From the Guidelines
No, Brilinta (ticagrelor) cannot replace Acetylsalicylic Acid (ASA or aspirin) in most clinical situations. In fact, Brilinta is typically prescribed alongside ASA as dual antiplatelet therapy, particularly for patients with acute coronary syndromes or those who have received coronary stents. The standard regimen involves Brilinta 90 mg twice daily plus ASA 81 mg daily for 12 months following an acute coronary event, after which patients may continue on ASA alone indefinitely, as recommended by the 2021 ESC guidelines for the management of acute coronary syndromes 1. These medications work through different mechanisms - Brilinta is a P2Y12 receptor antagonist that blocks ADP-mediated platelet activation, while ASA irreversibly inhibits the cyclooxygenase enzyme to prevent thromboxane A2 production. This complementary action provides more comprehensive platelet inhibition than either agent alone. Substituting one for the other would leave gaps in antiplatelet coverage and potentially increase cardiovascular risk. Additionally, Brilinta has a higher bleeding risk profile and requires twice-daily dosing, making it less suitable as a direct ASA replacement for long-term preventive therapy. The 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease also supports the use of ticagrelor on top of aspirin in patients with acute coronary syndromes, unless there are contraindications 1.
Some key points to consider:
- Brilinta and ASA have different mechanisms of action and work synergistically to provide comprehensive platelet inhibition.
- The use of Brilinta and ASA as dual antiplatelet therapy is recommended for patients with acute coronary syndromes or those who have received coronary stents, as stated in the 2021 ESC guidelines 1.
- Brilinta has a higher bleeding risk profile compared to ASA, which should be taken into account when making treatment decisions.
- The 2018 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS also recommends ticagrelor on top of aspirin in patients with ACS, unless there are contraindications 1.
Overall, while Brilinta is an effective antiplatelet agent, it should not be used as a replacement for ASA in most clinical situations, but rather as an adjunct to ASA as part of dual antiplatelet therapy, as supported by the most recent and highest quality studies, including the 2021 ESC guidelines 1.
From the Research
Brilinta as a Replacement for ASA
- Brilinta (ticagrelor) is a P2Y12 inhibitor that has been shown to be effective in reducing the risk of major adverse cardiovascular events (MACE) in patients with acute coronary syndromes (ACS) 2, 3.
- The use of ticagrelor as a replacement for Acetylsalicylic Acid (ASA) has been studied in several trials, with some suggesting that ticagrelor may be a viable alternative to ASA in certain patient populations 4, 5.
- A systematic review and network meta-analysis found that aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, may be the optimal strategy for treating post-percutaneous coronary intervention patients with ACS 5.
- However, another study found that de-escalation from ticagrelor or prasugrel to clopidogrel within 30 days of PCI did not result in a significant difference in the composite outcome of all-cause mortality, urgent revascularization, stent thrombosis, stroke, and major bleeding at one year 6.
Key Findings
- Ticagrelor has been shown to be more effective than clopidogrel in reducing the incidence of MACE in patients with ACS 2, 3.
- The use of ticagrelor as a replacement for ASA may be associated with a lower risk of MACE and all-cause hospitalization compared with clopidogrel after PCI for ACS 3.
- However, the optimal duration and choice of antiplatelet therapy in patients with ACS undergoing PCI remain controversial, and further studies are needed to confirm these findings 6, 5.