Administration Matters: Successful Management of Ticagrelor Resistance Challenges in a High-Risk Patient

Q: What are the key findings of this study?

Crushed ticagrelor 180 mg via G-tube and pre-dose metoclopramide 5 mg reduced P2Y12 reaction units from 231 to 140 PRU (goal <180 PRU) in a patient with initial ticagrelor nonresponse.

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Ticagrelor nonresponse in a patient with vertebral artery dissection and pseudoaneurysm (n=1). Intervention: Crushed ticagrelor plus metoclopramide vs. Whole tablet ticagrelor and cangrelor infusion. Primary outcome: VerifyNow P2Y12 reaction units (PRU) with goal <180 PRU.

Q: What does this research mean for the field?

Apparent ticagrelor resistance can be successfully overcome by administering crushed tablets alongside a prokinetic agent like metoclopramide to improve absorption. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To describe the evaluation and successful pharmacotherapeutic management of apparent ticagrelor resistance in a high-risk neurointerventional patient.

Ashley Schuler; Connie H. Yoon; Anna Sahlstrom Drury; Nirav A. Vora

doi:10.21203/rs.3.rs-11039449/v1

October 1, 2026Open Access

Administration Matters: Successful Management of Ticagrelor Resistance Challenges in a High-Risk Patient

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Key result

Crushed ticagrelor with metoclopramide lowers PRU from 231 to 140, overcoming initial nonresponse.

n=1

Why the study?

Does crushing ticagrelor tablets and co-administering metoclopramide improve platelet inhibition (PRU <180) in a patient with dysphagia, PEG tube, and apparent ticagrelor nonresponse undergoing vertebral artery flow diversion embolization?

Key Points

To describe the evaluation and successful pharmacotherapeutic management of apparent ticagrelor resistance in a high-risk neurointerventional patient.
Case report of a 33-year-old woman undergoing planned left vertebral artery flow diversion embolization requiring dual antiplatelet therapy.
Platelet reactivity was evaluated using VerifyNow PRU testing before and after re-loading doses and during altered administration strategies.
Pre-procedural steady-state testing resulted at 179 PRU (goal <180 PRU), and a 180 mg ticagrelor re-load increased levels to 231 PRU, requiring temporary cangrelor infusion for nonresponse.
Oral administration of crushed ticagrelor tablets successfully improved drug absorption and led to a significant reduction in PRU levels.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does crushing ticagrelor tablets and co-administering metoclopramide improve platelet inhibition (PRU <180) in a patient with dysphagia, PEG tube, and apparent ticagrelor nonresponse undergoing vertebral artery flow diversion embolization?

P

Population

1 33-year-old South Asian female with dysphagia, PEG tube, recent medullary stroke, and vertebral artery dissection with pseudoaneurysm undergoing flow diversion embolization.

I

Intervention

Crushed ticagrelor 180 mg loading dose and aspirin 81 mg administered via G-tube, followed by maintenance crushed ticagrelor 90 mg administered orally with oral metoclopramide 5 mg given 30 minutes prior to ticagrelor doses (after inadequate platelet inhibition with whole-tablet oral ticagrelor and intravenous cangrelor infusion titrated up to 1.7 mcg/kg/min).

O

Outcome

Platelet reactivity measured by VerifyNow P2Y12 reaction units (PRU) with a therapeutic goal of <180 PRU.surrogate

Main Result

Absolute Event Rate: 140% vs 231%

This case demonstrates that apparent ticagrelor nonresponse in high-risk neuroendovascular patients with dysphagia or feeding tubes may be due to impaired absorption and can be successfully overcome by crushing ticagrelor tablets and co-administering metoclopramide.

Limitations

Single patient case report
CYP2C19 allele testing was unavailable

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Implication

May overcome ticagrelor nonresponse via G-tube; leaves open generalizability and clinical outcomes.

Abstract

We present the case of a 33-year-old South Asian woman with immune thrombocytopenia during pregnancy, recent right medullary stroke secondary to vertebral artery dissection complicated by dysphagia requiring percutaneous endoscopic gastrostomy (PEG) tube placement, and a new left vertebral artery dissection with pseudoaneurysm formation. She presented for planned left vertebral artery flow diversion embolization of the pseudoaneurysm. She was initiated on aspirin and P2Y12 inhibition with ticagrelor two weeks prior to the procedure and reported adherence with regimen. A steady-state VerifyNow PRU (P 2 Y 12 reaction units) Test obtained before the procedure resulted at 179 PRU (goal <180 PRU), prompting re-loading with ticagrelor 180 mg. The post-load level resulted at 231 PRU, and the patient was subsequently started on a cangrelor infusion due to concern for ticagrelor nonresponse.

Discussion

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Cite This Study

Schuler et al. (2026) conducted a case report in Ticagrelor nonresponse in a patient with vertebral artery dissection and pseudoaneurysm (n=1). Crushed ticagrelor plus metoclopramide vs. Whole tablet ticagrelor and cangrelor infusion was evaluated on VerifyNow P2Y12 reaction units (PRU) with goal <180 PRU. Crushed ticagrelor 180 mg via G-tube and pre-dose metoclopramide 5 mg reduced P2Y12 reaction units from 231 to 140 PRU (goal <180 PRU) in a patient with initial ticagrelor nonresponse.

synapsesocial.com/papers/6ae28f4acbadf70daf6c44d3 https://doi.org/10.21203/rs.3.rs-11039449/v1

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Administration Matters: Successful Management of Ticagrelor Resistance Challenges in a High-Risk Patient

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Administration Matters: Successful Management of Ticagrelor Resistance Challenges in a High-Risk Patient

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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