What is the recommended dose of Brilinta (ticagrelor) after stent placement?

Brilinta Dosing After Stent Placement

For patients receiving a stent after acute coronary syndrome (ACS), administer ticagrelor (Brilinta) with a 180 mg loading dose as early as possible before or at the time of PCI, followed by 90 mg twice daily for at least 12 months, combined with low-dose aspirin 81 mg daily. 1, 2

Loading Dose Protocol

• Give 180 mg ticagrelor loading dose as early as possible or at the time of PCI for all ACS patients undergoing stent placement (bare-metal or drug-eluting stents) 1
• The loading dose achieves rapid platelet inhibition within 30 minutes with peak effect at approximately 2 hours 2
• This applies to both STEMI and UA/NSTEMI patients receiving stents during PCI 1

Maintenance Dosing Regimen

• Administer 90 mg twice daily (every 12 hours) for at least 12 months after stent placement in ACS patients 1, 2
• This maintenance dose applies equally to both bare-metal stents (BMS) and drug-eluting stents (DES) placed during ACS 1
• Combine with aspirin 81 mg daily (not higher doses) to reduce bleeding risk while maintaining efficacy 1, 2

The 2013 ACC/AHA guidelines specifically note that the recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily, which is lower than the typical aspirin dose used with other P2Y12 inhibitors 1.

Duration of Therapy

• Continue ticagrelor for a minimum of 12 months after stent placement in ACS patients 1
• Extension beyond 12 months may be considered in selected patients, though this carries a Class IIb recommendation 1
• Earlier discontinuation (less than 12 months) is reasonable only if bleeding risk outweighs the anticipated cardiovascular benefit 1

Critical Contraindications and Warnings

• Do not use ticagrelor in patients with prior stroke or TIA due to increased risk of intracranial hemorrhage 2
• This is a Class III: Harm recommendation specifically for prasugrel in STEMI patients with prior stroke/TIA, and similar caution applies to ticagrelor 1
• Discontinue at least 5 days before elective surgery to reduce bleeding risk 2

Important Clinical Considerations

• Never abruptly discontinue ticagrelor as this increases cardiovascular event risk 2
• The twice-daily dosing requires strict adherence due to ticagrelor's reversible binding and shorter half-life compared to clopidogrel 2
• Doses should be taken approximately 12 hours apart to maintain consistent platelet inhibition 2
• Ticagrelor demonstrates superior platelet inhibition compared to clopidogrel, with greater suppression of platelet reactivity both after loading and during maintenance therapy 3

Special Populations

• For elderly patients (≥75 years) and those with low body weight (<60 kg), exercise particular caution regarding bleeding risk, though standard dosing remains recommended 2
• Proton pump inhibitor use does not affect ticagrelor's antiplatelet effect (unlike clopidogrel) 3

Common Pitfalls to Avoid

• Do not reduce the ticagrelor dose based on platelet function testing - routine dose de-escalation based on platelet reactivity testing is not recommended and has been associated with adverse outcomes 1
• Do not use higher aspirin maintenance doses (>81 mg daily) with ticagrelor, as this increases bleeding without improving efficacy 1
• Ensure patient counseling on the need for and risks of dual antiplatelet therapy before stent placement, as premature discontinuation dramatically increases stent thrombosis risk 1