What are the guidelines for transitioning from Plavix (clopidogrel) to Brilinta (ticagrelor)?

Guidelines for Transitioning from Plavix (Clopidogrel) to Brilinta (Ticagrelor)

When transitioning from clopidogrel to ticagrelor, administer a loading dose of 180 mg ticagrelor, then continue with 90 mg twice daily maintenance dosing, while discontinuing clopidogrel immediately without tapering. 1, 2

Transition Protocol

Step 1: Initial Assessment

• Verify indication for switching (e.g., high-risk ACS, stent placement, recurrent ischemic events on clopidogrel)
• Confirm patient can take ticagrelor (no history of intracranial hemorrhage, no active bleeding)
• Ensure patient is not taking medications contraindicated with ticagrelor

Step 2: Medication Administration

• Discontinue clopidogrel immediately (no washout period needed)
• Administer ticagrelor loading dose of 180 mg regardless of timing of last clopidogrel dose 1
• Begin maintenance dose of ticagrelor 90 mg twice daily

Step 3: Aspirin Adjustment

• Adjust aspirin dose to 81 mg daily when used with ticagrelor 1
• Higher aspirin doses (>100 mg) may reduce ticagrelor's effectiveness 1

Important Considerations

Clinical Benefits

• Ticagrelor provides more rapid, consistent, and greater platelet inhibition than clopidogrel 3
• Ticagrelor has been shown to reduce mortality and the composite outcome of death from vascular causes, MI, or stroke compared to clopidogrel 4
• The American College of Cardiology/American Heart Association guidelines recommend ticagrelor in preference to clopidogrel for patients with NSTE-ACS treated with either an early invasive or ischemia-guided strategy 1

Special Populations

• For patients ≥70 years old: Consider bleeding risk, as clopidogrel may cause fewer bleeding events in elderly patients 5
• Contraindications for ticagrelor include previous intracranial hemorrhage or ongoing bleeds 1

Medication Adherence

• Emphasize the importance of twice-daily dosing with ticagrelor (vs. once-daily with clopidogrel) 2
• Educate patient that missing doses significantly increases thrombotic risk, especially within 8-12 hours of the last dose 2
• If a dose is missed and remembered within 12 hours, take immediately; if >12 hours have passed, skip and take next scheduled dose 2

Perioperative Management

• Ticagrelor should be discontinued at least 5 days before any planned surgery 1, 2
• This is the same discontinuation timeframe as clopidogrel 1

Common Pitfalls to Avoid

1. Aspirin Dosing Error: Using aspirin doses >81 mg with ticagrelor can reduce its effectiveness
2. Inadequate Patient Education: Failing to emphasize the twice-daily dosing requirement
3. Medication Interactions: Not checking for potential drug interactions (particularly with CYP3A4 inhibitors/inducers)
4. Side Effect Management: Not warning patients about potential dyspnea (occurs in up to 15% of patients) 1
5. Missed Loading Dose: Skipping the loading dose when transitioning, which delays optimal platelet inhibition

By following these guidelines, you can effectively transition patients from clopidogrel to ticagrelor while maximizing efficacy and minimizing risks.