What is the recommended dosing of Brilinta (ticagrelor) after a cardiovascular (CVS) event?

Recommended Dosing of Brilinta (Ticagrelor) After Cardiovascular Events

For patients who have experienced a cardiovascular event, the recommended dosing of ticagrelor (Brilinta) is a 180 mg loading dose followed by 90 mg twice daily maintenance dose, in combination with low-dose aspirin (81 mg daily recommended). 1

Initial Dosing Strategy

• Loading dose: 180 mg (given as a single dose)
• Maintenance dose: 90 mg twice daily
• Duration: 12 months for acute coronary syndrome (ACS) patients 2, 1
• Concomitant therapy: Must be used with low-dose aspirin (81 mg daily recommended) 1

Important Considerations

Aspirin Dosing

• Higher aspirin doses (>100 mg) reduce ticagrelor's effectiveness and should be avoided 1, 3
• This is emphasized in the FDA's "Boxed Warning" for ticagrelor 1

Duration of Therapy

• For ACS patients (with or without ST-segment elevation): 12 months of therapy is recommended 2
• For patients receiving drug-eluting stents (DES) for non-ACS indications: minimum 12 months of P2Y12 inhibitor therapy 2
• For patients receiving bare metal stents (BMS) for non-ACS indications: minimum 1 month, ideally up to 12 months 2

Switching from Other P2Y12 Inhibitors

• When switching from clopidogrel to ticagrelor, patients should receive the full 180 mg loading dose of ticagrelor regardless of prior clopidogrel therapy 1
• Clopidogrel should be discontinued when ticagrelor is started 2

Clinical Efficacy

Ticagrelor has demonstrated superior efficacy compared to clopidogrel in the PLATO trial, with significant reductions in:

• Composite endpoint of cardiovascular death, MI, or stroke (9.8% vs 11.7%, p<0.001) 4
• Myocardial infarction (5.8% vs 6.9%, p=0.005) 4
• Cardiovascular death (4.0% vs 5.1%, p=0.001) 4
• All-cause mortality (4.5% vs 5.9%, p<0.001) 4

Safety Considerations and Contraindications

Bleeding Risk

• Monitor for bleeding complications, which are more common with ticagrelor than clopidogrel 1
• Non-CABG-related major bleeding is higher with ticagrelor (4.5% vs 3.8%, p=0.03) 4
• Discontinue ticagrelor at least 5 days before any surgery 1

Absolute Contraindications

• Active pathological bleeding 1
• History of intracranial hemorrhage 2
• Ongoing bleeds 2

Relative Contraindications/Cautions

• High bleeding risk 1
• Prior stroke/TIA 1
• Concomitant use with strong CYP3A4 inhibitors or inducers 1

Monitoring

• Monitor for bleeding complications
• Watch for adverse effects such as dyspnea, bradycardia, and ventricular pauses 1
• When co-administered with statins, monitor for muscle pain, tenderness, weakness, and elevated creatine kinase levels 1

Common Pitfalls to Avoid

1. Using aspirin doses >100 mg daily, which reduces ticagrelor's effectiveness
2. Premature discontinuation of therapy before the recommended duration
3. Failing to provide the loading dose when switching from clopidogrel
4. Not discontinuing ticagrelor at least 5 days before planned surgery
5. Using ticagrelor in patients with contraindications such as active bleeding or history of intracranial hemorrhage

By following these evidence-based recommendations, clinicians can optimize the use of ticagrelor after cardiovascular events to reduce morbidity and mortality while managing bleeding risks.