Compounding Pharmacists Support Long-Term Management of Ischemic Stroke in Young Adults
If you consider stroke a disease that primarily targets the elderly, you’ll be surprised to learn that one-third of all strokes occur before the age of 65. The risk does increase with age, but as stroke-related deaths in the elderly are dropping, the number of ischemic strokes in young adults is rising. Beyond recuperating from the stroke, these patients must follow a strict medication, diet and exercise regimen for the rest of their lives. Compounding pharmacists can guide them through medication management and compounded options that help these young adults stick with the plan.
Stats for Ischemic Stroke in Young Adults
The vast majority of the nearly 800,000 yearly strokes in the United States—82 to 92 percent—are ischemic strokes.1 Ten to 15 percent of ischemic strokes occur in young adults, and that number is predicted to rise.2 The definition of “young adult” varies with researchers using age ranges that start at 19 or 20 and span to ages 45 to 54. One study published in the Journal of Neurology reviewed information from 104 patients between 19 to 45 who were treated for acute ischemic stroke. Based on TOAST and ASCO classifications, the following causes were reported3:
- Cardiac origin – 21.2 percent based on TOAST vs 10.6 percent based on ASCO
- Macroangiopathic – 10.6 percent vs 8.7 percent
- Microangiopathic – 9.6 percent vs 9.6 percent
- Other causes – 19.2 percent vs 13.5 percent
- Undetermined causes – 39.4 percent vs 19.2 percent
Acute ischemic stroke is often associated with cardiac dysfunction and arrhythmia, which holds true for nearly one-fourth of young adults. But the fact that nearly 40 percent of acute ischemic strokes can’t be traced to a specific cause means that long-term management is crucial.
Risk Factors and Prognosis for Ischemic Stroke
Due to their age, experts used to associate stroke in young adults with rare risk factors, such as inflammatory arteritis, cardiomyopathy, reversible cerebral vasoconstriction syndrome and several hypercoagulable factors, but more recent studies show that rare risk factors were overestimated, while traditional vascular risk factors may have been underestimated. The top risk factors reported in the Journal of Neurology were:
- Smoking – 55.2 percent
- Hypertension – 31.4 percent
- Hyperlipidemia – 27.6 percent
Another study found similar results but in a different order. Dyslipidemia topped the list at nearly 53 percent, followed by smoking and hypertension.4 About 30 percent of young adults suffers an ischemic stroke as a result of patent foramen ovale.
The one-year survival rate is in the range of 77 percent, but the long-term prognosis doesn’t improve due to their age. Like all stroke patients, a patient’s outlook depends on individual risk factors, such as:
- Older than 40
- History of transient ischemic attack
- History of type 1 diabetes
- Taking antihypertensive medication
- Cardiac pathology
As the number of risk factors increase, prognosis decreases. Compared with the general population of stroke patients, the long-term prognosis for young adult stroke patients is worse, as they have a higher death rate and an increased risk of cardiovascular events. Young adults are also more likely to experience functional limitations that affect their quality of life. Even 10 years after their ischemic stroke, 13 percent of young adults still don’t function independently.5 While these statistics are grim, it’s important to focus on the flip side—87 percent of survivors continue to live their lives, knowing they must follow a strict medical regimen and lifestyle changes in order to protect their health and prevent another stroke.
Pharmaceutical and Lifestyle Treatments Need Support from Pharmacists
Young adults who suffered a stroke due to an unknown cause must follow long-term monitoring for atrial fibrillation and strictly adhere to the medications prescribed by their physician, which may include:
- Antiplatelet therapy: Aspirin can be used alone, but clopidogrel or a combination of aspirin and dipyridamole are safer and more effective for preventing stroke recurrence and other vascular events. Clopidogrel has a higher risk of adverse effects such as rash and diarrhea, but a lower chance of stomach upset or bleeding compared with aspirin.
- Anticoagulant therapy: Long-term treatment is essential for patients with atrial fibrillation or other conditions that cause blood clots. Warfarin, dabigatran, apixaban, rivaroxaban and edoxaban can all be considered.
- Antihypertensive medications: Elevated LDL and total cholesterol increase the risk of ischemic stroke, while lowering blood pressure can reduce the risk by 30 to 40 percent. Any class of antihypertensive can be used. Evidence supports statin therapy, especially if the patient also has atherosclerosis. Diuretics alone or together with angiotensin-converting enzyme inhibitor also work for some patients. Fibrates and niacin are no longer recommended by the American Heart Association (AHA) because evidence doesn’t support their ability to raise HDL or reduce secondary stroke risk.
The American Heart Association Guidelines for secondary prevention of stroke emphasize nutrition and lifestyle with the goal of controlling weight, blood pressure and diabetes. Patients who had have an ischemic stroke should be screened for diabetes, obesity and sleep apnea. If necessary, they should be referred for a nutritional assessment and dietary planning that includes, for example, a low-fat Mediterranean-style diet. Additionally, patients should be recommended for smoking cessation when necessary. Adding folic acid, either in supplemental or dietary form, may also help prevent future strokes.
Compounding pharmacists can help support the complex and lifelong regimen these young adults must follow. A few ways to help improve compliance to their regimen include:
- Compounded options: For patients taking multiple medications, recommend a combined tablet or alternate forms such as liquid or sublingual to make it easier to take meds.
- Topical pain treatments: Topical NSAIDs may be an option for patients who need pain relief but can’t risk the adverse effects of oral NSAIDs.
- Medication review: Most of these patients will take multiple prescription and OTC meds. Scheduling a regular time to review doses, check for interactions and assess compliance is one of the most critical ways you can help young stroke survivors.
Pharmacists Can Help Ensure Long-Term Medication Adherence in the Management of Ischemic Stroke in Young Adults
Whether it’s three months, a year or 10 years following an ischemic stroke, young adults depend on the consistent counseling and answers they receive from pharmacists. You have the opportunity to provide diverse services such as blood pressure screening, compounded pharmaceuticals and OTC products that help ensure these patients live a long and productive life.
Pharmaceutica North America provides the high-quality bulk pharmaceuticals, compounding kits and OTC supplements you need to promote the health of your patients. Contact us today to learn how we can support the needs of your pharmacy.
- “Ischemic Stroke,” November 2015, http://emedicine.medscape.com/article/1916852-overview ↩
- “Six Things to Know About Strokes in Young Patients,” April 2016, http://www.pharmacytimes.com/news/6-things-to-know-about-stroke-in-young-patients/P-3 ↩
- “Ischemic Stroke in Young Adults: Classification and Risk Factors,” April 2012, http://www.ncbi.nlm.nih.gov/pubmed/21927959 ↩
- “Risk Factor and Etiology Analysis of Ischemic Stroke in Young Adult Patients,” March 2014, http://www.ncbi.nlm.nih.gov/pubmed/24418315 ↩
- “Stroke in Young Adult: Risk Factors and Prognosis,” February 2015, http://www.neurologyadvisor.com/stroke/stroke-young-adults-risk-factors-prognosis/article/396250/ ↩