From the Guidelines
The decision to continue ticagrelor in an elderly patient with previous hemorrhoid bleeding who weighs 57 kilograms should be made with caution, and I recommend reassessing the indication for ticagrelor and considering a dose reduction or alternative antiplatelet therapy. For elderly patients with bleeding risk, particularly those with lower body weight, standard ticagrelor dosing (90 mg twice daily) may pose excessive bleeding risk 1. If ticagrelor is absolutely necessary (such as after recent acute coronary syndrome or stent placement), consider reducing to 60 mg twice daily if the patient is beyond the first year post-event. Alternatively, switching to clopidogrel 75 mg daily might provide a better safety profile while maintaining some antiplatelet effect 1. The bleeding risk with ticagrelor is higher than with clopidogrel, and the patient's previous hemorrhoid bleeding suggests vulnerability to bleeding complications. Lower body weight (57 kg) is also associated with increased bleeding risk on standard antiplatelet doses 1. Regular monitoring for bleeding signs, maintaining adequate hydration, and avoiding NSAIDs or other medications that increase bleeding risk would be prudent if antiplatelet therapy must continue 1. Some key considerations include:
- The patient's weight is below 60 kg, which increases the risk of bleeding with standard doses of antiplatelet medications 1
- The patient has a history of hemorrhoid bleeding, indicating a potential increased risk of bleeding complications 1
- Ticagrelor's benefits were observed irrespective of prior therapy with clopidogrel, but the risk of bleeding must be carefully weighed against the potential benefits 1
From the Research
Considerations for Continuing Ticagrelor in an Elderly Patient
- The patient's history of hemorrhoidal bleeding and low body weight (57 kilograms) are important factors to consider when deciding whether to continue ticagrelor 2, 3, 4.
- Studies have shown that ticagrelor is associated with an increased risk of bleeding, particularly non-CABG and non-procedure-related major bleeding, compared to clopidogrel 2, 3, 4.
- However, the risk of bleeding with ticagrelor may be mitigated by using a lower dose, such as half-dose ticagrelor, which has been shown to be effective and safe in certain patient populations 5.
- The patient's age and weight are also important considerations, as older patients and those with lower body weight may be at increased risk of bleeding with ticagrelor 2, 3.
- The decision to continue ticagrelor should be based on a careful assessment of the patient's individual risk factors and the potential benefits and risks of treatment 6, 2, 3, 4.
Bleeding Risk with Ticagrelor
- The PLATO trial found that ticagrelor was associated with an increased risk of non-CABG and non-procedure-related major bleeding, primarily after 30 days on treatment 2.
- The study by 3 found that ticagrelor was associated with a higher risk of bleeding in patients who did not undergo coronary artery bypass graft surgery.
- The study by 4 found that a ticagrelor-based DAPT strategy was associated with significantly more bleeding complications, including severe bleeding complications, compared to a clopidogrel-based strategy.
Dose Adjustment and Monitoring
- The use of half-dose ticagrelor may be considered in patients who are at high risk of bleeding, such as older patients or those with lower body weight 5.
- Close monitoring of the patient's bleeding risk and adjustment of the dose or treatment strategy as needed is crucial to minimize the risk of bleeding complications 6, 2, 3, 4.