Ticlopidine

May cause life-threatening hematologic reactions, including neutropenia, agranulocytosis, thrombotic thrombocytopenia purpura (TTP), and aplastic anemia. Routine monitoring is required (see Monitoring Parameters). Monitor for signs and symptoms of neutropenia including WBC count. Discontinue if the absolute neutrophil count falls to 3 or if laboratory signs of TTP or aplastic anemia occur.

Because of structural similarities, cross-reactivity is possible among the thienopyridines (clopidogrel, prasugrel, and ticlopidine); use with caution or avoid in patients with previous thienopyridine hypersensitivity. Use of ticlopidine is contraindicated in patients with hypersensitivity to ticlopidine. Disease-related concerns:

Use with caution in patients with platelet disorders, bleeding disorders and/or at increased risk for bleeding (eg, PUD, trauma, or surgery).

Use with caution in patients with mild-to-moderate hepatic impairment. Use is contraindicated with severe hepatic impairment.

Use with caution in patients with moderate-to-severe renal impairment (experience is limited); bleeding times may be significantly prolonged and the risk of hematologic adverse events (eg, neutropenia) may be increased. Concurrent drug therapy issues:

Use with caution in patients receiving either anticoagulants (eg, heparin, warfarin) or other platelet aggregation inhibitors; bleeding risk is increased. Special populations:

An individualized and multidisciplinary approach should be utilized to determine therapy discontinuation and management in patients with acute lower GI bleed (LGIB) who are on antiplatelet medications; risk of ongoing bleeding should be weighed with risk of thromboembolic events. In patients receiving dual antiplatelet therapy (aspirin plus P2Y12 receptor blocker [eg, clopidogrel, prasugrel, ticagrelor, ticlopidine]) or thienopyridine monotherapy, the thienopyridine should generally be resumed as soon as possible and at least within 7 days, taking into account control of bleeding and cardiovascular risk (aspirin should not be discontinued); however, dual antiplatelet therapy should not be discontinued in the 90 days post-acute coronary syndrome or 30 days post-coronary stenting (Strate 2016). Other warnings/precautions:

In patients who have received bare-metal or drug-eluting stents (sirolimus or paclitaxel), premature interruption of antiplatelet therapy may result in stent thrombosis with subsequent fatal and nonfatal myocardial infarction. If ticlopidine is used, duration of therapy, in general, is determined by the type of stent placed (bare metal or drug eluting) and whether an ACS event was ongoing at the time of placement (Levine, 2011).

Consider discontinuing 10 to 14 days before elective surgery (except in patients with cardiac stents that have not completed their full course of dual antiplatelet therapy; patient-specific situations need to be discussed with cardiologist; AHA/ACC/SCAI/ACS/ADA Science Advisory provides recommendations).