Is it okay to start aspirin, lovenox (enoxaparin), and Brilinta (ticagrelor) after 12 hours of Integrilin (eptifibatide) in a patient with a newly placed stent?

Post-Stent Antiplatelet Management with Integrilin Bridge

The described regimen is acceptable and follows established bridging protocols, but aspirin and Brilinta (ticagrelor) should ideally be started immediately after stent placement alongside Integrilin, not delayed until after the 12-hour infusion ends. Lovenox (enoxaparin) is not standard therapy post-stent and requires specific justification.

Optimal Antiplatelet Timing Post-Stent

Standard DAPT Initiation

• Aspirin and ticagrelor should be loaded at the time of PCI, not delayed until after glycoprotein IIb/IIIa inhibitor completion 1
• For ACS patients undergoing PCI, ticagrelor 180 mg loading dose followed by 90 mg twice daily is recommended immediately, regardless of glycoprotein IIb/IIIa inhibitor use 1
• Aspirin 75-100 mg daily should be initiated at the time of stent placement and continued indefinitely 1

Integrilin (Eptifibatide) as Bridge Therapy

• Eptifibatide is recognized as acceptable bridging therapy when oral antiplatelet agents must be temporarily interrupted, particularly in the perioperative setting 1
• However, in the immediate post-stent period, eptifibatide is typically used as adjunctive therapy alongside—not instead of—oral DAPT 2
• The 12-hour infusion duration is reasonable, as eptifibatide has a short half-life (approximately 2.5 hours) and platelet function recovers within 4-8 hours of discontinuation 2

Critical Issue: Lovenox (Enoxaparin) Post-Stent

Standard Post-PCI Anticoagulation

• Enoxaparin is NOT standard therapy after successful stent placement in patients without other indications for anticoagulation 1
• Post-PCI anticoagulation (heparin, enoxaparin, bivalirudin) is typically discontinued after the procedure unless there is a separate indication such as atrial fibrillation, venous thromboembolism, or mechanical heart valve 1

Triple Therapy Concerns

• If enoxaparin represents bridging to warfarin or a DOAC for atrial fibrillation or another indication, this creates "triple therapy" (aspirin + ticagrelor + anticoagulation) 1
• Triple therapy increases bleeding risk 2-3 fold and should be limited to maximum 6 months or omitted after hospital discharge 1
• Ticagrelor is specifically NOT recommended in the triple therapy setting; clopidogrel is preferred if triple therapy is necessary 1

Recommended Correction to Current Regimen

Immediate Actions

• Start aspirin 81-100 mg daily immediately if not already given 1
• Give ticagrelor 180 mg loading dose now (if not already given), followed by 90 mg twice daily 1
• Continue eptifibatide infusion for the planned 12-hour duration 2
• Discontinue enoxaparin unless there is a compelling indication for anticoagulation (atrial fibrillation, LV thrombus, venous thromboembolism) 1

If Anticoagulation is Truly Indicated

• Switch from ticagrelor to clopidogrel 75 mg daily (600 mg loading dose if not previously loaded) 1
• Limit triple therapy duration to maximum 6 months, with consideration for even shorter duration (1-4 weeks) based on bleeding risk 1
• Add a proton pump inhibitor for gastrointestinal protection 1, 3

Standard Post-Stent DAPT Duration

For ACS Patients

• Default DAPT duration is 12 months with aspirin plus ticagrelor 1, 4
• Consider 6-month duration only in high bleeding risk patients (PRECISE-DAPT score ≥25) 1, 4
• Extended DAPT beyond 12 months may be considered in patients who tolerate therapy without bleeding complications 1, 4, 5

For Stable CAD Patients

• Minimum 1 month of DAPT with aspirin plus clopidogrel after drug-eluting stent placement 1, 6, 7
• 6-12 months is standard for most stable patients 6, 7

Common Pitfalls to Avoid

• Do not delay oral DAPT initiation waiting for glycoprotein IIb/IIIa inhibitor completion—these therapies should overlap 1
• Do not use enoxaparin routinely post-stent without a specific indication for anticoagulation 1
• Do not use ticagrelor if triple therapy is required—switch to clopidogrel 1
• Do not discontinue DAPT in the first month post-stent except for life-threatening bleeding 1
• Ensure bleeding risk assessment is performed and documented to guide DAPT duration decisions 1, 4, 5