Transient ischaemic attack
Goals and outcomes
Goals
 | To correctly diagnose |
| To arrange urgent specialist assessment |
| To reduce risk of subsequent episodes or stroke |
Outcome Measures
| Time from presentation to GP to initial specialist assessment. |
Background information
CONTENT
| What is it? |
| How common is it? |
| How do I know my patient has it? |
| What else might it be? |
| Complications and prognosis |
What is it ?
| A transient ischaemic attack (TIA) is defined as sudden onset of focal neurological deficit or loss of monocular vision, which recovers within 24 hours and after adequate investigation is presumed to be due to embolic or thrombotic vascular disease. The majority of episodes last less than 30 minutes. [Rodgers, 1998; Warlow and Davenport, 1996] |
| The source of the embolism is from atheromatous plaques in the aorta, carotid or vertebrobasilar arteries, and occasionally the heart. |
How common is it ?
| Incidence of transient ischaemic attack (TIA) is 0.42 per 1000 population. [Rodgers, 1998] |
| A GP with a list size of 2000 patients will see five new patients with TIA or stroke each year. [Eccles et al. 1998] |
| About 15% of patients who suffer their first ever stroke have had preceding TIAs. [Warlow and Davenport, 1996] |
How do I know my patient has it ?
| Clinical history of sudden onset of transient focal neurological deficit or loss of monocular vision, usually lasts no longer than 30 minutes. If deficit lasts longer than 24 hours then defined as stroke. |
| Carotid (anterior) territory symptoms occur in 80% of patients: weakness or sensory symptoms affecting an arm, leg, or face, monocular visual loss (amaurosis fugax), dysphasia. |
| Vertebrobasilar (posterior) territory symptoms occur in 20% of patients: unsteadiness, diplopia, dysphagia, homonymous hemianopia, weakness (unilateral or bilateral), sensory symptoms (unilateral or bilateral). |
| Global symptoms by themselves are rarely due to TIA (for example, unsteadiness, dizziness, syncope). |
| Examination is rarely helpful, unless neurological signs are still present, but may provide clues such as hypertension, carotid bruits, or atrial fibrillation. Bruits are an unreliable guide to the presence or severity of carotid stenosis. |
[Rothwell and Warlow, 1997; DTB 1998]
What else might it be ?
There are many differential diagnoses of transient ischaemic attack (TIA), which include:
| Migrainous aura |
| Retinal/vitreous haemorrhage |
| Temporal arteritis (Giant cell arteritis) |
| Focal epileptic seizure |
| Intracranial structural lesion (eg, tumours, subdural haematomas) |
| Multiple sclerosis |
| Labyrinthine disorders |
| Peripheral nerve lesions |
| Transient global amnesia |
| Psychological disorders (includes hyperventilation) |
| Metabolic disturbance (eg, hypoglycaemia) [SIGN, 1997a; Warlow and Davenport, 1996] |
Complications and prognosis
| Subsequent stroke: The risk of stroke in the first year following a TIA is about 10%, with an annual risk of 7% during the next four years (seven times the risk of the normal population). [DTB, 1998; SIGN, 1997b; Warlow and Davenport, 1996] The risk is greater with frequent TIAs, cerebral rather than ocular events, and severe carotid stenosis. [Rodgers, 1998; Warlow and Davenport, 1996] |
| Other atheromatous event: The annual risk of myocardial infarction is about 2 - 3% and 35% of patients will eventually die of cardiac disease. The combined risk of stroke, myocardial infarction, or vascular death is about 9% per year.[Rodgers, 1998; Warlow and Davenport, 1996] |
Management issues
CONTENT
| General Issues |
| Antiplatelet treatment |
| Anticoagulation |
| Other drug treatments |
| Surgery |
General issues
| The diagnosis of transient ischaemic attack (TIA) is often uncertain, with considerable variation between different doctors regarding the likelihood of such a diagnosis. [Rothwell and Warlow, 1997] |
| Patients with suspected TIA require urgent assessment, as there is a significant risk of subsequent stroke that is greatest in the first few weeks following a TIA. [SIGN, 1997a; Rodgers, 1998; Warlow and Davenport, 1996] Local arrangements for this vary, although many districts now have fast-track assessment clinics. |
| Other vascular risk factors must be dealt with, eg smoking, hypertension, hyperlipidaemia, and diabetes mellitus. [SIGN, 1997a] |
| Hypertension is the single most important modifiable risk factor, with 26% of strokes attributable to raised blood pressure. [Medicines Resource, 1998] |
| Hyperlipidaemia should be managed in line with secondary prevention recommendations (see Hyperlipidaemia € secondary prevention clinical recommendation). Patients have a high risk of coronary heart disease and there is some evidence that lipid-lowering therapy may reduce the risk of stroke. [SMAC, 1997; SIGN, 1997a; Medicines Resource, 1998] |
Antiplatelet treatment
| Computed tomography is not necessary before starting treatment in patients with suspected or definite TIA. [Eccles et al. 1998] |
| Aspirin is first line therapy for secondary prevention of TIA/stroke. It inhibits platelet activation by inhibiting platelet cyclo-oxygenase and thromboxane A2 production. [Hankey et al. 1998] It reduces the 3 year risk of subsequent stroke, myocardial infarction or vascular death in patients with TIA by 22% (equivalent to treating 100 TIA patients for 3 years to prevent 4 major vascular events). [Antiplatelet Trialists' Collaboration. 1994; Eccles et al. 1998; Hankey et al. 1998] A dose of 75 mg is effective and is recommended in preference to higher doses, and should be continued long-term in at risk patients. [SIGN, 1997a; Eccles et al. 1998]. |
| Dipyridamole (with or without aspirin) is another option. Dipyridamole inhibits phosphodiesterase, resulting in increased intraplatelet levels of cyclic AMP and inhibition of thromboxane A2. Until recently there was little evidence of any benefit from dipyridamole, given alone or in combination with aspirin. [The American Canadian Co-operative Study Group., 1985; Antiplatelet Trialists' Collaboration. 1994] New evidence from the secondary prevention European Stroke Prevention Study 2 (ESPS2) showed modified-release dipyridamole (400mg daily) to be as effective at preventing stroke as very low dose aspirin (50mg daily), with 16% and 18% reduction in risk respectively. The combination was more effective than either drug given alone, with a 37% reduction in risk. All treatments were more effective than placebo. [Diener et al. 1996] The main concern regarding the validity of the results of this trial is that a lower than currently recommended dose of aspirin was used. [Medicines Resource, 1998] Current recommendation is still to use aspirin as first line therapy for the secondary prevention of stroke. [SIGN, 1997a; DTB, 1998; Eccles et al. 1998] Dipyridamole is advised for patients who are unable to tolerate aspirin.[DTB 1998] The combination might be considered for patients who have a TIA despite aspirin use [Rodgers, 1998], although there is no agreed consensus on this and some argue that a higher dose of aspirin should simply be given. There may be local guidance regarding its use. |
Anticoagulation
| Warfarin is much more effective than aspirin for the secondary prevention of TIA/stroke in patients with atrial fibrillation. [Koudstaal, 1998; Koudstaal, 1998] It should be considered when a definite source of cardiac embolism is identified eg, atrial fibrillation, valvular heart disease, recent MI, or dilated cardiomyopathy (see AF clinical recommendation). [Rothwell and Warlow, 1997; SIGN, 1997a; Rodgers, 1998] |
Other drug treatments
| Clopidrogrel and ticlodipine inhibit adenosine diphosphate (ADP)-mediated platelet activation. They may be more effective than aspirin, but more comparative data is needed. [Hankey et al. 1998] |
| Clopidrogrel has recently been licensed in the UK and may be appropriate for patients intolerant of aspirin or dipyridamole. It is considerably more expensive than aspirin. [Medicines Resource, 1998] |
| Ticlodipine has just become licensed for use in TIA and stroke. However, its use is limited by the need for regular blood monitoring due to the risk of neutropaenia and thrombocytopaenia, and its high cost compared with aspirin |
Surgery
| Carotid endarterectomy in a patient with severe symptomatic carotid stenosis (> 70% stenosis) markedly reduces the risk of stroke. [SIGN, 1997b; DTB 1998] In the trials, the perioperative risk of disabling stroke or death was less than 5%, although the risk outside trials is likely to be higher. [SIGN, 1997b; Rodgers, 1998] A careful balancing of risks and benefits is needed, taking into account co-morbidity, the expected life-span of the patient, and the likely risks of surgery. |
| Angioplasty - some reports of success, but more data awaited. [SIGN, 1997b] |
References
Cited
- Anonymous (1994) Collaborative overview of randomised trials of antiplatelet therapy - I: Prevention of death, myocardial infraction, and stroke by prolonged antiplatelet therapy in various categories in patients. BMJ 308, 81-106.
- Anonymous (1998) BNF. 36 edn, British Medical Association & Royal Pharmaceutical Society of Great Britain.
- Anonymous (1998) Managing carotid stenosis. Drug & Therapeutics Bulletin 36, 9-12.
- Anonymous (1998) Stroke prevention. Medicines Resource 199-202.
- Anon (1997) Which prophylactic aspirin? Drug & Therapeutics Bulletin 35, 7-8.
- Diener, H.C., Cunha, L., Forbes, C., Sivenius, J., Smets, P. and Lowenthal, A. (1996) European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. Journal of the Neurological Sciences 143, 1-13.
- Eccles, M., Freemantle, N. and Mason, J. (1998) North of England evidence based guideline development project: guideline on the use of aspirin as secondary prophylaxis for vascular disease in primary care. North of England Aspirin Guideline Development Group. BMJ 316, 1303-1309.
- Hankey, G. J., Sudlow, C. L. M., and Dunbabin, D. W. Thienopyridine derivatives (ticlopidine, clopidogrel) versus aspirin in the secondary prevention of stroke and other important vascular events among high risk patients. (Protocol for a Cochrane Review). The Cochrane Library (Issue 4, 1998). Update Software.
- Koudstaal, P. Secondary prevention following stroke or transient ischemic attack in patients with nonrheumatic atrial fibrillation: anticoagulant therapy versus control. The Cochrane Library (Issue 4, 1998). Update Software.
- Koudstaal, P. Secondary prevention following stroke or transient ischemic attack in patients with nonrheumatic atrial fibrillation: anticoagulant versus antiplatelet therapy. The Cochrane Library (Issue 4, 1998). Update Software.
- Rodgers, H. (1998) Features and treatment of transient ischaemic attacks. The Prescriber 9, 31-36.
- Rothwell, P.M. and Warlow, C.P. (1997) Management of transient ischaemic attacks: from clinical trials to individual patients. In: Horizons in Medicine No. 8, pp. 315-332. The Royal College of Physicians]
- Scottish Intercollegiate Guidelines Network (SIGN) (1997a) Management of patients with stroke Part 1.: Assessment, investigation, immediate management and secondary prevention. Pub. no. 13,
- Scottish Intercollegiate Guidelines Network (SIGN) (1997b) Management of patients with stroke Part 2 : Management of carotid stendosis and carotid endarterectomy. Pub. no. 14,
- Standing Medical Advisory Committee (SMAC) (1997) The Use of Statins. 11061 HCD, London: The Department of Health.
- The American Canadian Co-operative Study Group. (1985) Persantine Aspirin Trial in Cerebral Ischemia Part 2: endpoint results. Stroke 16, 406-415.
- Warlow, C.P. and Davenport, R.J. (1996) The management of transient ischaemic attacks. Prescribers' Journal 36, 1-8.
Background
- Anonymous (1997) Dipyridamole (Drug Update). Wolfson Unit, Claremont Place, Newcastle upon Tyne: NHS Northern and Yorkshire Regional Drug & Therapeutics Centre.
- Anonymous (1998) NNTs for stroke prevention. Bandolier 38,
- Sandercock, P. (1998) Transient ischaemic attacks: new treatments, new questions. Quarterly Journal of Medicine 91, 337-339.
Scenario: TIA (not in Atrial Fibrillation)
Which Therapy
| Strongly consider urgent assessment (eg, via fast-track TIA assessment clinic) - arrangements may vary depending on the local situation. |
| Treatment should not be delayed while waiting for this. |
| Aspirin is first line treatment. |
| Dipyridamole is an alternative for those intolerant to aspirin. |
| Combination of aspirin with dipyridamole might be considered for patients who have further TIAs on aspirin (although as yet no agreed consensus on this). |
| Both standard and modified release preparations of dipyridamole, and combinations of these with aspirin, are offered as there is no current consenus on which preparation to use. |
| Local guidance may be available regarding the use of these agents. |
| Deal with other vascular risk factors eg, smoking, hypertension, hyperlipidaemia, diabetes. (see relevant clinical recommendations) |
Clinically relevant side effects and cautions
See BNF for full details
Refer or Investigate
Refer ?
| Strongly consider urgent assessment (eg, via fast-track TIA assessment clinic) to clarify the diagnosis and decide on best management |
Investigate ?
| Initial primary care investigations : consider baseline blood tests (FBC, ESR, electrolytes, lipids, glucose), ECG and chest x-ray |
| Further investigations may be carried out in secondary care/TIA assessment clinics, and include carotid duplex ultrasound (and angiography in those identified as having possibly greater than 70% stenosis of the carotid artery); echocardiography if heart disease suspected; and cranial CT or MRI scanning. |
Shared Advice
| A transient ischaemic attack (TIA) occurs when a tiny 'flake' of clotted blood temporarily blocks the blood flow to a part of the brain. |
| Aspirin is advised. A low dose taken each day 'thins' the blood. This reduces the chance of blood clots forming causing a further TIA or stroke. |
| Dipyridamole is an alternative 'blood thinning' medicine if aspirin has side effects. |
| Aspirin with dipyridamole may be advised in certain situations. |
| Reducing risk factors is also important. Smoking should stop. Blood pressure and blood lipids needs to be checked and lowered if high. |
| Referral to a specialist is often advised after a TIA. This is to clarify the diagnosis. Some people with TIA also have very narrowed arteries leading to the brain and surgery may then be an option. |
Drug Rationale
Drugs not included
| Enteric coated aspirin is not usually required because the difference in gastro-intestinal toxicity at 75mg between plain and enteric coated tablets is minimal. [DTB, 1997]. |
| Clopidrogrel: recently licensed for the secondary prevention of stroke and may be moderately more effective than aspirin, but more data is needed. [Hankey et al. 1998; Medicines Resource, 1998] It is also very expensive. Clopidrogel might be considered in patients intolerant of both aspirin and dipyridamole. |
| Ticlodipine has just become licensed for use in TIA and stroke. However, its use is limited by the need for regular blood monitoring due to the risk of neutropaenia and thrombocytopaenia, and its high cost compared with aspirin. [Medicines Resource, 1998] |
| Warfarin and other anticoagulants: not advised for the secondary prevention of stroke in patients with TIA, unless underlying cardiac disorder or atrial fibrillation. |
Drugs included
| Aspirin 75mg is safe and effective in the secondary prevention of stroke. The 75mg dose is as effective as higher doses of aspirin. [Eccles et al. 1998] [Antiplatelets Trialists' Collaboration 1994] [Medicines Resource, 1998]. |
| Dipyridamole: evidence is strongly suggestive that this is as effective as low dose aspirin in the secondary prevention of stroke. [Diener et al. 1996]. It is advised for patients who are unable to tolerate aspirin. |
| Combination of aspirin and dipyridamole: there is as yet no consensus on when this should be used. Data from ESPS2 is very encouraging, but many feel more data is needed. Some suggest that it may be useful in patients who have further TIAs on aspirin. [Rodgers, 1998] |
| Both standard and modified release preparations of dipyridamole, and combinations of these with aspirin, are offered as there is no current consenus on which preparation to use. Modified-release preparations only are licensed for this indication. [DTB, 1998]. However these preparations are considerably more expensive than the standard release generic preparation and there may be local guidelines on their use. |
Therapy Group: Aspirin
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Aspirin 75mg tablets
for age: 192 to 3060
bu23.|Aspirin 75mg disp tabs|28 tablet(s)|Take one tablet daily|license|£0.07|£0.5|No warning|OK
Patient info: These may be purchased cheaply from a pharmacy
Therapy Group: Intolerant of aspirin- Dipyridamole
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Dipyridamole standard tablets - three times daily
for age: 192 to 3060
bu15.|Dipyridamole 100mg tablets|84 tablet(s)|Take one tablet three times a day|no license|£4.95||No warning|OK
Patient info:
Dipyridamole modified release -twice daily
for age: 192 to 3060
bu1C.|Dipyridamole 200mg m/r caps|60 capsules|Take one capsule twice a day|license|£9.75||No warning|OK
Patient info:
Therapy Group: Combination of Dipyridamole + aspirin
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Dipyridamole + aspirin modified release capsules
for age: 192 to 3060
bu41.|Dipyrid+Asp 200mg/25mg m/r cap|60 capsules|Take one capsule twice a day|license|£9.75||No warning|OK
Patient info:
Dipyridamole std+aspirin-separate bottles
for age: 192 to 3060
bu15.|Dipyridamole 100mg tablets|84|tablet(s)|Take one tablet three times a day|no license|£4.95||No warning|OK
Patient info:
bu23.|Aspirin 75mg disp tabs|28|tablet(s)|Take one tablet daily|license|£0.07|£0.5|No warning|OK
Patient info:
Dipyridamole MR+aspirin-separate bottles
for age: 192 to 3060
bu1C.|Dipyridamole 200mg m/r caps|60|capsules|Take one capsule twice a day|license|£9.75||No warning|OK
Patient info:
bu23.|Aspirin 75mg disp tabs|30|tablet(s)|Take one tablet daily|license|£0.07|£0.5|No warning|OK
Patient info:
Scenario: TIA (with Atrial Fibrillation)
Which Therapy
Confirm diagnosis of atrial fibrillation by ECG
Clinically relevant side effects and cautions
 | Previous intracranial haemorrhage |
| Gastrointestinal bleeding or genitourinary bleeding in preceding 6 months |
| Severe haemorrhage during previous anticoagulant therapy |
| Recent surgery to eye or central nervous system |
| Proliferative diabetic retinopathy |
| Repeated falls or unstable gait predisposing to head trauma |
| Recurrent syncope or uncontrolled seizure disorder |
| Uncontrolled hypertension |
| Inability to obtain adequate follow-up monitoring |
| Inability to comply with treatment |
| Chronic alcohol habituation |
| Chronic renal failure |
| Thrombocytopaenia (platelets < 100) |
| Anaemia (Hb < 10) |
| Concomitant use of NSAIDs |
Follow up?
| Patients on warfarin need regular monitoring of INR. |
| Ideally this should take place in an organised setting, with adequate management, follow-up and recall procedures. |
| INR target is 2.5 (range 2.0 - 3.0) |
Refer or Investigate
Refer ?
| Strongly consider urgent assessment (eg, via fast-track TIA assessment clinic) to clarify the diagnosis and decide on best management |
| Referral may be necessary for management of atrial fibrillation (see atrial fibrillation clinical recommendation) |
Investigate ?
| Confirm the diagnosis of atrial fibrillation by ECG. Base-line blood tests (FBC, ESR, U&Es, lipids, thyroid function tests). Consider CXR. |
Shared Advice
| Atrial fibrillation can cause turbulent blood flow in the heart. This can cause a tiny blood clot to form which may travel to the brain and cause a transient ischaemic attack |
| Warfarin is advised to anticoagulate ('thin the blood'). This reduces the chance of further blood clots forming |
| For every 1000 people with atrial fibrillation who take warfarin, about 30 strokes per year will be prevented |
| There is a slight risk with warfarin treatment. For every 1000 people taking warfarin, about 3 will have a serious bleeding complication. |
| Regular blood tests check that the blood is 'thinned' by the right amount. This reduces the chance of bleeding complications. |
| Aspirin is an alternative if warfarin cannot be taken but is not as effective as warfarin. |
Drug Rationale
Drugs not included
| Other oral anticoagulants eg nicoumalone (acenocoumarol) or phenindione are seldom used.[BNF, 1998]. |
| Other antiplatelet agents are not offered as there is no trial data on efficacy in secondary prevention of TIA in patients with atrial fibrillation. |
| Enteric coated aspirin is not usually required because the difference in toxicity at 75mg between plain and enteric coated tablets is minimal [DTB, 1997]. |
Drugs included
| Warfarin is the anticoagulant of choice. [BNF, 1998]. |
| Aspirin (75mg) daily is a less effective alternative for patients intolerant of warfarin. The 75mg dose is as effective as higher doses of aspirin. [Eccles et al. 1998; Koudstaal, 1998; Koudstaal, 1998] |
Therapy Group: Starting warfarin
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Prescription for 1mg, 3mg & 5mg
for age: 192 to 3060
bs17.|Warfarin 1mg tablets|56|tablet(s)|Take as directed|license|£1.55||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs18.|Warfarin 3mg tablets|56|tablet(s)|Take as directed|license|£1.73||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs19.|Warfarin 5mg tablets|56|tablet(s)|Take as directed|license|£2.57||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Therapy Group: Continuing warfarin
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Warfarin 1mg alone
for age: 192 to 3060
bs17.|Warfarin 1mg tablets|112 tablet(s)|Take as directed|license|£3.1||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 3mg alone
for age: 192 to 3060
bs18.|Warfarin 3mg tablets|112 tablet(s)|Take as directed|license|£3.45||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 5mg alone
for age: 192 to 3060
bs19.|Warfarin 5mg tablets|112 tablet(s)|Take as directed|license|£5.14||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 1mg + 3mg
for age: 192 to 3060
bs17.|Warfarin 1mg tablets|112|tablet(s)|Take as directed|license|£3.1||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs18.|Warfarin 3mg tablets|112|tablet(s)|Take as directed|license|£3.45||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 1mg + 5mg
for age: 192 to 3060
bs17.|Warfarin 1mg tablets|112|tablet(s)|Take as directed|license|£3.1||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs19.|Warfarin 5mg tablets|112|tablet(s)|Take as directed|license|£5.14||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 3mg + 5mg
for age: 192 to 3060
bs18.|Warfarin 3mg tablets|112|tablet(s)|Take as directed|license|£3.45||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs19.|Warfarin 5mg tablets|112|tablet(s)|Take as directed|license|£5.14||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Warfarin 1mg + 3mg + 5mg
for age: 192 to 3060
bs17.|Warfarin 1mg tablets|112|tablet(s)|Take as directed|license|£3.1||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs18.|Warfarin 3mg tablets|112|tablet(s)|Take as directed|license|£3.45||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
bs19.|Warfarin 5mg tablets|112|tablet(s)|Take as directed|license|£5.14||No warning|OK
Patient info: Make sure that you know which tablets to take each day. You should have an advice booklet to tell you about these tablets. Please ask the pharmacist if you are unsure.
Therapy Group: Aspirin
readCode|term30|quantity|useInstr|NHS|OTC|csmWarning|BioAvail
Aspirin 75mg tablets
for age: 192 to 3060
bu23.|Aspirin 75mg disp tabs|56 tablet(s)|Take one tablet daily|license|£0.13|£0.5|No warning|OK
Patient info: These may be purchased cheaply from a pharmacy