What is the antiplatelet regimen for a cardiac stent with Effient (prasugrel)?

From the Guidelines

The standard antiplatelet regimen for a cardiac stent with Effient (prasugrel) consists of dual antiplatelet therapy (DAPT) with prasugrel 10 mg daily plus aspirin 81 mg daily, with a loading dose of prasugrel 60 mg before the procedure, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. The treatment typically begins with the loading dose of prasugrel 60 mg followed by the daily maintenance dose.

• For patients weighing less than 60 kg or aged 75 years and older, a reduced prasugrel maintenance dose of 5 mg daily is recommended due to increased bleeding risk.
• The duration of DAPT depends on stent type and patient risk factors: generally at least 12 months for drug-eluting stents, as stated in the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 1.
• Prasugrel is contraindicated in patients with prior stroke or TIA and should be discontinued 7 days before elective surgery. This dual therapy is essential because prasugrel inhibits platelet aggregation by blocking the P2Y12 receptor while aspirin blocks the COX-1 pathway, providing complementary protection against stent thrombosis while the endothelium heals over the stent. The 2014 AHA/ACC guideline also recommends that a loading dose of a P2Y12 receptor inhibitor, such as prasugrel, should be given before the procedure in patients undergoing PCI with stenting 1.
• Aspirin should be continued indefinitely at a dose of 81 mg to 325 mg daily, as recommended by both the 2011 ACCF/AHA/SCAI guideline and the 2014 AHA/ACC guideline 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Initiate treatment with a single 60 mg oral loading dose (2). Continue at 10 mg once daily with or without food. Consider 5 mg once daily for patients <60 kg (2). Patients should also take aspirin (75 mg to 325 mg) daily (2). The antiplatelet regimen for a cardiac stent with Effient (prasugrel) is:

• A single 60 mg oral loading dose of prasugrel
• 10 mg of prasugrel once daily (or 5 mg once daily for patients <60 kg)
• Aspirin (75 mg to 325 mg) daily 2

From the Research

Antiplatelet Regimen for Cardiac Stent with Effient

The antiplatelet regimen for a cardiac stent with Effient (prasugrel) typically involves dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, such as prasugrel.

• The standard of care is to continue aspirin indefinitely at a low dose (75-100 mg daily) and administer a P2Y12 inhibitor for 12 months after percutaneous coronary intervention (PCI), unless the patient is at high risk for bleeding 3.
• Prasugrel is a P2Y12 inhibitor that has been shown to reduce the risk of non-fatal myocardial infarction compared to clopidogrel, but it is associated with a higher risk of bleeding 4.
• The choice of P2Y12 inhibitor, such as prasugrel or ticagrelor, should be made on an individual patient basis, taking into account the patient's risk of bleeding and other factors 5.
• In patients with acute coronary syndromes, prasugrel and ticagrelor have been shown to further reduce cardiovascular ischemic events compared to clopidogrel, but are associated with a higher bleeding risk 3, 5.
• The duration of DAPT may vary depending on the patient's individual risk factors and the type of stent used, but typically ranges from 12 months to indefinitely 3, 6.

Key Considerations

• Patients with a high risk of bleeding may require a shorter duration of DAPT or a different antiplatelet regimen 3, 7.
• The use of proton pump inhibitors, tight control of the international normalized ratio (INR), and only one month of DAPT can reduce the bleeding risk without an increase in stroke or stent thrombosis 7.
• The choice of antiplatelet therapy should be individualized based on the patient's specific needs and risk factors 5.

Evidence Summary

• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as prasugrel, is the standard of care for patients with a cardiac stent 3, 6, 5.
• Prasugrel has been shown to reduce the risk of non-fatal myocardial infarction compared to clopidogrel, but is associated with a higher risk of bleeding 4.
• The choice of P2Y12 inhibitor and duration of DAPT should be individualized based on the patient's risk factors and other considerations 3, 7, 5.