What can we take if experiencing bruising with Brillinta (ticagrelor) and can't take Plavix (clopidogrel)?

Management of Bruising with Ticagrelor (Brilinta) When Clopidogrel (Plavix) Cannot Be Used

For patients experiencing bruising with ticagrelor (Brilinta) who cannot take clopidogrel (Plavix), prasugrel (Effient) is the recommended alternative antiplatelet agent, with dose adjustment based on age and weight to minimize bleeding risk.

Alternative Antiplatelet Options

Prasugrel (Effient)

• Prasugrel is a reasonable alternative P2Y12 inhibitor when both ticagrelor and clopidogrel cannot be used 1
• Dosing considerations:
  • Standard dose: 60 mg loading dose, followed by 10 mg daily maintenance dose
  • For patients weighing <60 kg: Consider reduced maintenance dose of 5 mg daily 2
  • For patients ≥75 years: Generally not recommended unless high-risk situation (diabetes or history of prior MI) 2

Important Contraindications for Prasugrel

• History of stroke or transient ischemic attack (TIA) - absolute contraindication 2
• Active pathological bleeding 2
• Planned urgent CABG (coronary artery bypass graft) surgery 2

Management Algorithm for Bruising with Antiplatelet Therapy

1. Assess bleeding severity:

   • If severe bleeding (hemodynamic instability, significant hemoglobin drop):
     • Temporarily discontinue antiplatelet therapy
     • Consider platelet transfusion if urgent intervention needed 1

2. If non-severe bruising with ticagrelor:

   • Evaluate risk factors for bleeding:
     • Age ≥75 years
     • Weight <60 kg
     • Renal dysfunction
     • Concomitant medications that increase bleeding risk
     • History of bleeding disorders

3. Consider antiplatelet alternatives:

   • If clopidogrel cannot be used and ticagrelor causes bruising:
     • Switch to prasugrel with appropriate dose adjustments 1, 3
     • Ensure low-dose aspirin (75-100 mg) is used concurrently 3

4. Bleeding risk reduction strategies:

   • Add proton pump inhibitor to reduce gastrointestinal bleeding risk 3
   • Avoid NSAIDs and other medications that increase bleeding risk 1
   • Discontinue antiplatelet therapy at appropriate intervals before planned procedures:
     • Ticagrelor: ≥5 days before surgery
     • Prasugrel: ≥7 days before surgery 3

Important Considerations

• Duration of therapy: Maintain dual antiplatelet therapy for at least 12 months after ACS or stent placement unless bleeding risk is prohibitive 3

• Monitoring: Regular assessment of bleeding risk throughout treatment period

• Caution with prasugrel in:

  • Elderly patients (≥75 years)
  • Low body weight (<60 kg)
  • History of bleeding disorders
  • Concomitant use of anticoagulants 2

• Never discontinue antiplatelet therapy abruptly without consulting the prescribing physician, as this increases risk of stent thrombosis, myocardial infarction, and death 2

Pitfalls to Avoid

• Avoid switching between different P2Y12 inhibitors without proper transition protocols, as this may lead to periods of inadequate platelet inhibition 4

• Do not use prasugrel in patients with history of stroke or TIA due to increased risk of intracranial hemorrhage 2

• Avoid concomitant use of strong CYP3A4 inhibitors with ticagrelor 5

• Remember that platelet function testing may be useful in selected patients with recurrent ischemic/thrombotic events despite compliance with antiplatelet therapy 1