P2Y12 INHIBITORS
- Thienopyridines
- Clopidogrel (Plavix®)
- Prasugrel (Effient®)
- Ticlopidine (Ticlid®)
- Other
- Mechanism of action
- Platelets form blood clots when activated
- ADP (adenosine diphosphate) is a chemical released by activated platelets in response to inflammation
- ADP stimulates "P2Y12 receptors" on the surface of other platelets which causes them to become activated and join in the clotting process
- P2Y12 inhibitors block P2Y12 stimulation by ADP and inhibit platelet activation
- Clopidogrel, prasugrel, and ticlopidine irreversibly inhibit P2Y12 receptors, and ticagrelor is a reversible inhibitor
- Clopidogrel (Plavix®)
- Acute Coronary Syndrome (ACS)
- Plavix is indicated to reduce the rate of myocardial infarction and stroke (MI) in patients with non-ST-segment elevation ACS [unstable angina (UA)/non-ST-elevation myocardial
infarction (NSTEMI)], including patients who are to be managed medically and those who are to be managed with coronary revascularization.
Plavix should be administered in conjunction with aspirin.
- Plavix is indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically.
Plavix should be administered in conjunction with aspirin.
- Recent MI, Recent Stroke, or Established Peripheral Arterial Disease - In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI)
or recent stroke, Plavix is indicated to reduce the rate of MI and stroke.
- Prasugrel (Effient®)
- Acute Coronary Syndrome (ACS) - to reduce the rate of thrombotic cardiovascular events (including stent thrombosis) in patients
with ACS who are to be managed with percutaneous coronary intervention
- Ticagrelor (Brilinta®)
- Acute coronary syndrome or a history of myocardial infarction - to reduce the rate of cardiovascular death, myocardial infarction, and stroke. Ticagrelor also
reduces the rate of stent thrombosis in patients who have been stented for treatment of ACS.
- Ticlopidine (Ticlid®)
- Stroke and TIA - to reduce the risk of thrombotic stroke (fatal or nonfatal) in patients who have experienced stroke precursors,
and in patients who have had a completed thrombotic stroke
- Acute coronary syndrome - as adjunctive therapy with aspirin to reduce the incidence of subacute stent thrombosis in patients
undergoing successful coronary stent implantation
Acute coronary syndrome
- Patients who present to the ER with an acute heart attack will typically undergo one of four therapies:
- Percutaneous Coronary Intervention (PCI) with possible angioplasty and stent placement
- Fibrinolytic therapy (tPA, urokinase, streptokinase)
- Coronary Artery Bypass Grafting
- Medical therapy
- A number of large studies, substudies, and post-hoc analyses have looked at the use of P2Y12 inhibitors in patients who have suffered a heart attack
- The studies have a dizzying array of designs and outcome measures
- In general, studies have found P2Y12 inhibitors to be beneficial in the treatment of an acute heart attack
- There have been two recent head-to-head trials that have compared the newer drugs (prasugrel and ticagrelor) to clopidogrel
- Those two studies are detailed below followed by the AHA recommendations for P2Y12 inhibitor use in acute heart attack
- TRITON TIMI 38 Trial - Clopidogrel vs Prasugrel, NEJM (2007) [PubMed abstract]
- The TRITON TIMI 38 trial enrolled 13,608 patients with an acute coronary syndrome who were scheduled for PCI
- Main inclusion criteria: acute coronary syndrome (unstable angina or myocardial infarction); scheduled for PCI
- Main exclusion criteria: increased risk of bleeding; anemia; thrombocytopenia; history of pathologic intracranial findings
- Baseline characteristics: median age 61 years; unstable angina or NSTEMI - 74%, STEMI - 26%; index procedure, PCI - 99%, CABG - 1%; BMS only - 48%, DES - 47%
- Patients were randomized to 1 of 2 groups:
- Group 1 (6813 patients) - Prasugrel 60 mg loading dose followed by 10 mg once daily
- Group 2 (6795 patients) - Clopidogrel 300 mg loading dose followed by 75 mg once daily
- All patients also received aspirin 75 - 162 mg once daily throughout the trial
- Clopidogrel or prasugrel were given for 6 - 15 months
- Loading dose was given anytime between randomization and 1 hour after PCI
- PRIMARY OUTCOME: Composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke
- After 15 months, the following was seen:
- Primary outcome: Group 1 - 9.9%, Group 2 - 12.1% (HR 0.81, 95%CI [0.73 - 0.90], p<0.001)
- Death from cardiovascular causes: Group 1 - 2.1%, Group 2 - 2.4% (HR 0.89, 95%CI [0.70 - 1.12], p=0.31)
- Nonfatal MI: Group 1 - 7.3%, Group 2 - 9.5% (HR 0.76, 95%CI [0.67 - 0.85], p<0.001)
- Nonfatal stroke: Group 1 - 1.0%, Group 2 - 1.0% (HR 1.02, 95%CI [0.71 - 1.45], p=0.93)
- Overall mortality: Group 1 - 3.0%, Group 2 - 3.2% (HR 0.95, 95%CI [0.78 - 1.16], p=0.64)
- Non-CABG TIMI major bleeding: Group 1 - 2.4%, Group 2 - 1.8% (HR 1.32, 95%CI [1.03 - 1.68], p=0.03)
- Bleeding requiring transfusion: Group 1 - 4.0%, Group 2 - 3.0% (HR 1.34, 95%CI [1.11 - 1.63], p<0.001)
- The median duration of study drug treatment was 14.5 months
- In a post-hoc analysis, three subgroups of patients were identified that did not have a net clinical benefit with prasugrel - patients with a history of stroke or TIA, patients
≥ 75 years old, and patients weighing < 60 kg [14]
- Findings: In patients with acute coronary syndromes with scheduled percutaneous coronary intervention, prasugrel therapy was associated with significantly
reduced rates of ischemic events, including stent thrombosis, but with an increased risk of major bleeding, including fatal bleeding. Overall mortality did not differ significantly between
treatment groups.
- PLATO Trial - Clopidogrel vs Ticagrelor, NEJM (2009) [PubMed abstract]
- The PLATO trial enrolled 18,624 patients with an acute coronary syndrome
- Main inclusion criteria: acute coronary syndrome (myocardial infarction or unstable angina) starting within past 24 hours
- Main exclusion criteria: fibrinolytic therapy within past 24 hours; need for anticoagulation; increased risk of bradycardia; taking CYP3A4 strong inducer or inhibitor
- Baseline characteristics: median age 62 years; qualifying event, STEMI - 38%, NSTEMI - 42%, unstable angina - 17%; index procedure, PCI - 64%, CABG - 10%; stent type, BMS only - 42%,
DES - 18%
- Patients were randomized to 1 of 2 groups:
- Group 1 (9333 patients) - Ticagrelor 180 mg loading dose followed by 90 mg twice a day
- Group 2 (9291 patients) - Clopidogrel 300 mg loading dose followed by 75 mg once daily
- All patients also received aspirin 75 - 100 mg once daily throughout the study
- PRIMARY OUTCOME: Composite of death from cardiovascular causes, heart attack, or stroke
- After 12 months, the following was seen:
- Primary outcome: Group 1 - 9.8%, Group 2 - 11.7% (HR 0.84, 95%CI [0.77 - 0.92], p<0.001)
- Death from cardiovascular causes: Group 1 - 4.0%, Group 2 - 5.1% (HR 0.79, 95%CI [0.69 - 0.91], p=0.001)
- Myocardial infarction: Group 1 - 5.8%, Group 2 - 6.9% (HR 0.84, 95%CI [0.75 - 0.95], p=0.005)
- Stroke: Group 1 - 1.5%, Group 2 - 1.3% (HR 1.17, 95%CI [0.91 - 1.52], p=0.22)
- Overall mortality: Group 1 - 4.5%, Group 2 - 5.9% (HR 0.78, 95%CI [0.69 - 0.89], p<0.001)
- Major bleeding: Group 1 - 11.6%, Group 2 - 11.2% (HR 1.04, 95%CI [0.95 - 1.13], p=0.43)
- Bleeding requiring transfusion: Group 1 - 8.9%, Group 2 - 8.9% (HR 1.00, 95%CI [0.91 - 1.11], p=0.96)
- Dyspnea: Group 1 - 13.8%, Group 2 - 7.8% (HR 1.84, 95%CI [1.68 - 2.02], p<0.001)
- The median duration of study drug treatment was 277 days [16]
- Findings: In patients who have an acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly
reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rate of overall major bleeding but with an increase in the rate
of non-procedure-related bleeding.
- Professional Guidelines:
- The AHA guidelines for dual antiplatelet therapy (DAPT) in coronary artery disease are available at the links below
Secondary prevention of CVD
- Aspirin have been proven to be beneficial in the secondary prevention of CVD. The effects of P2Y12 inhibitors on the secondary prevention of CVD have been compared to aspirin in
several studies.
- In the CAPRIE study, aspirin was compared to clopidogrel. In the CHARISMA trial, aspirin was compared to the combination of clopidogrel and aspirin. In the PEGASUS-TIMI 54 trial,
aspirin was compared to the combination of ticagrelor and aspirin. These studies are detailed below.
- CAPRIE Trial - Clopidogrel vs Aspirin, Lancet (1996) [PubMed abstract]
- The CAPRIE trial enrolled 19,185 patients with a history of stroke, heart attack, or peripheral artery disease
- Main inclusion criteria: one of the following - recent ischemic stroke (onset ≥ 1 week and ≤ 6 months), recent heart attack (onset ≤ 35 days), history of intermittent
claudication (with ABI ≤ 0.85 or history of leg surgery for vascular disease)
- Main exclusion criteria: uncontrolled hypertension; history of bleeding or bleeding disorder; carotid endarterectomy after qualifying stroke
- Baseline characteristics: average age ∼ 62 years; patients with diabetes - 20%; qualifying criteria, stroke - 33.5%, heart attack - 33%, intermittent claudication - 33.5%
- Patients were randomized to 1 of 2 groups:
- Group 1 (9599 patients) - Clopidogrel 75 mg once daily
- Group 2 (9586 patients) - Aspirin 325 mg once daily
- PRIMARY OUTCOME: Composite of stroke, heart attack, or vascular death
- After an average follow-up of 1.91 years, the following was seen:
- Primary outcome (event rate per year): Group 1 - 5.32%/year, Group 2 - 5.83%/year (p=0.043)
- Overall mortality (event rate per year): Group 1 - 3.05%/year, Group 2 - 3.11%/year (p=0.71)
- GI bleeding: Group 1 - 1.99%, Group 2 - 2.66% (p<0.05)
- Any bleeding disorder: Group 1 - 9.27%, Group 2 - 9.28% (p>0.05) [4]
- Findings: Long-term administration of clopidogrel to patients with atherosclerotic vascular disease is more effective than aspirin in reducing the combined risk of
ischaemic stroke, myocardial infarction, or vascular death. The overall safety profile of clopidogrel is at least as good as that of medium-dose aspirin.
- CHARISMA trial - Clopidogrel + Aspirin vs Aspirin, NEJM (2006) [PubMed abstract]
- The CHARISMA trial enrolled 15,603 patients with documented CVD or multiple risk factors for CVD
- Main inclusion criteria: age ≥ 45 years; documented CVD (CAD, Stroke, TIA, PAD) or multiple risk factors for CVD (diabetes, dyslipidemia, hypertension, etc.)
- Main exclusion criteria: taking oral antithrombotics or NSAIDs on a long-term basis
- Baseline characteristics: median age 64 years; documented CVD - 78%, multiple risk factors - 21%; documented CAD - 37%, history of stroke/TIA - 28%, documented PAD - 18%
- Patients were randomized to one of two groups:
- Group 1 (7802 patients) - Clopidogrel 75 mg once daily + Aspirin 75 - 162 mg once daily
- Group 2 (7801 patients) - Placebo + Aspirin 75 - 162 mg once daily
- PRIMARY OUTCOME: Composite of myocardial infarction, stroke, or death from cardiovascular causes
- After a median follow-up of 28 months, the following was seen:
- Primary outcome: Group 1 - 6.8%, Group 2 - 7.3% (HR 0.93, 95%CI [0.83 - 1.05], p=0.22)
- Myocardial infarction (nonfatal): Group 1 - 1.9%, Group 2 - 2.0% (HR 0.94, 95%CI [0.75 - 1.18], p=0.59)
- Stroke (nonfatal): Group 1 - 1.9%, Group 2 - 2.4% (HR 0.79, 95%CI [0.64 - 0.98], p=0.03)
- Overall mortality: Group 1 - 4.8%, Group 2 - 4.8% (HR 0.99, 95%CI [0.86 - 1.14], p=0.90)
- Severe bleeding: Group 1 - 1.7%, Group 2 - 1.3% (HR 1.25, 95%CI [0.97 - 1.61], p=0.09)
- Moderate bleeding: Group 1 - 2.1%, Group 2 - 1.3% (HR 1.62, 95%CI [1.27 - 2.08], p<0.001)
- Treatment discontinuation: Group 1 - 20.4%, Group 2 - 18.2% (p<0.001)
- Findings: In this trial, there was a suggestion of benefit with clopidogrel treatment in patients with symptomatic atherothrombosis and a suggestion of harm in patients with
multiple risk factors. Overall, clopidogrel plus aspirin was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from
cardiovascular causes.
- PEGASUS-TIMI 54 Trial - Ticagrelor + Aspirin vs Aspirin alone, NEJM (2015) [PubMed abstract]
- The PEGASUS-TIMI 54 trial enrolled 21,162 patients with a history of myocardial infarction 1 - 3 years earlier
- Main inclusion criteria: myocardial infarction 1 - 3 years before enrollment; one of the following - age ≥ 65 years, diabetes requiring medication, a second prior
heart attack, multivessel CAD, or chronic renal failure (CrCl < 60 ml/min)
- Main exclusion criteria: planned use of other antiplatelet agent or anticoagulant; history of ischemic stroke or intracranial bleeding; GI bleed within previous 6 months
- Baseline characteristics: average age 65 years; qualifying event, STEMI - 53%, NSTEMI - 40%; history of PCI - 83%; multivessel disease - 60%;
median time since qualifying event - 1.7 years
- Patients were randomized to one of three groups:
- Group 1 (7050 patients) - Ticagrelor 90 mg twice a day + Aspirin 75 - 150 mg once daily
- Group 2 (7045 patients) - Ticagrelor 60 mg twice a day + Aspirin 75 - 150 mg once daily
- Group 3 (7067 patients) - Placebo + Aspirin 75 - 150 mg once daily
- PRIMARY OUTCOME: Composite of cardiovascular death, myocardial infarction, or stroke
- Patients were followed for a median of 33 months. Kaplan-Meier estimated rates at 3 years of follow-up were as follows:
- Primary outcome: Group 1 - 7.85%, Group 2 - 7.77%, Group 3 - 9.04% (HR for 1 vs 3 - 0.85, 95%CI [0.75 - 0.96], p=0.008; HR for 2 vs 3 - 0.84, 95% CI [0.74 - 0.95], p=0.004)
- Any stroke: Group 1 - 1.61%, Group 2 - 1.47%, Group 3 - 1.94% (HR for 1 vs 3 - 0.82, 95%CI [0.63 - 1.07], p=0.14; HR for 2 vs 3 - 0.75, 95% CI [0.57 - 0.98], p=0.03)
- Myocardial infarction: Group 1 - 4.40%, Group 2 - 4.53%, Group 3 - 5.25% (HR for 1 vs 3 - 0.81, 95%CI [0.69 - 0.95], p=0.01; HR for 2 vs 3 - 0.84, 95% CI [0.72 to 0.98], p=0.03)
- Overall mortality: Group 1 - 5.15%, Group 2 - 4.69%, Group 3 - 5.16% (HR for 1 vs 3 - 1.0, 95%CI [0.86 - 1.16], p=0.99; HR for 2 vs 3 - 0.89, 95% CI [0.76 - 1.04], p=0.14)
- Major TIMI bleeding events: Group 1 - 2.6%, Group 2 - 2.3%, Group 3 - 1.06% (p<0.001 for Group 1 or Group 2 vs Group 3)
- Bleeding requiring transfusion: Group 1 - 2.43%, Group 2 - 2.09%, Group 3 - 0.72% (p<0.001 for Group 1 or Group 2 vs Group 3)
- Significantly more patients in Group 1 and Group 2 discontinued treatment because of side effects than in Group 3 (Group 1 - 32%, Group 2 - 29%, Group 3 - 21%, p=<0.001 for each dose compared
to placebo) [31]
- Findings: In patients with a myocardial infarction more than 1 year previously, treatment with ticagrelor significantly reduced the risk of cardiovascular death,
myocardial infarction, or stroke and increased the risk of major bleeding.
- Professional Guidelines:
- The AHA/ACC recommend aspirin 75 - 162 mg once daily as first-line therapy in all patients with CAD who do not have a contraindication
- Treatment with clopidogrel 75 mg once daily is reasonable in patients who have a contraindication to aspirin
- Clopidogrel 75 mg once daily + aspirin 75 - 162 mg once daily "might" be reasonable in certain high-risk patients with CAD [3]
- StraightHealthcare analysis:
- Clopidogrel (Plavix®) and aspirin appear to have similar efficacy in the secondary prevention of CAD
- Patients with a contraindication to aspirin will benefit from clopidogrel
- The combination of clopidogrel and aspirin does not appear to be superior to either drug alone, and it may increase the risk of bleeding events
- In the PEGASUS-TIMI 54 study, the combination of ticagrelor and aspirin decreased cardiovascular events at the expense of more major bleeding events
Primary prevention of stroke
- Clopidogrel has been studied for the primary prevention of stroke in patients with atrial fibrillation
(see atrial fibrillation below)
- There is no indication to use P2Y12 inhibitors for the primary prevention of stroke in patients without atrial fibrillation
Secondary prevention of stroke
Atrial fibrillation
Peripheral artery disease (PAD)
- Peripheral artery disease is atherosclerotic vessel disease that affects the arteries of the legs and pelvis
- Antiplatelet therapy with either aspirin or clopidogrel is recommended in patients with PAD to help reduce the risk of MI, stroke and vascular death
- The EUCLID trial summarized below compared the effects of ticagrelor to clopidogrel in symptomatic PAD
- EUCLID trial - Clopidogrel vs Ticagrelor in Patients with Symptomatic PAD, NEJM (2017) -
[PMID 27959717]
- Design: Randomized, controlled trial (N=13,885, length= median 30 months)
- Treatment: Ticagrelor 90 mg twice daily vs Clopidogrel 75 mg once daily. Aspirin was not allowed.
- Primary outcome: First occurrence of any event in the composite of cardiovascular death, myocardial infarction,
or ischemic stroke (defined as any stroke not shown to be primarily hemorrhagic)
- Findings: In patients with symptomatic peripheral artery disease, ticagrelor was not shown to be superior to
clopidogrel for the reduction of cardiovascular events. Major bleeding occurred at similar rates among the patients in the two trial groups.
- Professional guidelines (AHA 2016):
- Antiplatelet therapy with aspirin alone (range 75–325 mg per day) or clopidogrel alone (75 mg per day) is recommended to reduce MI, stroke, and vascular death in patients with
symptomatic PAD
- In asymptomatic patients with PAD (ABI ≤ 0.90), antiplatelet therapy is reasonable to reduce the risk of MI, stroke, or vascular death
- In asymptomatic patients with borderline ABI (0.91 – 0.99), the usefulness of antiplatelet therapy to reduce the risk of MI, stroke, or vascular death is uncertain
- The effectiveness of dual-antiplatelet therapy (aspirin and clopidogrel) to reduce the risk of cardiovascular ischemic events in patients with symptomatic PAD is
not well established
- Dual-antiplatelet therapy (aspirin and clopidogrel) may be reasonable to reduce the risk of limb-related events in patients with symptomatic PAD after lower extremity revascularization [33]
- Clopidogrel (Plavix®)
- Bleeding
- The therapeutic effect of all P2Y12 inhibitors is their ability to prevent blood clotting
- By this mechanism, they will also increase the risk of unwanted bleeding
- A person's risk of bleeding on clopidogrel will depend on a number of variables including medical problems, medications, medical history, activity level, etc.
- In trials, the addition of clopidogrel to aspirin increased major bleeding events by about 1% compared to aspirin alone [12]
- Prasugrel (Effient®)
- Bleeding
- The therapeutic effect of all P2Y12 inhibitors is their ability to prevent blood clotting
- By this mechanism, they will also increase the risk of unwanted bleeding
- A person's risk of bleeding on prasugrel will depend on a number of variables including medical problems, medications, medical history, activity level, etc.
- In the TRITON TIMI 38 trial, prasugrel had a significantly higher rate of major bleeding (2.4% vs 1.8%) when compared to clopidogrel [13, 14]
- Ticagrelor (Brilinta™)
- Bleeding
- The therapeutic effect of all P2Y12 inhibitors is their ability to prevent blood clotting
- By this mechanism, they will also increase the risk of unwanted bleeding
- A person's risk of bleeding on prasugrel will depend on a number of variables including medical problems, medications, medical history, activity level, etc.
- In the PLATO trial, there was no significant difference in major bleeding events between ticagrelor and clopidogrel (11.6% vs 11.2%) [16]
- Shortness of breath (dyspnea)
- Some patients taking ticagrelor will experience shortness of breath
- Shortness of breath often resolves with continued treatment
- In the PLATO trial, 13.8% of patients on ticagrelor experienced shortness of breath compared to 7.8% taking clopidogrel [16]
- In the PEGASUS trial, 19% of patients taking ticagrelor 90 mg complained of shortness of breath compared to 6.4% of patients taking placebo [31]
- Ventricular pause
- Ventricular pause is a condition where there is a longer than normal amount of time between ventricular contractions
- Ticagrelor increases the incidence of these pauses. The effect appears to be from an undefined action on the sinoatrial node. [17]
- The effect appears to diminish after 30 days
- The pauses do not typically cause symptoms [16]
- Patients with certain heart conditions (see bradyarrhythmias below) should use caution when taking ticagrelor
- Increase in serum uric acid
- Ticagrelor causes a slight increase in uric acid levels
- In the PLATO study, uric acid levels increased by 0.6 mg/dl from baseline in the ticagrelor group (clopidogrel group increase 0.2 mg/dl)
- There was no difference in reports of gout between the two groups [15]
- Increase in serum creatinine
- Ticagrelor may cause an increase in serum creatinine levels
- In the PLATO study, 7.4% of patients had an increase of > 50% in their serum creatinine level compared to 5.9% of patients taking clopidogrel [15]
- There was no difference in renal outcomes between the two groups
- Ticlopidine (Ticlid®)
- Bleeding
- The therapeutic effect of all P2Y12 inhibitors is their ability to prevent blood clotting
- By this mechanism, they will also increase the risk of unwanted bleeding
- A person's risk of bleeding on ticlopidine will depend on a number of variables including medical problems, medications, medical history, activity level, etc.
- Neutropenia
- One of the main reasons ticlopidine is no longer widely used is because of the risk of neutropenia (decreased neutrophils in blood)
- Neutropenia may occur in 2-3% of patients taking ticlopidine
- The manufacturer recommends monitoring blood counts every 2 weeks through the first 3 months of therapy [18]
- Thrombotic Thrombocytopenic Purpura (TTP)
- Ticlopidine has been associated with TTP, a serious condition that causes a decrease in platelets
- The incidence of ticlopidine-induced TTP is unknown
- The manufacturer recommends monitoring blood counts every 2 weeks through the first 3 months of therapy [18]
- Diarrhea
- Ticlopidine may cause diarrhea (12.5% of patients on ticlopidine vs 4.5% on placebo) [18]
- Stomach upset
- Ticlopidine may cause stomach upset (7.0% of patients) [18]
- Rash
- Ticlopidine may cause a rash (5.1% of patients) [18]
- STOPPING BEFORE PROCEDURES
- Manufacturer recommendations for stopping P2Y12 inhibitors before surgery or procedures that have a high risk of bleeding:
- Clopidogrel (Plavix®) - stop for at least 5 days
- Prasugrel (Effient®) - stop for at least 7 days
- Ticagrelor (Brilinta™) - stop for at least 5 days
- NOTE: stopping therapy may increase the risk of cardiovascular events
- Professional guidelines:
- REVERSING P2Y12 INHIBITORS
- There is no proven agent that has been shown to reverse the antiplatelet effects of P2Y12 inhibitors
- Because it is biologically plausible that fresh platelets may overcome the inhibitory effect of P2Y12 inhibitors, platelet transfusions are often given to patients on P2Y12 inhibitors in emergency situations.
The efficacy of platelet transfusions in reversing the antiplatelet effects of P2Y12 inhibitors has not been validated in clinical trials.
- Clopidogrel and prasugrel irreversibly inhibit platelets, and ticagrelor is a reversible inhibitor
- Case studies and in vitro tests have suggested that the antiplatelet effects of ticagrelor may not be reversible with platelet transfusions. The ticagrelor PI states that
platelet transfusions did not reverse the antiplatelet effect of ticagrelor in healthy volunteers and is unlikely to be of clinical benefit in patients with bleeding. [15,28,29,30]
- PLATELET FUNCTION MONITORING
- The effects of P2Y12 inhibitors and aspirin on platelet reactivity can vary between individuals
- Assays are available that can measure platelet reactivity (e.g. VerifyNow®) in patients taking P2Y12 inhibitors and/or aspirin
- Theoretically, monitoring platelet reactivity and adjusting the dosage of P2Y12 inhibitors and aspirin based on the results should improve the effectiveness of antiplatelet therapy
- Two large studies have evaluated the effect of platelet function monitoring on outcomes in patients with CAD receiving coronary stents
- The ARCTIC study compared platelet function monitoring to no monitoring in patients (n=2440) undergoing coronary stenting. Patients were treated with aspirin + clopidogrel or prasugrel.
The study found no benefit of platelet function monitoring for the composite outcome of death, myocardial infarction, stent thrombosis, stroke,
or urgent revascularization at one year after stent implantation.
[PMID 23121439]
- The ANTARCTIC study compared platelet function monitoring to no monitoring in patients (n=877) aged ≥ 75 years who underwent coronary stenting for acute coronary syndrome.
Patients were treated with aspirin + clopidogrel or prasugrel. The study found no benefit of platelet function monitoring for the composite outcome of cardiovascular death,
myocardial infarction, stroke, stent thrombosis, urgent revascularization, and bleeding after one year of follow-up.
[PMID 27581531]
- SUMMARY: There is no evidence that platelet function monitoring improves outcomes in patients receiving antiplatelet therapy for coronary stents
- Clopidogrel (Plavix®)
- Active bleeding
- Known hypersensitivity
- Prasugrel (Effient®)
- Ticagrelor (Brilinta™)
- History of intracranial hemorrhage
- Active bleeding
- Known hypersensitivity
- Severe liver disease
- Ticlopidine (Ticlid®)
- Presence of a hemostatic disorder or active pathological bleeding (such as bleeding peptic ulcer or intracranial bleeding)
- Presence of hematopoietic disorders such as neutropenia and thrombocytopenia or a past history of either TTP or aplastic anemia
- Known hypersensitivity
- Severe liver disease
- KIDNEY DISEASE
- Clopidogrel (Plavix®)
- Severe kidney disease (CrCl 5 - 15 ml/min): drug effect is reduced. Manufacturer makes no specific dosage recommendation
- Moderate kidney disease (CrCl 30 - 60 ml/min): drug effect is reduced. Manufacturer makes no specific dosage recommendation [12]
- Prasugrel (Effient®)
- No dose adjustment is necessary in kidney disease [13]
- Ticagrelor (Brilinta™)
- No dose adjustment is necessary in kidney disease
- Has not been studied in dialysis patients [15]
- Ticlopidine (Ticlid®)
- Mild kidney disease (CrCl 60 - 89 ml/min): No dose adjustment necessary
- Moderate-to-severe kidney disease: Ticlopidine has not been studied extensively. Manufacturer makes no specific dosage recommendations [18]
- LIVER DISEASE
- Clopidogrel (Plavix®)
- No dosage adjustment is necessary in patients with liver disease
- NOTE: Patients with significant liver disease may be at increased risk of bleeding. See coagulopathy of liver disease. [12]
- Prasugrel (Effient®)
- No dosage adjustment is necessary in patients with mild-to-moderate liver disease (Child-Pugh Class A and B)
- Prasugrel has not been studied in patients with severe liver disease
- NOTE: Patients with significant liver disease may be at increased risk of bleeding. See coagulopathy of liver disease. [12]
- Ticagrelor (Brilinta™)
- No dosage adjustment is necessary in patients with mild liver disease
- Ticagrelor has not been studied in patients with moderate-to-severe liver disease
- Ticagrelor should not be used in severe liver disease
- NOTE: Patients with significant liver disease may be at increased risk of bleeding. See coagulopathy of liver disease. [15]
- Ticlopidine (Ticlid®)
- Ticlopidine should not be used by patients with severe liver disease
- In mild-to-moderate liver disease, drug dose may need to be adjusted
- The manufacturer makes no specific dosage recommendations [18]
- NOTE: Patients with significant liver disease may be at increased risk of bleeding. See coagulopathy of liver disease.
- HISTORY OF STROKE OR TIA (PRASUGREL)
- Prasugrel (Effient®)
- Prasugrel is contraindicated in patients with a prior history of stroke or TIA
- In the TRITON TIMI 38 trial, patients with a history of stroke or TIA had a higher rate of stroke on prasugrel when compared to clopidogrel (6.5% vs 1.2%) [13]
- GERIATRIC (PRASUGREL)
- Prasugrel (Effient®)
- Prasugrel is not recommended in patients ≥ 75 years old
- In the TRITON TIMI 38 trial, patients ≥ 75 years old had a higher risk of bleeding compared to those taking clopidogrel [13]
- LOW BODY WEIGHT (PRASUGREL)
- Prasugrel (Effient®)
- For patients weighing ≤ 60 kg (132 pounds), exposure to prasugrel's active metabolite is increased
- In the TRITON TIMI 38 trial, patients weighing ≤ 60 kg had an increased risk of bleeding
- Consider lowering the maintenance dose to 5 mg a day
- The efficacy and safety of the 5 mg dose has not been studied [13]
- BRADYARRHYTHMIAS (TICAGRELOR)
- Ticagrelor (Brilinta®)
- Ticagrelor can cause ventricular pauses (see side effects above)
- Patients with sick sinus syndrome, second or third degree AV block, or bradycardia-related syncope may be at increased risk of bradyarrhythmias when taking
ticagrelor. Use caution. [18]
- NOTE: Drug interactions presented here are NOT all-inclusive. Other interactions may exist. The interactions presented here are meant to encompass commonly
prescribed medications and/or interactions that are well-documented. Always consult your physician or pharmacist before taking medications concurrently. CLICK HERE
for more information on drug interactions.
- HIGH ALERT INTERACTIONS
- NOTE: High alert interactions are interactions that are known to be significant and occur between two medications that
are likely to be prescribed together
All P2Y12 Inhibitors
- Drugs that increase the risk of bleeding
- Other medications that inhibit coagulation may increase the risk of bleeding when taken with P2Y12 inhibitors
- In some conditions (ex. after stent placement), it may be appropriate to take P2Y12 inhibitors with these drugs
- Drugs that may increase the risk of bleeding include:
- Warfarin (Coumadin®)
- Direct thrombin inhibitors (dabigatran, Pradaxa®)
- Aspirin
- Factor Xa inhibitors (rivaroxaban, Xarelto®, apixaban, Eliquis®)
- NSAIDS (ibuprofen, naproxen, Aleve®, Celebrex®, Motrin®, etc.)
- SSRIs and SNRIs (Prozac®, Cymbalta®, Paxil®, Effexor®, Zoloft®, etc.)
- Vorapaxar (Zontivity®)
Clopidogrel (Plavix®)
- CYP2C19 Inhibitors
- CYP2C8 substrates
- The acyl-β-glucuronide metabolite of clopidogrel is a CYP2C8 strong inhibitor
- Clopidogrel may increase exposure to CYP2C8 substrates
- Bupropion (Wellbutrin®)
- Clopidogrel inhibits CYP2B6 which can lead to elevated bupropion levels (Wellbutrin®, Contrave®)
- When taken together, doses of bupropion may need to be decreased
- PPIs (Prilosec®, omeprazole, Nexium®, etc.)
- Repaglinide (Prandin®)
- Repaglinide is a sensitive CYP2C8 substrate. Clopidogrel increases repaglinide exposure by 4 - 5 fold.
- Repaglinide should not be given with clopidogrel
- If concomitant use cannot be avoided, initiate repaglinide at a dose of 0.5 mg before each meal and titrate based on blood sugars. Do not exceed 4 mg/day.
- When clopidogrel is added to repaglinide, repaglinide doses should be reduced to no more than 4 mg/day
Ticagrelor (Brilinta™)
- Strong CYP3A Inhibitors and Inducers
- Ticagrelor should not be taken with strong CYP3A4 inhibitors or inducers
- Simvastatin (Zocor®)
- Ticagrelor may cause higher blood levels of simvastatin
- The manufacturer recommends the simvastatin dose not exceed 40 mg when taken with Ticagrelor
- Lovastatin (Mevacor®)
- Ticagrelor may cause higher blood levels of lovastatin
- The manufacturer recommends the lovastatin dose not exceed 40 mg when taken with Ticagrelor
Ticlopidine (Ticlid®)
- Bupropion (Wellbutrin®)
- Ticlopidine inhibits CYP2B6 which can lead to elevated bupropion levels (Wellbutrin®, Contrave®)
- When taken together, doses of bupropion may need to be decreased
- METABOLISM AND ELIMINATION
- NOTE: Drugs can be metabolized by more than one enzyme. Drugs may be metabolized by an enzyme and inhibit/induce the enzyme at
the same time. Drug transporters (ex. p-glycoprotein) can play a role in drug metabolism. Not all drug interactions are clinically significant. Consult your physician or pharmacist
if you are taking medications together and are concerned about a possible interaction.
- Clopidogrel (Plavix®)
- Prasugrel (Effient®)
- Ticagrelor (Brilinta™)
- Ticlopidine (Ticlid®)
- OTHER
- Opiate medications - opiate agonists may slow gastric emptying and delay the absorption of P2Y12 inhibitors. Consider
parenteral antiplatelet agents in acute coronary syndrome.
- Phenytoin (Dilantin®) - Ticlopidine may raise phenytoin levels. Monitor levels when starting concurrent therapy.
- Digoxin - Ticagrelor may increase digoxin levels. Monitor levels when starting concurrent therapy.
- P2Y12 INHIBITORS + ANTICOAGULATION
- In some cases, anticoagulation and antiplatelet therapy are both indicated in the same patient. An example of this would be a patient with atrial fibrillation who has heart
stents placed. In this scenario, anticoagulation, aspirin, and a P2Y12 inhibitor are all indicated.
- Recommendations for combining anticoagulation and antiplatelet therapy are reviewed at the link below
- OVERVIEW
- Clopidogrel (Plavix®) is a prodrug which means it must be metabolized by the body before it becomes active (active metabolite)
- The enzyme that converts clopidogrel to its active metabolite is CYP2C19
- If CYP2C19 is inhibited by another drug, or if a person has weak CYP2C19 enzymes (poor metabolizer), then clopidogrel may not be metabolized extensively, and its
effectiveness may diminish
- CLOPIDOGREL AND PPIs
- A handful of widely prescribed medications, namely proton pump inhibitors (PPIs, Prilosec®, Nexium®,
etc.), inhibit CYP2C19
- PPIs are often prescribed with clopidogrel because they decrease the risk of bleeding from aspirin and/or clopidogrel
- The COGENT trial detailed below looked at the effect of taking omeprazole (Prilosec®) with clopidogrel on clinical outcomes. Omeprazole is
a moderate CYP2C19 inhibitor that is widely prescribed.
- COGENT trial - Clopidogrel + Omeprazole vs Clopidogrel alone NEJM (2010) [PubMed abstract]
- The COGENT trial enrolled 3873 patients who had an indication for 12 months of clopidogrel therapy
- Main inclusion criteria: anticipated therapy with aspirin and clopidogrel for 12 months including patients with acute coronary syndrome and/or stent placement
- Main exclusion criteria: medical need for PPI, H2 antagonist, sucralfate, or misoprostol; erosive esophagitis; previous gastric surgery; recent fibrinolysis
- Baseline characteristics: median age 68 years; positive for H. Pylori - 48%; using NSAIDs - 8.6%; cardiovascular history, PCI - 71%, ACS - 42%, MI - 29%, PAD - 12%, stroke - 7.8%;
history of GI bleed or ulcer - 4.1%
- Patients were randomized to one of two groups:
- Group 1 (1876 patients) - Omeprazole 20 mg once daily + clopidogrel 75 mg once daily
- Group 2 (1885 patients) - Placebo + clopidogrel 75 mg once daily
- All patients also received enteric coated aspirin 75 - 325 mg once daily
- COPRIMARY OUTCOMES: The primary cardiovascular endpoint was a composite of death from cardiovascular causes, nonfatal myocardial infarction, coronary
revascularization (PCI or CABG), or ischemic stroke. The primary gastrointestinal outcome was a composite of upper GI clinical events (defined as bleeding, ulcer,
pain with erosions, obstruction, or perforation)
- After a median follow-up of 106 days, the following was seen:
- Primary outcome (cardiovascular events at 180 days): Group 1 - 4.9%, Group 2 - 5.7% (HR 0.99, 95%CI [0.68 - 1.44], p=0.96)
- Primary outcome (gastrointestinal events at 180 days): Group 1 - 1.1%, Group 2 - 2.9% (HR 0.34, 95%CI [0.18 - 0.63], p<0.001)
- The trial was truncated because of loss of funding [19]
- Findings: Among patients receiving aspirin and clopidogrel, prophylactic use of a PPI reduced the rate of upper gastrointestinal bleeding. There was no apparent
cardiovascular interaction between clopidogrel and omeprazole, but our results do not rule out a clinically meaningful difference in cardiovascular events due to use of a PPI.
- StraightHealthcare analysis:
- All PPIs may inhibit CYP2C19 to some degree [22]
- The most widely studied PPI for this interaction is omeprazole (Prilosec®)
- The COGENT trial was a randomized, controlled trial designed specifically to look at the effect of taking omeprazole (Prilosec®) with clopidogrel
- The trial found no effect of omeprazole on cardiovascular outcomes, and a benefit in bleeding outcomes
- The main weakness of the trial is its short follow-up (median 106 days) because of loss of funding
- CONCLUSION: Based on the available evidence, there is no reason to avoid PPI use with clopidogrel. There is no evidence that one PPI is less
likely to interact than any other.
- CLOPIDOGREL AND POOR METABOLIZERS
- OVERVIEW
- Different forms of a gene are called alleles. Individuals and populations can vary in the alleles they carry for a gene.
- Variations in alleles that code for CYP enzymes can affect the performance of these enzymes. Some alleles may decrease the activity of
the enzyme (loss-of-function alleles), while other alleles may increase the activity.
- Studies have shown that the prevalence of CYP2C19 alleles varies by ethnicity (see below), and these variations affect the metabolic activity of the CYP2C19 enzyme. The most
common CYP2C19 loss-of-function alleles are the *2 and *3 variants. The *17 variant is a common gain-of-function allele that increases CYP2C19 activity.
- One loss-of-function allele leads to a 47% reduction in CYP2C19 activity, and two loss-of-function alleles leads to a 65% reduction
- People with one loss-of-function allele are considered "intermediate metabolizers," and people with two loss-of-function alleles are considered "poor metabolizers"
- Prevalence of at least one loss-of-function allele by ethnicity:
- Asians: 51 - 55%
- African-Americans: 33 - 40%
- Caucasians: 24 - 30%
- Mexican-Americans: 18% [22]
- Prevalence of two loss-of-function alleles by ethnicity (poor metabolizers):
- Chinese: 14%
- African-Americans: 4%
- Caucasians: 2% [12]
- STUDIES
- Post-hoc analyses from 4 trials have looked at the effect of CYP2C19 metabolizer status and its effect on outcomes in patients treated with clopidogrel
- TRITON TIMI 38 Post-hoc Analysis (2009)
- In TRITON TIMI 38 trial, patients with acute coronary syndrome who were to undergo PCI were randomized to clopidogrel or prasugrel
- In the post-hoc analysis, investigators took 1477 patients treated with clopidogrel and tested their blood to see if they were normal CYP2C19 metabolizers or poor CYP2C19 metabolizers
- Differences in the study outcomes were then compared between the two groups
- Results:
- The primary outcome in the TRITON TIMI 38 trial was a composite of death from cardiovascular causes, heart attack, or stroke
- CYP2C19 Poor metabolizers had an absolute increase in the primary outcome of 4.1% when compared to normal metabolizers (p=0.01)
- CYP2C19 Poor metabolizers had an absolute increase in stent thrombosis of 1.8% when compared to normal metabolizers (p=0.02) [20]
- CURE and ACTIVE A Post-hoc Analysis (2010)
- In the CURE trial, patients with acute coronary syndrome were randomized to clopidogrel or placebo
- In the ACTIVE A trial, patients with
atrial fibrillation were randomized to clopidogrel or placebo in addition to aspirin
- In the post-hoc analysis, investigators took a total of 5059 patients from CURE and 1156 patients from ACTIVE-A who were treated with clopidogrel and tested their
blood to see if they were normal CYP2C19 metabolizers or poor CYP2C19 metabolizers
- The study also compared patients who were "strong metabolizers" of CYP2C19 to normal and poor metabolizers
- Differences in the study outcomes were then compared between the two groups
- Results from CURE trial:
- The primary outcome in the CURE trial was a composite of death from cardiovascular causes, heart attack, or stroke
- The effect of clopidogrel in reducing the primary outcome was the same for poor metabolizers and normal metabolizers when compared to placebo
- CYP2C19 strong metabolizers derived more benefit from clopidogrel than patients who were not strong metabolizers [21]
- Results from ACTIVE A trial:
- The primary outcome in the ACTIVE-A trial was a composite of stroke, blood clot, heart attack, or vascular death
- The effect of clopidogrel in reducing the primary outcome was the same for poor metabolizers and normal metabolizers when compared to placebo
- CYP2C19 strong metabolizers did not derive more benefit from clopidogrel than patients who were not strong metabolizers [21]
- CHANCE Trial Post-hoc Analysis, JAMA (2016) [PubMed abstract]
- In the CHANCE trial, patients with a TIA or minor stroke were randomized to aspirin + clopidogrel or aspirin
only for 90 days. The primary outcome was recurrent stroke within 90 days. The study was performed in China where CYP2C19 loss-of-function alleles are more prevalent.
- In the post-hoc analysis, researchers compared outcomes between carriers (n=1726) of loss-of-function alleles and noncarriers (n=1207). Patients were considered carriers if they had ≥ 1
loss-of-function allele.
- Results:
- Primary outcome in carriers: Aspirin - 10.8%, Aspirin + clopidogrel - 9.4% (HR 0.93, 95%CI [0.69 - 1.26], p=0.64)
- Primary outcome in noncarriers: Aspirin - 12.4%, Aspirin + clopidogrel - 6.7% (HR 0.51, 95%CI [0.35 - 0.75], p<0.01)
- A significant interaction (p=0.02) was found between carrier status and the primary outcome
- Professional Guidelines:
- AHA/ACC
- The AHA/ACC issued a statement in 2010 in regards to clopidogrel and CYP2C19 metabolism (PPI use and poor metabolizers)
- The statement is mostly a review of the available evidence (much of which is contradictory), and offers no real guidance [22]
- FDA
- The FDA placed a "boxed warning" on clopidogrel stating that the effectiveness of clopidogrel is diminished in poor metabolizers. It recommends that patients be tested to determine if they
are poor metabolizers. Poor metabolizers should have their therapy adjusted. [12]
- StraightHealthcare analysis:
- Results from the studies above are conflicting. The trials differed by indication for clopidogrel along with outcome measures and duration. This makes it difficult to draw
conclusions about the effect of metabolizer status on outcomes.
- To date, no randomized controlled trial has been performed to specifically address the effect of metabolizer status on outcomes with clopidogrel
- Based on the available evidence, it is unclear if CYP2C19 metabolizer status affects outcomes with clopidogrel. Patients at high risk for loss of function alleles
(e.g. Asians, African-Americans) may want to undergo testing before taking clopidogrel.
- Clopidogrel has been available in the US since 1997. Its safety and side effects are well known.
- Prasugrel has been available in the US since 2009. Its long term effects are not well known.
- Ticagrelor has been available in the US since 2011. Its long term effects are not well known.
- Generic:
- Clopidogrel (Plavix®)
- Prasugrel (Effient®)
- Ticlopidine (Ticlid®)
- Possible generic:
| DRUG |
PATENT EXPIRES |
| Ticagrelor (Brilinta™) |
JUL 2018 |
- NOTE: Drug companies typically file multiple patents on their drugs in order to protect them from competition. The patent expiration
listed here is the date that the earliest patent on the drug expires (accounting for pediatric exclusivity). Because drug companies
use numerous techniques to extend the life of their patents, it does not necessarily mean a generic will become available
around this date.
- COST SAVINGS OPPORTUNITIES
- Clopidogrel is available as a generic and is cheaper than prasugrel and ticagrelor which do not have generics
- There are some differences between the drugs - see class differences below
- Ticlopidine is not widely prescribed anymore because of unfavorable side effects
- DIFFERENCES BETWEEN DRUGS IN CLASS
- What is PMID?
- PI = Manufacturer's Package Insert
- # PMID
1 - 23247304 AHA GL on STEMI
2 - 22800849 AHA GL on non-ST MI
3 - 23166211 AHA GL on CAD
4 - 8918275 CAPRIE
5 - 16531616 CHARISMA
6 - 15276392 MATCH
7 - 18753638 PROFESS
8 - 20966421 AHA GL on secondary stroke prevent
9 - 16765759 ACTIVE W
10 - 19336502 ACTIVE A
11 - 22858728 2012 AHA GL on A fib
12 - Clopidogrel PI
13 - Prasugrel PI
14 - 17982182 TRITON TIMI 38
15 - Ticagrelor PI
16 - 19717846 PLATO
17 - 21545948
18 - Ticlopidine PI
19 - 20925534 COGENT
20 - 19106084 TRITON POST-HOC
21 - 20979470 CURE and ACTIVE-A POST-HOC
22 - 21060077 AHA/ACC statement on CYP2C19
23 - 21182487
24 - 23991622
25 - 24177257
26 - 25037988
27 - 25399658
28 - 25641006 in vitro platelet reversibility
29 - 25564918 - Case study on ticagrelor
30 - 23609292 - platelet transfusion study
31 - 25773268 - PEGASUS-TIMI 54
32 - 24682347 - AHA 2014 A fib GL
33 - 27840332 - 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary
