Alternatives to Aspirin

The question then arises as to prevention in patients who cannot tolerate aspirin. Persantin and sulphinpyrazone do not appear to be of value alone, nor is there evidence that they add anything to aspirin when given in combination. (30,57).

While ticlopidine (Ticlid) has been shown to have an efficacy in stroke prevention similar to that of aspirin it has not been adequately tested after myocardial infarction. Furthermore, ticlopidine leads to a severe neutropenia in about 0.8% of patients.(58)

Clopidogrel (Plavix), a derivative of ticlopidine, appears to be safer, and has been shown in a large randomised trial to have a prophylactic effect after myocardial infarction which is virtually identical to aspirin.(59)

Other Alternatives to Aspirin are being vigorously sought and have been somewhat optimistically termed ‘Super-aspirins’! The hope is that new preparations can be found that will be be significantly superior to aspirin, the certainty is that any that do reach the market will be vastly more expensive than aspirin. At the same time, the mechanism of action on platelets of these new drugs is likely to be different to aspirin and so their effects could be additive. It is to be hoped therefore that clinical trials will be factorial - an opportunity sadly missed in CAPRIE.(59)

Clopidogerel (Plavix)
In CAPRIE59 aspirin and Clopidgrel, a derivative of Ticlopidine, were compared over a three year period in over 20,000 patients with recent ML, stroke or peripheral vascular disease.

All cause deaths:
aspirin 3.05%; Clopidogrel 3.11% (difference P=0.71)
Incidence of all vascular events:
aspirin 5.83% Clopidogrel 5.32% (difference P=0.04)
Vascular deaths:
aspirin 2.06% Clopidogrel 2.00% (difference P=0.29)