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STROKE SERIES · ARTICLE 10 OF 12
Stroke medications
Anti-clotting, BP, statin and AFib drugs.
After a stroke, most patients go home on more medications than they came in with — usually four or five new tablets. They look like a lot at first. Each one is doing a specific job, and together they cut the risk of a second stroke by 70 – 80%. That is the single most impactful intervention we can offer.
This article walks through the main medication groups, what each one does, the side effects to know about, the bleeding risk that comes with anti-clotting drugs, and the single rule that determines so much of long-term outcome: never stop a stroke medication on your own.
Important note
This article describes how the main stroke medications work. It is not personal medical advice and does not replace a prescription. Specific drug choice, dose and combinations should always be made with your clinic.
The main groups
Most stroke survivors leave hospital on a combination of:
1. Anti-platelet drugs (aspirin, clopidogrel) — for ischaemic stroke not caused by AFib.
2. Anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran, edoxaban) — for AFib-related stroke.
3. Statins — for almost everyone after ischaemic stroke.
4. BP medications — for everyone with high BP.
5. Diabetes medications — if diabetic.
1. Anti-platelet drugs — aspirin and clopidogrel
Anti-platelet drugs reduce the “stickiness” of platelets — the small blood cells that form clots. They don't dissolve clots already there; they reduce the chance of new clots forming.
Aspirin
The original. Used after ischaemic stroke for over 50 years. Low-dose aspirin (75 – 150 mg daily, often 100 mg in SA) reduces second-stroke risk by about 20%.
Side effects: mild stomach upset is common (take with food); a small risk of stomach ulcers and gastrointestinal bleeding. Long-term aspirin sometimes causes very minor bruising or nosebleeds.
SA availability: free at public clinics. R20 – R50 / month privately.
Clopidogrel
A more powerful anti-platelet alternative or addition. Used as a substitute when aspirin can't be tolerated, or in combination with aspirin in the first weeks after some strokes. Dose: 75 mg daily.
Side effects: similar bleeding risk to aspirin. Some patients have less stomach upset.
SA availability: free at public clinics; R80 – R200 / month privately.
The short combination
After a minor stroke or TIA, patients are often started on both aspirin AND clopidogrel for 21 – 90 days, then continued on one of them alone for life. The combination provides better early protection but has more bleeding risk if used long-term. Your clinic will time this.
2. Anticoagulants — for AFib-related stroke
Anti-platelets are not enough for AFib-related strokes. The clots that form in the heart from AFib need a stronger blood thinner. Two options:
Warfarin
The classic anticoagulant. Used for over 70 years. Very effective at preventing AFib-related stroke — reduces risk by about 64%.
The catch: warfarin's effect varies day to day depending on diet, other medications, and individual metabolism. It needs regular blood tests (the INR, or International Normalised Ratio) — usually monthly once stable — to make sure the dose is right.
Side effects: bleeding is the main one. Bruising easily, nosebleeds, bleeding gums when brushing — minor signs. Severe bleeding (blood in urine, black stools, bleeding from a cut that won't stop, large bruises without trauma) — urgent clinic visit.
Drug and food interactions are many. Tell every clinician you take warfarin. Keep vitamin K intake (leafy greens) consistent — see article 8.
SA availability: free at public clinics. R30 – R100 / month privately.
DOACs — direct oral anticoagulants
A newer class with several major advantages over warfarin: no routine blood tests, much fewer food interactions, somewhat lower brain-bleeding risk. SA-available DOACs include:
• Apixaban (Eliquis) — twice daily.
• Rivaroxaban (Xarelto) — once daily, with food.
• Dabigatran (Pradaxa) — twice daily.
• Edoxaban (Lixiana) — once daily.
The disadvantage: DOACs are more expensive than warfarin. They are on some medical aid formularies and increasingly on the SA public sector list, but availability varies by hospital and province.
Cost: R300 – R900 / month privately. Some medical aids cover them.
Bleeding is the main risk of anticoagulants
If you are on warfarin or a DOAC, watch for: black or blood-streaked stools, vomiting blood, blood in the urine, severe headache (could be brain bleed), bruising without trauma, bleeding that won't stop.
Same-day clinic visit or emergency department if any of these occur. Many can be reversed if caught early.
3. Statins — for almost everyone after ischaemic stroke
Statins lower LDL cholesterol AND stabilise existing plaque, reducing the chance of a future plaque rupture. They cut second-stroke risk by about 20%, similar to their effect after heart attack.
Standard South African choices:
• Simvastatin 40 mg at night — public sector standard.
• Atorvastatin 40 – 80 mg — also common, slightly more potent.
• Rosuvastatin 20 – 40 mg — most potent but more expensive.
Side effects: muscle aches (1 – 5%, mostly mild), mild liver enzyme rises (1 – 2%, usually harmless), slight rise in blood sugar (the cardiovascular benefit far outweighs this). Severe muscle problems are rare.
SA availability: free at public clinics. R30 – R80 / month privately for generics. The Cholesterol Series Article 9 covers statins in detail.
4. BP medications
Almost every stroke survivor will be on at least one BP drug. The choice depends on the patient's other conditions. The main groups (covered in detail in BP Series Article 9):
Group Examples Notes ACE inhibitors Enalapril, perindopril, lisinopril Often first choice; cough is a common side effect. ARBs Losartan, telmisartan Alternative if cough on ACE inhibitor. Calcium channel blockers Amlodipine, nifedipine Particularly good in Black SA patients; can cause ankle swelling. Diuretics Hydrochlorothiazide, indapamide Useful in combination. Beta-blockers Carvedilol, bisoprolol Especially for heart-related stroke causes.
Most stroke survivors end up on 2 – 3 BP drugs in combination. Many of these combinations are available as single pills, which makes adherence easier.
5. Diabetes medications
If diabetic, blood sugar control reduces vascular damage and supports stroke recovery. The Diabetes Series covers each drug class in detail. For stroke survivors, two classes worth knowing about:
• Metformin — first-line for most Type 2 diabetics, almost always continued after stroke.
• SGLT2 inhibitors (empagliflozin, dapagliflozin) — newer drugs that reduce heart failure and may reduce stroke risk independently. Increasingly recommended for diabetics with established cardiovascular disease, including stroke. Discuss with your clinic.
The “but I feel fine” trap
This is the same trap that catches patients with high BP, cholesterol and diabetes — and it catches stroke survivors twice as hard, because the stroke itself was a frightening event but the daily life afterwards usually feels fine.
Most stroke prevention medications work in the background. You don't feel them. You don't feel anything when they're working. You also don't feel anything in the weeks after stopping — until the day a second stroke happens.
Stroke medication is for life. Not for “until you feel better”. For life.
The numbers are stark. People who stop their stroke medications have roughly the same risk of a second stroke as people who never started them. The risk reduction is paid in daily adherence; stopping forfeits it.
How to take stroke medications well
• Take everything at the same time every day. Pair it with brushing your teeth, breakfast, or another anchor habit.
• Use a pill organiser. The R30 plastic 7-day box at any pharmacy is one of the cheapest medical interventions that makes the biggest difference.
• Keep a written or phone list of all your medications. Carry it to every clinic visit. Show it at every emergency department.
• Don't stop on your own. If a tablet is causing problems, talk to the clinic — there is almost always an alternative.
• If you miss a dose, take it as soon as you remember. Unless it is nearly time for the next dose — skip the missed one. Never double up.
• Keep a small supply ahead. Don't run out before refill day.
• Watch for new prescriptions from other doctors. Tell every doctor about your stroke medications, particularly your anticoagulant or anti-platelet. Many common drugs interact.
What about supplements and traditional medicine?
Many supplements and traditional medicines interact with stroke drugs — particularly anticoagulants. The most important ones to mention:
• Ginkgo biloba, ginger, garlic supplements, ginseng, vitamin E — all increase bleeding risk with warfarin or DOACs.
• St John's wort — interferes with warfarin, some BP drugs, and DOACs.
• Many traditional and herbal medicines have variable, unmeasured effects on blood-clotting.
Tell your clinic about everything you take, including traditional medicines. There is no shame in this; the interaction risk is real and your safety matters more than your privacy.
Drug interactions to know about
Interaction What happens NSAIDs (ibuprofen, diclofenac) with aspirin or anticoagulant Markedly increased bleeding risk. Use paracetamol instead for pain. Grapefruit juice with statins Raises levels of simvastatin and atorvastatin in the blood. Other statins are fine. Some antibiotics with warfarin Can sharply raise INR. Tell the prescriber you take warfarin. Decongestants with BP drugs Some cold-and-flu remedies raise BP. Check labels for “high blood pressure” warnings. Certain HIV drugs with stroke drugs Several interactions. Your HIV doctor should coordinate.
The recovery medications — not for prevention
A few medications you might be on for the consequences of the stroke rather than to prevent the next one:
• Antidepressants — for post-stroke depression. Some (SSRIs like sertraline, citalopram) also support motor recovery.
• Anti-spasticity drugs — for muscle tightness on the affected side. Baclofen, tizanidine.
• Anti-epileptic drugs — for post-stroke seizures, which affect about 5 – 10% of stroke survivors.
• Pain medications — for shoulder pain or central post-stroke pain. Paracetamol first, then sometimes amitriptyline, gabapentin or pregabalin.
• Laxatives or bladder medications — for bowel or bladder control problems.
The bigger picture
Stroke prevention medication is one of the great success stories in modern medicine. A patient who has had a small ischaemic stroke and takes their tablets — aspirin or clopidogrel, a statin, BP medication, AFib management if needed — has roughly the same long-term life expectancy as someone who never had a stroke. The medications are cheap, available, and well-evidenced.
The failure mode is almost always adherence — patients stopping because they feel fine, because of side effects, because they forget, because the prescription runs out. The work of staying well after stroke is mostly the work of staying on the tablets, week after week, year after year.
The next article in the series covers stroke in special cases — young adults, pregnancy, HIV, AFib in detail, sickle cell disease, and the unusual causes that don't fit the standard picture.
Where to get more help
Your nearest public clinic — for free prescriptions, monthly refills, and side-effect management.
Your community pharmacist — will explain dose, interactions and timing for free.
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586.
Phila Today High Blood Pressure Series Article 9 and Cholesterol Series Article 9 — companion articles on BP medications and statins.
Phila Today Stroke Series — next: stroke in special cases — young adults, pregnancy, HIV, AFib, sickle cell.
Phila Today · Article 10 of 12 in the Stroke Series