Summary
Clopidogrel monopoly as an exclusive oral antiplatelet agent used in combination with
aspirin or as a monotherapy for treatment or/and prevention of occlusive thrombotic
vascular events has been recently challenged. Based on the indirect comparison of
TRITON and PLATO trial data, ticagrelor is clearly superior to prasugrel in a population
of patients with acute coronary syndrome (ACS) because of absolute mortality reduction,
realistic second myocardial infarction (MI) prevention, growing over time vascular
outcome benefit, fewer haemorrhagic fatalities, potentially less coronary artery bypass
graft (CABG)- related bleeding events, and lack of cancer risks. Despite an unfavourable
immediate safety profile, ticagrelor has a lot of room to compensate for agitation,
dyspnea, and ventricular pauses, if used in appropriate patients. It will be naïve
and wrong to assume that ticagrelor will completely substitute clopidogrel, especially
considering higher discontinu-ation rates after ticagrelor, generic competition, and
other health economics issues. However, unless the regulatory authorities discover
some unexpected serious flaws with PLATO, the ticagrelor will substantially change
the present landscape of oral antiplatelet therapy, especially in high-risk patients,
diabetics, and those with repeated vascular events including stent thrombosis. In
contrast, a too exclusive trial design, a lack of persistent vascular benefit despite
issues with event adjudication, growing-over-time bleeding complications, an issue
with cancer, and finally an increase in mortality risk among unstable angina and non
ST-elevated myocardial infarction will likely prevent a broad prasugrel implementation,
unless more reassuring evidence becomes available.
Keywords
Prasugrel - ticagrelor - clopidogrel - clinical trials - outcomes
