What is the dose of Efient (prasugrel) given following a stent placement?

Prasugrel (Efient) Dosing After Stent Placement

For patients receiving a stent, prasugrel should be given as a 60 mg loading dose at the time of PCI, followed by a maintenance dose of 10 mg daily for at least 12 months. 1, 2

Loading Dose

• 60 mg oral loading dose should be administered as early as possible or at the time of PCI 1
• This loading dose provides rapid and potent platelet inhibition, with approximately 90% of patients achieving at least 50% inhibition of platelet aggregation within 1 hour 2, 3

Maintenance Dose

• 10 mg oral dose once daily 1, 2
• Should be continued for at least 12 months after stent placement (for both drug-eluting stents and bare-metal stents) 1
• Always given in combination with aspirin (75-325 mg daily, with 81 mg daily preferred) 1, 4

Special Considerations

Weight-Based Dosing

• For patients weighing <60 kg, consider lowering the maintenance dose to 5 mg daily due to increased exposure to the active metabolite and higher bleeding risk 2
• The effectiveness and safety of the 5 mg dose have not been prospectively studied 2

Contraindications

• Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack due to increased risk of bleeding 1

Timing Considerations

• In STEMI patients presenting within 12 hours of symptom onset, the loading dose can be administered at the time of diagnosis 2
• In UA/NSTEMI patients, the loading dose is typically given after coronary anatomy is established 2

Clinical Benefits and Risks

Prasugrel demonstrates superior efficacy compared to clopidogrel:

• Significantly reduces ischemic events (9.9% vs 12.1%) 5
• Significantly reduces stent thrombosis (1.1% vs 2.4%) 6, 5
• Provides more consistent platelet inhibition with fewer poor responders (97.4% vs 87.6%) 3

However, this comes with an increased risk of bleeding:

• Major bleeding (2.4% vs 1.8%) 5
• Life-threatening bleeding (1.4% vs 0.9%) 5

Administration

• Can be taken with or without food 2
• Should be continued for the full recommended duration to prevent stent thrombosis 1
• Patients should be counseled on the importance of not discontinuing therapy without consulting their cardiologist 4

Practical Considerations

• For patients requiring urgent CABG after prasugrel treatment, the risk of significant bleeding is substantial 2
• Elective non-cardiac surgery should be delayed if possible, with aspirin maintained if surgery is needed earlier 4
• Prasugrel is not affected by genetic variations in CYP2C19 function (unlike clopidogrel), making it more reliable in patients who might be poor metabolizers of clopidogrel 2