How to manage prasugrel and ticagrelor in daily practice

• New antiplatelet agents are more potent than clopidogrel.
• Attention must be paid to drug interactions with new antiplatelet agents.
• Ticagrelor should be stopped 5 days before an invasive procedure.
• Prasugrel should be stopped 7 days before an invasive procedure.
• Prasugrel or ticagrelor should not be associated with oral anticoagulants.

Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.