Can Brilinta (ticagrelor) monotherapy be prescribed?

From the Guidelines

Brilinta (ticagrelor) monotherapy can be prescribed, but typically only after an initial period of dual antiplatelet therapy (DAPT) and under specific conditions, as supported by the most recent guidelines 1. The decision to prescribe ticagrelor monotherapy should be based on individual patient characteristics, including their risk of ischemic events and bleeding.

• The standard dose for ticagrelor monotherapy is 60-90 mg twice daily.
• This approach has gained acceptance based on clinical trials showing that ticagrelor monotherapy after a short DAPT period can reduce bleeding complications while maintaining protection against ischemic events, as seen in studies like PEGASUS-TIMI 54 1.
• The rationale behind this strategy is that the highest risk of stent thrombosis occurs in the first few months after PCI, justifying initial DAPT, while the long-term bleeding risk of continued DAPT may outweigh its benefits in many patients.
• Patients should be monitored for dyspnea, bleeding, and bradyarrhythmias, which are potential side effects of ticagrelor.
• Patients should also be advised to take ticagrelor consistently at the same times each day and not to discontinue it without consulting their healthcare provider.
• The 2024 ESC guidelines for the management of chronic coronary syndromes provide guidance on the use of ticagrelor monotherapy, recommending it as an option for high ischemic risk patients without high bleeding risk, in addition to aspirin plus rivaroxaban 2.5 mg b.i.d. 1.

From the Research

Brilinta Monotherapy Prescription

• Brilinta (ticagrelor) monotherapy can be prescribed in certain cases, as evidenced by studies such as TWILIGHT-HBR 2, which showed that ticagrelor monotherapy reduced the incidence of bleeding compared to ticagrelor plus aspirin in patients at high bleeding risk undergoing percutaneous coronary intervention.
• The study found that among high bleeding risk patients who completed 3-month dual antiplatelet therapy without experiencing major adverse events, aspirin discontinuation followed by ticagrelor monotherapy significantly reduced bleeding without increasing ischemic events 2.
• Another study, a meta-analysis of randomized clinical trials, found that P2Y12 inhibitor monotherapy, including ticagrelor, was associated with a lower risk of major adverse cardiac and cerebrovascular events compared to aspirin monotherapy, without a significant difference in major bleeding 3.
• The use of ticagrelor monotherapy is supported by its mechanism of action as a reversible and selective adenosine diphosphate (ADP) receptor antagonist, which provides greater inhibition of platelet aggregation than clopidogrel 4.
• However, the decision to prescribe ticagrelor monotherapy should be made on an individual patient basis, taking into account the patient's clinical circumstances and risk factors, as well as the potential benefits and risks of the treatment 5, 6.

Key Findings

• Ticagrelor monotherapy reduces bleeding risk in patients at high bleeding risk undergoing percutaneous coronary intervention 2.
• P2Y12 inhibitor monotherapy, including ticagrelor, is associated with a lower risk of major adverse cardiac and cerebrovascular events compared to aspirin monotherapy 3.
• Ticagrelor has a faster onset of action and provides greater inhibition of platelet aggregation than clopidogrel 4.

Patient Selection

• Patients at high bleeding risk who have completed 3-month dual antiplatelet therapy without experiencing major adverse events may be suitable for ticagrelor monotherapy 2.
• The decision to prescribe ticagrelor monotherapy should be made on an individual patient basis, taking into account the patient's clinical circumstances and risk factors 5, 6.