Which is better for antiplatelet therapy: Brillinta (ticagrelor) or Plavix (clopidogrel)?

Ticagrelor (Brilinta) is Superior to Clopidogrel (Plavix) for Antiplatelet Therapy in Most Acute Coronary Syndrome Patients

Ticagrelor is recommended over clopidogrel for antiplatelet therapy in most patients with acute coronary syndrome (ACS) due to superior reduction in mortality and cardiovascular events, unless the patient has a high bleeding risk or specific contraindications. 1

Comparative Efficacy and Safety

Acute Coronary Syndrome (ACS) Patients

• Ticagrelor provides:

  • Greater platelet inhibition compared to clopidogrel 2
  • Lower rates of cardiovascular death, myocardial infarction, and stroke 1
  • Reduced stent thrombosis risk 1
  • More consistent antiplatelet effect (not affected by genetic variations)

• Dosing regimen:

  • Ticagrelor: 180 mg loading dose, followed by 90 mg twice daily 3
  • Clopidogrel: 600 mg loading dose, followed by 75 mg daily 3

Stable Coronary Artery Disease

• For stable ischemic heart disease patients undergoing PCI:
  • Clopidogrel (75 mg daily) is the standard P2Y12 inhibitor 1
  • Minimum duration of 1 month for bare metal stents and 6 months for drug-eluting stents 1

Patient-Specific Considerations

When to Choose Clopidogrel Over Ticagrelor

Clopidogrel is preferred in the following scenarios:

1. High bleeding risk patients:

   • Age ≥75 years 4
   • History of bleeding complications
   • Low body weight (<60 kg)
   • Concomitant oral anticoagulation 3

2. Specific contraindications to ticagrelor:

   • History of intracranial hemorrhage
   • Active bleeding
   • Severe dyspnea (ticagrelor-specific side effect)
   • Need for strong CYP3A inhibitors/inducers

3. Cost considerations:

   • Clopidogrel is available as generic and typically less expensive

Special Populations

• Elderly patients (≥70 years): The POPular AGE trial showed clopidogrel led to fewer bleeding events without increasing ischemic outcomes in elderly NSTE-ACS patients compared to ticagrelor 4

• Patients requiring oral anticoagulation: Clopidogrel is preferred over ticagrelor when triple therapy is needed 3

Duration of Therapy

• ACS patients with PCI: 12 months of DAPT (dual antiplatelet therapy) is recommended 1

  • Consider shorter duration (6 months) if high bleeding risk (PRECISE-DAPT ≥25) 3

• Stable CAD patients with PCI: 6 months of DAPT is standard 3

  • Consider shorter duration (1-3 months) if high bleeding risk 3

Important Clinical Pearls

• When switching from clopidogrel to ticagrelor, give a 180 mg loading dose of ticagrelor regardless of timing and dose of clopidogrel 1

• Always use low-dose aspirin (75-100 mg daily) with P2Y12 inhibitors 1

• Add a proton pump inhibitor to reduce gastrointestinal bleeding risk when using DAPT 1, 3

• Discontinue ticagrelor ≥5 days and clopidogrel ≥7 days before planned surgery 3

Conclusion

While ticagrelor demonstrates superior efficacy in reducing cardiovascular events in most ACS patients, the choice between ticagrelor and clopidogrel should consider bleeding risk, comorbidities, concomitant medications, and patient-specific factors. For most ACS patients without high bleeding risk or contraindications, ticagrelor provides greater protection against ischemic events and mortality.