Yes, both prasugrel and Brilinta (ticagrelor) are taken after PCI
Both prasugrel and ticagrelor are recommended P2Y12 inhibitors for dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS), administered as a loading dose followed by daily maintenance dosing. 1
Dosing Regimens
Prasugrel:
- Loading dose: 60 mg orally
- Maintenance: 10 mg once daily
- Reduce to 5 mg daily if body weight <60 kg
- Consider 5 mg daily if age ≥75 years (use cautiously due to increased bleeding risk) 1, 2
Ticagrelor (Brilinta):
- Loading dose: 180 mg orally
- Maintenance: 90 mg twice daily
- Can be chewed for faster action 1
When to Use Each Agent
For ACS patients undergoing PCI, it is reasonable to use ticagrelor or prasugrel in preference to clopidogrel to reduce ischemic events including stent thrombosis. 1, 3 Both agents demonstrated superior efficacy compared to clopidogrel in landmark trials (PLATO for ticagrelor, TRITON-TIMI 38 for prasugrel), though both carry higher bleeding risk. 1, 3
Critical Contraindications and Cautions
Prasugrel is absolutely contraindicated in patients with:
- Prior stroke or transient ischemic attack (TIA) - associated with net harm including increased intracranial hemorrhage 1, 3, 2
- Active pathological bleeding 2
Prasugrel should generally be avoided in patients ≥75 years due to increased fatal and intracranial bleeding risk, except in high-risk situations (diabetes or prior MI) where benefit may outweigh risk. 2
Timing of Administration
The loading dose timing depends on clinical presentation:
- STEMI within 12 hours: Loading dose can be given at diagnosis, though most receive it at time of PCI
- UA/NSTEMI or delayed STEMI: Loading dose typically given after coronary anatomy is known to avoid delaying urgent CABG if needed 1
Duration of Therapy
Both agents should be continued with aspirin (75-100 mg daily) for at least 12 months after PCI. 1 The DAPT score can help determine whether to extend therapy beyond 12 months - scores ≥2 favor prolonged DAPT, while scores <2 do not. 3
Comparative Effectiveness
Recent meta-analyses show no significant difference between prasugrel and ticagrelor in terms of mortality, major adverse cardiovascular events, myocardial infarction, stroke, stent thrombosis, or major bleeding. 4 Both are equally effective options when appropriately selected based on patient-specific contraindications and risk factors.
Key Pitfall to Avoid
Do not use prasugrel in patients with prior stroke/TIA - this is a hard contraindication due to demonstrated harm. 1, 3, 2 Always screen for stroke history before initiating prasugrel. For these patients, ticagrelor is the preferred potent P2Y12 inhibitor.