What are the recommended doses of ticagrelor (Brilinta) and prasugrel (Effient) for dual antiplatelet therapy after an acute coronary event?

Recommended Doses of Ticagrelor and Prasugrel for Dual Antiplatelet Therapy After Acute Coronary Events

For patients with acute coronary syndrome (ACS), ticagrelor should be administered as a 180 mg loading dose followed by 90 mg twice daily, while prasugrel should be given as a 60 mg loading dose followed by 10 mg once daily, both in combination with aspirin. 1

First-Line P2Y12 Inhibitor Selection

• Ticagrelor (180 mg loading dose, 90 mg twice daily) plus aspirin is recommended as first-line therapy for ACS patients regardless of initial treatment strategy, including patients previously treated with clopidogrel (which should be discontinued when ticagrelor is started) 1, 2

• Prasugrel (60 mg loading dose, 10 mg once daily) plus aspirin is recommended for P2Y12 inhibitor-naïve patients with NSTE-ACS or STEMI undergoing PCI, unless there is high risk of life-threatening bleeding or other contraindications 1

• Clopidogrel should be used when ticagrelor or prasugrel are contraindicated, such as in patients with prior intracranial bleeding or those requiring oral anticoagulation 1, 2

Important Dosing Considerations for Prasugrel

• Prasugrel should be initiated with a single 60 mg oral loading dose and continued at 10 mg orally once daily 3

• Prasugrel is contraindicated in patients with a history of prior transient ischemic attack (TIA) or stroke due to increased risk of cerebrovascular events 3, 1

• For patients weighing <60 kg, consider lowering the maintenance dose to 5 mg daily due to increased exposure to the active metabolite and higher bleeding risk 3

• Prasugrel is generally not recommended for patients ≥75 years of age due to increased risk of fatal and intracranial bleeding 3

Important Dosing Considerations for Ticagrelor

• Ticagrelor should be administered as a 180 mg loading dose followed by 90 mg twice daily 1, 2

• When switching from clopidogrel to ticagrelor, the 180 mg loading dose of ticagrelor should be given regardless of timing and loading dose of clopidogrel 1

• Unlike prasugrel, ticagrelor can be used in patients with prior stroke or TIA 1, 2

Duration of Therapy

• Standard duration of DAPT with a P2Y12 inhibitor plus aspirin is 12 months for ACS patients treated with coronary stent implantation 1, 2

• Duration may be shortened (<12 months) if excessive bleeding risk exists (e.g., PRECISE-DAPT score ≥25) 1, 2

Measures to Minimize Bleeding Risk

• Use radial over femoral access for coronary procedures when performed by an expert radial operator 1, 2

• Maintain a daily aspirin dose of 75-100 mg when used with DAPT 1

• Prescribe a proton pump inhibitor (PPI) in combination with DAPT to reduce gastrointestinal bleeding risk 1, 2

Common Pitfalls to Avoid

• Not switching from clopidogrel to ticagrelor in ACS patients when indicated 1, 2

• Administering prasugrel to patients with prior stroke or TIA (contraindicated) 1, 3

• Using prasugrel in medically managed ACS patients (not recommended) 1

• Discontinuing DAPT prematurely, especially within the first month after stent placement 1, 2

• Not reducing prasugrel dose in patients weighing <60 kg or using prasugrel in patients ≥75 years 3