¿Es clopidogrel superior a Ticagrelor en sindrome coronaria agudo?

Ticagrelor tiene varios beneficios teóricos sobre clopidogrel : es reversible

inhibidor de plaquetas, el metabolismo hepático no es necesario para la activación (poco  intraindividual variabilidad en la respuesta), inicia acción mas rapida y más rápida.

The new anti-platelet ticagrelor: Is it better than the old \"new\" clopidogrel?

  • Ticagrelor has several theoretical benefits over clopidogrel: it is a reversible platelet inhibitor, hepatic metabolism not required for activation (less intra-individual variability in response), and faster onset/offset of action.3,4
    •Benefits of ticagrelor seem maintained in higher risk groups like those with renal insufficiency 5and diabetes. 6

    • oTicagrelor proposed as an alternative in clopidogrel non-responders.7
  • Unanswered concerns:
    • No clear explanation why ticagrelor worse in North America.8
  • Dyspnea unexplained3but is not associated with structural cardiacdamage or pulmonary function test abnormalities.9,10
    Ticagrelor is significantly more expensive than clopidogrel ($310/90 days vs.$100/90 days)11and requires twice-daily dosing.
  • Given the cost, increased harms, and uncertainty around effectiveness in NorthAmerica, clinicians should:
    • Consider clopidogrel a reasonable alternative in intolerant patients startedon ticagrelor in hospital.
  • Prescrire Int. 2011 Oct;20(120):229-33. Ticagrelor. Acute coronary syndromes: nothing new.
    • Ticagrelor and its active metabolite are substrates and inhibitors of cytochrome P450 isoenzymes and P-glycoprotein, creating a risk of multiple pharmacokinetic interactions. Pharmacodynamic interactions are also likely to occur, especially with antithrombotic agents and heart-rate-lowering drugs. In practice, in patients with an acute coronary syndrome treated with angioplasty and stenting, and who are also receiving aspirin, it remains to be shown whether the harm-benefit balance of ticagrelor is clearly better than that of clopidogrel. In other settings, there is no firm evidence that ticagrelor is better than aspirin alone.
  • Ticagrelor (Brilinta)
    • Common Drug ReviewCDEC Meeting – November 16, 2011
    • Page 1 of 6Notice of CDEC Final Recommendation – December 16, 2011© 2011 CADTHCDEC FINAL RECOMMENDATIONTICAGRELOR(Brilinta – AstraZeneca)Indication: Prevention of Thrombotic Events in Acute Coronary Syndromes
    • Recommendation:The Canadian Drug Expert Committee (CDEC) recommends that ticagrelor not be listed at thesubmitted price.
    • Reasons for the Recommendation:
    • 1.   The pre-specified subgroup analysis (by region), in the one large randomized controlled trial(RCT) of patients with acute coronary syndromes (ACS), did not provide evidence of thesuperiority of ticagrelor compared with clopidogrel in a North American patient population tosupport a higher price for ticagrelor.
    • 2.   Given the limitations identified with the manufacturer’s pharmacoeconomic submission, theCommittee noted that the cost-effectiveness ofticagrelor could not be properly assessed.
    • 3.   The daily cost of ticagrelor ($2.96) is greater than clopidogrel ($2.58).
  • En 2012 se publica una revisión sistemática Network meta-analysis of prasugrel, ticagrelor, high- and standard-dose clopidogrel in patients scheduled for percutaneous coronary interventions:
    • This review found potentially relevant differences in efficacy and bleeding risk between antiplatelet drugs prasugrel, ticagrelor and high-dose clopidogrel in patients undergoing percutaneous coronary interventions, but that these conclusions were not definitive as they were not based on direct comparisons of treatments. Despite some limitations, the authors’ conclusions reflect the evidence and are likely to be reliable.
    • Authors’ conclusions

      The new antiplatelet treatments, high-dose clopidogrel, ticagrelor and prasugrel, significantly reduced non-fatal cardiac endpoints compared with standard-dose clopidogrel; only ticagrelor showed reduced mortality and did not increase bleeding risks compared with standard-dose clopidogrel. Indirect comparisons between novel antiplatelet agents suggested that ticagrelor showed the most favourable bleeding profile, although this should be confirmed by further randomised trials directly comparing the new antiplatelet treatments.

    • Implications of the review for practice

      Practice: The authors stated that high-dose clopidogrel was more effective than standard-dose clopidogrel and represented an alternative for patients, particularly in light of economic constraints and increasing availability of generic clopidogrel







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