Prasugrel is indicated in-

• Unstable angina
• Non ST-elevation Myocardial infarction
• Patients with ST-elevation myocardial infarction (STEMI) when managed with either primary or delayed PCI

Angina

Myocardial Infarction

• Initiate treatment with a single 60 mg oral loading dose
• Continue at 10 mg once daily with or without food.  Consider 5 mg once daily for patients < 60 kg
• Patients should also take aspirin (75 mg to 325 mg) daily 

Side effects of prasugrel include-

• Bleeding, including life-threatening and fatal bleeding
• Thrombotic thrombocytopenic purpura

Bleeding

Purpura

• Prasugrel can cause significant, sometimes fatal, bleeding.
• Do not use Prasugrel in patients with active pathological bleeding or a history of transient ischemic attack or stroke.
• In patients ≥ 75 years of age, Prasugrel is generally not recommended, because of the increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior MI) where its effect appears to be greater and its use may be considered.
• Do not start Prasugrel in patients likely to undergo urgent coronary artery bypass graft surgery (CABG).  When possible, discontinue Prasugrel at least 7 days prior to any surgery. Additional risk factors for bleeding include:
  • body weight < 60 kg
  • propensity to bleed
  • concomitant use of medications that increase the risk of bleeding (e.g., warfarin, heparin, fibrinolytic therapy, chronic use of non-steroidal anti-inflammatory drugs [NSAIDS])
• Suspect bleeding in any patient who is hypotensive and has recently undergone coronary angiography, percutaneous coronary intervention (PCI), CABG, or other surgical procedures in the setting of Prasugrel. If possible, manage bleeding without discontinuing Prasugrel.  Discontinuing Prasugrel, particularly in the first few weeks after acute coronary syndrome, increases the risk of subsequent cardiovascular events.
• Discontinuation of Prasugrel: Premature discontinuation increases risk of stent thrombosis, MI, and death.
• Thrombotic thrombocytopenic purpura (TTP): TTP has been reported with Prasugrel.