Proposal to fund ticagrelor for people with minor stroke or high risk TIA
What we’re proposing
We are proposing to extend the funding of ticagrelor from 1 November 2025 to include the treatment of people who have experienced a minor stroke or a high-risk cerebrovascular transient ischemic attack (TIA).
This proposal follows the recent discontinuation of dipyridamole long-acting 150 mg tablets (Pytazen SR brand) by the supplier. We have heard that dipyridamole is sometimes used following a stroke to treat a small number of people for whom antiplatelet agents such as clopidogrel are clinically unsuitable.
The discontinuation of dipyridamole means that this group of people may no longer have a suitable funded treatment available to them.
More information about the dipyridamole discontinuation and what we have done to manage it is available on our website.
Consultation closes at 5:00pm, Wednesday 17 September 2025 and feedback can be emailed to consult@pharmac.govt.nz
What would the effect be?
This proposal would mean that from 1 November 2025 ticagrelor would be funded in the community and Health New Zealand hospitals for a period of 21 days following a minor stroke or high-risk transient ischemic attack (TIA), for the prevention of atherothrombotic events for people who are not expected to respond to or tolerate clopidogrel.
Who we think will be interested
- People who have had, or are at risk of stroke or TIA
- Whānau, families, partners, loved ones and caregivers of people who have had, or are at risk of minor stroke or high-risk TIA
- Healthcare professionals involved in the treatment and management of stroke or TIA
- The National Stroke Network
- Patient support groups
- Pharmacies and pharmacy staff
- Wholesalers
- Pharmaceutical manufacturers and suppliers
About ticagrelor
Ticagrelor is an anti-platelet, or ‘blood thinning’, medication that helps to prevent the formation of blood clots that could lead to a thrombotic event such as a stroke or TIA. Ticagrelor is a tablet that is taken twice daily. Ticagrelor is currently funded subject to special authority criteria(external link) for use in thrombosis prevention in neurological stenting, percutaneous coronary intervention (PCI) with stent deployment, and in people with ST-elevation or non-ST elevation acute coronary syndrome.
Special Authority funding criteria [PDF](external link)
Ticagrelor works without needing liver enzyme activation, unlike clopidogrel. Some people don’t produce these enzymes well due to their genes which means ticagrelor may work better for people who don’t respond to clopidogrel.
About minor stroke or high-risk TIA
A minor stroke is a sudden interruption of blood flow to part of the brain. People who experience a minor stroke typically experience symptoms such as weakness in one limb or on one side of the body, speech difficulties, numbness or tingling in one part of the body, drooping of one side of the face, and problems with coordination or balance.
Transient ischemic event (TIA) is a temporary period of symptoms similar to a stroke and may last up to a few hours. People who experience a TIA categorised at high risk have a high risk of experiencing a stroke within the following 24 to 48 hours. The key factors used to assess this risk include age, blood pressure, clinical features such as muscle weakness, speech disturbance, the duration of the TIA and the presence of diabetes.
Our clinical advisors have told us that a minor stroke is one that has a National Institute of Health Stroke Score (NIHSS) of 3 or less. A high-risk TIA is one that has an age, blood pressure, clinical features, duration of symptoms, diabetes (ABCD2) score of 4 or more.
Why we’re proposing this
In 2022 we received an application to fund ticagrelor for the treatment of minor stroke or high-risk TIA and for the prevention of atherothrombotic events. In 2022, we received clinical advice on this application from Pharmac’s Pharmacology and Therapeutics Advisory Committee (PTAC), which recommended the funding of ticagrelor for these groups with a low priority.
Ticagrelor funding application for these indications(external link)
In making this recommendation, PTAC considered the lack of funded alternative treatment options for patients who do not respond well to clopidogrel due to genetic factors. This proposal would also provide an option for people who are unable to take clopidogrel because they are allergic to it.
We understand that dipyridamole may be being used as an alternative to clopidogrel for this small group of people. In 2024 the supplier of dipyridamole told us that it was discontinuing supply of dipyridamole and remaining stock would run out during 2025.
People who are currently receiving dipyridamole should discuss their options with their healthcare professional.
Progressing this proposal would mean that people who experience a minor stroke or high-risk TIA would have access to a suitable funded treatment option.
Some people may have been receiving dipyridamole for a number of years following a minor stroke or high-risk TIA. These people would not have access to ticagrelor as a result of this proposal, as funding would be limited to a period of 21 days after a minor stroke or high-risk TIA in accordance with clinical advice.
We have received advice that that the long-term, ongoing use of ticagrelor for the treatment of stroke or TIA should be considered separately from this proposal due to the limited evidence available supporting the long-term use of ticagrelor in stroke and TIA compared to the short term use considered in this proposal. No funding application has been received for this use at this time. More information about how to submit funding applications is available on our website.
Details about our proposal
From 1 November 2025 ticagrelor would be funded in the community (Section B) and Health New Zealand Hospitals (Part II Section H) of the Pharmaceutical Schedule subject to the following access criteria.
Special Authority for Subsidy
Initial application (acute minor stroke or high-risk transient ischemic attack)* from any relevant practitioner. Approvals valid for 1 month for applications meeting the following criteria:
All of the following:
- Patient has been diagnosed with a minor stroke (NIHSS score 3 or less) or high-risk transient ischemic attack (ABCD2 score 4 or more); and
- Either:
- Patient is expected to be a poor metaboliser of clopidogrel, with documented clinical rationale; or
- Patient is allergic to clopidogrel**; and
- Ticagrelor to be prescribed for a maximum of 21 days following minor stroke or TIA.
Renewal (subsequent minor stroke or high-risk transient ischemic attack) from any relevant practitioner. Approvals valid for 1 month where the patient has been diagnosed with a minor stroke (NIHSS score 3 or less) or high-risk transient ischemic attack (ABCD2 score 4 or more);
Notes: indications marked with * are unapproved indications. Note: ** Clopidogrel allergy is defined as a history of anaphylaxis, urticaria, generalised rash or asthma (in non-asthmatic patients) developing soon after clopidogrel is started and is considered unlikely to be caused by any other treatment.
Similar criteria would apply in Part II of Section H of the Pharmaceutical Schedule.
These proposed criteria have been informed by feedback from our specialist clinical advisors and engagement with the National Stroke Network. We have been told that CYP2C19 gene testing may not be available across the entire country, and the wait for testing results could mean people are delayed receiving treatment immediately post stroke or high-risk TIA where it is most critical.
We have proposed criteria which would allow ticagrelor to be used in situations where clopidogrel has been considered but is not clinically appropriate as the person is not expected to respond to or tolerate treatment.
The National Stroke Network would provide guidance to help clinicians identify people who would be expected to be resistant to clopidogrel.
The access criteria for ticagrelor for thrombosis prevention in neurological stenting and percutaneous coronary intervention with stent deployment include different criteria for demonstrating clopidogrel resistance. These criteria differ from each other and are different from what is proposed. More information about the existing ticagrelor criteria is available on our website.
Schedule listing for ticagrelor(external link)
We understand that it would be desirable for the same requirement for demonstrating clopidogrel resistance to be used across the different indications for ticagrelor. This will require further work by Pharmac to understand the impacts of this and may require further clinical advice. No changes to the access criteria for currently funded ticagrelor indications are proposed at this time.
To provide feedback
Send us an email: consult@pharmac.govt.nz by 5:00pm, 17 September 2025
All feedback received before the closing date will be considered by Pharmac’s Board (or its delegate) prior to making a decision on this proposal.
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