Prasugrel (Effient) is a potent (more so than clopidogrel) P2Y12 platelet inhibitor commonly used in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). It helps prevent platelet aggregation and reduces the risk of recurrent cardiovascular events, including stent thrombosis. Here are three important prasugrel clinical practice pearls to remember when using this medication.

1. Avoid prasugrel in patients with a history of stroke or TIA

Prasugrel is contraindicated in patients with a history of stroke or transient ischemic attack (TIA). There is a boxed warning for this concern, and you should absolutely know this for your board exam! Clinical trials demonstrated an increased risk of bleeding, including intracranial hemorrhage, in these patients. This is an especially important medication reconciliation consideration when evaluating patients being discharged after an acute coronary syndrome or coronary stent placement.

2. Be cautious in patients 75 years and older

Prasugrel is generally not recommended in patients 75 years and older because of an increased risk of fatal and intracranial bleeding. There are exceptions where clinicians may consider prasugrel, such as patients with diabetes or a history of myocardial infarction, when the potential benefits outweigh the risks. The Beers Criteria recommends using this medication with caution in older adults. If prasugrel is used in this population, a lower 5 mg daily maintenance dose may be considered.

3. Body weight below 60 kg increases bleeding risk

Patients weighing less than 60 kg have an increased risk of bleeding with prasugrel. The usual maintenance dose is 10 mg once daily, but a reduced maintenance dose of 5 mg once daily should be considered in patients weighing less than 60 kg. This is particularly important in smaller, older adults where bleeding risk may already be elevated. Always verify the patient’s weight before finalizing the maintenance dose.

Looking for more info on prasugrel? Check out this podcast episode.

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