From the Guidelines
For patients post-stroke, the recommended dosing of ticagrelor for dual antiplatelet therapy (DAPT) is 180 mg loading dose followed by 90 mg twice daily, typically in combination with aspirin 75-100 mg daily. This regimen is based on the most recent guidelines from the International Journal of Stroke, as outlined in a systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization 1. The guidelines recommend initiating DAPT with aspirin and ticagrelor as early as possible, ideally within 24 hours of symptoms onset, after an intracranial hemorrhage is excluded on neuroimaging studies.
Key points to consider when prescribing ticagrelor for DAPT post-stroke include:
- The duration of DAPT is typically 30 days for patients with mild-moderate ischemic stroke or high-risk TIA, after which long-term single antiplatelet therapy is recommended 1.
- Ticagrelor works by reversibly binding to the P2Y12 receptor on platelets, preventing ADP-mediated platelet activation and aggregation, providing enhanced protection during the critical early period after stroke when recurrence risk is highest.
- The intensified antiplatelet effect of ticagrelor also increases bleeding risk, which is why the dual therapy is limited to the short term.
- Renal dose adjustment is not typically required, but ticagrelor should be used cautiously in patients with severe hepatic impairment.
- Patients should be advised to take ticagrelor with food if they experience dyspepsia, and they should be warned about possible dyspnea, which is usually self-limiting.
It is essential to weigh the benefits of ticagrelor against the potential risks, particularly the increased risk of bleeding, and to closely monitor patients during the treatment period. The guidelines emphasize the importance of individualized treatment decisions, taking into account the patient's specific clinical characteristics and risk factors 1.
From the Research
Ticagrelor Dosing for Dual Antiplatelet Therapy (DAPT) Post-Stroke
- The recommended dosing of Ticagrelor for DAPT in patients post-stroke is not explicitly stated in the provided studies, but the efficacy and safety of ticagrelor in combination with aspirin have been compared to clopidogrel and aspirin in several studies 2, 3, 4, 5.
- A network meta-analysis published in 2022 found that both clopidogrel and aspirin, and ticagrelor and aspirin, were superior to aspirin alone in preventing recurrent stroke and death, with no statistically significant difference between the two DAPT regimens 2.
- A systematic review and meta-analysis published in 2023 found that ticagrelor reduced the risk of stroke and ischemic stroke compared to the control group, and was associated with an increased risk of major or minor bleeding 3.
- An updated network meta-analysis published in 2024 found that ticagrelor plus aspirin was superior to aspirin in preventing stroke recurrence, and may be a considerable option for patients after a minor stroke or TIA 4.
- A bayesian network meta-analysis published in 2025 found that ticagrelor plus aspirin was significantly more effective than clopidogrel plus aspirin in preventing post-stroke neurological dysfunctions, recurrent stroke, and major vascular events, but was associated with an increased risk of any bleeding and mild bleeding 5.
Safety and Efficacy Considerations
- The safety profile of ticagrelor in combination with aspirin for DAPT post-stroke is still being established, with some studies reporting an increased risk of bleeding complications 3, 5.
- The use of intravenous thrombolysis with alteplase in acute ischemic stroke patients on ticagrelor is a topic of debate, with some cases reporting successful treatment without bleeding complications, while others have reported hemorrhagic complications 6.
- The decision to use ticagrelor for DAPT post-stroke should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3, 4, 5.