Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
2.9 Antiplatelet drugs
Related guidance: NICE Technology Appraisal TAG210 (2010): Clopidogrel and modified-release dipyridamole

NICE TA420 Ticagrelor for preventing atherothrombotic events after myocardial infarction
Ticagrelor for the treatment of acute coronary syndromesTechnology appraisal guidance [TA236] October 2011
Anti-platelet drugs

Consideration should be given to providing PPI cover for patients on antiplatelets to minimise risk of GI bleeds
Aspirin75mg dispersible tablets: £0.99pATT meta-analysis : Aspirin for primary prevention of CVD
Aspirin is not licensed for the primary prevention of vascular events but there remains the possibility for particular sub-groups of individuals at higher CV risk that the risk:benefit of aspirin is favourable. Until more evidence is available, the use of Aspirin 75mg for primary prevention should be based on an individual risk assessment.

NICE NG28 Type 2 diabetes in adults: management (2015) recommends that antiplatelet therapy (aspirin or clopidogrel) should not be offered to adults with type 2 diabetes without cardiovascular disease.

Aspirin is included in the formulary for:
- Secondary prevention of CV events: see notes regarding use in combination with Dipyridamole or Clopidogrel below
NB There is evidence that:
- Aspirin doses >75mg daily increase GI toxicity and general bleed risk
Enteric-coated Aspirin does not reduce GI events and may be less effective
NICE NG128 Stroke and TIA May 2019
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

75mg tablets: £1.44Clopidogrel is recommended by NICE 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 TIA(off license criteria apply for individual patient assessment)
Clopidogrel is also included in the formulary for:
- patients with true aspirin allergy who require secondary prevention of cardiac or vascular disease
- patients who have had an NSTEMI, regardless of treatment (up to 12 months)
- patients who have had a STEMI and received a bare-metal or drug-eluting stent for up to 12 months (new for 2013)
- patients who have had a STEMI and medical management with or without reperfusion treatment with a fibrinolytic agent [new 2013] (at least 1 month and up to 12 months).
 - alternative to aspirin in people who also have other clinical vascular disease, in line with Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (NICE TA 210), and who have:
- had an MI and stopped dual antiplatelet therapy or
- had an MI more than 12 months ago [new 2013].

In all cases where clopidogrel is initially used in combination with aspirin, when the clopidogrel is stopped, anti-platelet therapy continues with aspirin 75mg daily alone.

Patients requiring treatment with clopidogrel and PPI should avoid omeprazole and esomeprazole which may reduce the effects of clopidogrel on platelet function and lead to poorer long-term patient outcomes (death and readmission). The effect of clopidogrel is also antagonised by calcium-channel blockers and some statins
Dipyridamole m/r200mg m/r capsules: £10.06 (60)Modified-release dipyridamole alone is recommended by NICE 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, or if clopidogrel (unlicensed use) has been excluded.

Prescribers should ensure that all prescriptions for prasugrel have a stop date and that no repeats are issued after that date.
5mg tablets: £47.56
10mg tablets:£47.56
Prasugrel 10mg in combination with aspirin is recommended as an option for preventing atherothrombotic events in people with acute coronary syndromes having percutaneous coronary intervention, only when:
• immediate primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction is necessary or
• stent thrombosis has occurred during clopidogrel treatment or
• the patient has diabetes mellitus.
Treatment should continue for 12 months unless discontinued earlier, e.g. for side effects (NICE TA317: Acute coronary syndrome - prasugrel)

Prescribers should ensure that all prescriptions for ticagrelor have a stop date and that no repeats are issued after that date

60 & 90mg tabs £54.60 (56)NICE TA236: Ticagrelor for the treatment of acute coronary syndromes Oct 2011
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 defined in section 1.2. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.

Dose is 180mg stat, then 90mg bd for 1 year in combination with aspirin unless contraindicated
In patients with acute coronary syndromes and with a high risk of an atherothrombotic event treatment may be started without interruption (continuation therapy) at 60mg bd after the initial 1‑year treatment with ticagrelor 90 mg or other adenosine diphosphate (ADP) receptor inhibitor therapy

Ticagrelor for preventing atherothrombotic events after myocardial infarction NICE TA420 Dec 2016
Ticagrelor 60 mg twice daily is the recommended dose when extended treatment is needed for patients with a history of myocardial infarction of at least 1 year and a high risk of an atherothrombotic event. Treatment can also be started up to 2 years from the myocardial infarction, or within 1 year after stopping previous ADP receptor inhibitor treatment.

Unless contraindicated, ticagrelor should always be given with a daily low maintenance dose of aspirin 75 mg to 150 mg.

There are limited data on the efficacy and safety of ticagrelor beyond 3 years of extended treatment.
Hyperglycaemia in ACS
Hyperglycaemia is common in people admitted to hospital with ACS. Hyperglycaemia at the time of admission with ACS is a powerful predictor of poorer survival and increased risk of complications while in hospital, regardless of whether or not the patient has diabetes.
All patients with hyperglycaemia after ACS and without known diabetes tests for should be tested for • HbA1c levels before discharge and • fasting blood glucose levels no earlier than 4 days after the onset of ACS.
GPs should offer at least annual monitoring of HbA1c and fasting blood glucose levels to people without known diabetes who have had hyperglycaemia after an episode of ACS