Risk of GI Bleeding with Brilinta (Ticagrelor)

Bleeding Risk Profile

The American Heart Association notes that ticagrelor increases the risk of gastrointestinal bleeding, particularly when used in combination with aspirin as dual antiplatelet therapy, with a 2-3 fold increased risk compared to aspirin alone 1, 2
The absolute risk increase for GI bleeding with dual antiplatelet therapy (ticagrelor plus aspirin) compared to aspirin alone is approximately 0.6% to 2.0% 2
Case fatality rates for GI bleeding associated with dual antiplatelet therapy are relatively low (0% to 0.3%), but GI bleeding remains a significant predictor of death with a relative risk of 2.5 2

A history of bleeding or other complications of peptic ulcer disease is the strongest risk factor for GI bleeding in patients taking ticagrelor, according to the American College of Cardiology 1, 2
Advanced age significantly increases the absolute risk of GI bleeding in patients taking ticagrelor, as noted by the European Society of Cardiology 4, 1
Concurrent use of anticoagulants, steroids, or NSAIDs increases the risk of GI bleeding in patients taking ticagrelor, as reported by the European Heart Journal 4, 1
Helicobacter pylori infection is a risk factor for GI bleeding in patients taking ticagrelor, according to the American Heart Association 1

The American College of Cardiology recommends proton pump inhibitors (PPIs) to reduce GI bleeding risk in high-risk patients taking ticagrelor 1, 3
PPIs are more effective than histamine H2 receptor antagonists (H2RAs) in preventing upper GI bleeding in patients on antiplatelet therapy, as noted by the American Heart Association 3
Routine use of either a PPI or an H2RA is not recommended for patients at lower risk of upper GI bleeding, according to the American College of Cardiology 5

For high-risk patients, the European Society of Cardiology recommends adding PPI prophylaxis and considering testing for and treating H. pylori infection 1, 3
The American College of Cardiology suggests avoiding concomitant use of NSAIDs when possible in high-risk patients taking ticagrelor 4
For patients requiring endoscopic procedures, the American College of Cardiology recommends considering timing of procedures relative to ticagrelor initiation and temporarily discontinuing ticagrelor if clinically appropriate 6, 7