What alternative Dual Antiplatelet Therapy (DAPT) can be used if clopidogrel (Plavix) causes taste disturbances?

Switch to Ticagrelor or Prasugrel for Clopidogrel-Induced Taste Disturbances

If clopidogrel causes taste disturbances in a patient requiring DAPT, switch to ticagrelor (180 mg loading dose, then 90 mg twice daily) as the first-line alternative, or prasugrel (60 mg loading dose, then 10 mg daily) if the patient meets specific criteria. 1, 2

Primary Recommendation: Ticagrelor

• Ticagrelor is the preferred alternative to clopidogrel for patients experiencing taste disturbances, as it is recommended as first-line therapy for acute coronary syndrome regardless of prior clopidogrel exposure 1, 2

• The European Society of Cardiology explicitly recommends switching from clopidogrel to ticagrelor early after hospital admission at a loading dose of 180 mg, irrespective of timing and loading dose of clopidogrel, unless contraindications exist 1

• Ticagrelor provides superior efficacy compared to clopidogrel and does not share the taste disturbance side effect profile 2, 3

Alternative Option: Prasugrel

• Prasugrel (60 mg loading dose, 10 mg daily) is an appropriate alternative for P2Y12 inhibitor-naïve patients with NSTE-ACS or STEMI undergoing PCI 1, 2

• However, prasugrel has critical contraindications that must be screened for:

  • Absolute contraindication: Prior stroke or transient ischemic attack (increased cerebrovascular event risk: 6.5% vs 1.2% with clopidogrel) 1, 3
  • Not recommended: Age ≥75 years or body weight <60 kg 1, 3
  • Contraindication: Previous intracranial hemorrhage or ongoing bleeding 1

Key Contraindications to Consider

• Ticagrelor contraindications include previous intracranial hemorrhage or ongoing bleeding 1

• Important drug interaction: Ticagrelor is contraindicated with itraconazole and should not be used during and for 2 weeks after itraconazole treatment 4

• If the patient has prior stroke/TIA, ticagrelor is the only potent P2Y12 inhibitor option, as prasugrel is contraindicated 2, 3

Practical Implementation

• When switching from clopidogrel to ticagrelor, administer the 180 mg loading dose immediately without waiting for clopidogrel washout 1

• Maintain aspirin at 75-100 mg daily (or 81 mg in the US) when using either ticagrelor or prasugrel 1, 2

• Add a proton pump inhibitor (preferably pantoprazole or rabeprazole over omeprazole/esomeprazole) to minimize gastrointestinal bleeding risk 1

Duration and Monitoring

• Continue DAPT for 12 months unless excessive bleeding risk exists (e.g., PRECISE-DAPT score ≥25), in which case consider 6 months 1, 2

• Both ticagrelor and prasugrel have faster onset of action (within 30 minutes) compared to clopidogrel (2 hours), providing more reliable platelet inhibition 3

Common Pitfalls to Avoid

• Do not continue clopidogrel if taste disturbances are affecting medication adherence, as this increases risk of thrombotic events 2

• Do not prescribe prasugrel without first confirming absence of prior stroke/TIA, as this significantly increases cerebrovascular event risk 1, 3

• Do not use routine platelet function testing to guide the switch, as this is not recommended 1