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Antiplatelet (phosphodiesterase inhibitor + adenosine reuptake inhibitor) Pregnancy: Avoid unless essential — limited data; aspirin alone preferred for antiplatelet indication in pregnancy.

Dipyridamole

Brand names: Persantin, Persantin Retard, Asasantin Retard (with aspirin)

Adult dose

Dose: Secondary prevention of ischaemic stroke / TIA: Persantin Retard (MR) 200 mg BD, usually combined with aspirin 75 mg OD (Asasantin Retard 200/25 BD provides combined dose). Adjunct to oral anticoagulation in prosthetic valve: 300–600 mg/day in 3–4 divided doses.
Route: Oral
Frequency: BD (MR) or TDS–QDS (IR)
Max: 600 mg/day
Take 1 hour before or 2 hours after meals (food reduces absorption). Modified-release form preferred for long-term use.

Clinical pearls

  • ESPS-2 and PRoFESS trials: aspirin + dipyridamole MR vs aspirin alone for stroke 2° prevention — aspirin/dipyridamole more effective in ESPS-2 but tied with clopidogrel monotherapy in PRoFESS. NICE TA210 recommends EITHER clopidogrel monotherapy OR aspirin + MR dipyridamole.
  • Headache is the leading cause of discontinuation — counsel that it usually improves over 1–2 weeks; consider paracetamol cover for first week.
  • MR formulation has markedly fewer headaches than IR — always prescribe Persantin Retard or Asasantin Retard for chronic use.
  • IV dipyridamole used in pharmacological cardiac stress testing — reverse with IV aminophylline 50–100 mg if severe symptoms. Inform patients to stop caffeine 24 hours pre-test.
  • Caution in coronary artery disease — coronary steal phenomenon can worsen angina; rarely first-line antiplatelet in IHD (aspirin or clopidogrel preferred).

Contraindications

  • Hypersensitivity to dipyridamole
  • Active bleeding
  • Severe coronary artery disease, recent MI (caution — coronary steal)
  • Severe aortic stenosis (caution)
  • Acute heart failure (caution)
  • Phaeochromocytoma (untreated)

Side effects

  • Headache (very common — peaks first 1–2 weeks, often abates with continued use; 20% discontinuation rate)
  • GI upset: diarrhoea, nausea, dyspepsia
  • Flushing, dizziness, hypotension
  • Bleeding (additive with antiplatelets/anticoagulants)
  • Tachycardia, palpitations
  • Coronary steal — exacerbation of angina (especially during IV stress test use)
  • Thrombocytopenia (rare)

Interactions

  • Adenosine: ↑ adenosine effect markedly — reduce IV adenosine dose by 4× during cardiac stress imaging; explicitly contraindicated for routine adenosine arrhythmia bolus
  • Aspirin: synergistic — combination therapy (Asasantin Retard) is the indication itself
  • Anticoagulants (warfarin, DOACs): ↑ bleeding risk
  • Theophylline / caffeine: antagonise dipyridamole's adenosine effect — can blunt response in cardiac stress imaging
  • Cholinesterase inhibitors: antagonise effect

Monitoring

  • FBC if bleeding signs
  • Headache control 1–2 weeks
  • Stroke recurrence at 3 and 12 months

Reference: BNF 90; SmPC Persantin Retard / Asasantin Retard; NICE TA210 (2010); ESPS-2 J Neurol Sci 1996;143:1; PRoFESS NEJM 2008;359:1238; ESO Stroke Guidelines 2022. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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