Platelet Inhibition with Ticagrelor

Introduction to Ticagrelor Dosing

The American College of Cardiology recommends a standard loading dose of ticagrelor as 180 mg, not 90 mg, for achieving potent and prompt platelet inhibition 1, 2, 3, 4
A 90 mg dose of ticagrelor represents the maintenance dose given twice daily after the initial loading dose, achieving peak platelet inhibition approximately 2 hours after administration 1, 2, 3

Peak inhibitory effect with a 90 mg maintenance dose of ticagrelor occurs approximately 2 hours after administration, with levels of inhibition exceeding those obtained with clopidogrel loading doses 1
Ticagrelor achieves platelet inhibition within 30 minutes that exceeds levels obtained with 300-600 mg clopidogrel loading doses, producing potent and consistent platelet inhibition with significantly less variability compared to clopidogrel 1, 2

Ticagrelor is a reversible P2Y12 inhibitor with a plasma half-life of approximately 12 hours, requiring twice-daily dosing, and allowing for faster platelet function recovery after discontinuation compared to clopidogrel 3
It is recommended to wait at least 5 days after the last dose of ticagrelor before surgery to allow adequate recovery of platelet function 2, 3, 5

The aspirin dose used with ticagrelor should not exceed 100 mg daily, as higher aspirin doses may reduce ticagrelor's efficacy, according to the Journal of the American College of Cardiology 4
Ticagrelor causes dyspnea in 10-15% of patients, typically within the first week of treatment, and is a P-gp inhibitor that can increase levels of concomitant medications like dabigatran 3, 5, 6

The American College of Chest Physicians recommends ticagrelor 90 mg twice daily plus low-dose aspirin 75-100 mg daily for acute coronary syndromes without PCI, preferred over clopidogrel plus aspirin 7
The European Heart Society recommends ticagrelor 90 mg twice daily plus low-dose aspirin for ACS with PCI and stent placement, with preference over clopidogrel plus aspirin 7
The duration of dual antiplatelet therapy is 12 months unless contraindications such as excessive bleeding risk exist, as recommended by the European Heart Society 8
For extended treatment beyond 12 months, the European Heart Society suggests considering prolonged treatment in patients with high thrombotic risk and without increased risk for major bleeding, with a 60 mg twice daily dose approved for this indication 8

The American Heart Association recommends that the aspirin dose used with ticagrelor should not exceed 100 mg daily, with 81 mg being the preferred maintenance dose 7, 9

The American Heart Association recommends clopidogrel over ticagrelor in most patients with atrial fibrillation undergoing PCI who require concomitant oral anticoagulation due to lower bleeding risk, but ticagrelor may be reasonable in patients at high ischemic/thrombotic and low bleeding risks 9

The European Heart Society suggests considering a de-escalation strategy from ticagrelor to clopidogrel as an alternative treatment regimen in NSTE-ACS patients, with a loading dose of 600 mg clopidogrel administered after ticagrelor is discontinued, followed by 75 mg daily maintenance 8