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Intravenous P2Y12 ADP Receptor Antagonist (Direct-Acting, Reversible) Pregnancy: Avoid — no human data; animal studies show fetal harm.

Cangrelor (IV P2Y12 Inhibitor — Acute PCI)

Brand names: Kengrexal

Adult dose

Dose: 30 mcg/kg IV bolus before PCI, then 4 mcg/kg/min IV infusion for at least 2 hours or duration of PCI (whichever is longer)
Route: IV bolus then infusion
Frequency: Single PCI course
Max: Infusion rate 4 mcg/kg/min; maximum infusion duration 4 hours
Only IV P2Y12 inhibitor — onset within 2 minutes, fully reversible within 60 minutes of stopping infusion. Critical use case: bridge antiplatelet therapy when oral P2Y12 not yet effective (loading takes 1–2+ hours for clopidogrel; 30 min for ticagrelor). Transition to oral P2Y12 immediately after infusion ends — do NOT use clopidogrel during infusion (competitive binding reduces efficacy).

Paediatric dose

Route:
Not licensed in paediatrics.

Dose adjustments

Renal

No dose adjustment required — not renally cleared.

Hepatic

No dose adjustment required.

Clinical pearls

  • CHAMPION PHOENIX trial (Bhatt et al. NEJM 2013): cangrelor vs clopidogrel 600 mg at time of PCI — 22% relative reduction in primary endpoint (death/MI/ischaemia-driven revascularisation/stent thrombosis) at 48h; no significant increase in severe bleeding
  • Bridging use: the primary niche for cangrelor is procedural bridging in patients on oral anticoagulants undergoing urgent PCI who have not received adequate oral P2Y12 loading, or CABG patients being bridged off thienopyridines. The 60-minute washout to restore platelet function is critical for managing urgent surgical bleeding
  • Transition protocol: administer ticagrelor 180 mg OR prasugrel 60 mg at any time during cangrelor infusion, OR clopidogrel 300–600 mg immediately after infusion ends — do NOT give clopidogrel during infusion as it loses efficacy

Contraindications

  • Active significant bleeding
  • Hypersensitivity to cangrelor
  • Intent to use thienopyridine (clopidogrel, prasugrel) during infusion — competitive receptor binding; administer only after infusion ends

Side effects

  • Bleeding (major: 0.2%; minor: 4.6% — CHAMPION PHOENIX)
  • Dyspnoea (adenosine-like effect — brief, usually resolves spontaneously)
  • Hypotension (during initial bolus)

Interactions

  • Clopidogrel/prasugrel (do NOT co-administer — cangrelor occupies P2Y12 receptors, blocking thienopyridine active metabolite from binding; give oral P2Y12 only after infusion ends)
  • Ticagrelor and prasugrel (can be administered during or after cangrelor — different binding mechanism for ticagrelor is less affected; prasugrel can be given after infusion stops)

Monitoring

  • Platelet aggregation (VerifyNow P2Y12 if available — confirms antiplatelet effect)
  • Bleeding signs at PCI access site and systemically
  • BP and HR (haemodynamic monitoring during bolus)

Reference: BNFc; BNF 90; CHAMPION PHOENIX (Bhatt et al. NEJM 2013); ESC PCI Guidelines 2023; MHRA SPC Kengrexal. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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