What is the recommended dosing regimen for Brilinta (ticagrelor) post-PCI?

Ticagrelor Dosing Regimen Post-PCI

For patients undergoing PCI, ticagrelor should be administered with a 180 mg loading dose followed by 90 mg twice daily maintenance dose for at least 12 months. 1

Loading Dose Recommendations

• A loading dose of 180 mg ticagrelor should be given as early as possible before or at the time of PCI 1
• The loading dose is essential for achieving rapid platelet inhibition, with significant antiplatelet effect observed within 30 minutes and peak effect at approximately 2 hours 2
• For patients with acute coronary syndrome (ACS), the 180 mg loading dose is particularly important to reduce early thrombotic events 1
• The loading dose should be administered regardless of whether the patient was previously on clopidogrel therapy, as ticagrelor's benefits were observed irrespective of prior therapy with clopidogrel 1

Maintenance Dose Protocol

• Following the loading dose, patients should receive ticagrelor 90 mg twice daily for at least 12 months after PCI 1
• The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily (lower dose) to reduce bleeding risk while maintaining efficacy 1
• Ensure doses are taken approximately 12 hours apart to maintain consistent platelet inhibition throughout the day 2
• For patients receiving drug-eluting stents (DES), continuation of ticagrelor beyond 12 months may be considered in selected patients 1

Special Considerations

• Ticagrelor should not be administered to patients with a history of prior stroke or transient ischemic attack due to increased risk of intracranial hemorrhage 1
• When possible, discontinue ticagrelor at least 5 days before any surgery to reduce bleeding risk 1
• For elderly patients (≥75 years) and those with low body weight (<60 kg), the standard dosing regimen is still recommended but with closer monitoring for bleeding complications 2
• Patient compliance with the twice-daily dosing regimen is especially important due to ticagrelor's reversible binding and shorter half-life compared to other P2Y12 inhibitors 1, 2

Comparison with Other P2Y12 Inhibitors

• Ticagrelor provides more rapid and consistent platelet inhibition compared to clopidogrel, even at higher clopidogrel doses 3
• In patients with STEMI, ticagrelor significantly reduces major adverse cardiovascular events (MACE) within the first 2 weeks after primary PCI compared to twice-daily clopidogrel 4
• For patients transitioning from fibrinolytic therapy to PCI, ticagrelor provides more potent platelet inhibition compared to clopidogrel 3

Common Pitfalls and Caveats

• Abrupt discontinuation of ticagrelor should be avoided due to increased risk of cardiovascular events 2
• Medication adherence is particularly important with ticagrelor due to its twice-daily dosing requirement; consider medication organizers or reminder systems to prevent dosing errors 2
• If a dose is accidentally missed, the patient should take the next scheduled dose (do not double dose) and resume the normal schedule 2
• If an accidental double dose occurs, the patient should skip the next scheduled dose and resume normal twice-daily dosing the following day 2