Is Brillinta (ticagrelor) the same as Plavix (clopidogrel)?

Are Brillinta and Plavix the Same?

No, Brillinta (ticagrelor) and Plavix (clopidogrel) are not the same medication—they are two distinct P2Y12 inhibitors with different chemical structures, mechanisms of action, and clinical profiles, though both prevent platelet aggregation when used with aspirin in acute coronary syndromes. 1

Key Pharmacological Differences

Chemical Class and Mechanism:

• Clopidogrel (Plavix) is a thienopyridine that irreversibly binds to the P2Y12 receptor and requires hepatic conversion to its active metabolite, resulting in delayed onset of action (several hours after loading dose) 1, 2
• Ticagrelor (Brillinta) is a cyclopentyl-triazolopyrimidine that directly and reversibly binds to the P2Y12 receptor at a different site than ADP, requiring no metabolic activation and achieving platelet inhibition within 30 minutes 2, 3

Potency and Consistency:

• Ticagrelor provides more rapid and potent platelet inhibition than clopidogrel, with greater suppression of platelet reactivity during both loading and maintenance phases 4
• Clopidogrel exhibits significant interpatient variability in pharmacodynamic response due to genetic polymorphisms affecting hepatic metabolism, creating "hyporesponders" at increased risk for major adverse cardiovascular events (MACE) and stent thrombosis 1, 5
• Ticagrelor demonstrates consistent platelet inhibition across patients without the genetic variability seen with clopidogrel 5, 6

Clinical Efficacy: Ticagrelor is Superior

The 2025 ACC/AHA guidelines recommend ticagrelor over clopidogrel (Class IIa recommendation) for patients with acute coronary syndromes based on superior reduction in cardiovascular outcomes. 1

Evidence from the PLATO Trial:

• Ticagrelor reduced the composite endpoint of cardiovascular death, myocardial infarction, or stroke by 16% compared to clopidogrel in ACS patients 1
• Among patients managed without planned invasive strategy, ticagrelor showed a 15% reduction in MACE, consistent with the overall trial benefit 1, 5
• Ticagrelor demonstrated nominal reduction in all-cause mortality compared to clopidogrel 1
• Ticagrelor reduced stent thrombosis more effectively than clopidogrel 1

Bleeding Risk Profile

Both agents increase bleeding risk compared to aspirin alone, but with different patterns:

• Ticagrelor increases non-CABG major bleeding compared to clopidogrel 1
• However, overall major bleeding rates were comparable between ticagrelor and clopidogrel in the PLATO trial 3, 7
• In high bleeding risk patients (PRECISE-DAPT score ≥25), ticagrelor showed no difference in net adverse clinical events compared to clopidogrel, with lower ischemic events balanced against higher bleeding 8

Unique Side Effects

Ticagrelor causes dyspnea in 10-15% of patients, which is usually mild to moderate and not seen with clopidogrel. 1, 2, 3 This is a class-specific effect unrelated to bleeding or cardiac function.

Ticagrelor may also cause ventricular pauses ≥3 seconds, which are largely asymptomatic. 2, 3

When to Use Clopidogrel Instead

Clopidogrel remains the recommended P2Y12 inhibitor in specific situations: 1

• Patients with prior stroke or transient ischemic attack (ticagrelor not contraindicated, but prasugrel is contraindicated) 1
• High bleeding risk patients where the bleeding risk outweighs ischemic benefit 1
• Contraindications to ticagrelor (previous intracranial hemorrhage, ongoing bleeding) 1
• Intolerance to ticagrelor (particularly dyspnea) 1
• When ticagrelor is unavailable 1
• Older patients (≥75 years) where an open-label trial showed similar ischemic events with less bleeding using clopidogrel versus ticagrelor 1

Surgical Considerations

Recovery of platelet function differs significantly:

• Ticagrelor should be discontinued 5 days before surgery due to its reversible binding, allowing faster recovery of platelet function 2
• Clopidogrel requires 5-7 days for platelet function to return to normal after discontinuation due to irreversible binding 1

Clinical Bottom Line

For most patients with acute coronary syndromes, ticagrelor is the preferred P2Y12 inhibitor over clopidogrel due to superior reduction in cardiovascular death, myocardial infarction, and stroke. 1 Clopidogrel serves as an effective alternative when ticagrelor cannot be used due to contraindications, intolerance, high bleeding risk, or unavailability. 1 The choice should prioritize mortality and morbidity reduction, with ticagrelor demonstrating clear superiority in the highest quality randomized trial evidence. 1, 3