Managing Insufficient Medication After a Stroke: Key Considerations

What should I do if the medication dosage is insufficient?

On the morning of December 16, Grandpa returned home from exercising.
On the bus, he slept the entire way, and when he got home, he was eating breakfast while still dozing off.
The family noticed something unusual and thought his blood sugar might be high, so they urged him to inject insulin (they discovered he hadn't injected insulin for three days).
However, at that moment, Grandpa was disoriented and unable to self-administer the insulin, so the family quickly helped him with the injection.
The next day, the family believed that after administering insulin, his blood sugar would drop and everything would be fine.
However, they suddenly noticed that Grandpa was speaking strangely and couldn't name the fruits on the calendar.
They called Hospital A to inquire whether they should take him to the emergency room.
The operator transferred them to the education department, which advised that there was no need for an emergency visit, believing he still recognized family members but was just unable to name the fruits, possibly due to his body not adapting to the drop in blood sugar.
However, on the third day, Grandpa had not improved; he still couldn't name the fruits and even misnamed family members.
He also couldn't use his usual blood pressure monitor.
At this point, the family rushed him to the emergency room.
After hearing the family's description, the emergency physician suspected a stroke, and indeed, a CT scan revealed that Grandpa had a cerebral infarction.
Three days had passed, so the emergency room administered one dose of a thrombolytic agent and arranged for hospitalization.
However, on Saturday and Sunday, the attending physician did not administer the thrombolytic agent but only added one dose of a neuroprotective agent and continued his usual medication (Grandpa has cardiovascular disease and takes one dose of Berkey daily).
It wasn't until Monday that the attending physician appeared and instructed Grandpa to take three doses of the thrombolytic agent at once, informing him that he would be discharged the next day.
On December 22, he was discharged, and the attending physician only prescribed a seven-day supply of medication (thrombolytic agent and neuroprotective agent) and advised him to visit a hospital that performs carotid artery stenting (the carotid ultrasound showed severe stenosis).
On December 24, the family took Grandpa to another hospital, Hospital B.
The physician indicated that they would perform a CT scan with contrast to confirm the diagnosis and scheduled it for January 8.
However, no medication was prescribed.
The family has the following questions for the physician: 1.
The previous hospital only prescribed a seven-day supply of medication, which is insufficient until January 8.
What should they do? Is there a way to obtain the medication at minimal cost? Can family members go back to the previous hospital to get the medication for Grandpa? 2.
Why is the thrombolytic agent prescribed by the previous hospital self-paid at 42 NT dollars per dose? 3.
Shouldn't the medication dosage have been increased earlier, rather than waiting until the third day? 4.
Grandpa was taken to the hospital three days after the stroke, and it took until the evening to receive one dose of the thrombolytic agent.
This delay has wasted critical time for treatment.
Is there a chance for recovery? (Currently, Grandpa has difficulty naming certain terms.) 5.
After the stroke, Grandpa seems mentally fatigued and unwell.
How long will it take for him to regain his physical strength and mental well-being?

Bu zhi suo cuo, 30~39 year old female. Ask Date: 2020/12/25

Dr. Jiang Junyi reply Neurology

Hello, based on your description, it is recommended to seek treatment for cardiovascular disease at a hospital accessible by ambulance within your home area, integrating medical information.
Clopidogrel (Plavix) functions similarly to aspirin as a preventive medication for stroke.
The acute management of cardiovascular and cerebrovascular conditions currently includes thrombolysis and thrombectomy.

Regarding the health insurance coverage criteria for Clopidogrel:
1.
It is limited to patients with atherosclerotic disease who have a history of stroke, myocardial infarction, or peripheral artery disease and meet one of the following conditions:
a.
Allergy to acetylsalicylic acid (such as aspirin).

b.
Clinical diagnosis of peptic ulcer or upper gastrointestinal bleeding/perforation history caused by acetylsalicylic acid, with the occurrence time noted in the medical record.

c.
Clinical diagnosis of peptic ulcer within the past year, with clear documentation of typical symptoms and onset time in the medical record.

d.
Confirmation of peptic ulcer or history of upper gastrointestinal bleeding/perforation through upper gastrointestinal endoscopy or X-ray within the past year, with the examination date noted in the medical record.
However, patients who cannot tolerate acetylsalicylic acid and whose condition does not allow for endoscopy or gastrointestinal X-ray (such as elderly patients with stroke or myocardial infarction or those who are bedridden) are exempt from this limitation.

2.
Clopidogrel may be used in conjunction with acetylsalicylic acid during and for three months following an interventional stenting procedure, with the procedure date noted in the medical record.

3.
It may be used in hospitalized patients with acute coronary syndrome (unstable angina and non-ST elevation myocardial infarction) for a maximum of nine months in combination with acetylsalicylic acid, with hospitalization dates documented in the medical record.

For acute treatment of stroke, it typically refers to thrombolysis or thrombectomy to restore blood flow.
Thrombolytic therapy must be administered within three hours, as there is a risk of intracranial hemorrhage; the longer the delay or the more severe the patient's symptoms, the higher the risk of bleeding.
Early administration reduces the risk of bleeding and can be performed at regional or local hospitals.

Thrombectomy is performed similarly to cardiac catheterization, where the thrombus is removed via the artery within eight hours of cerebral infarction or within 24 hours of brainstem infarction.
The removal methods can be categorized into aspiration or direct retrieval of the thrombus, primarily conducted at medical centers or regional teaching hospitals.

Rescue for ischemic stroke involves different treatment approaches depending on the onset time.
Therefore, if family members suspect a stroke, they should promptly call 119 for an ambulance and not drive the patient themselves.

Clinically, four major factors influence prognosis:
1.
Severity of the stroke: Embolism can occur in various areas of the brain, and if it affects critical regions (e.g., language, swallowing, memory, mobility), prognosis depends on the location and severity of the blockage at the time of onset.

2.
Treatment: Whether appropriate treatment is received is the second major factor affecting prognosis.
The most significant issues with medication treatment are delayed administration and the severity of the embolism; the earlier the medication is given after onset, the lower the risk.
If the patient is already in a coma, the effectiveness of thrombolytic medication is limited.
Coagulation function must be assessed before administration; if blood tests indicate poor coagulation or renal function, there may be risks associated with medication use.

3.
Age at onset: The age at which the stroke occurs can also affect future recovery.

4.
Rehabilitation: Rehabilitation is a crucial factor influencing recovery prognosis.
The first three to six months post-stroke are critical for rehabilitation, as neurological function can regenerate or recover rapidly within six months.
Delaying rehabilitation beyond six months may result in slower progress.
Therefore, family members should encourage active rehabilitation for stroke patients.

Most importantly, controlling risk factors is essential to reduce the likelihood of a recurrent stroke.
It is advisable to discuss subsequent treatment and management (such as risk factor control and post-stroke rehabilitation plans) with your grandfather's attending physician.
Wishing you and your grandfather good health and peace.

Dr.
Jiang Junyi, Department of Neurology, Taoyuan Hospital, cares for you.

Reply Date: 2020/12/25

More Info

Managing insufficient medication after a stroke is a critical concern, especially in the context of your grandfather's recent medical history. The situation you've described highlights several key considerations that are essential for ensuring proper care and recovery.

1. Medication Supply and Access: It is crucial to ensure that your grandfather has an adequate supply of his medications, especially after a stroke. Given that the previous hospital only provided a seven-day supply of Plavix (Clopidogrel) and other medications, this is insufficient for the time until the next scheduled appointment on January 8. One option is to contact the previous hospital and explain the situation, requesting an extension of the prescription or a refill. In many cases, hospitals can provide a bridge prescription to cover the gap until the next appointment. Additionally, you may want to explore local pharmacies or community health resources that might offer assistance with medication costs or access.

2. Understanding Medication Costs: The fact that Plavix is self-paid at a cost of 42 NTD per tablet can be concerning, especially for long-term use. The reason for this could be due to the specific health insurance policies in place, which may not cover certain medications unless specific criteria are met. It is advisable to consult with the healthcare provider about potential alternatives that might be covered by insurance or to inquire about patient assistance programs that pharmaceutical companies often provide.

3. Timeliness of Treatment: The delay in administering Plavix and other medications during your grandfather's hospital stay raises concerns about the management of his condition. Ideally, after a stroke, especially one caused by a clot (ischemic stroke), timely administration of antiplatelet or anticoagulant therapy is crucial to prevent further complications. The first few days post-stroke are critical for recovery, and any delay in treatment can impact the prognosis. It is essential to discuss these concerns with the healthcare team to understand their rationale and ensure that future care is more proactive.

4. Recovery Potential: The potential for recovery after a stroke depends on several factors, including the severity of the stroke, the area of the brain affected, and the timeliness of treatment. While it is difficult to predict the exact timeline for recovery, it is generally observed that significant improvements can occur within the first three to six months post-stroke, especially with appropriate rehabilitation. Engaging in physical, occupational, and speech therapy can significantly enhance recovery outcomes. Encouraging your grandfather to participate in rehabilitation activities as soon as possible is vital.

5. Mental and Emotional Health: Post-stroke, many patients experience changes in mood, cognition, and overall mental health. It is not uncommon for individuals to feel fatigued or exhibit signs of depression or anxiety after such an event. Monitoring your grandfather's emotional state and encouraging him to engage in social activities or support groups can be beneficial. Additionally, discussing any concerning symptoms with his healthcare provider can lead to appropriate interventions, such as counseling or medication adjustments.

In summary, managing insufficient medication after a stroke requires proactive communication with healthcare providers, understanding medication access and costs, and ensuring timely treatment. Recovery is a multifaceted process that involves not only physical rehabilitation but also emotional and psychological support. Engaging with healthcare professionals and advocating for your grandfather's needs will be crucial in navigating this challenging time.

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