Chewing versus Swallowing Ticagrelor to Accelerate Platelet Inhibition in Acute Coronary Syndrome - the CHEERS study

Abstract

It was the study objective to evaluate whether chewing a 180 mg loading dose of ticagrelor versus an equal dose of traditional oral administration, enhances inhibition of platelet aggregation 1 hour (h) after administering a ticagrelor loading dose in non-ST elevation myocardial infarction (NSTEMI) patients. Dual anti-platelet therapy represents standard care for treating NSTEMI patients. Ticagrelor is a direct acting P2Y12 inhibitor and, unlike clopidogrel and prasugrel, does not require metabolic activation. Fifty NSTEMI patients were randomised to receive either a chewing loading dose of 180 mg ticagrelor or an equal standard oral dose of ticagrelor. Platelet reactivity was evaluated by VerifyNow at baseline, 1 and 4 h post-loading dose. Results are reported in P2Y12 reaction units. Patients then continued to receive standard 90 mg oral ticagrelor twice daily. Baseline characteristics did not differ between the two groups. P2Y12 reaction units in the chewing group compared with the standard group at 0, 1 and 4 h after ticagrelor loading dose were: 245 vs 239 (p=0.59), 45 vs 130 (p=0.001) and 39 vs 60 (p=0.12), respectively, corresponding to a relative inhibition of platelet aggregation of 83 % vs only 47 % at 1 h (p< 0.001), and 84 % vs 77 % (p=0.59) at 4 h. Major adverse cardiac and cardiovascular events at 30 days were low (2 %), occurring in only one patient in the standard group. In conclusion, chewing a 180 mg ticagrelor loading dose is feasible and facilitates both faster and improved early inhibition of platelet aggregation in NSTEMI patients, compared with a standard oral-loading dose.

Comparison of bioavailability and antiplatelet action of ticagrelor in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction: A prospective, observational, single-centre study

“…On the other hand, crushing of ticagrelor tablets appears to be an economical and efficient method to enhance and accelerate its bioavailability and onset of action in patients with acute coronary syndrome [27–29]. Alternative administration strategies, such as chewed ticagrelor, were also shown to provide superior platelet inhibition compared with integral pills [30, 31]. Moreover, insufficient platelet blockade after ticagrelor LD in STEMI could be overcome by bridging therapy with intravenous agents.…”

Oral NAloxone to overcome the moRphine effect in acute COronary syndrome patients treated with TICagrelor — NARCOTIC trial

“…The results of the latest studies aiming to evaluate the impact of ticagrelor administration strategy on its PK/PD profile show superiority of chewed ticagrelor in terms of platelet reactivity units (PRU) measured with VerifyNow in non-STEMI patients at 1 h where it was found to be significantly lower [23]. In a study by Venetsanos et al [24] PRU were also significantly lower in patients presenting with stable angina pectoris in the chewed-ticagrelor arm in comparison with integral ticagrelor arm.…”

Determinants of high platelet reactivity in patients with acute coronary syndromes treated with ticagrelor

“…Alternative method of ticagrelor administration are chewed tablets. This formulation provides a quicker onset of platelet inhibition than integral pills during the initial 60 minutes after ticagrelor LD in both STEMI and NSTEMI patients 32,33 . Moreover, different analgesic strategies to alleviate ischaemia-driven chest pain were proposed to avoid or surpass the negative impact of morphine on ticagrelor bioavailability and its antiplatelet action 34 .…”