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1. Scope1.1 This clinical guideline covers the assessment and management of patients

presenting with acute onset stroke symptoms and suspected transient ischaemic attack (TIA).

2. Background and Definitions2.1 Stroke is the third most common cause of death in the UK. Each year in England,

approximately 110,000 people have a first or recurrent stroke and a further 20,000 people have a transient ischaemic attack. More than 900,000 people in England are living with the effects of stroke, with about half of these dependent on other people for help with everyday activities. Most strokes occur in people older than 65 years, but they can occur at any age.1

2.2 Strokes and transient ischaemic attacks (TIAs) are acute neurological events, presumed to be vascular in origin, that are caused by cerebral ischaemia, cerebral infarction, or cerebral haemorrhage.2

2.3 Stroke2.3.1 Stroke is defined by the World Health Organisation as a clinical syndrome

consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin’.3 The signs

Guideline ID CG20

Version 1.0

Title Stroke and Transient Ischaemic Attacks

Approved by Clinical Effectiveness Group

Date Issued 01/01/2013

Review Date 31/12/2016

Directorate Clinical

Authorised Staff

Ambulance Care Assistant Paramedic (non-ECP) Emergency Care Assistant Nurse (non-ECP) Student Paramedic ECP Advanced Technician Doctor

Clinical Publication Category

Guidance (Green) - Deviation permissible; Apply clinical judgement



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and symptoms of a non-disabling stroke last for more than 24 hours but resolve later, leaving no permanent disability. In contrast, a disabling stroke results in permanent deficit/s.

2.3.2 Strokes can be classified by their main causes as either ischaemic (85%) or haemorrhagic (15%).2

2.3.3 Ischaemic strokes are caused when a blood vessel in the brain is blocked, for example by a blood clot or by the fatty material from an atherosclerotic plaque. The brain cells in the part of the brain served by the affected blood vessel die due to a lack of oxygen and nutrients. There are two main types of ischaemic stroke:

▲ Thrombotic ischaemic stroke - A blood clot spontaneously forms in an artery in the brain. This is a common complication of atherosclerosis;

▲ Embolic ischaemic stroke - Part of the fatty material from an atherosclerotic plaque or a clot in a larger artery or the heart breaks off and travels downstream until it is trapped in a narrower artery in the brain. Embolic strokes are common complications of atrial fibrillation and atherosclerosis of the carotid arteries.

2.3.4 There are two main types of haemorrhagic stroke: ▲ Intracerebral haemorrhagic stroke - Bleeding from a blood vessel within the brain. High blood pressure is the main cause of intracerebral haemorrhagic stroke;

▲ Subarachnoid haemorrhagic stroke - Bleeding from a blood vessel between the surface of the brain and the arachnoid tissues that cover the brain.

2.3.5 Although subarachnoid haemorrhage (SAH) is classified as a type of stroke it is not included in this guideline. A sudden and violent headache is characteristic of subarachnoid haemorrhage, which should be managed according to JRCALC guidelines.

2.4 Transient Ischaemic Attack (TIA)2.4.1 Transient Ischemic Attacks (TIAs) are caused by a temporary reduction in the

blood supply to part of the brain, due to a thrombosis or embolism.2 Small blood clots commonly form on an area of atheroma within the main vessels, or within the atria in patients with atrial fibrillation. A TIA occurs when they break away, traveling up the artery until it occludes a smaller cerebral artery.

2.4.2 The signs and symptoms of a TIA are identical to that of a stroke; the only factor which distinguishes a TIA is the duration of the symptoms, which by definition



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must fully resolve within 24 hours. The symptoms are transient, as small clots break up rapidly. Any patient without fully resolved focal neurological signs and symptoms must be assumed to have had a stroke.

2.4.3 A TIA is an indicator that further clots may occur, with the risk of experiencing a stroke increased by up to forty-five times the normal risk in the week following a TIA, in the most high risk patients.4

2.4.4 Effective timely management of transient ischaemic attacks reduces mortality, morbidity and the use of NHS resources.5

3. Guidance3.1. Assessment3.1.1 Assess the patient using the CABCD approach and exclude hypoglycaemia and

other stroke mimics. Stroke mimics marked with an asterisk (*) have transient symptoms that can also mimic those of a transient ischaemic attack:

▲ Hypoglycaemia*; ▲ Conditions which cause dizziness, faintness, or disturbed balance*; ▲ Migraine*; ▲ Neurological abnormalities; ▲ Mass lesions such as subdural hematoma, cerebral abscess, primary central nervous system tumours, and metastatic tumours;

▲ Postictal states, focal seizures, and generalized seizures*; ▲ Hyperglycaemia; ▲ Factitious stroke; ▲ Psychological disorders, including anxiety*; ▲ Physical trauma, including concussion*.

3.1.2 The clinician must establish whether the symptoms are typical of a cerebral event. If the answer to all of the following questions is yes, the symptoms are almost certainly due to cerebral ischaemia or haemorrhage.

▲ Are the neurological symptoms focal? ▲ Are the focal neurological symptoms negative? ▲ Was the onset of the focal neurological symptoms sudden? ▲ Were the neurological symptoms maximal at onset?

3.1.3 Follow the Stroke/Suspected TIA Care Pathway detailed in Figure 1.



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3.1.4 Figure 1- Stroke/Suspected TIA Care Pathway

3.2 FAST Examination3.2.1 Assess the patient using the Face, Arms, Speech Test (FAST):

▲ Facial weakness: ● Ask the person to smile or show their teeth; ● The FAST test is positive if there is new facial asymmetry (e.g. the mouth

or the area around their eye droops).

Does the patient meet the acute stroke pre-alert criteria?

▲FAST positive. ▲Blood sugar level greater than 3.5mmol (following treatment if necessary) ▲Time between onset of symptoms and predicted arrival at thrombolysis centre within the time window set for the centre (Appendix 1). ▲18 years or older - no upper age limit.

Is the patient high risk (any of the following are present)?

▲ABCD2 4 or higher (5 or higher in Cornwall) ▲Previous potential TIAs within the past 7 days. ▲Atrial Fibrillation ▲Prescribed warfarin or other anticoagulants (including dabigatran, rivaroxaban, apixaban, edoxaban). ▲Diagnosed blood clotting disorder. ▲Unable to be supplied aspirin due to PGD contraindication.

Minimise on scene time,

rapid conveyance to a stroke

centre offering a thrombolysis

service‘STROKE 60’

Normal conveyance to local hospital

Hospital assessment

within 24hrs

Low RiskRefer to TIA

Clinic

Stroke / Suspected TIA Care Pathway

YES Acute stroke signs and symptoms present?

NO

YES NO YES NO



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▲ Arm weakness: ● Raise the person’s arms to 90° if they are sitting or 45° if they are lying.

Ask the person to maintain their arms in that position, with their eyes open when you let go and count aloud to 10. As you let go keep your hands just below their arms, so that you can gently support a limb should it suddenly flop downwards;

● The FAST test is positive if when you let go, one arm falls or drifts down.

▲ Speech problems: ● During the conversation determine if their speech is slurred or the person

has difficulty finding the name for commonplace objects. Assess this by asking them to repeat the sentence ‘you can’t teach an old dog new tricks’, and asking them to identify common objects (e.g. cup, table, chair, keys, pen). If they have difficulty seeing, place the objects in their hands;

● The FAST test is positive if their speech is slurred/abnormal or they are unable to state the names of common objects.

3.2.2 If unable to assess any element/s of the FAST test due to prior neurological deficit, record this on the PCR.

3.2.3 If there was a witness present establish the time of onset and whether the deficits detected are of new onset.

3.3 MEND Exam3.3.1 FAST is an effective rapid screening tool, but it is less effective at identifying the

subtle signs of a stroke or TIA. If you have completed the Advanced Stroke Life Support course, the Miami Emergency Neurological Deficit (MEND) examination should be completed (Figure 2), with each element recorded as free text on the PCR. Where a stroke is conveyed this should not delay transport.

3.3.2 Figure 2 - Miami Emergency Neurological Deficit (MEND) Examination

Mental Status

▲ Level of consciousness (AVPU) ▲ Speech “You can’t teach an old dog new tricks” ▲ Questions (age and month) ▲ Commands (close, keep shut then open eyes)

Cranial Nerves ▲ Facial Droop (show teeth or smile) ▲ Visual fields (four quadrants) ▲ Horizontal gaze (side to side)

Limbs

▲ Motor - Arm drift (close eyes, hold out arms) ▲ Leg drift (open eyes, left each leg separately. ▲ Sensory - Arms and legs ▲ Coordination - Arms and legs - Finger-nose and heel-shin



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3.4 ABCD2 Risk Assessment Score3.4.1 Where the focal neurological signs and symptoms have completely resolved, the

ABCD2 score (Figure 3) should be applied as a simple way of predicting the risk of stroke over the next seven days.6 The scoring of clinical features and duration of symptoms is based on either examination or history. For example, a patient who reported focal weakness which resolved 2 hours prior to assessment, would still receive a score of 2 for the clinical features element.

3.4.2 Figure 3 - ABCD2 Scoring System

3.5 Management - Acute Stroke (On-going Signs and Symptoms) 3.5.1 Stoke is a medical emergency, with every minute that thrombolysis is delayed

impacting on the extent of the patients future recovery. The priority is to convey the patient to a hospital providing acute stroke services for assessment for thrombolysis.

3.5.2 At the earliest opportunity confirm whether the patient meets the acute stroke pre-alert criteria (Appendix 1):

▲ FAST positive; ▲ Blood sugar level greater than 3.5mmol (following treatment if necessary); ▲ Time between onset of symptoms and predicted arrival at a stroke centre within the time window set for the centre (Appendix 1);

▲ 18 years or older - no upper age limit.

Area Criteria Points

Age Aged over 60 years 1

Blood PressureHypertension (Systolic >140 and/or diastolic >90mmHg)

1

Clinical Features Speech disturbance without weakness 1

Focal weakness; clinical features of TIA 2

Duration of Symptoms

10-59 minutes 1

Over 60 minutes 2

DiabetesPatient has diabetes, taking either oral or injectable medication

1



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3.6 Patients Meeting the Acute Stroke Pre-alert Criteria3.6.1 Solo-responder (RRV, Officer):

▲ Request/confirm priority 1 (P1) back-up as soon as it is established that the patient meets the stroke pre-alert criteria. Ask the Clinical Hub to advise the crew of the required moving and handling equipment (e.g. carry chair);

▲ Provide oxygen therapy if SpO2 <95%; ▲ Gain IV access if time permits.

3.6.2 Double Crewed Ambulance (DCA): ▲ If backing up a solo responder ensure that the moving and handling equipment requested is taken directly to scene;

▲ Provide/continue oxygen therapy if SpO2 <95%; ▲ Minimise on-scene time. ▲ If patient meets acute stroke pre-alert criteria:

● Convey under emergency driving conditions; ● Provide an ATMIST pre-alert to the stroke centre; ● Gain IV access en-route if time permits.

3.6.3 The specific pathways for each hospital are detailed in Appendix 1. If the nearest hospital is not offering a stroke thrombolysis service (e.g. non 24/7 services), bypass the patient to the next nearest hospital offering stroke thrombolysis, provided that the receiving hospital agrees to accept the patient and they will arrive within the centre’s thrombolysis time window. An incident report must be completed if the hospital declines to accept the patient.

3.6.4 Evidence shows that direct conveyance to a CT scanner can reduce the door to scan and consequently door to thrombolysis time for acute stroke patients. The centres which offer this pathway are detailed in Appendix 2.

3.6.5 A small number of people have severe comorbidity and might not benefit from admission. If after discussion with the person and their family or carer a decision is made not to admit, the reasons for this must be clearly documented. Consider accessing support and guidance from a senior clinician (ECP, GP) to support the decision making process.

3.7 Patients Not Meeting the Acute Stroke Pre-alert Criteria3.7.1 If patient presents with acute stroke symptoms, but does not meet the pre-alert

criteria (e.g. no known onset time), convey to nearest appropriate hospital under normal driving conditions. Place an ATMIST pre-alert where required by the hospital.



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3.8 Management of Suspected Transient Ischaemic Attack (TIA)3.8.1 The diagnosis of TIA relies on the recognition of clinical features associated with

focal cerebral dysfunction. As stroke symptoms will have resolved by the time of assessment, accurate diagnosis is challenging, requiring the process to be based on the patient or witness recollection of events. The role of the ambulance clinician is to identify patients who are suspected of experiencing a TIA, rather than making a definitive diagnosis.

3.8.2 The FAST test must be conducted and confirm that the patient has no new focal neurological symptoms at the time of assessment. A thorough history to identify any previous focal neurological symptoms must also be obtained. Where trained, assess the patient using the MEND exam; all the elements must be negative.

3.8.3 If you are confident that all focal neurological deficits have resolved, treat the patient as a potential TIA; if not follow the stroke pathway. Apply the ABCD2 score. Research indicates that patients with a score of three or below have a 0% seven day risk of stroke, compared to a 11.7% risk in those with a score above five.6 Patients with a total ABCD2 score of three or less (4 or less in Cornwall due to rapid access local TIA services) are considered low risk, and can therefore be left at home and referred directly to a TIA clinic provided that none of the following exclusion criteria are present:

▲ Previous potential TIAs within the past 7 days; ▲ Atrial Fibrillation; ▲ Patients taking warfarin or other anticoagulants (including dabigatran, rivaroxaban, apixaban, edoxaban)

▲ Patients with haemophilia or other coagulation defects ▲ Unable to be supplied aspirin due to PGD contraindication.

3.8.4 In the absence of any of the exclusion criteria detailed in Para 3.3.3, patients are considered low risk and may be left on scene with a referral to a TIA clinic. Supply the patient with a pack containing a 7 day course of 300mg aspirin under the Trust’s PGD. If the patient is already prescribed 75mg aspirin, advise them to cease taking the 75mg tablets until review at the TIA clinic and replace with the 300mg aspirin. The patient should be advised to take one 300mg aspirin from the pack prior to the ambulance clinician leaving scene. Refer the patient to a TIA clinic according to local pathways (Appendix 3), and inform the patient’s GP via local mechanisms. If aspirin is unable to be supplied due to the presence of contraindications to the PGD, the patient must be referred to their GP or hospital for assessment within 24 hours. Where no local care pathways exist consider discussing the case with a senior clinician (ECP or GP) and the need for same day hospital admission.



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3.8.5 Patients who have an ABCD2 score of 4 or above (5 and above in Cornwall due to rapid access local TIA services), or any of the exclusion criteria detailed in Para 3.3.3 are considered high risk and must be referred to an Emergency Department for assessment. A single dose of oral aspirin 300mg must be administered if the patient meets the administration guidance detailed in Appendix 4.

3.9 National Ambulance Clinical Quality Indicator3.9.1 Ambulance clinicians must ensure that the high quality of care that they deliver

is reflected through the achievement of the National ACQIs for the management of stroke, which is divided into two indicators:

▲ The percentage of Face Arm Speech Test (FAST) positive stroke patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a hyperacute stroke centre within 60 minutes of call.

▲ The percentage of suspected stroke patients (assessed face to face) who receive an appropriate care bundle:

● Recording FAST test; ● Recording blood pressure; ● Recording blood glucose.

4. Incident Closure4.1 Patients who have experienced a suspected TIA and are not conveyed to hospital

must be provided with a copy of the PCR, a 7 days course of aspirin 300mg tablets and a TIA patient information leaflet. The requirement not to drive until after their TIA clinic must be emphasised.

5. Documentation 5.1 In line with Trust Policy, a Patient Clinical Record must be completed and

annotated appropriately. It is particularly important that each element of the stroke care bundle is recorded, with the rationale for any patient not arriving at hospital within 60 minutes of the call being recorded on the PCR (e.g. distance to hospital). In the case of TIA, the signs and symptoms which have resolved must be clearly recorded to assist the TIA clinic.

5.2 Any deviation from this clinical guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system.



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6. References 1. Nice Institute for Health and Clinical Excellence (2008) Stroke: Diagnosis and

initial management of acute stroke and transient ischaemic attack (TIA). NICE.

2. Clinical Knowledge Summaries http://www.cks.nhs.uk/stroke_and_tia [accessed 18th September, 2012].

3. World Health Organisation (1978) Cerebrovascular disorders: a clinical and research classification. Geneva. World Health Organization.

4. National Audit Office (2005) Reducing Brain Damage: Faster access to better stroke care. London. NAO.

5. Intercollegiate Stroke Working Party (2004) National clinical guidelines for stroke. 2nd ed. London. Royal College of Physicians.

6. Johnston S.C, Rothwell P, Nyuyen-Huynh M.N, Giles M, Elkins J.S, Bernstein A.L. and Sidney S. (2007) Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. The Lancet. 369: 283-292.



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Appendix 1 - Stroke 60 Pathways:

Hospital Contact Tel Time Window

Operating Hours Notes

Bristol Royal Infirmary

01173 422928 3.5 hours Day & EveningSeven day service

If service not available, contact Frenchay Hospital.

Derriford Hospital Plymouth

01752 245345 6 hours 24/7

Dorset County Hospital Dorchester

01305 257919 4.5 hours 24/7

Frenchay Hospital 01179 560303 3.5 hours 24/7 If hospital decline to accept patient, record on PCR and convey to local hospital

Gloucester Royal Hospital

08454 225126 3.5 hours 24/7

Great Western Hospital Swindon

01793 604100 3.5 hours 24/7

North Devon District Hospital Barnstaple

01271 344463 6 hours 24/7

Poole General Hospital

01202 661021 4.5 hours 24/7

Royal Bournemouth Hospital

01202 704165 4.5 hours 24/7

Royal Cornwall Hospital Truro

01872 252153 6 hours 24/7

Royal Devon & Exeter Hospital Exeter

07825 716447 6 hours 24/7

Royal United Hospital Bath

01225 319078 3.5 hours 24/7

Salisbury District Hospital

01722 320424 3.5 hours 24/7

Taunton Hospital 01823 342906 4.5 hours 24/7

Torbay Hospital 01803 654070 6 hours 24/7

Weston General Hospital

01934 618340 3.5 hours Day serviceMonday-Frid

If service not available, contact Bristol Royal Infirmary or Frenchay Hospital, dependent on location.

Yeovil District Hospital

01935 475122 4.5 hours 24/7



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Appendix 2 - Hospital Direct to CT Stroke 60 Pathways

Hospital Procedure

Bristol Royal InfirmaryFrenchay HospitalRoyal United HospitalGloucester Royal Hospital

▲ During pre-alert state that you are attending a patient who meets the AGWS Network acute stroke pre-alert criteria and request to speak to the ED consultant. The ED consultant will discuss further details, such as co-morbidities, to confirm patient is suitable for direct access to CT scan. ▲ If patient confirmed as suitable, provide consultant with ETA and patient’s name and DOB. ▲ Minimise on-scene duration and convey patient under emergency driving conditions in accordance with Stroke 60 Care Pathway. ▲ On arrival at emergency department, one member of the crew priority registers the patient. The other crew member to accompany ED consultant and nurse to CT scanner. Once the patient is in the CT scanner, crew member to return to ED with ambulance stretcher and complete any remaining documentation and clear.

Royal Cornwall HospitalDerriford Hospital

▲ Provide pre alert, confirm Stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. ▲ On arriving at the receiving hospital you will be met by the stroke nurse co-ordinator. It the CT scanner is available you will be instructed to transfer the patient directly onto the scanner and complete your handover.

Musgrove Park Hospital ▲ Provide pre alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. ▲ During the operating window (Mon to Friday 09:00hrs – 17:00Hrs), on arriving at the receiving hospital you will be met by a member of the stroke team. It the CT scanner is available you will be instructed to transfer the patient directly onto the scanner and complete your handover.

Torbay Hospital Royal Devon and Exeter Hospital

▲ Provide pre alert, confirm stroke patient, minimise on-scene duration and convey patient under emergency driving conditions. ▲ On arriving at the receiving emergency department of the chosen hospital you will be met by the stroke nurse co-ordinator. Following handover you will be instructed to transfer the patient onto a hospital trolley, they will then be taken to the CT scanner by the stroke nurse co-ordinator.

Royal Bournemouth Hospital

▲ Complete direct to CT checklist. If CT indicated pre-alert Emergency Department stating ‘Stroke Code 1, acute stroke meeting thrombolysis criteria. Patient being transported directly to CT scanner. Please alert crash call to meet patient at scanner’. ▲ Transfer the patient directly to the scanner, which is located immediately left once inside the main hospital entrance.



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Important Additional InformationIf direct to CT is not available, acute stroke patients who meet the acute stroke pre-alert criteria must still be conveyed to an Emergency Department offer a stroke thrombolysis service as an emergency in accordance with the Stroke 60 Care Pathway.

Appendix 3 - TIA Clinics

Hospital Contact Fax Referral Method

Telephone Number to be Left with Patient

Bristol Royal Infirmary 01173 424003 FAX 01173 424800

Dorset County Hospital Dorchester

01305 255263 FAX 01305 255484

Frenchay Hospital 01173 403515 FAX 01173 405452

Gloucester Royal Hospital 08454 226326 FAX 08454 225157

Great Western Hospital Swindon

01793 604075 FAX 01793 605166

Poole General Hospital 01202 442993 FAX 01202 442483

Royal Bournemouth Hospital 01202 705442 FAX 01202 705387

Royal Cornwall Hospital Truro 01209 881632 FAX 01209 881622

Royal Devon & Exeter Hospital Exeter

01392 402595 FAX 01392 402552

Royal United Hospital Bath 01225 821287 FAX 01225 821186

Salisbury District Hospital 01722 429146 FAX 01722 336262

Taunton Hospital 01823 344747 FAX 01823 343438

Torbay Hospital 01803 655777 FAX 01803 656617

Weston General Hospital 01934 647025 FAX 01934 647183

Yeovil District Hospital 01935 384446 FAX 01935 255484



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Appendix 4 - Aspirin Administration GuidanceWhen a 7 day course of aspirin is supplied to a patient, this occurs under the Patient Group Direction (PGD), as this is required to enable Nurses and Paramedics to legally supply the medicine. Nurses and Paramedics are however able to administer a single 300mg dose to patients who are admitted to hospital outside of the PGD, as the legislation for administering a medicine is different to that covering the supply. The guidance below, which mirrors the PGD, must be used for administration.

Clinical Situation

Inclusion criteria ▲ Adults 16 years and over presenting with a possible Transient Ischaemic Attack who are being conveyed to hospital.

Exclusion criteria ▲ Patients who do not fulfil the TIA pathway criteria: ● Patients with an ABCD2 score higher than the limit agreed by the

Trust with local TIA services ● Previous potential TIAs within the past 7 days ● Atrial Fibrillation ● Patients taking warfarin or other anticoagulants (including

dabigatran, rivaroxaban, apixaban, edoxaban) ● Patients with haemophilia or other coagulation defects (decreases

platelet aggregation and increases bleeding time). ▲ Previous or active peptic ulceration; ▲ Children <16yrs; ▲ Evidence of hypersensitivity to aspirin or other NSAIDS (those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated); ▲ Pregnancy; ▲ Breastfeeding; ▲ Severe hepatic impairment (increased risk of GI bleeding); ▲ Severe renal impairment (increased risk of GI bleeding, sodium and water retention, deterioration in renal function); ▲ Patients already taking anti-platelet drugs e.g 300mg aspirin or clopidogrel (See advice below under action if excluded).

Cautions ▲ Patients already taking ● NSAIDs (check OTC use) ● Lithium ● Corticosteroids ● Ciclosporin ● Methotrexate ● Tacrolimus ● SSRIs (citalopram, sertraline, escitalopram, venlafaxine)

▲ Uncontrolled hypertension; ▲ G6PD deficiency (an inherited condition in which the body doesn’t have enough of the enzyme G6PD, which helps red blood cells function normally; ▲ Asthma (patient may be sensitive to NSAIDS); ▲ Excessive alcohol consumption.



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Appendix 4 - Aspirin Administration Guidance (cont.)

Clinical Situation (cont.)

Side effects ▲ Hypersensitivity reactions including skin rashes (common), angioedema and bronchospasm. ▲ Gastro-intestinal discomfort, nausea, diarrhoea and occasionally bleeding and ulceration. (NB Systemic as well as local effects contribute to GI damage) ▲ Haemorrhage

Interactions ▲ Aspirin antagonises the diuretic effect of spironolactone. ▲ Ensure history includes other medication taken as risk of a GI event is increased if patient taking another drug that can cause an increased GI risk in their own right i.e. anticoagulants, clopidogrel, low dose aspirin, SSRI, methotrexate or corticosteroids. ▲ Aspirin reduces excretion of methotrexate increasing the risk of toxicity. ▲ Metoclopramide increases the rate of absorption of aspirin and increases its effect.

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