NHS Somerset recommends people prescribed long term NSAIDs, antiplatelet or an anticoagulant should be considered for co-prescribing with a PPI to reduce GI bleed risk.
For PPIs see NHS Somerset Formulary Gastric acid disorders and ulceration.
Related guidance:
- Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.
- Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed.
- Offer the following as soon as possible, but certainly within 24 hours, to everyone presenting with acute stroke who has had a diagnosis of intracerebral haemorrhage excluded by brain imaging:
• aspirin 300 mg orally if they do not have dysphagia or
• aspirin 300 mg rectally or by enteral tube if they do have dysphagia.
Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks. - Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported.
- Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin.
- Ensure that people with disabling ischaemic stroke who are in atrial fibrillation are treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered.
- For people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, stop anticoagulation treatment for 1 week and substitute aspirin 300 mg.
- Ensure that people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation.
- Clopidogrel is recommended as an option to prevent occlusive vascular events:
• for people who have had an ischaemic stroke or who have peripheral arterial disease or multivascular disease or
• for people who have had a myocardial infarction only if aspirin is contraindicated or not tolerated. - Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events:
• for people who have had a transient ischaemic attack or
• for people who have had an ischaemic stroke only if clopidogrel is contraindicated or not tolerated. - Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events:
• for people who have had an ischaemic stroke only if aspirin and clopidogrel are contraindicated or not tolerated or
• for people who have had a transient ischaemic attack only if aspirin is contraindicated or not tolerated. - Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation.
Antiplatelet treatment (CKS November 2022)
Type 2 diabetes in adults: management NICE guideline (NG28 December 2015,updated June 2022)
- Do not offer antiplatelet therapy (aspirin or clopidogrel) to adults with type 2 diabetes without cardiovascular disease.
- Do not routinely offer aspirin for primary prevention of CVD.
Acute coronary syndromes NICE guideline (NG185 November 2020)
- For people with acute STEMI who are having primary PCI, offer:
• Prasugrel, as part of dual antiplatelet therapy with aspirin, if they are not already taking an oral anticoagulant (use the maintenance dose in the prasugrel summary of product characteristics; for people aged 75 and over, think about whether the person’s risk of bleeding with prasugrel outweighs its effectiveness, in which case offer ticagrelor or clopidogrel as alternatives)
• Clopidogrel, as part of dual antiplatelet therapy with aspirin, if they are already taking an oral anticoagulant. - Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, to people with acute STEMI not treated with PCI, unless they have a high bleeding risk.
- Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, for people with acute STEMI not treated with PCI, if they have a high bleeding risk.
- For people with unstable angina or NSTEMI who are having coronary angiography, offer:
• prasugrel or ticagrelor, as part of dual antiplatelet therapy with aspirin, if they have no separate indication for ongoing oral anticoagulation (if using prasugrel, only give it once coronary anatomy has been defined and PCI is intended, and use the maintenance dose in the prasugrel summary of product characteristics; for people aged 75 and over, think about whether the person’s risk of bleeding with prasugrel outweighs its effectiveness)
• clopidogrel, as part of dual antiplatelet therapy with aspirin, if they have a separate indication for ongoing oral anticoagulation. - Offer aspirin to all people after an MI and continue it indefinitely, unless they are aspirin intolerant or have an indication for anticoagulation.
- Offer aspirin to people who have had an MI more than 12 months ago and continue it indefinitely.
- Continue dual antiplatelet therapy for up to 12 months after an MI unless contraindicated.
- For people with aspirin hypersensitivity who have had an MI, clopidogrel monotherapy should be considered as an alternative treatment.
- People with a history of dyspepsia should be considered for treatment in line with the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.
- After appropriate treatment, people with a history of aspirin-induced ulcer bleeding whose ulcers have healed and who are negative for Helicobacter pylori should be considered for treatment in line with the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.
- Offer clopidogrel instead of aspirin to people who also have other clinical vascular disease, in line with the NICE technology appraisal guidance on clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events, and who have:
• had an MI and stopped dual antiplatelet therapy or
• had an MI more than 12 months ago. - For people who have a separate indication for anticoagulation, take into account all of the following when thinking about the duration and type (dual or single) of antiplatelet therapy in the 12 months after an acute coronary syndrome:
• bleeding risk
• thromboembolic risk
• cardiovascular risk
• person’s wishes. - Be aware that the optimal duration of aspirin therapy has not been established, and that long-term continuation of aspirin, clopidogrel and oral anticoagulation (triple therapy) significantly increases bleeding risk.
- For people already on anticoagulation who have had PCI, continue anticoagulation and clopidogrel for up to 12 months. If the person is taking a direct oral anticoagulant, adjust the dose according to bleeding risk, thromboembolic risk and cardiovascular risk.
- For people with a new indication for anticoagulation who have had PCI, offer clopidogrel (to replace prasugrel or ticagrelor) for up to 12 months and an oral anticoagulant licensed for the indication, which best matches the person’s:
• bleeding risk
• thromboembolic risk
• cardiovascular risk
• wishes. - For people already on anticoagulation, or those with a new indication, who have not had PCI (medical management, CABG), continue anticoagulation and, unless there is a high risk of bleeding, consider continuing aspirin (or clopidogrel for people with contraindication for aspirin) for up to 12 months.
- Do not routinely offer prasugrel or ticagrelor in combination with an anticoagulant that is needed for an ongoing separate indication for anticoagulation.
- For people with an ongoing indication for anticoagulation 12 months after an MI, take into consideration all of the following when thinking about the need for continuing antiplatelet therapy:
• indication for anticoagulation
• bleeding risk
• thromboembolic risk
• cardiovascular risk
• person’s wishes. - For secondary prevention, offer people who have had MI treatment with the following drugs:
• angiotensin-converting enzyme (ACE) inhibitor
• dual antiplatelet therapy (aspirin plus a second antiplatelet) unless they have a separate indication for anticoagulation.
Stable angina: management Clinical guideline (CG126 July 2011, updated August 2016)
- Consider aspirin 75 mg daily for people with stable angina, taking into account the risk of bleeding and comorbidities.
Atrial fibrillation: diagnosis and management NICE guideline (NG196 April 2021, updated June 2021)
- Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation.
- Ticagrelor, in combination with aspirin, is recommended within its marketing authorisation as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event.
- Treatment should be stopped when clinically indicated or at a maximum of 3 years.
- Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes (ACS) that is, people:
• with ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or
• with non-ST-segment-elevation myocardial infarction (NSTEMI) or
• admitted to hospital with unstable angina – defined as ST or T wave changes on electrocardiogram suggestive of ischaemia plus one of the characteristics - age 60 years or older; previous myocardial infarction or previous coronary artery bypass grafting (CABG); coronary artery disease with stenosis of 50% or more in at least two vessels; previous ischaemic stroke; previous transient ischaemic attack, carotid stenosis of at least 50%, or cerebral revascularisation; diabetes mellitus; peripheral arterial disease; or chronic renal dysfunction, defined as a creatinine clearance of less than 60 ml per minute per 1.73 m2 of body-surface area.
- Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.
- Prasugrel 10 mg in combination with aspirin is recommended as an option for preventing atherothrombotic events in adults with acute coronary syndrome (unstable angina, non-ST segment elevation myocardial infarction or ST segment elevation myocardial infarction) having primary or delayed percutaneous coronary intervention.
- Treatment for up to 12 months is recommended unless stopping prasugrel is clinically indicated.
Hypertension in pregnancy NICE Quality standard (QS35 July 2013, updated July 2019)
- Pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75 mg to 150 mg of aspirin to take daily from 12 weeks until birth.
- Women are at an increased risk of pre-eclampsia if they have 1 high risk factor or more than 1 moderate risk factor for pre-eclampsia.
- High risk factors include:
• hypertensive disease in a previous pregnancy
• chronic kidney disease
• autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension.
Moderate risk factors include:
• first pregnancy
• age 40 years or older
• pregnancy interval of more than 10 years
• body mass index (BMI) of 35 kg/m2 or more at first visit
• family history of pre-eclampsia
• multi-fetal pregnancy.
Using antiplatelet medicines during breastfeeding (SPS July 2023)
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Antithrombotic drugs, Antiplatelet drugs | |||
 Aspirin - suitable for self-care | 75mg dispersible tablet: £0.73 | Enteric coated aspirin is non-formulary as current evidence suggests it does not exert a demonstrably protective effect on the gastric mucosa and its effect in the secondary prevention of arterial thrombosis is unclear. Offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75 mg to 150 mg of aspirin to take daily from 12 weeks until birth. Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately. Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed. Offer the following as soon as possible, but certainly within 24 hours, to everyone presenting with acute stroke who has had a diagnosis of intracerebral haemorrhage excluded by brain imaging: • aspirin 300 mg orally if they do not have dysphagia or • aspirin 300 mg rectally or by enteral tube if they do have dysphagia. Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time start definitive long-term antithrombotic treatment. Start people on long-term treatment earlier if they are being discharged before 2 weeks. Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic stroke for whom previous dyspepsia associated with aspirin is reported. Offer an alternative antiplatelet agent to anyone with acute ischaemic stroke who is allergic to or genuinely intolerant of aspirin. Ensure that people with disabling ischaemic stroke who are in atrial fibrillation are treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered. For people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation, stop anticoagulation treatment for 1 week and substitute aspirin 300 mg. Ensure that people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation. For secondary prevention, offer people who have had MI treatment with dual antiplatelet therapy (aspirin plus a second antiplatelet) unless they have a separate indication for anticoagulation. Consider aspirin 75 mg daily for people with stable angina, taking into account the risk of bleeding and comorbidities. For acute tension-type headache and migraine, take 1 to 3 (300mg) tablets with water, every 4 hours. Do not take more than 4 doses in any 24 hours. Antiplatelets should not be prescribed routinely for the primary prevention of cardiovascular disease, however, they may be considered in people at high risk of stroke or myocardial infarction. Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation. Do not offer antiplatelet therapy (aspirin or clopidogrel) to adults with type 2 diabetes without cardiovascular disease. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s. |
|
| 300mg dispersible tablet: £1.23 (32) | |||
| NHS Somerset classify Aspirin enteric coated and modified release as Black (not recommended) as per Traffic light guidance. | |||
| Clopidogrel | 75mg tablet: £1.36 | Clopidogrel is recommended as an option to prevent occlusive vascular events (including TIA): • for people who have had an ischaemic stroke or who have peripheral arterial disease or multivascular disease or • for people who have had a myocardial infarction only if aspirin is contraindicated or not tolerated. Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation. |
|
| Dipyridamole | 200mg modified-release capsule: £13.15 (60) | Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events: • for people who have had a transient ischaemic attack or • for people who have had an ischaemic stroke only if clopidogrel is contraindicated or not tolerated. Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events: • for people who have had an ischaemic stroke only if aspirin and clopidogrel are contraindicated or not tolerated or • for people who have had a transient ischaemic attack only if aspirin is contraindicated or not tolerated. |
|
| Prasugrel | 5mg tablet: £37.60 | ||
| 10mg tablet: £7.50 | |||
| Ticagrelor | 60mg tablet: £54.60 | ||
| 90mg tablet: £54.60 | |||
| 90mg orodispersible tablet sugar free: £54.60 | |||