Periprocedural Management of Antithrombotic Therapy – Adult - Inpatient/Ambulatory Consensus Care Guideline Appendix B. Considerations for Antiplatelet Bridging With Cangrelor National Guidelines4 CHEST Guidelines 2022: Perioperative Management of Antithrombotic Therapy Guidance Statement 39: “In patients with coronary stents who require interruption of antiplatelet drugs for an elective surgery/procedure, we suggest against routine bridging therapy with a glycoprotein IIb-IIIa inhibitor, cangrelor, or LMWH over routine use of bridging therapy (Conditional recommendation, low certainty of evidence) Guideline implementation considerations: • A bridging approach may be considered in selected high-risk patients, for example in those with a recent (within 3 months) coronary stent in a critical location.” Cangrelor Drug Information Mechanism of Action Cangrelor is a reversible ultra-shorting-acting direct P2Y12 inhibitor Time to Peak Within 2 minutes Half-Life of Elimination ~ 3 to 6 minutes Bridging Therapy Dose (Off-Label Use)4,8,9 • Routine use not suggested • Consult UW Health Interventional Cardiology prior to initiating cangrelor as bridging therapy • UW Health restricts cangrelor use to high-risk patients with cardiac stents placed in the previous 6 to 12 months who require surgical intervention with interruption in thienopyridine therapy • Continue low dose ASA throughout • Prior to the procedure: o Start cangrelor 48 to 72 hours after oral P2Y12 inhibitor discontinuation¥ o Dose = 0.75 mg/kg/minute IV continuous infusion o STOP cangrelor 1 to 3 hours prior to the procedure¥ • 1 to 6 hours after the procedure, when adequate hemostasis is achieved: o Can the patient take oral medications? ▪ If Yes → restart oral P2Y12 inhibitor including an oral loading dose • Clopidogrel preferred over prasugrel or ticagrelor due to lower bleeding risk ▪ If No → restart cangrelor infusion and continue for a minimum of 48 hours and maximum of 7 days total • When able to tolerate oral medications, STOP cangrelor immediately prior to restarting oral P2Y12 inhibitor including an oral loading dose o Clopidogrel preferred over prasugrel or ticagrelor due to lower bleeding risk ¥ UW Health-specific recommendation, based on institutional standards and/or expert opinion of guideline workgroup members References: 4. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;doi:10.1016/j.chest.2022.07.025 8. Rossini R, Masiero G, Fruttero C, et al. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH Open. 2020;04(04):e437-e445. doi:10.1055/s-0040-1721504 9. Angiolillo DJ, Rollini F, Storey RF, et al. International Expert Consensus on Switching Platelet P2Y ₁₂ Receptor– Inhibiting Therapies. Circulation. 2017;136(20):1955-1975. doi:10.1161/circulationaha.117.031164 Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 02/2023 Effective 2/17/2023. Contact CCKM@uwhealth.org for previous versions