When should Cangrelor (cangrelor) drip be stopped prior to Percutaneous Endoscopic Gastrostomy (PEG) placement?

When to Stop Cangrelor Prior to PEG Placement

Cangrelor should be discontinued 1 hour before PEG placement to allow complete recovery of platelet function.

Pharmacologic Rationale

Cangrelor's unique pharmacokinetic profile makes timing straightforward:

• Platelet function recovers within 60 minutes of stopping the infusion, as cangrelor is a reversible P2Y12 inhibitor with immediate offset 1
• This rapid recovery distinguishes cangrelor from oral P2Y12 inhibitors like clopidogrel (requires 5-7 days) or prasugrel (requires 7 days) 1, 2
• The drug has an elimination half-life of approximately 3-9 minutes, allowing predictable and complete dissociation from platelet receptors 1

Practical Implementation for PEG

Recommended stopping time: 1 hour before procedure start

PEG placement is classified as a high-risk endoscopic procedure for bleeding 1. Given this classification:

• Stop the cangrelor infusion 1 hour prior to the anticipated procedure start time 1
• No bridging with other antiplatelet agents is needed during this brief interruption 3
• Verify hemostasis is adequate before proceeding, though platelet function testing is not routinely recommended 2

Post-Procedure Resumption

• Resume cangrelor within 1-3 hours after PEG placement if hemostasis is secure and no active bleeding is present 1
• The rapid onset of action (within minutes) provides immediate platelet inhibition upon restarting 1
• If transitioning back to oral P2Y12 inhibitors, administer the loading dose (clopidogrel 600mg or prasugrel 60mg) at the end of or after the cangrelor infusion to avoid competitive binding 1

Critical Caveats

Assess thrombotic risk before any interruption:

• For patients with recent coronary stents (<6-12 months), particularly drug-eluting stents, consult interventional cardiology before stopping any antiplatelet therapy 1, 3
• If the patient is on dual antiplatelet therapy (DAPT), continue aspirin throughout the periprocedural period 1
• The 1-hour window applies specifically to cangrelor; do not extrapolate this timing to oral P2Y12 inhibitors 1, 2

Bleeding risk considerations:

• While cangrelor overdosing (even >2.5 times the recommended dose) has not been associated with increased major bleeding in PCI studies, minor bleeding rates are higher than with clopidogrel 4, 1
• Real-world bridging protocols have shown feasibility with cangrelor discontinuation 6-7 hours before surgery, though 1 hour is sufficient based on pharmacology 5