From the Guidelines
The most effective reversal strategy for intracranial bleeding associated with Brilinta (Ticagrelor) is to immediately stop the medication and provide supportive care, as there is no specific reversal agent available, and platelet transfusions have limited effectiveness due to ticagrelor's persistent inhibition of newly transfused platelets 1.
Management Approach
The management of intracranial bleeding associated with ticagrelor focuses on discontinuation of the medication and supportive care. This includes:
- Immediately stopping ticagrelor and all other antiplatelet or anticoagulant medications
- Considering neurosurgical consultation for potential intervention
- Maintaining hemodynamic stability
- Monitoring neurological status closely
- Obtaining serial neuroimaging to track bleeding progression ### Role of Platelet Transfusions Platelet transfusions may be given, typically 1-2 units, although their effectiveness is limited because ticagrelor and its active metabolite continue to inhibit newly transfused platelets 2.
Use of Desmopressin
In severe cases, some clinicians have used desmopressin (DDAVP) 0.3 mcg/kg IV to enhance platelet function, though evidence for this approach is limited 3.
Natural Resolution
Unlike some other antiplatelet agents, ticagrelor's effects persist for 3-5 days after discontinuation due to its reversible binding and active metabolites. Platelet function typically normalizes within 5 days after stopping the medication.
Key Considerations
- The primary strategy remains supportive care while allowing the drug's effects to naturally diminish over time
- Ticagrelor is not reversed by platelet transfusions, and a monoclonal antibody against ticagrelor is being investigated as a potential antidote 1
From the Research
Reversal Strategy for Intracranial Bleeding Associated with Brilinta (Ticagrelor)
- The management of ticagrelor-induced bleeding is challenging, and platelet transfusion is ineffective 4.
- A study investigated the efficacy of four haemostatic agents (recombinant activated factor VII, fibrinogen concentrate, tranexamic acid, and factor XIII concentrate) to improve haemostatic capacity in the presence of ticagrelor 5.
- The results showed that none of the haemostatic agents corrected ticagrelor-induced platelet inhibition, but recombinant activated factor VII shortened coagulation times, fibrinogen concentrate increased clot firmness, and factor XIII decreased fibrinolysis 5.
- Another study found that platelet transfusion and desmopressin administration in the presence of ticagrelor had very little, if any, haemostatic effect 4.
- The use of platelet transfusions to reverse the effects of antiplatelet agents in patients with intracranial hemorrhage has shown mixed results, and other strategies such as desmopressin and recombinant factor VIIa have been proposed 6.
- Routine platelet transfusion may not be warranted in patients taking antiplatelet medication who experience a traumatic intracranial hemorrhage, as it may increase intensive care unit length of stay and mortality risk 7.
- Treatment of patients on antithrombotic drugs who have intracranial hemorrhage includes reversal of anticoagulant drugs in almost all cases, but the optimal strategy for reversing the effects of ticagrelor is not well established 8.