From the FDA Drug Label
As shown in Figure 3, discontinuation of cangrelor infusion, followed by administration of the irreversible P2Y12 platelet inhibitors clopidogrel or prasugrel led to a 1-hour decrease in IPA followed by an increase in inhibition of platelet aggregation beginning at about one hour The expected antiplatelet effect of a 600 mg loading dose of clopidogrel or a 60 mg loading dose of prasugrel was blocked when clopidogrel or prasugrel was administered during a cangrelor infusion In contrast, the antiplatelet effect of a 180 mg ticagrelor loading dose was not altered significantly when ticagrelor was administered during cangrelor infusion
The protocol for transitioning from cangrelor to clopidogrel is to discontinue the cangrelor infusion and then administer a 600 mg loading dose of clopidogrel. The anti-platelet effect of clopidogrel will be blocked if administered during the cangrelor infusion, so it should be given after the infusion is stopped. Platelet function will decrease for about 1 hour after stopping cangrelor, and then increase as the clopidogrel takes effect 1. Key points:
- Discontinue cangrelor infusion
- Administer 600 mg loading dose of clopidogrel after infusion is stopped
- Anti-platelet effect of clopidogrel will be blocked if given during cangrelor infusion
From the Research
Transitioning from Cangrelor to Clopidogrel
- The protocol for transitioning from cangrelor to clopidogrel involves administering clopidogrel after cangrelor is stopped, as cangrelor blocks the binding to the platelet P2Y12 receptor of the active metabolite of thienopyridines, including clopidogrel 2.
- Studies have shown that transitioning from cangrelor to clopidogrel is safe and effective, with low rates of stent thrombosis and bleeding events 3, 4.
- The CHAMPION PHOENIX trial demonstrated that cangrelor provided improved anti-ischemic protection compared with clopidogrel, without increasing the risk of severe bleeding 5.
Key Considerations
- Cangrelor should be discontinued before administering clopidogrel, as the active metabolite of clopidogrel is present in blood for a short interval after administration 2.
- The timing of transitioning from cangrelor to clopidogrel may vary depending on the clinical scenario and the patient's individual needs 3, 4.
- Other oral P2Y12 inhibitors, such as prasugrel and ticagrelor, may also be used as transition therapy, with different pharmacodynamic characteristics and interactions with cangrelor 6, 2, 5.
Clinical Evidence
- The ExcelsiorLOAD2 trial compared the efficacy of prasugrel, ticagrelor, and clopidogrel in transitioning from cangrelor, and found that prasugrel and ticagrelor provided superior platelet inhibition compared with clopidogrel 6.
- The ARCANGELO study evaluated the safety of cangrelor and transition to oral P2Y12 inhibitors in patients undergoing percutaneous coronary intervention, and found low rates of bleeding and major adverse cardiac events 4.