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

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

When switching from ticagrelor to clopidogrel, administer a 600 mg loading dose of clopidogrel 24 hours after the last dose of ticagrelor to avoid gaps in platelet inhibition. 1

Indications for Switching

Several clinical scenarios may warrant switching from ticagrelor to clopidogrel:

1. Side effects or drug intolerance (Class IIb, Level of Evidence C) 1:

   • Dyspnea (common with ticagrelor)
   • Bleeding complications
   • Compliance issues with twice-daily dosing

2. Need for oral anticoagulation 1:

   • When triple therapy is required (dual antiplatelet therapy + anticoagulant)
   • Clopidogrel is preferred over ticagrelor in combination with anticoagulants

3. High bleeding risk patients 2:

   • Elderly patients (≥70 years)
   • History of bleeding events
   • Low body weight
   • Renal impairment

4. Cost considerations:

   • Clopidogrel is available generically and more affordable 3

Switching Protocol

Timing and Dosing

• Wait 24 hours after the last ticagrelor dose before administering clopidogrel 1
• Give a 600 mg loading dose of clopidogrel 1
• Continue with 75 mg daily maintenance dose of clopidogrel 4
• Continue aspirin at low dose (75-100 mg daily) 4

Monitoring After Switch

• Monitor for signs of bleeding
• Assess for recurrent ischemic symptoms
• Consider platelet function testing in high-risk patients, though routine testing is not recommended (Class III) 1

Special Considerations

Elderly Patients

• Clopidogrel may be preferred in patients ≥70 years due to lower bleeding risk 2
• The POPular AGE trial showed clopidogrel led to fewer bleeding events without increasing ischemic events in elderly patients 2

Patients with High Bleeding Risk

• For patients meeting Academic Research Consortium high bleeding risk criteria, consider earlier switch to clopidogrel 1
• Major criteria include age ≥75 years, severe renal impairment, or recent bleeding events 1

Patients Requiring Anticoagulation

• When oral anticoagulation is needed, switching to clopidogrel is recommended 1
• Triple therapy duration should be minimized to reduce bleeding risk 1

Potential Pitfalls

1. Inadequate platelet inhibition:

   • Clopidogrel has less potent antiplatelet effects than ticagrelor 5
   • Some patients may be poor metabolizers of clopidogrel due to CYP2C19 genetic variants

2. Timing errors:

   • Switching too early can lead to excessive platelet inhibition
   • Switching without a loading dose may result in a gap in protection

3. Drug interactions:

   • Proton pump inhibitors (particularly omeprazole) may reduce clopidogrel effectiveness 1
   • Consider using alternative PPIs if gastric protection is needed

Duration of Therapy After Switch

• Continue DAPT for the originally planned duration (typically 12 months after ACS) 4
• For patients at high bleeding risk, shorter duration (3-6 months) may be appropriate 1
• For patients at high thrombotic risk and low bleeding risk, extended DAPT beyond 12 months may be considered 4

Remember that premature discontinuation of DAPT increases the risk of stent thrombosis, myocardial infarction, and death. Any switch between P2Y12 inhibitors should be done carefully with appropriate loading doses to maintain adequate platelet inhibition throughout the transition.