What should be done if a patient experiences shortness of breath while taking ticagrelor (Brilinta)?

Management of Shortness of Breath with Ticagrelor (Brilinta)

For patients experiencing shortness of breath while taking ticagrelor, reassurance and continuation of therapy is recommended in most cases, as dyspnea is typically mild to moderate and self-limiting, while the cardiovascular benefits of ticagrelor outweigh this side effect. 1

Understanding Ticagrelor-Induced Dyspnea

• Dyspnea is a common side effect of ticagrelor, occurring in approximately 14-39% of patients, compared to only 7-9% with clopidogrel or placebo 1, 2
• The mechanism is thought to be related to ticagrelor's ability to inhibit adenosine reuptake by erythrocytes, thereby increasing circulating adenosine levels 1
• Dyspnea typically occurs within the first week of treatment and is rarely severe enough to necessitate discontinuation 3

Assessment Algorithm

1. Evaluate severity of dyspnea:

   • Assess vital signs including oxygen saturation, respiratory rate, heart rate, and blood pressure 1
   • Rule out other potential causes of dyspnea such as heart failure, pulmonary edema, or respiratory infection 1

2. Categorize dyspnea severity:

   • Mild to moderate: Patient reports shortness of breath but has normal oxygen saturation and no signs of respiratory distress 1
   • Severe: Patient has significant respiratory distress, abnormal vital signs, or dyspnea that substantially impacts quality of life 1, 4

Management Based on Severity

For Mild to Moderate Dyspnea (Most Common)

• Reassure the patient that this is a known side effect and typically does not indicate a serious problem 1
• Continue ticagrelor therapy as the cardiovascular benefits outweigh the discomfort of mild dyspnea 1, 3
• Implement non-pharmacological interventions such as positioning the patient upright and using relaxation techniques 1
• Monitor symptoms at follow-up visits to ensure they do not worsen 1

For Severe or Persistent Dyspnea

• Consider switching to an alternative P2Y12 inhibitor such as clopidogrel or prasugrel 1, 4
• Note the potential trade-offs:
  • Clopidogrel has less potent antiplatelet effects than ticagrelor, potentially increasing cardiovascular risk 3
  • Prasugrel is contraindicated in patients with prior stroke/TIA and requires caution in patients ≥75 years or <60 kg 3
• When switching:
  • To clopidogrel: Give a loading dose of 600 mg followed by 75 mg daily 3
  • To prasugrel: Give a loading dose of 60 mg followed by 10 mg daily (5 mg if <60 kg) 3

Special Considerations

• Timing of dyspnea: If dyspnea occurs shortly after starting ticagrelor and is mild, it will often improve or resolve within days to weeks despite continued therapy 5
• Patients with respiratory conditions: Studies have shown that ticagrelor does not significantly worsen pulmonary function in patients with mild asthma or mild-to-moderate COPD 6
• Premature discontinuation risk: Stopping ticagrelor without appropriate alternative antiplatelet therapy significantly increases the risk of cardiovascular events, especially within the first year after ACS or stent placement 4

Common Pitfalls to Avoid

• Premature discontinuation of ticagrelor due to mild dyspnea can increase the risk of cardiovascular events 1, 4
• Failure to distinguish between ticagrelor-induced dyspnea and dyspnea from other causes can lead to inappropriate management 1
• Overlooking other side effects of ticagrelor that may occur concurrently, such as bradycardia with ventricular pauses 1, 7

Documentation and Follow-up

• Document the severity of dyspnea, interventions attempted, and the patient's response 1
• Schedule appropriate follow-up to reassess symptoms and ensure adherence to therapy 1
• Educate patients about the importance of not discontinuing ticagrelor without consulting their healthcare provider 4