Ticagrelor vs prasugrel one-month maintenance therapy: Impact on platelet reactivity and bleeding events

Abstract

Platelet reactivity (PR) and bleeding events following therapy with ticagrelor vs prasugrel have not been adequately studied. We aimed to compare PR and bleeding events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) while on ticagrelor vs prasugrel for one month. Consecutive patients who were discharged either on ticagrelor 90 mg bid maintenance dose (MD) or prasugrel 10 mg MD were invited for PR assessment (VerifyNow, in PRU) at one month. High PR (HPR) was defined as >208 PRU. Bleeding events [Bleeding Academic Research Consortium (BARC) classification] were monitored. Out of 937 screened patients, 512 were analysed, 278 under ticagrelor MD and 234 under prasugrel MD. PR at 30 days (C-statistic of the propensity score model 0.63, 0.58-0.67 95% CI, p<0.001) was lower when on ticagrelor compared with prasugrel (33.3, 95% CI 29.3-37.3 vs 84.6, 95% CI 73.6-95.6, p<0.001). In the analysed population more BARC type 1 bleeding events were observed with ticagrelor compared to prasugrel (36.7% vs 28.2%, p=0.047). In 221 propensity score matched pairs, BARC type 1 bleeding rate was marginally higher in ticagrelor vs prasugrel treated patients (35.7% vs 27.1%, p=0.05). BARC type ≥2 events did not differ between groups 5 (2.3%) vs 5 (2.3%). HPR rate was higher for prasugrel-treated patients (5.4% vs 0%, p<0.001). In conclusion, in patients with ACS undergoing PCI, ticagrelor MD produces a significantly higher platelet inhibition compared to prasugrel MD. This pharmacodynamic difference might be associated with more nuisance bleeding events with ticagrelor use.

One-Year Post-Discharge Resource Utilization and Treatment Patterns of Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention and Treated with Ticagrelor or Prasugrel

“…Bleeding utilization results from this study align with evidence from these indirect comparisons and other studies suggesting no significant difference in non-CABG-associated bleeding between ticagrelor and prasugrel [8,[30][31][32]. Besides bleeding, the other major side effect of ticagrelor is dyspnea [6], which did not differ between prasugrel and clopidogrel in the TRITON-TIMI 38 trial [5].…”

Diabetes mellitus and platelet reactivity in patients under prasugrel or ticagrelor treatment: an observational study

“…All patients participated in an ongoing study of platelet function testing for prediction of bleeding events (Clinical Trials Gov. NCT01774955), while part of PR data have been previously reported [ 19 ]. Platelet function testing was performed using the VerifyNow (Accumetrics Inc., San Diego, CA, USA) P2Y 12 function assay, measured in P2Y12 reaction units (PRU).…”

“…DM was not reported among factors affecting PR under prasugrel in some, though not in all studies, while prasugrel pharmacokinetics was not influenced by DM status in TRITON-TIMI 38 [ 16 – 20 ]. Moreover, in patients under ticagrelor therapy, DM was not among factors influencing PR [ 19 , 21 ]. Furthermore, the impact of insulin therapy on PR in DM patients treated with novel P2Y 12 receptors blockers has not been previously analyzed.…”

A Prospective, Randomized, Open-Label, Blinded, Endpoint Study Exploring Platelet Response to Half-Dose Prasugrel and Ticagrelor in Patients with the Acute Coronary Syndrome: HOPE-TAILOR Study

“…Thus, authors indicated that a lower dose strategy was appropriate for antiplatelet management in Japanese patients with acute/stable coronary disease undergoing percutaneous coronary intervention [25,26]. In contrast to prasugrel, ticagrelor, a nonthienopyridine, direct-acting P2Y 12 receptor antagonist, had significantly greater platelet inhibition and more bleeding events than prasugrel during chronic MD therapy [27,28]. Recently, a comparison of two 2 ticagrelor doses on antiplatelet potency assessed by VerifyNow in Chinese NSTE-ACS patients showed that half-dose therapy was noninferior to standard-dose therapy regarding the inhibition of platelet aggregation (84 vs. 86%) after 5 days of treatment [29].…”