What is the management of ticagrelor (antiplatelet medication) after an ischemic or hemorrhagic stroke?

Management of Ticagrelor After Stroke

For patients with ischemic stroke, dual antiplatelet therapy with ticagrelor (180 mg loading dose, then 90 mg twice daily) plus aspirin (300-325 mg loading dose, then 75-100 mg daily) for 30 days is recommended for mild-to-moderate acute non-cardioembolic ischemic stroke or high-risk TIA, followed by long-term single antiplatelet therapy. 1

Ischemic Stroke Management

Acute Management (First 30 Days)

• For mild-to-moderate ischemic stroke (NIHSS ≤5) or high-risk TIA (ABCD2 ≥4):

  • Dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin should be initiated as early as possible, ideally within 24 hours of symptom onset 1
  • Loading doses: Ticagrelor 180 mg + Aspirin 300-325 mg 1
  • Maintenance doses: Ticagrelor 90 mg twice daily + Aspirin 75-100 mg daily 1
  • Duration: 30 days 1

• For moderate-to-severe ischemic stroke (NIHSS >5):

  • Preliminary evidence suggests ticagrelor may be safe in moderate-to-severe stroke, but this requires further study 2
  • The THALES trial demonstrated that ticagrelor plus aspirin reduced the risk of recurrent stroke or death within 30 days compared to aspirin alone (5.5% vs 6.6%) 3

Long-term Management (After 30 Days)

• After the initial 30-day DAPT period, transition to single antiplatelet therapy 1
• Options include:
  • Aspirin 75-100 mg daily
  • Clopidogrel 75 mg daily
  • Ticagrelor monotherapy (evidence is limited for long-term use after stroke) 1

Special Considerations

Intracranial Atherosclerotic Stenosis (ICAS)

• In patients with ≥30% intracranial stenosis ipsilateral to the ischemic event, ticagrelor plus aspirin showed greater benefit:
  • Risk of recurrent stroke or death at 30 days: 9.9% with ticagrelor+aspirin vs 15.2% with aspirin alone 1
  • Notably, bleeding events were not significantly higher in this subgroup 1

Hemorrhagic Stroke

• Ticagrelor is contraindicated in patients with a history of hemorrhagic stroke 4
• The FDA label specifically warns against using ticagrelor in patients with a history of intracranial hemorrhage 4

Prior History of Stroke or TIA

• Caution is advised when using ticagrelor in patients with prior stroke or TIA due to potential increased risk of intracranial hemorrhage 1, 4
• However, meta-analyses suggest ticagrelor may reduce the risk of incident strokes among patients with prior history of ischemic stroke or TIA 5

Safety Considerations

Bleeding Risk

• Severe bleeding occurred in 0.5% of patients receiving ticagrelor-aspirin compared to 0.1% with aspirin alone in the THALES trial 3
• Intracranial hemorrhage was also significantly increased with DAPT (0.4% vs 0.1%) 1
• Risk factors for bleeding include:
  • Age >75 years
  • Body weight <60 kg
  • Concomitant use of anticoagulants or NSAIDs 4

Medication Adherence

• Due to its twice-daily dosing regimen, adherence to ticagrelor is crucial 6
• Missing even one dose during the first 30 days after stroke can increase thrombotic risk 6
• If a dose is missed and remembered within 12 hours, take immediately; if >12 hours have passed, skip the missed dose and take the next scheduled dose 6

Aspirin Dosing with Ticagrelor

• The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily 1
• High-dose aspirin (>100 mg daily) in combination with ticagrelor is not recommended 1

Perioperative Management

• Discontinue ticagrelor at least 5 days before planned surgery to minimize bleeding risk 6
• For urgent/emergent procedures, the risk of bleeding must be weighed against the risk of thrombotic events 6

By following these evidence-based recommendations, clinicians can optimize the use of ticagrelor after stroke to reduce recurrent ischemic events while minimizing bleeding complications.