Should a patient who accidentally took two morning doses of Ticagrelor (Ticagrelor) 90 mg skip their usual night dose?

Management of Accidental Double Dose of Ticagrelor

The patient who accidentally took two morning doses of ticagrelor 90 mg should skip the usual night dose to avoid excessive antiplatelet effect and increased bleeding risk.

Rationale for Skipping the Night Dose

• Ticagrelor is a direct-acting, reversible P2Y12 receptor antagonist with a more rapid onset and more consistent inhibition of platelet aggregation compared to other antiplatelet medications 1
• The standard maintenance dose of ticagrelor is 90 mg twice daily, with approximately 12 hours between doses 2
• Taking two doses (180 mg total) in the morning followed by another dose at night would result in excessive antiplatelet effect within a short timeframe, potentially increasing bleeding risk 3
• Ticagrelor is already associated with a higher risk of non-CABG bleeds compared to standard dose clopidogrel, making dose timing important 2

Pharmacological Considerations

• Ticagrelor is a parent compound that is active without requiring biotransformation, leading to faster onset of action and more consistent platelet inhibition 2, 1
• Significant antiplatelet effect is observed within 30 minutes of loading dose, with peak effect at approximately 2 hours 4
• The medication achieves steady-state concentrations with regular twice-daily dosing 5
• Doubling the morning dose followed by the regular evening dose would lead to excessive plasma concentrations and potentially increase bleeding risk 3, 6

Risk Management Approach

• Skip the evening dose to allow time for drug levels to normalize before resuming the regular dosing schedule the following morning 1
• Resume normal twice-daily dosing (90 mg every 12 hours) starting the next morning 2
• Monitor for any signs of bleeding over the next 24 hours, including:
  • Unusual bruising or petechiae
  • Gum bleeding
  • Blood in urine or stool 3
• No additional intervention is needed if the patient remains asymptomatic 1

Special Considerations

• Elderly patients (≥75 years) are at higher risk of bleeding complications with ticagrelor and require closer monitoring after any dosing errors 1, 7
• Patients with low body weight (<60 kg) may also have increased exposure to ticagrelor and higher bleeding risk 1
• If the patient is on dual antiplatelet therapy with aspirin, maintain the regular low-dose aspirin (81 mg daily) as recommended 2, 4
• Patient compliance with the twice-daily dosing regimen should be reinforced to prevent future medication errors 1

Important Precautions

• If the patient develops any significant bleeding symptoms after the double dose, seek immediate medical attention 3
• Patients should be advised to use medication organizers or reminder systems to prevent future dosing errors with twice-daily medications 1
• Ticagrelor should not be discontinued abruptly due to increased risk of cardiovascular events, making proper dosing adherence important 2