How long should a patient with a history of stroke continue taking Brillinta (ticagrelor) after the initial event?

Duration of Ticagrelor (Brillinta) After Stroke

For patients with non-cardioembolic ischemic stroke or TIA, ticagrelor should be continued for 30 days when used in combination with aspirin (dual antiplatelet therapy), followed by transition to single antiplatelet therapy (either aspirin or clopidogrel) for long-term secondary prevention up to 12 months total. 1, 2

Acute Phase: Dual Antiplatelet Therapy (DAPT)

For mild-to-moderate ischemic stroke (NIHSS ≤5) or high-risk TIA:

• Initiate ticagrelor 180 mg loading dose plus aspirin 300-325 mg within 24 hours of symptom onset 1, 3
• Continue ticagrelor 90 mg twice daily plus aspirin 75-100 mg daily for 30 days 1, 3, 4
• This regimen reduces the composite risk of stroke or death from 6.6% to 5.5% compared to aspirin alone (HR 0.83, P=0.02) 3
• The benefit is primarily in preventing disabling stroke (mRS >1), with a 23% relative risk reduction 4

Critical caveat: The aspirin dose must be limited to 75-100 mg daily when combined with ticagrelor, as higher doses paradoxically reduce ticagrelor's effectiveness and increase bleeding risk 1, 5

Transition Phase: After 30 Days

After completing 30 days of dual antiplatelet therapy:

• Discontinue ticagrelor 1
• Continue single antiplatelet therapy with either aspirin 81 mg daily or clopidogrel 75 mg daily 1
• Total antiplatelet duration should extend up to 12 months from the initial stroke event 1, 2

Long-Term Management: Beyond 12 Months

After 12 months post-stroke:

• The thrombotic risk returns to standard levels rather than high-risk 2
• Continue indefinite single antiplatelet therapy (aspirin or clopidogrel) for secondary prevention 1
• The specific agent choice can be aspirin 75-100 mg daily, clopidogrel 75 mg daily, or aspirin/extended-release dipyridamole 25/200 mg twice daily 1

Special Populations

For patients with ipsilateral atherosclerotic stenosis (≥30%):

• Ticagrelor shows superior benefit compared to aspirin alone, with a 32% relative risk reduction in stroke, MI, or death (HR 0.68, P=0.003) 6
• These patients particularly benefit from the full 30-day DAPT regimen 6

For patients without ipsilateral stenosis:

• No significant difference between ticagrelor and aspirin monotherapy (HR 0.97, P=0.72) 6
• Standard 30-day DAPT followed by single antiplatelet therapy remains appropriate 1

Safety Considerations

Bleeding risk with ticagrelor-aspirin combination:

• Severe bleeding occurs in 0.5% with DAPT versus 0.1% with aspirin alone 3
• Intracranial hemorrhage risk remains low at 0.2% 7
• The bleeding risk is acceptable given the stroke prevention benefit in appropriate patients 3, 4

Absolute contraindications to ticagrelor:

• Active pathological bleeding 5
• History of intracranial hemorrhage 5

Common Pitfalls to Avoid

• Do not continue dual antiplatelet therapy beyond 30 days in stroke patients, as bleeding risk outweighs benefit 1, 3
• Do not use aspirin >100 mg daily with ticagrelor, as this reduces efficacy 1, 5
• Do not use ticagrelor monotherapy initially in acute stroke—it was not superior to aspirin alone in the SOCRATES trial 7
• Do not discontinue all antiplatelet therapy at 30 days—transition to single agent and continue up to 12 months 1, 2