Management of Brilinta (Ticagrelor) 90 mg in Gastrointestinal Bleeding
Immediately discontinue Brilinta (ticagrelor) when GI bleeding occurs, as ticagrelor is contraindicated during active bleeding according to FDA labeling, and withhold dual antiplatelet therapy (DAPT) for approximately one week until hemostasis is achieved and hemoglobin stabilizes. 1, 2
Immediate Management During Active Bleeding
Discontinuation of Antiplatelet Therapy
- Withhold both aspirin and ticagrelor immediately when GI bleeding is identified, particularly if the patient presents with profound anemia (hemoglobin <8 g/dL) or hemodynamic instability 2
- The typical duration of DAPT interruption is one week based on ESC guideline case examples, though this must be balanced against thrombotic risk 2
- Ticagrelor is specifically contraindicated with itraconazole and other strong CYP3A4 inhibitors that may increase bleeding risk 1
Resuscitation and Stabilization
- Initiate fluid resuscitation with crystalloids using at least two large-bore catheters to restore hemodynamic stability 3, 4
- Transfuse red blood cells when hemoglobin falls below 7 g/dL in patients without cardiovascular disease, or consider a higher threshold of 8 g/dL in patients with underlying cardiac disease 3, 4
- Start high-dose intravenous PPI therapy immediately: 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 4
Diagnostic Approach
- Perform upper endoscopy within 24 hours of presentation after initial stabilization to identify the bleeding source 3, 4
- For hemodynamically unstable patients (shock index >1), consider urgent CT angiography before endoscopy to localize bleeding 3, 4
- Always consider an upper GI source even if the patient presents with bright red blood per rectum, as failure to do so leads to delayed diagnosis 4
Risk Stratification for Restarting Antiplatelet Therapy
Assess Thrombotic Risk
The decision to restart ticagrelor depends critically on the timing of the patient's coronary intervention and clinical indication 2:
Very High Thrombotic Risk (defer procedure/restart ASAP):
- ACS or PCI performed <6 weeks ago 2
- In this scenario, defer elective procedures and restart antiplatelet therapy as soon as bleeding is controlled 2
High Thrombotic Risk (careful timing required):
- ACS or PCI performed 6 weeks to 6 months ago 2
- Complex PCI (multiple overlapping stents, chronic total occlusion recanalization) 2
Moderate to Low Thrombotic Risk:
Assess Rebleeding Risk
- Identify and treat the bleeding source endoscopically (ulcer, rectal ulcer, hemorrhoids) 2
- Confirm negative stool occult blood test before restarting antiplatelet therapy 2
- Ensure hemoglobin has stabilized >12 g/dL after transfusion and source control 2
- Initiate oral esomeprazole or other PPI as prophylaxis against recurrent bleeding 2
Restarting Antiplatelet Therapy: The Critical Decision
When Hemostasis is Achieved
For patients with high thrombotic risk:
- Restart aspirin first on a background of PPI therapy after confirming hemostasis 2
- Introduce clopidogrel (not ticagrelor) approximately one month later after repeated testing confirms stable hemoglobin levels >12 g/dL 2
- Switch from ticagrelor to clopidogrel for long-term therapy, as the ESC guideline case demonstrates this de-escalation strategy reduces bleeding risk while maintaining adequate platelet inhibition 2
For patients with moderate to low thrombotic risk:
- Restart aspirin when cardiovascular risks outweigh GI risks, typically within 7 days of achieving hemostasis 3, 5, 4
- Continue aspirin plus PPI rather than restarting ticagrelor 4
- Consider clopidogrel as an alternative to ticagrelor for ongoing DAPT needs 2
Key Timing Considerations
- For low postprocedural bleeding risk, antiplatelet therapy can restart 24 hours after hemostasis 2
- For higher bleeding risk, delay therapeutic antiplatelet therapy for 48-72 hours 2
- Patients with recurrent GI bleeding on ticagrelor should be permanently switched to clopidogrel-based DAPT 2
Critical Pitfalls to Avoid
Common Errors in Management
- Do not use ticagrelor in stable CAD/elective PCI unless there is prior stent thrombosis on clopidogrel, as this is off-label and may inappropriately increase bleeding risk 2
- Never restart ticagrelor without addressing the bleeding source and confirming hemostasis with negative stool occult blood testing 2
- Do not continue DAPT interruption beyond necessary in very high-risk patients (PCI <6 weeks), as thrombotic risk may exceed bleeding risk 2
- Avoid epinephrine injection alone during endoscopic therapy; always combine with thermal coagulation or mechanical therapy 4
De-escalation Strategy
The ESC guideline case explicitly demonstrates that switching from ticagrelor to clopidogrel after GI bleeding is the preferred strategy, even in complex PCI cases 2. This approach:
- Reduces bleeding risk compared to continuing ticagrelor 2
- Maintains adequate platelet inhibition when combined with aspirin 2
- Should be implemented with ongoing PPI therapy 2
Duration of DAPT After Bleeding
- Standard duration is 6 months after elective PCI, but should be reduced to 3 months or even 1 month if high bleeding risk persists 2
- For complex PCI, DAPT longer than 6 months may be considered, but only after careful risk-benefit assessment 2
- The presence of recurrent GI bleeding strongly favors shorter DAPT duration with transition to single antiplatelet therapy plus PPI 2
Long-term Prevention
Mandatory Co-therapy
- All patients restarting antiplatelet therapy must receive PPI co-therapy to reduce rebleeding risk 2, 3, 4
- Continue PPI therapy indefinitely for patients requiring ongoing antiplatelet or anticoagulant therapy with previous ulcer bleeding 4
H. pylori Management
- Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if positive 4
- Eradication reduces ulcer recurrence and rebleeding rates in complicated ulcer disease 4