From the Guidelines
For dual antiplatelet therapy (DAPT) in patients post-stroke, the recommended dosing of ticagrelor is 90 mg twice daily (BID) for the first 30 days, as indicated by the most recent and highest quality study 1. This regimen typically includes aspirin 75-100 mg daily alongside ticagrelor. The initial higher dose of ticagrelor provides more intensive platelet inhibition during the period of highest recurrent stroke risk. Some key points to consider when initiating this therapy include:
- Starting as soon as possible after the stroke (ideally within 24 hours) for maximum benefit, as suggested by 1.
- Counseling patients to take ticagrelor with food to reduce gastrointestinal side effects and to avoid missing doses due to the short half-life of the medication.
- Being aware of the potential increased risk of severe bleeding associated with the use of ticagrelor plus aspirin, as noted in 1. This dosing strategy is based on clinical trials showing that more intensive antiplatelet therapy early after stroke or TIA significantly reduces the risk of recurrent ischemic events, with the benefit being greatest in the first few weeks, as discussed in 1. However, the long-term dosing after the initial 30 days is not explicitly stated in the most recent guideline 1, but considering the balance between efficacy and safety, 90 mg BID is the recommended dose for the initial period, and the decision to adjust the dose after 30 days should be based on individual patient risk factors and response to therapy.
From the Research
Dosing of Ticagrelor for Dual Antiplatelet Therapy
- The recommended dosing of ticagrelor for dual antiplatelet therapy (DAPT) in patients post-stroke is not explicitly stated as 90mg BID or 60mg BID in the provided studies 2, 3, 4, 5, 6.
- However, the studies suggest that ticagrelor is often administered at a dose of 90mg twice daily, as seen in the THALES trial 4.
- A study published in 2025 6 investigated the use of half-dose ticagrelor (45mg twice daily) in patients undergoing stent-assisted coiling or flow diversion of unruptured intracranial aneurysms, but this dose is not directly relevant to the context of post-stroke DAPT.
- The provided studies do not directly compare the efficacy and safety of 90mg BID versus 60mg BID ticagrelor in patients post-stroke, but they do suggest that ticagrelor is a viable option for DAPT in this population 2, 3, 5.
Efficacy and Safety of Ticagrelor
- The studies suggest that ticagrelor is effective in preventing recurrent strokes and death in patients with minor ischemic stroke or transient ischemic attack (TIA) 2, 3, 5.
- Ticagrelor has been shown to be superior to aspirin alone in preventing stroke recurrence, but there is no significant difference between ticagrelor and clopidogrel in this regard 2, 3, 5.
- The safety profile of ticagrelor is generally similar to that of clopidogrel, with an increased risk of major bleeding events 2, 3, 5.