Management of Prasugrel After 10 Years Post-PCI
According to current guidelines, your patient who has been on prasugrel for 10 years following PCI in 2012 should discontinue prasugrel therapy as extended dual antiplatelet therapy beyond 12-15 months is not routinely recommended unless there are specific high-risk features. 1
Current Guideline Recommendations
The 2018 ESC/EACTS guidelines on myocardial revascularization indicate that:
- Standard dual antiplatelet therapy (DAPT) duration after PCI is generally 12 months, irrespective of stent type 1
- Extended DAPT beyond 12 months may be considered only in specific high-risk scenarios 1
- After this period, single antiplatelet therapy (typically aspirin) is the standard of care
Assessment for Discontinuation
When evaluating this long-term prasugrel case, consider:
Bleeding risk assessment:
- Age (patients ≥75 years have increased bleeding risk with prasugrel)
- Weight (patients <60 kg have increased bleeding risk)
- History of prior bleeding events
- Concomitant medications that increase bleeding risk
Ischemic risk assessment:
- Presence of diabetes
- History of prior MI
- Complex coronary anatomy at time of PCI
- Recurrent ischemic events while on therapy
Discontinuation Process
If no high-risk features are present:
- Discontinue prasugrel and continue aspirin monotherapy (75-100 mg daily) indefinitely 1
- Consider a step-down approach if concerned about thrombotic risk:
- Switch from prasugrel to clopidogrel for 1-3 months before discontinuing to aspirin monotherapy
Special Considerations
Prasugrel contraindications: Remember that prasugrel is generally contraindicated in patients with history of stroke/TIA, active pathological bleeding, and should be used with caution in patients ≥75 years 2
Weight considerations: For patients <60 kg, the maintenance dose should be reduced to 5 mg daily due to increased bleeding risk 2, 3
High-risk patients: In patients with diabetes or prior MI history, longer-term therapy might be considered, but even in these cases, 10 years exceeds all guideline recommendations 4
Conclusion
The evidence strongly suggests that your patient has been on prasugrel for much longer than recommended by current guidelines. After 10 years post-PCI, the bleeding risk likely outweighs the ischemic protection benefit. A careful transition to aspirin monotherapy is the most appropriate management strategy based on current evidence.