What is the loading dose for Brilinta (ticagrelor) in acute myocardial infarction (MI)?

Brilinta Loading Dose in Acute MI

The loading dose for Brilinta (ticagrelor) in acute myocardial infarction is 180 mg, administered orally as soon as possible after presentation, regardless of whether the patient is managed with a conservative or invasive strategy. 1

Dosing Specifics

• Loading dose: 180 mg orally 1, 2
• Maintenance dose: 90 mg twice daily following the loading dose 1, 2
• Timing: Initiate on presentation for both NSTEMI and STEMI patients 1
• For patients undergoing PCI, administer as soon as possible before or at the time of PCI 1, 2

Aspirin Co-Administration

• Aspirin maintenance dose should be 81 mg daily when used in combination with ticagrelor (not the standard 75-160 mg used with other P2Y12 inhibitors) 1, 2
• This lower aspirin dose is specifically recommended to optimize the balance between efficacy and bleeding risk with ticagrelor 2

Clinical Context and Indications

Ticagrelor is recommended for all patients at moderate to high risk of ischemic events (e.g., elevated cardiac troponins), regardless of initial treatment strategy (conservative vs. invasive) 1. This applies to:

• NSTEMI patients at any risk level requiring dual antiplatelet therapy 1
• STEMI patients managed with early invasive strategy 1, 2
• Patients previously treated with clopidogrel (which should be discontinued when ticagrelor is started) 1

Key Advantages Over Clopidogrel

• Faster onset of action: Significant antiplatelet effect observed within 30 minutes of loading 1
• No biotransformation required: Parent compound is active, providing reversible P2Y12 inhibition 1
• Less variability in response: Minimal impact from genetic polymorphisms (CYP2C19) or drug interactions compared to clopidogrel 1

Critical Contraindications

Absolute contraindications include 1:

• Previous intracranial hemorrhage
• Active ongoing bleeding

Important Safety Considerations

• Increased bleeding risk: TIMI major bleeding rates are higher with ticagrelor (2.30-2.60%) compared to placebo (1.06%) or standard-dose clopidogrel 1, 3
• Surgical timing: If urgent CABG is required, discontinue ticagrelor at least 24 hours (ideally 5 days) before surgery if possible 1, 2
• The bleeding risk appears to decline after the first year of therapy in patients on long-term treatment 4, 3

Duration of Therapy

• Continue dual antiplatelet therapy for at least 12 months unless contraindicated by excessive bleeding risk 1
• For patients receiving drug-eluting stents, maintain therapy for at least 12 months 1