Resuming Acalabrutinib in Acute Coronary Syndrome
Acalabrutinib should be resumed in patients with acute coronary syndrome (ACS) once the patient is stabilized on dual antiplatelet therapy (DAPT), as there are no specific contraindications to continuing this medication alongside standard ACS management.
Understanding ACS Management and Medication Considerations
- Patients with ACS require dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for at least 12 months as the cornerstone of treatment 1, 2
- The European Society of Cardiology recommends continuing necessary chronic medications during ACS management unless specifically contraindicated 3
- Interruption of chronic medications like acalabrutinib can lead to disease reactivation, which could complicate ACS management 3
Approach to Resuming Acalabrutinib in ACS Patients
- Resume acalabrutinib once the patient is stabilized on DAPT and can take oral medications 3
- Standard ACS treatment includes parenteral anticoagulation and DAPT, which do not have documented interactions with acalabrutinib 3
- Monitor for potential bleeding risk, as both acalabrutinib and DAPT can independently increase bleeding risk 4, 5
DAPT Duration Considerations in ACS
- For patients with ACS treated with coronary stent implantation, DAPT is recommended for 12 months unless there are contraindications such as excessive bleeding risk 1
- In patients with high bleeding risk, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered 1
- For ACS patients managed with medical therapy alone, P2Y12 inhibitor therapy (clopidogrel or ticagrelor) should be continued for at least 12 months 1
Bleeding Risk Assessment and Management
- Assess bleeding risk using validated tools before resuming acalabrutinib alongside DAPT 6
- High bleeding risk is traditionally defined as a 1-year risk of serious bleeding of at least 4% or risk of intracranial hemorrhage of at least 1% 2
- Patients at higher bleeding risk include those ≥65 years old, with low body weight, diabetes, prior bleeding, or taking oral anticoagulants 2
- If bleeding risk is high, consider shorter duration (3-6 months) of DAPT while continuing acalabrutinib 2
Practical Recommendations for Monitoring
- Monitor complete blood counts regularly after resuming acalabrutinib in ACS patients on DAPT 3
- Ensure acalabrutinib is included in discharge medication reconciliation to prevent inadvertent discontinuation 3
- Consider proton pump inhibitor therapy to reduce gastrointestinal bleeding risk in patients on DAPT plus acalabrutinib 5
Common Pitfalls to Avoid
- Avoid unnecessarily prolonged interruption of acalabrutinib, as this may lead to disease progression 3
- Do not prescribe prasugrel to patients with history of stroke/TIA (increased risk of cerebrovascular events) or patients >75 years or <60 kg when resuming DAPT alongside acalabrutinib 2
- Avoid triple antithrombotic therapy (DAPT plus anticoagulation) unless absolutely necessary, as this significantly increases bleeding risk 7, 6