Brilinta 60 mg Indications
Brilinta (ticagrelor) 60 mg is indicated for extended dual antiplatelet therapy beyond 12 months in patients with a history of myocardial infarction who are at high ischemic risk and have tolerated initial DAPT without bleeding complications. This represents a distinct indication from the standard 90 mg twice-daily dose used for acute coronary syndrome.
Primary Indication for 60 mg Dose
The 60 mg twice-daily dose is specifically for long-term secondary prevention in post-MI patients who have completed their initial 12-month DAPT course. 1, 2
- Patients must have a history of myocardial infarction occurring at least 1 year prior 1
- They must be at high ischemic risk, defined as age ≥50 years plus at least one additional risk factor: age ≥65 years, diabetes requiring medication, a second prior spontaneous MI, multivessel coronary artery disease, or chronic renal dysfunction (creatinine clearance <60 mL/min) 1
- Patients must have tolerated the initial 12 months of DAPT without bleeding complications 1, 2
Distinction from Standard 90 mg Dose
The 90 mg twice-daily dose remains the standard for acute management:
- For acute coronary syndrome (ACS), ticagrelor 90 mg twice daily (after 180 mg loading dose) is the first-line regimen for the initial 12 months 1, 2, 3
- This applies to all ACS presentations: STEMI, NSTEMI, and unstable angina 2, 4
- The 90 mg dose is used regardless of whether patients undergo PCI, medical management, or CABG 2, 4
Clinical Context for Extended Therapy with 60 mg
After completing 12 months of DAPT with ticagrelor 90 mg twice daily, continuation with ticagrelor 60 mg twice daily may be preferred over clopidogrel or prasugrel for extended therapy in high-risk MI patients. 1
- This represents a Class IIb recommendation (may be considered) 1
- The lower 60 mg dose balances continued ischemic protection with reduced bleeding risk during extended therapy 1
- Patients must have low bleeding risk to qualify for extended DAPT beyond 12 months 1, 2
Contraindications Apply to Both Doses
Ticagrelor at any dose is contraindicated in patients with previous intracranial hemorrhage or ongoing active bleeding. 1
Bleeding Risk Mitigation Strategies
Even with the lower 60 mg dose for extended therapy, bleeding risk mitigation remains essential:
- Prescribe a proton pump inhibitor (PPI) with any DAPT regimen - this is a Class I recommendation 1, 2, 3
- Maintain aspirin at 75-100 mg daily (not higher doses) when combined with ticagrelor 1, 2, 3
- Pantoprazole or rabeprazole are preferred PPIs due to lowest drug interaction potential with antiplatelet agents 1, 2
Common Pitfall to Avoid
Do not confuse the 60 mg dose indication with acute ACS management - the 60 mg dose is exclusively for extended secondary prevention beyond 12 months in stable post-MI patients, not for acute events. 1 For any acute coronary syndrome presentation, the 90 mg twice-daily dose (after 180 mg loading) remains standard. 1, 2, 3