What is the recommended dosing regimen for Brilinta (ticagrelor) in patients with acute coronary syndrome?

Ticagrelor (Brilinta) Dosing Regimen for Acute Coronary Syndrome

For patients with acute coronary syndrome, ticagrelor should be administered with a loading dose of 180 mg followed by a maintenance dose of 90 mg twice daily for 12 months, in combination with low-dose aspirin (75-100 mg daily). 1

Initial Dosing

• Loading dose: 180 mg orally as a single dose 2, 1
• Maintenance dose: 90 mg twice daily 2, 1
• Duration: 12 months unless contraindicated due to excessive bleeding risk 2, 1

Concomitant Therapy

• Must be administered with aspirin 75-100 mg daily 1
• Important: Never exceed 100 mg daily aspirin dose when combined with ticagrelor as higher doses may reduce ticagrelor's effectiveness 1, 3
• If patient was previously on clopidogrel, it should be discontinued when ticagrelor is started 2, 1

Patient Selection

Ticagrelor is recommended for:

• All ACS patients (STEMI and NSTE-ACS) 1
• Patients regardless of whether they undergo PCI or are managed conservatively 1
• Patients at moderate to high risk of ischemic events (e.g., elevated cardiac troponins) 2

Contraindications

• Previous intracranial hemorrhage 2, 1
• Ongoing active bleeding 2, 1

Monitoring and Precautions

• Monitor for bleeding complications, especially in patients with bleeding risk factors 1
• Emphasize the importance of twice-daily dosing and adherence to prevent thrombotic events 1
• Consider discontinuing ticagrelor 3-5 days before planned surgery to minimize bleeding risk 1

Alternative P2Y12 Inhibitors

• Prasugrel: Recommended in P2Y12-inhibitor naïve patients proceeding to PCI (60 mg loading dose, 10 mg daily) 2
• Clopidogrel: Use only when ticagrelor or prasugrel are not available or contraindicated (600 mg loading dose, 75 mg daily) 2, 1

Clinical Evidence

The efficacy of ticagrelor was demonstrated in the PLATO trial, which showed that compared to clopidogrel, ticagrelor significantly reduced:

• Myocardial infarction (5.8% vs. 6.9%, p=0.005) 4
• Death from vascular causes (4.0% vs. 5.1%, p=0.001) 4
• Overall mortality (4.5% vs. 5.9%, p<0.001) 4
• Definite stent thrombosis (HR 0.66, p=0.03) 5

Common Pitfalls to Avoid

1. Using high-dose aspirin (>100 mg daily) which reduces ticagrelor's effectiveness 1, 3
2. Administering prasugrel in patients with unknown coronary anatomy (not recommended) 2
3. Poor adherence to twice-daily dosing schedule of ticagrelor
4. Failing to discontinue clopidogrel when switching to ticagrelor 2, 1
5. Not considering bleeding risk before initiating therapy (consider using PRECISE-DAPT score) 1