Why is Brilinta (ticagrelor) preferred over Plavix (clopidogrel)?

Brilinta (Ticagrelor) vs. Plavix (Clopidogrel) in Acute Coronary Syndromes

Ticagrelor (Brilinta) is preferred over clopidogrel (Plavix) in patients with acute coronary syndromes (ACS) due to its superior efficacy in reducing major adverse cardiovascular events, including myocardial infarction, stroke, and cardiovascular death. 1

Evidence Supporting Ticagrelor Over Clopidogrel

Superior Clinical Outcomes

• The 2025 ACC/AHA guidelines explicitly recommend ticagrelor or prasugrel in preference to clopidogrel for patients with ACS undergoing percutaneous coronary intervention (PCI) 1
• Ticagrelor demonstrates:
  • Faster onset of action than clopidogrel 2
  • Greater inhibition of platelet aggregation 2
  • More consistent antiplatelet effects with less variability between patients 3
  • Reduced incidence of myocardial infarction, stroke, and cardiovascular death compared to clopidogrel 2

Pharmacological Advantages

• Ticagrelor is a direct-acting, reversible P2Y12 inhibitor that does not require metabolic activation 2
• Clopidogrel is a prodrug requiring hepatic conversion to its active metabolite, leading to:
  • Delayed onset of action
  • Variable antiplatelet response between patients
  • Potential for drug interactions 3

Clinical Scenarios for Ticagrelor Use

Preferred Scenarios

• Patients with ACS undergoing PCI 1
• Patients with ACS managed medically (without PCI) 4
• Patients at higher risk for recurrent ischemic events 4

Scenarios Where Clopidogrel May Be Preferred

• Patients requiring long-term oral anticoagulation 1
• Patients at high bleeding risk with lower thrombotic risk 5
• Patients who experience dyspnea with ticagrelor (a known side effect) 2
• Patients with financial constraints (clopidogrel is available generically) 6

Important Considerations and Potential Drawbacks

Bleeding Risk

• Ticagrelor is associated with higher rates of non-CABG-related bleeding compared to clopidogrel 2
• For patients at high bleeding risk (PRECISE-DAPT score ≥25), the net clinical benefit between ticagrelor and clopidogrel may be similar 5

Side Effects Specific to Ticagrelor

• Dyspnea (usually mild to moderate) occurs more frequently with ticagrelor 2
• Ventricular pauses (largely asymptomatic) have been reported 2

Administration Requirements

• Ticagrelor requires twice-daily dosing (90mg BID) versus once-daily for clopidogrel (75mg daily) 4
• Must be used with low-dose aspirin (75-100mg daily) 4

Practical Algorithm for Antiplatelet Selection

1. For ACS patients undergoing PCI:

   • First choice: Ticagrelor or prasugrel
   • Second choice: Clopidogrel (if contraindications to ticagrelor/prasugrel exist)

2. For ACS patients requiring oral anticoagulation:

   • Prefer clopidogrel as the P2Y12 inhibitor 1

3. For patients with high bleeding risk:

   • Consider individual risk-benefit assessment
   • Clopidogrel may provide better net clinical benefit in specific high-bleeding-risk scenarios 5

4. For patients with dyspnea on ticagrelor:

   • Switch to clopidogrel if symptoms are intolerable

Dosing Recommendations

• Ticagrelor: 180mg loading dose, followed by 90mg twice daily maintenance 4
• Clopidogrel: 600mg loading dose, followed by 75mg daily maintenance 4

In conclusion, while ticagrelor offers superior cardiovascular protection compared to clopidogrel in ACS patients, the choice between these agents should consider the patient's bleeding risk, need for concomitant anticoagulation, tolerance of side effects, and cost considerations.