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de Havenon A, Sheth KN, Madsen TE, Johnston KC, Turan T, Toyoda K, Elm JJ, Wardlaw JM, Johnston SC, Williams OA, Shoamanesh A, Lansberg MG. Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities. Stroke 2021; 52:e635-e645. [PMID: 34517768 PMCID: PMC8478840 DOI: 10.1161/strokeaha.121.035002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol's pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Kevin N. Sheth
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Tracy E. Madsen
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Karen C. Johnston
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Tanya Turan
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Kazunori Toyoda
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Jordan J. Elm
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Joanna M. Wardlaw
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - S. Claiborne Johnston
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Olajide A. Williams
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Ashkan Shoamanesh
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Maarten G. Lansberg
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
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