April 11, 2025

Welcome to UH EMS-I’s Pharmacy Phriday. In our last installment, we reviewed the use of aspirin (ASA) within the Acute Coronary Syndrome Protocol. In this session, we will look at another oral antiplatelet medication, ticagrelor, used in a confirmed STEMI. 

When a patient has a heart attack, one of the treatment goals is to reduce clotting and the size of the infarcted area. Blood thinners are often a component of the treatment in meeting those goals. Blood thinners are quite common and are used in acute events as well as maintenance and prevention of thrombolytic events. 

Blood thinners don’t actually thin blood. They work by interfering with the natural processes that cause blood to clot, either by preventing platelets from sticking together or by slowing down the clotting process. Medicines that prevent platelet aggregation and the formation of clots, like ASA and ticagrelor, are referred to as antiplatelets. Medicines that interfere with or slow down the clotting process are called anticoagulants. An example of an anticoagulant is heparin, which we will review in our next installment.

In general, antiplatelets interfere with the binding of platelets, or the process that starts the formation of blood clots. Various antiplatelets have various pharmacologic actions, but all antiplatelet drugs inhibit platelet activation and aggregation.

UH EMS-I’s STEMI protocol reflects an approach to treatment often referred to as dual antiplatelet therapy (DAPT). This approach includes using ASA, the most common antiplatelet medication, plus ticagrelor, a P2Y12 inhibitor. Ticagrelor, our focus in this installment, blocks certain receptor sites and diminishes platelet activation by a compound in the blood clotting process called adenosine diphosphate (ADP). This approach addresses platelet inhibition from another aspect and meets the goal of the dual therapy theory.

One of the contraindications for administering ticagrelor is if the patient is currently taking an antiplatelet medication at home. Within the protocol, common antiplatelet medications have been listed for our reference. Some of the more common medications in this group include Plavix, Effient, and Ticlid. Other contraindications include bleeding, intracranial hemorrhage, liver failure, a patient greater than 80 years of age, cocaine or stimulant-induced STEMIs, or the pediatric patient. 

To avoid inappropriate administrations, a STEMI checklist is also a part of the protocol and should be reviewed before administering ticagrelor or heparin. Items included in the checklist are: 

• No sharp ripping/tearing chest or back pain. 

• No altered mental status 

• No known bleeds or concern of bleeding (i.e., GI bleeds, vomiting blood, blood in urine, etc.) 

• No trauma or CPR 

• No severe headache 

• If STEMI mimickers are present, must consult Medical Direction. 

The UH protocol allows the administration of ticagrelor orally for patients with a confirmed STEMI. When in doubt about the presence of a STEMI or any of the contraindications for the use of the medication, it is advisable to contact Medical Direction for advice.

The dosing of ticagrelor is 180 mg (two 90 mg tablets), given once, which should be chewed, and then swallowed. Literature suggests that having the patient chew the tablets may accelerate the onset of action of the antiplatelet effects of the medication.

Common side effects of ticagrelor listed include bleeding concerns as well as respiratory distress and shortness of breath. Be sure to monitor your patient for these serious side effects.

A final consideration noted in the protocols related to the administration of ticagrelor that we should highlight is the use of opiate pain medications at the same time. It is documented in numerous sources that ticagrelor’s absorption and effectiveness can be reduced when also administering an opiate for pain, primarily due to slowed gastric emptying. Co-administration of ticagrelor and fentanyl is also documented to increase the effects of the fentanyl possibly causing increased sedation and respiratory depression. For some of these reasons, the routine use of an opiate when using ticagrelor is discouraged.

Check in next week for our installment discussing the use of heparin, our anticoagulant used for STEMI patients. Till then, be safe! 

Sincerely, 

The UH EMS-I Team 

University Hospitals 

December 15, 2023

Welcome again to UH EMS-I’s Pharmacy Phriday. We hope you find this weekly CE article of value. Any comments, feedback, or suggestions are welcomed as we continue to consider how best to serve our providers. Comments may be sent to the EMS Institute or posted to the Institute’s Facebook page when these articles are posted.

In a previous installment, we reviewed the use of Aspirin (ASA) within the Acute Coronary Syndrome Protocol. In this session, we will look at another of the antiplatelet medications, Brilinta, used in a confirmed STEMI.

When a patient is having a heart attack, one of the treatment goals is to reduce clotting and the size of the infarcted area. Both antiplatelets and anticoagulants work to prevent clots in the blood vessels, but they work in different ways. Antiplatelets interfere with the binding of platelets or the process that actually starts the formation of blood clots. Anticoagulants interfere with the proteins, or factors, in the blood that are involved with the coagulation process. Different anticoagulants interfere with different factors to prevent clotting.

Aspirin is the most used antiplatelet medication administered for this purpose, but evidence supports a dual antiplatelet therapy (DAPT) that includes aspirin plus a P2Y12 inhibitor in patients suffering an acute coronary syndrome (ACS), and our UH protocol reflects that approach. The use of Brilinta blocks certain receptor sites and diminishes platelet activation by a compound in the blood clotting process called adenosine diphosphate (ADP). This approach addresses platelet inhibition from another aspect and meets the goal of the dual therapy theory. 

The use of blood thinners has become more common in the general population, and the number of antiplatelet and anticoagulant medications available and prescribed on the market has also grown. One of the contraindications for administering Brilinta is if the patient is currently taking an antiplatelet medication at home. Within the protocol, common antiplatelet medications have been listed for our reference. Some of the more common medications in this group include Plavix, Effient, and Ticlid. Other contraindications include:

• bleeding

• intracranial hemorrhage

• liver failure

• a patient greater than 80 years of age

• cocaine or stimulant-induced STEMIs

• the pediatric patient

To avoid inappropriate administrations, a STEMI checklist is also a part of the protocol to be used before administering Brilinta or Heparin. Items included in the checklist are:

• No sharp ripping/tearing chest or back pain

• No altered mental status

• No known bleeds or concern of bleeding (i.e., GI bleeds, vomiting blood, blood in urine, etc.)

• No trauma or post-arrest following CPR

• No severe headache

• If STEMI mimickers are present, you must consult medical direction

The UH protocol allows the administration of Brilinta orally for patients with a confirmed STEMI, either by the paramedic or online medical control. When in doubt about the presence of a STEMI or any of the contraindications, it is advisable to contact medical direction for advice. 

The dosing of Brilinta is 180 mg (two 90 mg tablets), given once, which should be chewed and then swallowed. Literature suggests that having the patient chew the tablets may accelerate the onset of action of the antiplatelet effects of the medication. Common side effects of Brilinta listed include bleeding concerns as well as respiratory distress and shortness of breath. Be sure to monitor your patient for these serious side effects.

A final consideration noted in the protocols related to the administration of Brilinta that we should highlight is the use of opiate pain medications at the same time.   It is documented in numerous sources that Brilinta’s absorption and effectiveness can be reduced when also administering an opiate for pain, primarily due to slowed gastric emptying. Co-administration of Brilinta and Fentanyl is also documented to increase the effects of the Fentanyl, possibly causing increased sedation and respiratory depression. For some of these reasons, the routine use of an opiate when using Brilinta is discouraged.

Be sure to check in next week for our next installment when we discuss the use of Heparin, our anticoagulant used for STEMI patients. Till then, be safe!

Sincerely,



The UH EMS-I Team

University Hospitals

October 7, 2022

Dear Colleagues,

Welcome again to UH EMS-I’s Pharmacy Phriday.  We hope you find this weekly CE article of value.  Any comments, feedback, or suggestions are welcomed as we continue to consider how best to serve our providers.  Comments may be sent to the EMS Institute or posted to the Institute’s Facebook page when these articles are posted.

In last week’s article, we reviewed the use of Aspirin (ASA) within the Acute Coronary Syndrome Protocol.  In this session, we will look at another of the antiplatelet medications used in a confirmed STEMI.

When a patient is having a heart attack, one of the treatment goals is to make the platelets in the blood more slippery with the use of platelet inhibitors, thus reducing the size of any clots as well as the size of the infarcted area.  Considering that “time is muscle,” efforts continue to improve pre-hospital treatment to meet that goal within the critical time of early symptom onset that EMS responds to on a regular basis. 

Aspirin is the most used antiplatelet medication administered for this purpose, but there is evidence that supports a dual antiplatelet therapy (DAPT) that includes aspirin plus a P2Y12 inhibitor in patients with acute coronary syndrome (ACS).  As discussed last session, ASA blocks a hormone (thromboxane) essential in the clotting process, thus inhibiting clotting.  Another essential part in the platelet activation process is the interaction of adenosine diphosphate (ADP) with the platelet’s P2Y12 receptor.  The use of Brilinta, the P2Y platelet inhibitor permitted within UH protocols, blocks the receptor sites and diminishes platelet activation induced by ADP.  This approach addresses platelet inhibition from another aspect and meets the goal of the dual therapy theory. 

The UH protocol allows the administration of Brilinta orally for patients with a confirmed STEMI that are transported to a facility that allows offline medical control.  When in doubt, contact the receiving facility prior to administration.  Dosing of Brilinta is 180 mg (two 90 mg tablets), given once, that should be chewed then swallowed.  Literature suggests that having the patient chew the tablets may accelerate the onset of action of the antiplatelet effects of the medication.

It is important to point out the indication for Brilinta is specific to a confirmed STEMI.  Be sure the patient is a STEMI patient!  Once again, if in doubt, contact medical direction.  Note the following statement from a recent study:

• Administering antiplatelet drugs when the likelihood of STEMI diagnosis is low could lead to an overtreatment of patients who will not ultimately undergo stenting, potentially exposing them to an increased bleeding risk with no potential benefit or even more deleterious consequence if, for example, urgent surgery is needed for aortic dissection.  However, pre-hospital STEMI diagnosis accuracy is now high, with false-positive diagnoses now <5%.  As a result, the net potential benefit of pre-hospital P2Y12 inhibition is considerable.  (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604087/)

Contraindications for Brilinta include bleeding, intracranial hemorrhage, liver failure, a patient greater than 80 years of age, or the pediatric patient. Also, note the warning in the algorithm related to patient use of other antiplatelet medications. Brilinta should not be used if the patient is taking any of these medications (a list of common ones is included in your protocol’s “key points” section for your quick reference). Another contraindication not yet listed in the UH protocols includes cocaine or stimulant-induced STEMIs. 

A common side effect of Brilinta listed in various literature (other than the bleeding concern as noted above) includes respiratory distress and shortness of breath. Be sure to monitor your patient for these serious side effects.

A final consideration noted in the protocols related to the administration of Brilinta that we should highlight is the use of opiate pain medications at the same time. It is documented in numerous sources that Brilinta’s absorption and effectiveness can be reduced when also administering an opiate for pain, primarily due to slowed gastric emptying. Co-administration of Brilinta and Fentanyl is also documented to increase the effects of the Fentanyl, possibly causing increased sedation and respiratory depression. 

As mentioned previously, instituting antiplatelet therapy in the early period of an MI after symptom onset provides the best opportunity for improving the outcome for the STEMI patient. Studies continue to search for best practices in this area. What is coming next? Newer agents? Other approaches? Stay tuned! UH EMS’s medical directors and protocol committee, along with the various specialists, are working hard to stay up to date in emergency care for our system.

Till next time, stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals