Ticagrelor Maintenance Dosing After Loading
The first maintenance dose of ticagrelor 90 mg should be given 12 hours after the 180 mg loading dose 1.
Dosing Schedule
Ticagrelor follows a twice-daily maintenance regimen:
- Loading dose: 180 mg orally (single dose)
- Maintenance dose: 90 mg orally twice daily
- Timing: First maintenance dose at 12 hours post-loading, then every 12 hours thereafter
This dosing schedule is explicitly outlined in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guidelines for ACS management 1. The twice-daily dosing reflects ticagrelor's pharmacokinetic profile, which requires consistent dosing intervals to maintain therapeutic platelet inhibition.
Key Clinical Considerations
Aspirin co-administration: When using ticagrelor, aspirin maintenance doses must be ≤100 mg daily. Higher aspirin doses (>100 mg) were associated with reduced ticagrelor efficacy in post-hoc analysis of the PLATO trial 1. After the initial aspirin loading dose of 162-325 mg, transition to low-dose aspirin (75-100 mg daily) immediately.
Contraindication with strong CYP3A4 inhibitors: Ticagrelor is contraindicated during and for 2 weeks after treatment with strong CYP3A4 inhibitors like itraconazole, as these dramatically increase ticagrelor concentrations and bleeding risk 2.
Common Pitfalls to Avoid
- Do not delay the first maintenance dose beyond 12 hours - this creates a gap in platelet inhibition that could increase thrombotic risk
- Do not use once-daily dosing - ticagrelor's pharmacokinetics require twice-daily administration for sustained effect
- Do not continue high-dose aspirin - this reduces ticagrelor's effectiveness; switch to 75-100 mg aspirin daily after loading
- Do not give an additional loading dose if the patient is already on maintenance ticagrelor therapy, unless switching from another P2Y12 inhibitor
The evidence consistently supports this 12-hour interval between loading and first maintenance dose across both STEMI and NSTE-ACS populations undergoing PCI 1.