When should ticagrelor (P2Y12 inhibitor) be ordered three times a day (tid)?

Ticagrelor Dosing: When to Order TID

Ticagrelor should never be ordered three times daily (TID); the standard dosing is twice daily (BID) according to all current guidelines and FDA labeling. 1

Standard Ticagrelor Dosing Regimen

The correct dosing for ticagrelor in acute coronary syndromes (ACS) is:

• Loading dose: 180 mg orally as a one-time dose
• Maintenance dose: 90 mg twice daily for the first year
• Extended therapy: 60 mg twice daily after the first year (if continued)

This dosing schedule is consistently recommended across all major cardiovascular guidelines 2.

Evidence Supporting BID Dosing

The twice-daily dosing regimen for ticagrelor is based on its pharmacokinetic and pharmacodynamic profile:

• Ticagrelor has a half-life of approximately 7-12 hours 3, 4
• Twice-daily dosing provides more consistent platelet inhibition than once-daily regimens 3
• Clinical trials demonstrating ticagrelor's efficacy and safety used the twice-daily dosing schedule 2

Key Guidelines on Ticagrelor Dosing

Multiple high-quality guidelines consistently recommend the same dosing schedule:

• ACC/AHA guidelines for STEMI management specify ticagrelor 90 mg twice daily as the maintenance dose 2
• ACC/AHA guidelines for NSTE-ACS management recommend ticagrelor 90 mg twice daily 2
• The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline confirms ticagrelor maintenance dose as 90 mg twice daily 2
• FDA labeling specifically states ticagrelor should be administered twice daily 1

Common Pitfalls to Avoid

1. Confusion with other antiplatelet agents: Unlike aspirin or clopidogrel that are dosed once daily, ticagrelor requires twice-daily administration due to its pharmacokinetic profile.

2. Medication adherence concerns: The twice-daily dosing regimen may present adherence challenges for some patients. This should be addressed through patient education rather than inappropriate dosing adjustment.

3. Aspirin dosing with ticagrelor: When using ticagrelor, the recommended maintenance dose of aspirin is specifically 81 mg daily (not higher doses) 2.

Clinical Algorithm for Ticagrelor Use

1. Initial presentation with ACS:

   • Loading dose: 180 mg orally
   • Start maintenance dose: 90 mg twice daily

2. Duration of therapy:

   • Continue 90 mg twice daily for 12 months
   • If extended therapy needed beyond 12 months: Switch to 60 mg twice daily 1

3. Special considerations:

   • Use with low-dose aspirin (81 mg daily)
   • Avoid in patients with history of intracranial hemorrhage
   • Discontinue at least 5 days before planned surgery

Conclusion

There is no clinical scenario where ticagrelor should be prescribed three times daily. The established dosing regimen based on pharmacokinetics, clinical trials, and all major guidelines is twice daily administration.