Treatment
Table 3. Additional Therapeutic Considerations for
Prasugrel and Ticagrelor
Prasugrel
• Patients weighing <60 kg have an increased exposure to the active metabolite of
prasugrel and an increased risk of bleeding on a 10-mg once-daily maintenance
dose. Consideration should be given to lowering the maintenance dose to 5 mg in
patients who weigh <60 kg, although the effectiveness and safety of the 5-mg dose
have not been studied prospectively.
• For post-PCI patients, a daily maintenance dose should be given for at least
12 months for patients receiving a drug-eluting stent (DES) and up to 12 months
for patients receiving a bare-metal stent (BMS) unless the risk of bleeding
outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor.
• Do not use prasugrel in patients with active pathological bleeding or a history of
TIA or stroke.
• In patients age ≥75 years, prasugrel is generally not recommended because of the
increased risk of fatal and intracranial bleeding and uncertain benefit except in
high-risk situations (patients with diabetes or a history of prior MI), in which its
effect appears to be greater and its use may be considered.
• Additional risk factors for bleeding include body weight <60 kg, propensity to
bleed, and concomitant use of medications that increase the risk of bleeding (eg,
warfarin, heparin, fibrinolytic therapy, or chronic use of NSAIDs).
• Do not start prasugrel in patients likely to undergo urgent CABG.
• When possible, discontinue prasugrel at least 7 days before any surgery.
Ticagrelor
• The recommended maintenance dose of ASA to be used with ticagrelor is 81 mg daily.
• The benefits of ticagrelor were observed irrespective of prior therapy with clopidogrel.
• When possible, discontinue ticagrelor at least 5 days before any surgery.
• Issues of patient compliance may be especially important.
• Consideration should be given to the potential and as yet undetermined risk of
intracranial hemorrhage (ICH) in patients with prior stroke or TIA.
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