What is the recommended Brilinta (ticagrelor) dosing regimen after percutaneous coronary intervention, including loading dose, maintenance dose, adjustments for patients aged ≥ 75 years, weighing ≤ 60 kg, or with moderate renal impairment, and the advised duration of therapy?

Brilinta (Ticagrelor) Dosing Post-PCI

Administer ticagrelor 180 mg loading dose immediately at ACS diagnosis or before PCI, followed by 90 mg twice daily for 12 months, combined with low-dose aspirin 75–100 mg daily. 1

Standard Dosing Regimen

Loading Dose

• Give ticagrelor 180 mg orally as soon as possible after acute coronary syndrome diagnosis and before any invasive procedure to achieve rapid platelet inhibition within 30 minutes. 1, 2

Maintenance Dose

• Continue ticagrelor 90 mg twice daily (approximately 12 hours apart) for a minimum of 12 months post-PCI, regardless of stent type or ACS subtype. 1, 3
• Combine with aspirin 75–100 mg daily (never exceed 100 mg, as higher doses reduce ticagrelor efficacy—this is an FDA black-box warning). 1, 3

Special Population Adjustments

Age ≥ 75 Years

• No dose adjustment required—maintain standard ticagrelor 90 mg twice daily dosing. 1
• Recent evidence demonstrates that ticagrelor 60 mg twice daily provides non-inferior platelet inhibition in elderly patients, but this lower dose is not yet guideline-recommended for the acute post-PCI period. 4

Body Weight ≤ 60 kg

• No dose adjustment required for ticagrelor (unlike prasugrel, which requires dose reduction to 5 mg daily in this population). 1

Moderate Renal Impairment

• No dose adjustment required—ticagrelor can be used at standard doses in patients with chronic kidney disease, including stage ≥3b CKD. 1, 5

Duration of Therapy

Standard Duration

• Continue dual antiplatelet therapy for 12 months in all ACS patients post-PCI who are not at high bleeding risk, irrespective of stent type (drug-eluting or bare-metal), ACS subtype, or completeness of revascularization. 1, 3

High Bleeding Risk

• Consider shortening DAPT to 6 months in patients with high bleeding risk (PRECISE-DAPT score ≥25), though this represents a compromise between ischemic and bleeding risk. 1, 3

Extended Therapy (Beyond 12 Months)

• After completing 12 months of ticagrelor 90 mg twice daily, patients at high ischemic risk who tolerated DAPT without bleeding may be considered for extended therapy with ticagrelor 60 mg twice daily plus aspirin. 3, 6
• High ischemic risk is defined as age ≥50 years plus at least one additional factor: age ≥65 years, diabetes requiring medication, second prior MI, multivessel CAD, or chronic renal dysfunction (CrCl <60 mL/min). 3

Critical Bleeding-Risk Mitigation

• Prescribe a proton pump inhibitor (PPI) to all patients on DAPT—this is a Class I recommendation to reduce gastrointestinal bleeding. 1, 3
• Use radial artery access over femoral access for PCI when performed by an experienced radial operator. 1, 3
• Maintain aspirin at 75–100 mg daily—higher doses increase bleeding without improving efficacy and specifically reduce ticagrelor's antiplatelet effect. 1, 3

Absolute Contraindications

• History of intracranial hemorrhage—ticagrelor is contraindicated due to increased risk of fatal intracranial bleeding. 3
• Active pathological bleeding—discontinue ticagrelor if life-threatening bleeding occurs. 3

Perioperative Management

• Stop ticagrelor at least 5 days before elective surgery to allow adequate platelet function recovery. 3, 2
• Never discontinue DAPT within the first 30 days after stent placement for elective non-cardiac surgery—the thrombotic risk is highest in the first month and premature cessation dramatically increases stent thrombosis, MI, and death. 1, 3

Common Pitfalls to Avoid

• Never use aspirin doses >100 mg daily with ticagrelor—this is explicitly warned against in FDA labeling and reduces ticagrelor's efficacy. 1, 3, 7
• Never discontinue DAPT prematurely, especially within the first month post-stent—this markedly increases stent thrombosis risk. 1, 3
• Never omit a PPI when prescribing DAPT—this simple intervention significantly reduces GI bleeding. 1, 3
• Never delay the loading dose—ticagrelor should be given immediately upon ACS diagnosis, before any invasive procedure. 1, 3
• Never assume ticagrelor requires dose adjustment for age, weight, or renal function—standard dosing applies across these populations (unlike prasugrel). 1