Dipyridamole

Dipyridamole

Clinical data
Trade names	Persantine, Curantyl
AHFS/Drugs.com	Monograph
MedlinePlus	a682830
Pregnancy category	B
Routes of administration	By mouth, IV
ATC code	B01AC07 (WHO)
Legal status
Legal status	UK: POM (Prescription only) US: ℞-only
Pharmacokinetic data
Bioavailability	37–66%[1]
Protein binding	~99%
Metabolism	Liver (glucuronidation)[2]
Biological half-life	α phase: 40 min, β phase: 10 hours
Excretion	Biliary (95%), urine (negligible)
Identifiers
IUPAC name 2,2',2'',2'''-(4,8-di(piperidin-1-yl)pyrimido[5,4-d]pyrimidine-2,6-diyl)bis(azanetriyl)tetraethanol
CAS Number	58-32-2
PubChem (CID)	3108
IUPHAR/BPS	4807
DrugBank	DB00975
ChemSpider	2997
UNII	64ALC7F90C
KEGG	D00302
ChEBI	CHEBI:4653
ChEMBL	CHEMBL932
ECHA InfoCard	100.000.340
Chemical and physical data
Formula	C24H40N8O4
Molar mass	504.626 g/mol
3D model (Jmol)	Interactive image
SMILES OCCN(CCO)C(N=C1N2CCCCC2)=NC3=C1N=C(N(CCO)CCO)N=C3N4CCCCC4
InChI InChI=1S/C24H40N8O4/c33-15-11-31(12-16-34)23-26-20-19(21(27-23)29-7-3-1-4-8-29)25-24(32(13-17-35)14-18-36)28-22(20)30-9-5-2-6-10-30/h33-36H,1-18H2 Key:IZEKFCXSFNUWAM-UHFFFAOYSA-N
(verify)

Dipyridamole (trademarked as Persantine and Curantyl) is a medication that inhibits blood clot formation^[3] when given chronically and causes blood vessel dilation when given at high doses over a short time.

Mechanism and effects

• Dipyridamole inhibits the phosphodiesterase enzymes that normally break down cAMP (increasing cellular cAMP levels and blocking the platelet aggregation response^[4] to ADP) and/or cGMP.
• It inhibits the cellular reuptake of adenosine into platelets, red blood cells, and endothelial cells leading to increased extracellular concentrations of adenosine.

Medical uses

• Dipyridamole is used to dilate blood vessels in people with peripheral arterial disease and coronary artery disease^[4]
• Dipyridamole has been shown to lower pulmonary hypertension without significant drop of systemic blood pressure
• It inhibits formation of pro-inflammatory cytokines (MCP-1, MMP-9) in vitro and results in reduction of hsCRP in patients.
• It inhibits proliferation of smooth muscle cells in vivo and modestly increases unassisted patency of synthetic arteriovenous hemodialysis grafts.^[5]
• It increases the release of t-PA from brain microvascular endothelial cells
• It results in an increase of 13-HODE and decrease of 12-HETE in the subendothelial matrix (SEM) and reduced thrombogenicity of the SEM.
• Pretreatment it reduced reperfusion injury in volunteers.
• It has been shown to increase myocardial perfusion and left ventricular function in patients with ischemic cardiomyopathy.
• It results in a reduction of the number of thrombin and PECAM-1 receptors on platelets in stroke patients.
• cAMP impairs platelet aggregation and also causes arteriolar smooth muscle relaxation. Chronic therapy did not show significant drop of systemic blood pressure.
• It inhibits the replication of mengovirus RNA.^[6]
• It can be used for myocardial stress testing as an alternative to exercise-induced stress methods such as treadmills.

Use in individuals with a history of stroke

A combination of dipyridamole and aspirin (acetylsalicylic acid/dipyridamole) is FDA-approved for the secondary prevention of stroke and has a bleeding risk equal to that of aspirin use alone.^[4] Dipyridamole absorption is pH-dependent and concomitant treatment with gastric acid suppressors (such as a proton pump inhibitor) will inhibit the absorption of liquid and plain tablets.^[7][8] Modified release preparations are buffered and absorption is not affected.^[9][10]

However, it is not licensed as monotherapy for stroke prophylaxis, although a Cochrane Review suggested that dipyridamole may reduce the risk of further vascular events in patients presenting after cerebral ischemia.^[11]

A triple therapy of aspirin, clopidogrel, and dipyridamole has been investigated, but this combination led to an increase in adverse bleeding events.^[12]

• Vasodilation occurs in healthy arteries, whereas stenosed arteries remain narrowed. This creates a "steal" phenomenon where the coronary blood supply will increase to the dilated healthy vessels compared to the stenosed arteries which can then be detected by clinical symptoms of chest pain, electrocardiogram and echocardiography when it causes ischemia.
• Flow heterogeneity (a necessary precursor to ischemia) can be detected with gamma cameras and SPECT using nuclear imaging agents such as Thallium-201, Tc99m-Tetrofosmin and Tc99m-Sestamibi. However, relative differences in perfusion do not necessarily imply any absolute decrease in blood supply in the tissue supplied by a stenosed artery.

Other uses

Dipyridamole also has non-medicinal uses in a laboratory context, such as the inhibition of cardiovirus growth in cell culture.

Overdose

Dipyridamole overdose
Classification and external resources
Specialty	emergency medicine
ICD-10	T46.3
ICD-9-CM	972.4
DiseasesDB	3840

Dipyridamole overdose can be treated with aminophylline^[2]:6 which reverses its dilating effect on the blood vessels. Symptomatic treatment is recommended, possibly including a vasopressor drug. Gastric lavage should be considered. Administration of xanthine derivatives (e.g., aminophylline) may reverse the hemodynamic effects of dipyridamole overdose. Since dipyridamole is highly protein bound, dialysis is not likely to be of benefit.

See also

• Acetylsalicylic acid/dipyridamole
• Cilostazol

References

1. Nielsen-Kudsk, F; Pedersen, AK (May 1979). "Pharmacokinetics of Dipyridamole". Acta Pharmacologica et Toxicologica. 44 (5): 391–9. PMID 474151.
2. "Aggrenox (aspirin/extended-release dipyridamole) Capsules. Full Prescribing Information" (PDF). Boehringer Ingelheim Pharmaceuticals, Inc. Retrieved 1 December 2016.
3. "Dipyridamole" at Dorland's Medical Dictionary
4. Brown DG, Wilkerson EC, Love WE (March 2015). "A review of traditional and novel oral anticoagulant and antiplatelet therapy for dermatologists and dermatologic surgeons". Journal of the American Academy of Dermatology. 72 (3): 524–34. doi:10.1016/j.jaad.2014.10.027. PMID 25486915.
5. Dixon BS, Beck GJ, Vazquez MA, et al. (2009). "Effect of dipyridamole plus aspirin on hemodialysis graft patency". N Engl J Med. 360 (21): 2191–2201. doi:10.1056/nejmoa0805840.
6. Dipyridamole in the laboratory: Fata-Hartley, Cori L.; Ann C. Palmenberg. "Dipyridamole reversibly inhibits mengovirus RNA replication". doi:10.1128/JVI.79.17.11062-11070.2005. Retrieved 2007-02-13.
7. Russell TL, Berardi RR, Barnett JL, O’Sullivan TL, Wagner JG, Dressman JB. pH-related changes in the absorption of "dipyridamole" in the elderly. Pharm Res (1994) 11 136–43.
8. Derendorf H, VanderMaelen CP, Brickl R-S, MacGregor TR, Eisert W. "Dipyridamole" bioavailability in subjects with reduced gastric acidity. J Clin Pharmacol (2005) 45, 845–50.
9. http://emc.medicines.org.uk/medicine/304/SPC/Persantin+Retard+200mg/#EXCIPIENTS
10. Stockley, Ivan (2009). Stockley’s Drug Interactions. The Pharmaceutical Press. ISBN 0-85369-424-9.
11. De Schryver EL, Algra A, van Gijn J (2007). Algra A, ed. "Dipyridamole for preventing stroke and other vascular events in patients with vascular disease.". Cochrane Database of Systematic Reviews (2): CD001820. doi:10.1002/14651858.CD001820.pub3. PMID 17636684.
12. Sprigg N, Gray LJ, England T, et al. (2008). Berger JS, ed. "A randomised controlled trial of triple antiplatelet therapy (aspirin, clopidogrel and dipyridamole) in the secondary prevention of stroke: safety, tolerability and feasibility". PLoS ONE. 3 (8): e2852. doi:10.1371/journal.pone.0002852. PMC 2481397. PMID 18682741.