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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