Bedside Snapshot

Use It For: ACS with PCI (ticagrelor or prasugrel preferred over clopidogrel); ACS managed medically (ticagrelor); acute ischemic stroke or high-risk TIA (ticagrelor only)
Adult Dose: Ticagrelor, ACS: 180 mg PO load, then 90 mg BID (60 mg BID after year 1)
Prasugrel, ACS with PCI: 60 mg PO load, then 10 mg daily (5 mg if under 60 kg)
Ticagrelor, stroke/TIA: 180 mg load, then 90 mg BID up to 30 days
Pediatric Dose: Not established in children: specialist/medical-control use only
Onset / Duration: Ticagrelor PO: maximal platelet inhibition about 2 hr; reversible, near baseline by about 5 days. Prasugrel PO: active metabolite peaks about 30 min; irreversible for the platelet lifespan
Do Not Give / Hold If: Active pathological bleeding; prior intracranial hemorrhage (ticagrelor); prior TIA or stroke (prasugrel); urgent CABG (start); hypersensitivity
Watch For: Bleeding (fatal bleeding is boxed); dyspnea (ticagrelor, usually mild and self-limiting); ventricular pauses or bradyarrhythmia (ticagrelor)
Reversal / Rescue: No specific reversal. Control the bleed; the two labels disagree on platelet transfusion (see Overdose & Toxicity Management)
Must Remember: Prasugrel is contraindicated after any prior TIA or stroke. Do not stop either drug early without cardiology input: stent thrombosis and MI risk rise

Indications

Emergency & Prehospital

ACS with PCI (NSTE-ACS or STEMI with primary or delayed PCI): ticagrelor or prasugrel is preferred over clopidogrel per 2025 ACC/AHA guidance. Both labels cover ACS managed with PCI.
ACS managed medically (no PCI): ticagrelor is labeled for ACS or prior MI, with or without revascularization. Prasugrel is labeled only for ACS managed with PCI.
Acute ischemic stroke (NIHSS ≤5) or high-risk TIA: ticagrelor with aspirin is the label indication, not for patients who were thrombolysed. Prasugrel is contraindicated.

ED / ICU / Transport

Bridging into PCI in a patient who has not had a P2Y12 inhibitor: IV cangrelor is a different drug. See Pharmacology and Interactions.
STEMI with fibrinolysis: not the usual US choice. US guidance endorses clopidogrel with fibrinolytics (see the clopidogrel page). ESC 2023 also names clopidogrel with aspirin after lytics. It finds insufficient evidence for ticagrelor or prasugrel with thrombolytics.
ACS or PCI in a patient who needs an oral anticoagulant: clopidogrel is generally preferred. See the clopidogrel page.

Other Uses

Coronary artery disease without prior MI or stroke (high risk): ticagrelor 60 mg BID with aspirin, to reduce MI, stroke and death (label). Efficacy was established in type 2 diabetes.
Single antiplatelet therapy after PCI: the label advises considering ticagrelor alone, based on the evolving thrombotic versus bleeding risk.

Dosing & Administration

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

Ticagrelor (Brilinta) tablets: 90 mg (yellow, round) and 60 mg (pink, round), film-coated
Prasugrel (Effient) tablets: 10 mg (beige) and 5 mg (yellow), film-coated, elongated hexagonal

Adult Dosing

Indication	Dose & Route	Repeat / Max	Notes
ACS with PCI: ticagrelor	Ticagrelor 180 mg PO load, then 90 mg PO BID	Load once; 90 mg BID for the first year, then 60 mg BID	First 90 mg dose 6–12 hr after the load. Maintenance aspirin 75–100 mg daily. Crushed tablets in water or via NG tube (CH8 or larger) are acceptable. ESC 2023: default DAPT with a potent P2Y12 inhibitor is generally 12 months; no de-escalation in the first 30 days, and it may be considered after 30 days. Choice of agent and duration per cardiology
ACS with PCI: prasugrel	Prasugrel 60 mg PO load, then 10 mg PO daily	Load once; max 10 mg/day	Consider 5 mg daily if under 60 kg (label: efficacy and safety of the 5 mg dose not prospectively studied). Generally not recommended at age 75 or older, except diabetes or prior MI. Aspirin 75–325 mg daily. In NSTE-ACS, load after coronary anatomy is known. Never give with a second oral P2Y12 inhibitor
ACS managed medically (no PCI): ticagrelor	Ticagrelor 180 mg PO load, then 90 mg PO BID	Load once; 90 mg BID first year, then 60 mg BID	Same dosing as the PCI row. Prasugrel is not labeled without PCI. Upstream loading before angiography: ESC 2023 does not recommend routine pre-angiography P2Y12 loading when angiography is planned within 24 hr; cardiology decides
CAD without prior MI or stroke (high risk): ticagrelor	Ticagrelor 60 mg PO BID	Max 120 mg/day	With aspirin 75–100 mg daily (label). Start per cardiology
Acute ischemic stroke or high-risk TIA: ticagrelor	Ticagrelor 180 mg PO load, then 90 mg PO BID; aspirin 300–325 mg load, then 75–100 mg daily	Up to 30 days of ticagrelor; max 90 mg BID	NIHSS ≤5 or high-risk TIA only. Not recommended in patients with NIHSS >5 or who received thrombolysis (the THALES exclusions)
Any prior TIA or stroke: prasugrel	Contraindicated	Do not start	Stop prasugrel if a stroke or TIA occurs on therapy (label). Use ticagrelor or clopidogrel per cardiology and neurology

Pediatric Dosing

Not established in children: neither label establishes safety or effectiveness in children. Do not use outside specialist direction.

Indication	Dose (per kg) & Route	Max Single / Max Total	Notes
All indications	Not established in children	—	Specialist use only (pediatric cardiology or hematology). The ticagrelor trial in sickle cell disease (ages 2 to under 18) did not show benefit; prasugrel missed its primary objective in the same population

Preparation & Administration

Route: oral only. Neither drug has an IV preparation.
Crushing: ticagrelor tablets may be crushed, mixed in water and given by mouth or nasogastric tube (CH8 or larger). Exposure does not drop. Prasugrel tablets should not be broken.
Food: either drug can go down with or without food (label).
Missed dose: ticagrelor: take the next dose at the scheduled time (label)
Single P2Y12 agent only: one at a time. Never pair ticagrelor or prasugrel with another oral P2Y12 inhibitor.

Dosing Notes:

Ticagrelor 180 mg can be given during or right after a cangrelor infusion (cangrelor label transition)
Prasugrel 60 mg goes in the moment a cangrelor infusion stops. Clopidogrel 600 mg goes in at the same point.
Ticagrelor and prasugrel loads in fibrinolysis, PCI timing and age-based choices depend on protocol. Confirm them with the cath lab or cardiology.

Contraindications & Precautions

Contraindications

Ticagrelor: history of intracranial hemorrhage; active pathological bleeding (such as peptic ulcer or ICH); hypersensitivity to ticagrelor or any component
Prasugrel: active pathological bleeding; prior TIA or stroke (any time); hypersensitivity to prasugrel or any component
Both: do not start in patients who need urgent CABG. This is a boxed warning, not a formal contraindication.

Precautions

Surgery: when possible, stop ticagrelor 5 days and prasugrel at least 7 days before major-bleeding-risk surgery. Restart the moment hemostasis allows.
Age 75 or older: prasugrel is generally not recommended, because of fatal and intracranial bleeding. The exception is diabetes or prior MI. Ticagrelor has no age-specific dose change. At least 15% of its trial population was 75 or older (label).
Body weight under 60 kg (prasugrel): higher exposure and more bleeding risk. Consider 5 mg maintenance (label).
Bleeding co-factors: warfarin, heparin, fibrinolytics and chronic NSAIDs add to the bleeding risk.
Severe hepatic impairment (ticagrelor): avoid it. Exposure is likely to rise (label).
Moderate to severe renal impairment (prasugrel): listed as a bleeding risk factor. No dose change (label).
Conduction disease (ticagrelor): trials excluded patients with sick sinus syndrome, second- or third-degree AV block, or bradycardia-related syncope who were not protected by a pacemaker.

Hold / Reassess If

Active bleeding. Manage the bleed without stopping if you can. If stopping is unavoidable, restart as soon as possible (both labels).
Ventricular pauses, new AV block or symptomatic bradycardia on ticagrelor. Get a 12-lead ECG and a cardiology review before any change.
New, prolonged or intolerable dyspnea on ticagrelor. Evaluate for ischemia, heart failure and pulmonary embolism first. If the drug is stopped, consider another antiplatelet (label).
Suspected central sleep apnea or Cheyne-Stokes breathing on ticagrelor. Assess clinically (label).
Low platelets with anemia, neurologic change or renal injury. Stop, and evaluate for TTP (both labels).

FDA Boxed Warning: The boxed warning is about bleeding. Do not use with active pathological bleeding or a history of ICH (ticagrelor), or TIA or stroke (prasugrel). Do not start in urgent CABG. Stopping early raises the risk of cardiovascular events, so manage the bleed without stopping if you can. Prasugrel is generally not recommended at age 75 or older. Under 60 kg, it carries added risk.

Adverse Effects & Toxicity

Common

Bleeding: the most common serious effect. Ticagrelor major non-CABG bleeding 3.9% vs 3.3% with clopidogrel (PLATO). Prasugrel CABG-related major or minor bleeding 14.1% vs 4.5% with clopidogrel (TRITON-TIMI 38)
Dyspnea (ticagrelor): about 14% (PLATO, PEGASUS) to 21% (THEMIS). Usually mild to moderate and self-limiting. Under 1% of PLATO patients quit the drug.
Ventricular pauses (ticagrelor): reported. Monitor the ECG.

Serious / Life-Threatening

Effect	Recognition	Management
Major or fatal bleeding	GI bleeding, hematuria, puncture-site or retroperitoneal bleeding, falling Hgb, hypotension (suspect bleeding after any recent angiography, PCI or surgery)	Manage bleeding without stopping if possible; transfuse per protocol; notify cardiology
Intracranial hemorrhage	Headache, vomiting, new deficit, falling GCS	Emergent CT; neurosurgery; stop per neurology and cardiology
TTP (rare)	Low platelets, schistocytes, neurologic change, renal injury, fever; can follow a brief exposure (under 2 weeks)	Stop; urgent hematology; plasma exchange
Hypersensitivity, including angioedema	Lip or tongue swelling, urticaria, wheeze, hypotension	Stop; treat as anaphylaxis per protocol
Bradyarrhythmia or ventricular pause (ticagrelor)	Bradycardia, pauses, AV block, syncope	12-lead ECG; support per ACLS; cardiology review
Central sleep apnea (ticagrelor)	Cheyne-Stokes pattern, recurrent apneas on sleep study or telemetry	Clinical assessment; sleep medicine referral

Overdose & Toxicity Management

Signs: bleeding is the expected pharmacologic effect. Ticagrelor may also cause GI upset or ventricular pauses.
Ticagrelor: no known reversal. It is not dialyzable. The label says platelet transfusion did not reverse the effect in healthy volunteers, and it is unlikely to help bleeding. Monitor the ECG.
Prasugrel: the label says platelet transfusion may restore clotting ability. Transfusions given within 6 hr of the load or 4 hr of a maintenance dose may be less effective. Per the label, dialysis is not likely to remove the active metabolite.
Platelet transfusion: the two labels disagree. Use blood bank, cardiology and neurocritical protocols. See the blood products page
Tranexamic acid: does not reverse platelet inhibition. Use it for its usual indications.

Monitoring

Parameter	When / How Often	Target / Act If
Clinical: bleeding	Every assessment; after procedures and sheath removal	New bleeding, falling BP or rising HR: manage the source, notify cardiology, STAT CBC
Clinical: neuro checks	Every assessment; after falls or head injury	New deficit or severe headache: emergent head CT
Cardiac rhythm (ticagrelor)	Per cardiology; 12-lead ECG if bradycardia or a pause is seen	Pause or symptomatic bradycardia: 12-lead ECG and hold decision with cardiology
Dyspnea (ticagrelor)	Each assessment after starting or increasing the dose	New or worse dyspnea: evaluate ischemia, heart failure and PE before attributing it to the drug
Laboratory: Hgb and platelets	Baseline; with bleeding; if TTP is suspected (CBC)	Falling Hgb: find the source. Falling platelets with anemia or neurologic change: smear and hematology
Medication review	Admission, handoff and each new order	New CYP3A inhibitor or inducer, opioid, statin dose or digoxin: review per the Interactions table
Procedure timing	Before surgery, neuraxial block or invasive procedure	Record last dose: ticagrelor 5 days and prasugrel 7 days before major-bleeding-risk surgery when possible

Interactions & Compatibility

Clinically Significant Interactions

Drug / Class	Effect	What To Do
Strong CYP3A inhibitors (ticagrelor): ketoconazole, itraconazole, voriconazole, clarithromycin, ritonavir and similar	Higher ticagrelor exposure; more dyspnea and bleeding	Avoid (label). Moderate CYP3A inhibitors such as diltiazem have lesser effects; the label does not call for a dose change
Strong CYP3A inducers (ticagrelor): rifampin, phenytoin, carbamazepine, phenobarbital	Lower ticagrelor exposure; reduced platelet inhibition	Avoid (label); choose another antiplatelet with cardiology
Opioids: morphine, fentanyl	Delayed and reduced absorption of either P2Y12 agent (slowed gastric emptying)	In ACS needing opioids, consider a parenteral antiplatelet agent; give the oral load as early as safe
Aspirin above 100 mg/day (ticagrelor)	Label advises avoiding higher doses; trial results favored 100 mg or less	Keep maintenance aspirin at 75–100 mg daily
Simvastatin or lovastatin above 40 mg/day (ticagrelor)	Higher statin exposure; statin adverse effects	Avoid doses above 40 mg/day
Digoxin (ticagrelor)	Ticagrelor inhibits P-glycoprotein; digoxin levels may rise	Monitor digoxin levels when ticagrelor is started or changed
Heparin, enoxaparin, warfarin, fibrinolytics, chronic NSAIDs	Additive bleeding	Expected in ACS and PCI; keep combined therapy as short as possible; evaluate any blood loss promptly
Other oral P2Y12 inhibitors (clopidogrel)	Duplicate P2Y12 blockade; additive bleeding	Do not give with ticagrelor or prasugrel (label). Switching agents needs a cardiology plan
Cangrelor (IV P2Y12 inhibitor)	Clopidogrel or prasugrel given during the infusion has no effect until the next dose	Give prasugrel 60 mg or clopidogrel 600 mg immediately after cangrelor stops; ticagrelor 180 mg can be given during or right after the infusion

Oral tablets only. No IV compatibility issues apply to ticagrelor or prasugrel. Verify any combination with an institutional compatibility resource.

Special Populations

Pediatrics: not established for either drug. Specialist use only. See the Pediatric Dosing table.
Neonates: no data exist. Not established.
Pregnancy: ticagrelor case reports have not identified a drug-associated risk of major birth defects or miscarriage. Animal developmental effects occurred only at high exposures. Prasugrel has no data in pregnant women. Weigh bleeding risk against thrombotic risk. Both raise bleeding risk at delivery.
Lactation: ticagrelor: breastfeeding is not recommended (label). Prasugrel: there are no human milk data. Metabolites were found in rat milk, so weigh the benefits of breastfeeding against the mother's need.
Older Adults: prasugrel is generally not recommended at 75 or older, except in diabetes or prior MI. Ticagrelor has no age-specific adjustment. Bleeding rises with age.
Renal Impairment: ticagrelor: no dose adjustment. Prasugrel: no dose adjustment. Moderate to severe impairment is a bleeding risk factor, and ESRD patients have limited data. Ticagrelor is not dialyzable. The prasugrel active metabolite is not likely to be removed by dialysis (labels).
Hepatic Impairment: ticagrelor: avoid in severe impairment. Prasugrel: no adjustment in mild to moderate impairment. Severe impairment is a bleeding risk factor (label).
Obesity / Dosing Weight: ticagrelor: fixed dose. Prasugrel: 5 mg maintenance if under 60 kg (label).

Field & Transport Considerations

Scope: prehospital loading with ticagrelor or prasugrel is protocol-dependent. It varies by state and agency protocol. Many systems do not carry either agent. The usual ED or cath lab order is the reference.
Storage & Stability: tablets stored at 25°C (77°F), excursions 15–30°C (59–86°F) (both labels). Keep in the original container
Carried Concentration: not applicable, these are oral tablets. The mix-up risk is real. Ticagrelor 60 mg vs 90 mg, prasugrel 5 mg vs 10 mg, and a 75 mg clopidogrel tablet can sit on the same shelf.
Infusions in Transport: not applicable for either drug. If the patient is on IV cangrelor, follow the cangrelor transition rules in the Interactions table
Altitude / Environment: neither label gives specific guidance.
Assessment on Ticagrelor: dyspnea is common and usually mild. It can mimic or mask worsening ischemia or heart failure, so record onset and severity. Pauses or bradycardia on the monitor warrant a 12-lead ECG.
Handoff Essentials: agent and dose, time of the load, aspirin dose and time, time of the last dose, planned PCI or CABG timing, and any bleeding or neurologic change

Clinical Pearls

Exam Discriminator, Which P2Y12 Inhibitor:

ACS heading to PCI: ticagrelor or prasugrel over clopidogrel (US guidance). ESC 2023 prefers prasugrel.
Prior TIA or stroke: never prasugrel
With fibrinolysis for STEMI: clopidogrel (US guidance)
Also on an oral anticoagulant? Clopidogrel is generally preferred.
In the cath lab and need IV P2Y12 inhibition: cangrelor

Load Early, Watch the Morphine: IV morphine and other opioids slow absorption of both oral agents. Here's the catch: the opioid delays the pill you need. In ACS, if you need an opioid, consider a parenteral antiplatelet agent. Do not hold the oral load for the opioid alone.

Surgery Timing: Urgent CABG? Do not start either drug. Planned surgery? Hold ticagrelor 5 days and prasugrel 7 days when possible.

Platelet Transfusion, Two Labels: Ticagrelor's label reports no reversal in volunteers. Prasugrel's label says transfusion may restore clotting, if given within 6 hr of the load or 4 hr of a maintenance dose. Neither drug has a reversal agent.

Dyspnea Is Common on Ticagrelor: Usually mild and self-limiting. Rule out ischemia, heart failure and pulmonary embolism before you blame the drug for new dyspnea.

Tablet Handling Trap: You can crush ticagrelor for an NG tube. Prasugrel tablets must not be broken. Check the product first.

Pharmacology

Mechanism of Action

Ticagrelor: binds the platelet P2Y12 ADP receptor directly and reversibly. The active drug and its major metabolite are about equipotent.
Prasugrel: a prodrug. Its active metabolite binds the P2Y12 receptor irreversibly. Inhibition lasts for the life of the platelet.
Clinical consequence: less ADP-driven platelet activation and aggregation. That reduces stent thrombosis and recurrent ischemic events.

Pharmacokinetics

Route	Onset	Peak	Duration
Ticagrelor PO (180 mg load)	Maximal platelet inhibition about 2 hr after the load	Parent drug about 1.5 hr; active metabolite about 2.5 hr	Reversible; near placebo by about 5 days
Prasugrel PO (60 mg load)	Active metabolite peaks about 30 min after dosing	About 30 min (active metabolite)	Irreversible; lasts for the platelet lifespan

Half-life: ticagrelor about 7 hr; ticagrelor active metabolite about 9 hr. Prasugrel active metabolite about 7 hr (range 2–15 hr)
Metabolism: ticagrelor is metabolized by CYP3A4, its major metabolizing enzyme. Prasugrel converts quickly to its active metabolite.
Elimination: ticagrelor is mainly cleared by the liver. Radiolabeled recovery was about 58% in feces and 26% in urine.
Protein binding: ticagrelor above 99%; prasugrel active metabolite about 98%

Names & Classification

Generic Names: Ticagrelor; prasugrel hydrochloride
Brand Names: Brilinta (ticagrelor); Effient (prasugrel); multiple generics
Pharmacologic Class: P2Y12 ADP-receptor inhibitors: ticagrelor is a reversible direct antagonist; prasugrel is a thienopyridine prodrug with an irreversible active metabolite
Therapeutic Class: Oral antiplatelet agents
Controlled Substance: Not controlled
ISMP High-Alert: No (not confirmed against the current ISMP list in this review; verify)
Look-Alike / Sound-Alike: None commonly reported

References

AstraZeneca Pharmaceuticals LP. (2026). Brilinta (ticagrelor) tablets: Prescribing information. DailyMed, U.S. National Library of Medicine (label revised May 2026). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f7b3f443-e83d-4bf2-0e96-023448fed9a8
Cosette Pharmaceuticals, Inc. (2022). Effient (prasugrel) tablets: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=69ea2d58-5353-4222-b61f-cab976fa7e5e
Chiesi USA, Inc. (2025). Kengreal (cangrelor) for injection: Prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=88b434fa-8891-4fd5-9d86-7ea64667c08f
Rao, S. V., O'Donoghue, M. L., Ruel, M., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes. Circulation, 151. https://doi.org/10.1161/CIR.0000000000001309
Byrne, R. A., Rossello, X., Coughlan, J. J., et al. (2023). 2023 ESC guidelines for the management of acute coronary syndromes. European Heart Journal, 44(38), 3720–3826. https://doi.org/10.1093/eurheartj/ehad191
Johnston, S. C., Amarenco, P., Denison, H., et al. (2020). Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA (THALES). New England Journal of Medicine, 383, 207–217. https://doi.org/10.1056/NEJMoa1916870
Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., et al. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke, 57(8). https://doi.org/10.1161/STR.0000000000000513
Maynard, S., Bye, A. P., & Desborough, M. J. R. (2026). Can drug-induced platelet dysfunction be reversed? Research and Practice in Thrombosis and Haemostasis, 10, 103286. https://doi.org/10.1016/j.rpth.2025.103286

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