CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

July 25th, 2011

Panel: Will You Prescribe Ticagrelor (Brilinta)?

The FDA recently approved ticagrelor (Brilinta) to reduce cardiovascular death and MI in patients with acute coronary syndromes. The drug’s label will include a boxed warning about bleeding risks and will state that aspirin doses greater than 100 mg/day decrease the drug’s efficacy. We asked a panel of experts this question:

Will you prescribe ticagrelor? If so, to which patients? If not, why not?

David Cohen (Saint Luke’s, Kansas City): I think that ticagrelor will play a role in my clinical practice. The main advantage of ticagrelor over other available oral antiplatelet drugs (clopidogrel and prasugrel) is its relative reversibility and comparatively shorter biologic half-life. Accordingly, I think the main group of patients I will treat with ticagrelor are those who present with non–ST-elevation ACS who are being seen “upstream” prior to cardiac catheterization or for whom conservative therapy (rather than an invasive strategy) is chosen. The decision about which agent to continue after an invasively managed patient undergoes PCI will need to be individualized, taking into account multiple factors including bleeding risk, affordability (including insurance coverage), and the patient’s ability to comply reliably with a twice-daily regimen.

David Moliterno (U. Kentucky): We will definitely be using ticagrelor at the University of Kentucky. It is a terrific new agent for ischemic heart disease, but with remaining important questions regarding its real-world application — which patients, when, and for how long? Like many place throughout the U.S. healthcare market, we have practical limitations regarding cost, compliance, and concomitant medications.

Jeffrey Trost (Johns Hopkins): I would prescribe ticagrelor, based on the strength of the clinical efficacy data of the PLATO trial, to patients with acute coronary syndrome. It is hard to ignore the relative reductions in mortality, recurrent myocardial infarction, and stent thrombosis that favor ticagrelor, with equivalent safety to clopidogrel in terms of bleeding. However, aside from efficacy and safety, what patients care about most is ease of use and cost, and ticagrelor is inferior to clopidogrel on both counts. As a twice-daily drug with a higher cost than once-daily clopidogrel, I won’t be prescribing this drug to patients who have difficulty affording their medications or difficulty taking medications at all. I certainly will tell these patients why I think ticagrelor is better, but I will also understand if they prefer a cheaper, once-daily alternative. I will be prescribing this drug to patients who are willing to take a twice-daily drug and are comfortable with the cost of taking it.

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5 Responses to “Panel: Will You Prescribe Ticagrelor (Brilinta)?”

  1. VAZHA AGLADZE, MD., PhD says:
    July 26, 2011 at 1:12 am

    As a new drug with better outcomes(PLATO), of course, it must be used, but twice a daily regimen and high cost will enforce doctors to think a lot before prescribing.

    Competing interests pertaining specifically to this post, comment, or both:
    NONE

  2. Bharath Rajagopalan, MD says:
    July 26, 2011 at 10:34 am

    I think I would be using Ticagrelor mostly for patients with nstemi before cath considering its shorter duration of action so that if the pts need cabg it would be easier. I would be hesitant to use it as first line for people post pci for stents as the risk associated with missing a dose is too high. If some one failed clopidogrel, it can considered along with prasugrel. Also the speculation of using high dose Asa and Ticagrelor needs to be explored more.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  3. Mohamed Wafiq Shoukry, Master degree in Cardiology says:
    July 26, 2011 at 10:46 am

    I will prescribe,,we have an advantage of significant reduction of mortality, recurrent MI and Stent thrombosis over clopidogrel , also its reversibility over short duration we should consider it very well as considerable number of ACS patients going to CABG after diagnostic Coronary angio and they are on anti platelets,,, may be some of patient who can not afford , or the insurance not covering its cost will be maintained on clopidogrel.

  4. Chong Guan Chan, MBBS says:
    July 27, 2011 at 12:04 pm

    The surgeons will like it.

    Competing interests pertaining specifically to this post, comment, or both:
    Nil

  5. Christopher Paul Cannon, MD says:
    July 29, 2011 at 7:29 am

    I can’t wait to use it! Regarding the issue of “missed doses”, it is only after missing 3 doses that the level of platelet inhibition would start to fall below what clopidogrel taken regularly would be. this is because the level of platelet inhibition is twice as high to start, so missing one dose still leaves a patient (24 hours later) at a higher level of platelet inhibition than clopidogrel. Thus, this initial fear is not really an issue.

    Competing interests pertaining specifically to this post, comment, or both:
    I was a lead investigator in two trials with ticagrelor.