Antiplatelet drug: Difference between revisions
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**[[Cangrelor]] | **[[Cangrelor]] | ||
**[[Ticagrelor]] | **[[Ticagrelor]] | ||
==Are third-generation agents better than second-generation agents?== | |||
=== Studies of all patients=== | |||
The ALPHEUS [[randomized controlled trial]] found no benefit of [[ticagrelor]] versus [[clopidogrel]] among stable coronary patients undergoing high-risk elective PCI (primary outcome in 35% vs 36% of patients)<ref name="pmid33202219">{{cite journal| author=Silvain J, Lattuca B, Beygui F, Rangé G, Motovska Z, Dillinger JG | display-authors=etal| title=Ticagrelor versus clopidogrel in elective percutaneous coronary intervention (ALPHEUS): a randomised, open-label, phase 3b trial. | journal=Lancet | year= 2020 | volume= 396 | issue= 10264 | pages= 1737-1744 | pmid=33202219 | doi=10.1016/S0140-6736(20)32236-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33202219 }} </ref>. | |||
The POPular AGE [[randomized controlled trial]] found no benefit of [[ticagrelor]] versus [[clopidogrel]] among patients aged 70 years or older with non-ST-elevation acute coronary syndrome (MACE in 11% vs 12% of patients)<ref name="pmid32334703">{{cite journal| author=Gimbel M, Qaderdan K, Willemsen L, Hermanides R, Bergmeijer T, de Vrey E | display-authors=etal| title=Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. | journal=Lancet | year= 2020 | volume= 395 | issue= 10233 | pages= 1374-1381 | pmid=32334703 | doi=10.1016/S0140-6736(20)30325-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32334703 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=32926825 Review in: Ann Intern Med. 2020 Sep 15;173(6):JC28] </ref> | |||
===Studies of patients with CYP2C19 loss-of-function ==== | |||
The CHANCE-2 [[randomized controlled trial]] found benefit of [[ticagrelor]] versus [[clopidogrel]] (primary outcome: 6% vs 7.6%; hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.94; P = 0.008) among Chinese patients with minor ischemic stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function alleles<ref name="pmid34708996">{{cite journal| author=Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC | display-authors=etal| title=Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. | journal=N Engl J Med | year= 2021 | volume= 385 | issue= 27 | pages= 2520-2530 | pmid=34708996 | doi=10.1056/NEJMoa2111749 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34708996 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=35226525 Review in: Ann Intern Med. 2022 Mar;175(3):JC30] </ref>. | |||
== Is there a best third-generation antiplatelet drug?== | |||
The ISAR-REACT 5 [[randomized controlled trial]] found benefit of [[prasugrel]] versus [[ticagrelor]] (primary outcome: 6.9% vs 9.3%; hazard ratio, 1.36; 95% confidence interval, 1.09 to 1.70; P = 0.006) among patients with "acute coronary syndromes and for whom invasive evaluation was planned"<ref name="pmid34708996">{{cite journal| author=Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC | display-authors=etal| title=Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. | journal=N Engl J Med | year= 2021 | volume= 385 | issue= 27 | pages= 2520-2530 | pmid=34708996 | doi=10.1056/NEJMoa2111749 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34708996 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=35226525 Review in: Ann Intern Med. 2022 Mar;175(3):JC30] </ref>. | |||
==Should drug selection be driven by genetic testing and platelet function testing?== | ==Should drug selection be driven by genetic testing and platelet function testing?== | ||
Guided therapy (drug choice based on genetic testing and platelet function testing may improve outcomes<ref name="pmid33865495">{{cite journal| author=Galli M, Benenati S, Capodanno D, Franchi F, Rollini F, D'Amario D | display-authors=etal| title=Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. | journal=Lancet | year= 2021 | volume= 397 | issue= 10283 | pages= 1470-1483 | pmid=33865495 | doi=10.1016/S0140-6736(21)00533-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33865495 }} </ref>. | Guided therapy (drug choice based on genetic testing and platelet function testing may improve outcomes according to a [[systematic reveiw]]<ref name="pmid33865495">{{cite journal| author=Galli M, Benenati S, Capodanno D, Franchi F, Rollini F, D'Amario D | display-authors=etal| title=Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. | journal=Lancet | year= 2021 | volume= 397 | issue= 10283 | pages= 1470-1483 | pmid=33865495 | doi=10.1016/S0140-6736(21)00533-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33865495 }} </ref>. | ||
However, the key POPular Genetics [[randomized controlled trial]] found no benefit from a CYP2C19 guided therapy (primary outcome: 5.1 vs 5.9%;P = 0.44) among patients undergoing primary PCI with stent implantation<ref name="pmid31479209">{{cite journal| author=Claassens DMF, Vos GJA, Bergmeijer TO, Hermanides RS, van 't Hof AWJ, van der Harst P | display-authors=etal| title=A Genotype-Guided Strategy for Oral P2Y12 Inhibitors in Primary PCI. | journal=N Engl J Med | year= 2019 | volume= 381 | issue= 17 | pages= 1621-1631 | pmid=31479209 | doi=10.1056/NEJMoa1907096 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31479209 }} </ref>. | |||
==See also== | ==See also== | ||
Revision as of 21:41, 13 August 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
An antiplatelet drug is a member of a class of pharmaceuticals that decreases platelet aggregation and inhibits thrombus formation. They are effective in the arterial circulation, where anticoagulants have little effect.
They are widely used in primary and secondary prevention of thrombotic cerebrovascular or cardiovascular disease.
The Most Important Antiplatelet Drugs
- COX-2 inhibitor / Cyclooxygenase inhibitors
- Phosphodiesterase inhibitors
- Cilostazol (Pletal)
- Glycoprotein IIB/IIIA inhibitors (intravenous use only)
- Abciximab (ReoPro)
- Eptifibatide (Integrilin)
- Tirofiban (Aggrastat)
- Defibrotide
- P2Y12 (Adenosine diphosphate receptors) inhibitors (thienopyridines)
- Clopidogrel (Plavix)
- Ticlopidine (Ticlid)
- P2Y12 (Adenosine diphosphate receptors) inhibitors (non-thienopyridines) - third generation
Are third-generation agents better than second-generation agents?
Studies of all patients
The ALPHEUS randomized controlled trial found no benefit of ticagrelor versus clopidogrel among stable coronary patients undergoing high-risk elective PCI (primary outcome in 35% vs 36% of patients)[1].
The POPular AGE randomized controlled trial found no benefit of ticagrelor versus clopidogrel among patients aged 70 years or older with non-ST-elevation acute coronary syndrome (MACE in 11% vs 12% of patients)[2]
Studies of patients with CYP2C19 loss-of-function =
The CHANCE-2 randomized controlled trial found benefit of ticagrelor versus clopidogrel (primary outcome: 6% vs 7.6%; hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.94; P = 0.008) among Chinese patients with minor ischemic stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function alleles[3].
Is there a best third-generation antiplatelet drug?
The ISAR-REACT 5 randomized controlled trial found benefit of prasugrel versus ticagrelor (primary outcome: 6.9% vs 9.3%; hazard ratio, 1.36; 95% confidence interval, 1.09 to 1.70; P = 0.006) among patients with "acute coronary syndromes and for whom invasive evaluation was planned"[3].
Should drug selection be driven by genetic testing and platelet function testing?
Guided therapy (drug choice based on genetic testing and platelet function testing may improve outcomes according to a systematic reveiw[4].
However, the key POPular Genetics randomized controlled trial found no benefit from a CYP2C19 guided therapy (primary outcome: 5.1 vs 5.9%;P = 0.44) among patients undergoing primary PCI with stent implantation[5].
See also
External links
References
- ↑ Silvain J, Lattuca B, Beygui F, Rangé G, Motovska Z, Dillinger JG; et al. (2020). "Ticagrelor versus clopidogrel in elective percutaneous coronary intervention (ALPHEUS): a randomised, open-label, phase 3b trial". Lancet. 396 (10264): 1737–1744. doi:10.1016/S0140-6736(20)32236-4. PMID 33202219 Check
|pmid=value (help). - ↑ Gimbel M, Qaderdan K, Willemsen L, Hermanides R, Bergmeijer T, de Vrey E; et al. (2020). "Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial". Lancet. 395 (10233): 1374–1381. doi:10.1016/S0140-6736(20)30325-1. PMID 32334703 Check
|pmid=value (help). Review in: Ann Intern Med. 2020 Sep 15;173(6):JC28 - ↑ 3.0 3.1 Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC; et al. (2021). "Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA". N Engl J Med. 385 (27): 2520–2530. doi:10.1056/NEJMoa2111749. PMID 34708996 Check
|pmid=value (help). Review in: Ann Intern Med. 2022 Mar;175(3):JC30 - ↑ Galli M, Benenati S, Capodanno D, Franchi F, Rollini F, D'Amario D; et al. (2021). "Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis". Lancet. 397 (10283): 1470–1483. doi:10.1016/S0140-6736(21)00533-X. PMID 33865495 Check
|pmid=value (help). - ↑ Claassens DMF, Vos GJA, Bergmeijer TO, Hermanides RS, van 't Hof AWJ, van der Harst P; et al. (2019). "A Genotype-Guided Strategy for Oral P2Y12 Inhibitors in Primary PCI". N Engl J Med. 381 (17): 1621–1631. doi:10.1056/NEJMoa1907096. PMID 31479209.