What is the recommended dosing regimen for Brilinta (ticagrelor) in patients undergoing stent placement?

Brilinta Dosing for Stent Placement

For patients undergoing stent placement, administer a loading dose of 180 mg ticagrelor as early as possible before or at the time of PCI, followed by 90 mg twice daily for at least 12 months, combined with aspirin 81 mg daily.

Loading Dose Protocol

• Give 180 mg ticagrelor loading dose as early as possible or at the time of PCI for all patients undergoing stent placement in the setting of acute coronary syndrome (ACS) 1, 2
• The loading dose achieves rapid platelet inhibition within 30 minutes with peak effect at approximately 2 hours 2
• This loading dose applies regardless of whether the patient was previously on clopidogrel, which should be discontinued when ticagrelor is commenced 1

Maintenance Dosing Regimen

• Administer 90 mg ticagrelor twice daily for at least 12 months after stent implantation (both bare-metal stents and drug-eluting stents) in ACS patients 1, 2
• Doses must be taken approximately 12 hours apart to maintain consistent platelet inhibition throughout the day 2
• Combine with aspirin 81 mg daily (not higher doses) to reduce bleeding risk while maintaining efficacy 1, 2

Duration Considerations by Clinical Scenario

For ACS patients with stent placement:

• Continue dual antiplatelet therapy (DAPT) with ticagrelor 90 mg twice daily plus aspirin for 12 months as the standard duration 1
• Continuation beyond 12 months may be considered in selected high-risk patients to reduce major adverse cardiovascular events 2

For stable coronary artery disease (non-ACS) with stent placement:

• Ticagrelor is approved for ACS patients specifically; clopidogrel is the recommended P2Y12 inhibitor for stable disease 1
• However, if ticagrelor is used in stable disease, the same 90 mg twice daily dosing applies 1

Critical Safety Considerations

Absolute contraindications:

• Do not use ticagrelor in patients with prior stroke or transient ischemic attack due to increased risk of intracranial hemorrhage 1, 2
• Avoid in patients with history of intracranial hemorrhage or active bleeding 1

Perioperative management:

• Discontinue ticagrelor at least 5 days before elective surgery to reduce bleeding risk 2
• Continue aspirin perioperatively if bleeding risk allows 1
• Never abruptly discontinue ticagrelor due to increased risk of cardiovascular events 2

High-risk populations requiring caution:

• Elderly patients (≥75 years) have increased bleeding risk 2
• Patients with low body weight (<60 kg) require careful monitoring 2
• Patients at high bleeding risk (PRECISE-DAPT score ≥25) may warrant shorter DAPT duration 1

Medication Adherence Emphasis

• Twice-daily dosing compliance is critical because ticagrelor has reversible binding and shorter half-life compared to clopidogrel 2, 3
• Counsel patients extensively on the importance of adherence before stent placement 1
• If patients are unwilling or unable to comply with 12 months of DAPT, alternative therapies (such as bare-metal stents with shorter DAPT duration) should be pursued 1

Common Pitfalls to Avoid

• Do not use higher aspirin maintenance doses (>100 mg) with ticagrelor, as 81 mg daily is preferred to minimize bleeding while maintaining efficacy 1, 2
• Do not give prasugrel to patients with prior stroke/TIA, but ticagrelor is also contraindicated in this population 1, 2
• Do not routinely perform platelet function testing to adjust antiplatelet therapy before or after elective stenting 1
• Ensure proton pump inhibitor (PPI) co-administration with DAPT to reduce gastrointestinal bleeding risk 1