Recommendation 22. For patients receiving prasugrel who are experiencing significant side effects (excluding bleeding) or who are unable to tolerate the drug (and for whom ticagrelor is not an option), we suggest de-escalating to clopidogrel directly at 75 mg daily (without a loading dose) at the time of the next scheduled prasugrel dose (Weak Recommendation; Moderate-Quality Evidence).

Values and preferences. The suggested strategies are formulated on the basis of a systematic review of the literature evaluating pharmacodynamic evidence for optimal platelet inhibition, balanced with an absence of significant bleeding complications. Studies in which patients were identified as nonresponders using platelet function testing before randomization were excluded because of generalizability concerns.