Titrated Initiation of Acetylsalicylic Acid-Dipyridamole Therapy Reduces Adverse Effects and Improves Tolerance in Patients With Stroke

Background Standard aspirin (acetylsalicylic acid [ASA])-dipyridamole therapy twice daily is associated with high rates of discontinuation in large part because of headache and gastrointestinal side effects. Attempts to address dipyridamole-induced headache through reduced dose initiation have produced variable results. Moreover, it has been suggested that migraineurs are more likely to have a dipyridamole-induced headache. Objective We sought to evaluate whether titrated initiation of ASA-dipyridamole in patients with stroke/transient ischemic attack (TIA) improves tolerance and to assess the appearance of headache in those with pre-existing history of headaches. Methods ASA-dipyridamole (25/200 mg) once daily together with ASA (81 mg) daily was started in 130 patients given the diagnosis of stroke/TIA with instructions to increase ASA-dipyridamole to twice daily after 7 days and discontinue ASA (81 mg). Patients received a telephone call on days 7 and 14 to assess for adverse events, discontinuation, and recurrent stroke/TIA. Results Two patients were lost to follow-up. After 2 weeks, 113 patients were using the medication without any major complications. Fifteen patients were off therapy; 10 (8%) patients stopped because of headache and/or gastrointestinal symptoms, whereas 4 patients were switched to other antiplatelet agents by their primary care physician as a matter of choice rather than ASA-dipyridamole side effects. One patient had recurrent stroke because of intracranial dissection and was switched to anticoagulation. Only 4 of 27 (14%) patients with a history of headache discontinued therapy. Conclusions Titrated initiation of ASA-dipyridamole (25/200 mg) appears to have low discontinuation rate and ∼90% tolerance after 2 weeks. History of migraine or tension headaches was not directly associated with discontinuation because of headaches.