Should a loading dose of ticagrelor (P2Y12 inhibitor) be given after suspension due to surgery?

Ticagrelor Loading Dose After Surgical Interruption

Yes, a loading dose of ticagrelor (180 mg) should be administered when restarting therapy after suspension due to surgery. 1

Rationale for Loading Dose

When ticagrelor therapy is interrupted for surgery, platelet function gradually recovers as the drug is eliminated from the body. This creates a window of vulnerability where patients have reduced antiplatelet protection, potentially increasing their risk of thrombotic events.

Pharmacodynamic Considerations

• Ticagrelor is a reversible P2Y12 receptor antagonist with a half-life of 7-9 hours 2
• After discontinuation, there is a gradual increase in platelet aggregation
• Significant interindividual variability exists in platelet function recovery 3
• Without a loading dose, it may take multiple maintenance doses to reach therapeutic antiplatelet effect

Guideline Recommendations

The European Society of Cardiology (ESC) guidelines provide clear direction on this issue:

• For patients undergoing surgery requiring ticagrelor interruption, the medication should be discontinued 3-5 days before surgery 4
• When resuming therapy post-surgery, a loading dose of 180 mg should be administered, followed by the maintenance dose of 90 mg twice daily 1, 4

The case-based implementation of ESC guidelines specifically describes a patient who had ticagrelor interrupted for surgery and received a 180 mg loading dose when therapy was resumed 4.

Timing of Ticagrelor Resumption

• Resume ticagrelor with a loading dose within 24 hours after surgery if hemostasis is adequate 4
• In high bleeding risk surgeries, consider the following approach:
  • Stop ticagrelor 3-5 days before surgery
  • Resume with 180 mg loading dose when hemostasis is adequate (typically within 24 hours)
  • Continue with maintenance dose of 90 mg twice daily

Special Considerations

Bleeding Risk

• Monitor closely for bleeding complications after administering the loading dose
• Consider delaying the loading dose if there are concerns about surgical site hemostasis
• The addition of a proton pump inhibitor is recommended to reduce gastrointestinal bleeding risk 1

Bridging Therapy

For patients at very high thrombotic risk who require ticagrelor interruption:

• Consider bridging with intravenous antiplatelet agents (e.g., tirofiban) during the perioperative period 4
• When resuming oral therapy, administer the ticagrelor loading dose and discontinue the IV agent 2 hours later

Practical Algorithm for Ticagrelor Management Around Surgery

1. Pre-surgery:

   • Discontinue ticagrelor 3-5 days before elective surgery 4
   • Continue aspirin if bleeding risk allows 4

2. Post-surgery:

   • Assess for adequate hemostasis
   • Administer ticagrelor 180 mg loading dose within 24 hours after surgery 4, 1
   • Continue with maintenance dose of 90 mg twice daily

3. High thrombotic risk patients:

   • Consider bridging with tirofiban during the perioperative period
   • Administer ticagrelor loading dose (180 mg) when resuming therapy
   • Discontinue tirofiban 2 hours after ticagrelor loading dose 4

The evidence clearly supports administering a loading dose when restarting ticagrelor after surgical interruption to rapidly achieve therapeutic antiplatelet effect and minimize the risk of thrombotic events.