Is it safe to perform Esophageal Variceal Ligation (EVL) on a patient taking Brilinta (ticagrelor)?

Safety of Esophageal Variceal Ligation (EVL) in Patients Taking Brilinta (Ticagrelor)

Performing EVL on a patient taking Brilinta (ticagrelor) carries significant bleeding risk and should be approached with caution, with proton pump inhibitor prophylaxis and consideration of temporarily adjusting antiplatelet therapy if clinically appropriate.

Bleeding Risk Considerations

• EVL is an effective procedure for treating esophageal varices, but it inherently creates shallow ulcers at the ligation sites that may bleed 1
• Post-EVL ulcers are a common complication, occurring in approximately 14% of cases 1
• Ticagrelor (Brilinta) is a potent, reversible adenosine diphosphate (ADP) receptor antagonist that provides greater inhibition of platelet aggregation than clopidogrel, potentially increasing bleeding risk 2

Risk Mitigation Strategies

• Proton pump inhibitors (PPIs) should be administered after EVL to reduce the size of post-EVL ulcers and potentially decrease the risk of post-EVL ulcer bleeding 1
• In a small randomized controlled trial, pantoprazole (40 mg IV after EVL followed by 40 mg oral daily for 9 days) significantly reduced the size of post-EVL ulcers compared to placebo 1
• Although not statistically significant in this small study, all three post-EVL bleeding episodes occurred in the placebo group, suggesting PPI therapy may help prevent this complication 1

Procedural Considerations

• EVL sessions are typically repeated at 7-14 day intervals until variceal obliteration, which usually requires 2-4 sessions 1
• The most common complications of EVL are transient dysphagia and chest discomfort 1
• Severe complications such as ulcer bleeding at the ligation site are more likely with EVL than with non-selective beta-blockers 1

Recommendations for Patients on Ticagrelor

• Assess the indication and urgency of the EVL procedure - if prophylactic, consider whether it can be delayed until antiplatelet therapy is completed 1
• For urgent EVL (such as for active bleeding), the procedure should proceed with additional precautions 1
• Use PPI therapy before and after the procedure to reduce ulcer size and potential bleeding risk 1
• Consider close monitoring post-procedure with readiness to manage potential bleeding complications 1
• Follow-up endoscopy may be needed sooner than the standard 1-6 months after eradication to assess for complications 1

Alternative Approaches to Consider

• For primary prophylaxis of variceal bleeding, non-selective beta-blockers (propranolol or nadolol) or carvedilol may be considered as alternatives to EVL in patients at high bleeding risk due to antiplatelet therapy 1
• If EVL must be performed while on ticagrelor, more frequent follow-up and extended PPI therapy may be warranted 1

Conclusion

While specific guidelines addressing EVL in patients on ticagrelor are lacking, the procedure carries an increased bleeding risk that must be carefully weighed against its benefits. Proton pump inhibitor therapy is strongly recommended to reduce ulcer-related bleeding risk, and close post-procedural monitoring is essential 1.