogrel or modified-release dipyridamole who do not meet the new criteria should have the option to continue treatment until it is appropriate to stop.
The guidance update was prompted by the availability of clopidogrel as a generic and by the publication of two major secondary prevention studies in patients with ischaemic stroke:
- ESPRIT (n = 2,736), which reported a significantly reduced risk of non-fatal stroke, non-fatal myocardial infarction, major bleeding or death from vascular causes for modified-release dipyridamole plus aspirin versus aspirin alone (hazard ratio [HR] 0.80; 95% CI 0.66–0.98).
- PRoFESS (n = 20,332), which showed that treatment with modified-release dipyridamole plus aspirin was associated with similar rates of recurrent stroke as treatment with clopidogrel.