When to stop Cangrelor (generic name: cangrelor) prior to surgery?

Cangrelor Discontinuation Prior to Surgery

Cangrelor should be discontinued 3-6 minutes prior to surgery due to its ultra-short half-life, allowing for immediate restoration of platelet function. 1

Pharmacological Properties of Cangrelor

• Cangrelor is an intravenous, reversible P2Y12 platelet receptor inhibitor with an immediate onset of action and an ultra-short elimination half-life of approximately 3-6 minutes 1
• Unlike oral P2Y12 inhibitors that require days for clearance, cangrelor's platelet inhibition effects dissipate rapidly after discontinuation of the infusion 1
• Cangrelor's metabolism is independent of hepatic function and occurs through dephosphorylation to its primary metabolite, which has negligible anti-platelet activity 1

Timing of Discontinuation Before Surgery

• Due to cangrelor's ultra-short half-life, the infusion can be discontinued just minutes before surgical incision 2
• In cardiac surgery settings, cangrelor infusion is typically stopped 5 minutes before the cardiopulmonary bypass is discontinued 2
• In real-world bridging protocols, cangrelor has been discontinued approximately 6.6 ± 1.5 hours prior to surgical incision, though this is considerably longer than needed based on its pharmacokinetic profile 3

Comparison with Other P2Y12 Inhibitors

For context, the recommended discontinuation times for oral P2Y12 inhibitors before surgery are:

• Clopidogrel: 5 days before elective surgery 2
• Prasugrel: 7 days before elective surgery 2
• Ticagrelor: 3-5 days before elective surgery 2, 4

Cangrelor as a Bridging Strategy

• Cangrelor can be used as a bridging strategy for patients at high thrombotic risk who require surgery and need to discontinue oral P2Y12 inhibitors 2, 5
• The BRIDGE trial demonstrated that cangrelor effectively maintains platelet inhibition in patients awaiting CABG surgery without increasing post-CABG bleeding complications compared to placebo 5
• The recommended bridging dose is 0.75 μg/kg/min, which is lower than the dose used during PCI (30 μg/kg bolus followed by 4 μg/kg/min) 5, 3

Safety Considerations

• Studies have shown no significant difference in major bleeding complications between cangrelor and placebo in patients undergoing CABG surgery 5, 6
• In the BRIDGE trial, excessive CABG surgery-related bleeding occurred in 11.8% of cangrelor-treated patients versus 10.4% in the placebo group (RR, 1.1 [95% CI, 0.5-2.5], P = .763) 5
• Minor bleeding episodes may be numerically higher with cangrelor, though not statistically significant 5

Practical Recommendations

• For most surgical procedures, cangrelor can be discontinued 3-6 minutes before surgical incision due to its ultra-short half-life 1
• For cardiac surgery, discontinue cangrelor 5 minutes before the end of cardiopulmonary bypass 2
• In patients with high thrombotic risk, cangrelor can be resumed 9 ± 6 hours after surgery if needed 3
• Unlike oral P2Y12 inhibitors, there is no need for routine bridging therapy with cangrelor in most patients undergoing elective surgery 2

Important Caveats

• The American College of Chest Physicians guidelines suggest against routine bridging therapy with cangrelor for patients with coronary stents requiring elective surgery, except in selected high-risk patients 2
• Platelet function testing is not routinely recommended prior to surgery to guide perioperative antiplatelet management 2
• Resumption of appropriate antiplatelet therapy should occur as soon as possible after surgery when bleeding risk is not excessive 2