What is the recommended dose of Ticagrelor (antiplatelet agent) for patients, 60mg twice daily (bid) vs 90mg twice daily (bid)?

Ticagrelor Dosing: 90 mg vs 60 mg Twice Daily

For acute coronary syndrome (ACS) including STEMI and NSTE-ACS within the first year, use ticagrelor 90 mg twice daily; for long-term secondary prevention in stable patients more than 1 year post-MI, use ticagrelor 60 mg twice daily. 1

Acute Phase (First Year Post-ACS)

Ticagrelor 90 mg twice daily is the established dose for acute management:

• For patients with STEMI undergoing primary PCI, administer a 180 mg loading dose followed by 90 mg twice daily maintenance for up to 12 months 1
• For NSTE-ACS patients (whether treated invasively or with ischemia-guided strategy), use 90 mg twice daily for up to 12 months 1
• This dose demonstrated superiority over clopidogrel in the PLATO trial, reducing the composite endpoint of cardiovascular death, MI, or stroke from 11.7% to 9.8% (HR 0.84, P<0.001) 1, 2
• The 90 mg dose also reduced all-cause mortality (4.5% vs 5.9%, P<0.001) compared to clopidogrel 2

Critical caveat: Aspirin dose must be limited to 81 mg daily when using ticagrelor, as higher aspirin doses (>100 mg) reduce ticagrelor's efficacy 1

Long-Term Secondary Prevention (Beyond 1 Year Post-MI)

Ticagrelor 60 mg twice daily is the FDA-approved dose for extended therapy:

• For stable patients with prior MI (1-3 years post-event) who have additional cardiovascular risk factors, use 60 mg twice daily 1
• The PEGASUS-TIMI 54 trial demonstrated that both 90 mg and 60 mg doses showed equivalent efficacy, but the 60 mg dose has a more favorable benefit-risk profile 1
• Treating 1,000 post-MI patients with 60 mg twice daily results in 4 fewer ischemic events and 3 more bleeding events per year, compared to 4 fewer ischemic events and 4 more bleeding events with 90 mg twice daily 1
• At 3 years, the 60 mg dose reduced the primary endpoint (CV death, MI, or stroke) from 9.04% to 7.77% (HR 0.84, P=0.004) 1

Practical Algorithm for Dose Selection

Use this stepwise approach:

1. Timing from index MI:

   • <1 year post-ACS: Use 90 mg twice daily 1

   • 1 year post-MI with additional risk factors: Use 60 mg twice daily 1

2. Additional risk factors for extended therapy include:

   • Age ≥65 years, diabetes mellitus, second prior MI, multivessel coronary disease, or chronic kidney disease (not requiring dialysis) 3

3. Bleeding risk assessment:

   • The 60 mg dose causes slightly less major bleeding (2.30% vs 1.06% placebo at 3 years) compared to 90 mg dose (similar efficacy but 4 vs 3 bleeding events per 1,000 patient-years) 1
   • For patients at higher bleeding risk (age ≥75 years, weight <60 kg), the 60 mg dose is preferable for long-term therapy 4

Common Pitfalls to Avoid

• Do not use high-dose aspirin: Aspirin must be 81 mg daily with ticagrelor; doses >100 mg reduce efficacy and increase bleeding 1
• Do not abruptly discontinue: Stopping ticagrelor suddenly increases cardiovascular event risk; ensure compliance with twice-daily dosing 4
• Do not use 60 mg for acute ACS: The 60 mg dose is only validated for long-term secondary prevention, not acute management 1
• Monitor for dyspnea: Up to 15% of patients experience dyspnea with ticagrelor, though rarely severe enough to require discontinuation 1
• Consider proton pump inhibitor: Add PPI for gastrointestinal bleeding prophylaxis, especially in high-risk patients on dual antiplatelet therapy 1

Special Populations

• Peripheral artery disease: The 60 mg dose showed particular benefit in reducing major adverse limb events (HR 0.65, P=0.026) and had favorable outcomes for CV and all-cause mortality in PAD patients 5
• Elderly patients (≥75 years): Require closer monitoring for bleeding complications; the 60 mg dose is preferred for extended therapy 4
• Low body weight (<60 kg): May have increased drug exposure; consider 60 mg dose for long-term therapy 4