Dipyridamole

Dipyridamole, sold under the brand name Persantine among others, is an antiplatelet drug of the nucleoside transport inhibitor and PDE3 inhibitor class that inhibits blood clot formation when given chronically and causes blood vessel dilation when given at high doses over a short time.

Dipyridamole

Clinical data
Trade names	Persantine, others
AHFS/Drugs.com	Monograph
MedlinePlus	a682830
Routes of administration	By mouth, intravenous
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]
Elimination 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 Y
PubChem CID	3108
IUPHAR/BPS	4807
DrugBank	DB00975 Y
ChemSpider	2997 Y
UNII	64ALC7F90C
KEGG	D00302 Y
ChEBI	CHEBI:4653 Y
ChEMBL	ChEMBL932 Y
CompTox Dashboard (EPA)	DTXSID6040668
ECHA InfoCard	100.000.340
Chemical and physical data
Formula	C24H40N8O4
Molar mass	504.636 g·mol−1
3D model (JSmol)	Interactive image
SMILES C1CCN(CC1)C2=NC(=NC3=C2N=C(N=C3N4CCCCC4)N(CCO)CCO)N(CCO)CCO
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 Y Key:IZEKFCXSFNUWAM-UHFFFAOYSA-N Y
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Medical uses

• Dipyridamole is used to dilate blood vessels in people with peripheral arterial disease and coronary artery disease.^[3]
• Dipyridamole has been shown to lower pulmonary hypertension without significant drop of systemic blood pressure.
• It inhibits proliferation of smooth muscle cells in vivo and modestly increases unassisted patency of synthetic arteriovenous hemodialysis grafts.^[4]
• Cyclic adenosine monophosphate 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.^[5]
• It can be used for myocardial stress testing as an alternative to exercise-induced stress methods such as treadmills.

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.^[3] 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.^[6][7][8][9]

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.^[10]

A triple therapy of aspirin, clopidogrel, and dipyridamole has been investigated, but this combination led to an increase in adverse bleeding events.^[11]

Interactions

Due to its action as a phosphodiesterase inhibitor, dipyridamole is likely to potentiate the effects of adenosine. This occurs by blocking the nucleoside transporter (ENT1) through which adenosine enters erythrocyte and endothelial cells.^[12]

According to Association of Anaesthetists of Great Britain and Ireland 2016 guidelines, dipyridamole is considered to not cause risk of bleeding when receiving neuroaxial anaesthesia and deep nerve blocks. It does not therefore require cessation prior to anaesthesia with these techniques, and can continue to be taken with nerve block catheters in place.^[13]

Overdose

Dipyridamole overdose can be treated with aminophylline^[2]: 6 or caffeine which reverses its dilating effect on the blood vessels. Symptomatic treatment is recommended, possibly including a vasopressor drug. Gastric lavage should be considered. Since dipyridamole is highly protein bound, dialysis is not likely to be of benefit.

Mechanisms of action

Dipyridamole has two known effects, acting via different mechanisms of action:

• Dipyridamole inhibits the phosphodiesterase enzymes that normally break down cAMP (increasing cellular cAMP levels and blocking the platelet aggregation, response^[3] to ADP) and/or cGMP.
• Dipyridamole inhibits the cellular reuptake of adenosine into platelets, red blood cells, and endothelial cells, leading to increased extracellular concentrations of adenosine.