Comparative Effectiveness and Safety of Ticagrelor versus Prasugrel in Patients with Acute Coronary Syndrome: A Retrospective Cohort Analysis

Abstract

STUDY OBJECTIVE To compare the effectiveness and safety of ticagrelor versus prasugrel in preventing recurrent cardiovascular disease (CVD) and major bleeding events in patients with acute coronary syndrome (ACS). DESIGN Retrospective cohort analysis. DATA SOURCE Truven Commercial and Medicare Supplemental claims database (2011)(2012)(2013)(2014)(2015)(2016). PATIENTS Study consisted of adults with ACS who newly initiated ticagrelor or prasugrel within 7 days of their first ACS diagnosis and had no prior use for at least 12 months; after propensity score matching, 10,073 patients were in each group. METHODS The primary study outcomes, first occurrence of a recurrent nonfatal CVD event (composite of myocardial infarction and stroke) and occurrence of a major bleeding event, were compared between the ticagrelor and prasugrel groups. Secondary outcomes included occurrence of minor bleeding events, defined based on the presence of bleeding events in outpatient claims. Cox proportional hazards models after propensity score matching were used to obtain the hazard ratio (HR) and 95% confidence interval (CI). In the Cox proportional hazards model, the use of ticagrelor was associated with a decreased risk of recurrent nonfatal CVD events (HR 0.80, 95% CI 0.70-0.92) and major bleeding events (HR 0.54, 95% CI 0.41-0.70) compared with prasugrel. Additionally, the use of ticagrelor was associated with a lower risk of minor bleeding events compared with prasugrel (HR 0.71, 95% CI 0.65-0.78). CONCLUSION In this population-based cohort of incident ACS patients, ticagrelor was associated with a reduced rate of recurrent nonfatal CVD events, major and minor bleeding events compared with prasugrel. KEY WORDS acute coronary syndrome, ticagrelor, prasugrel, effectiveness. (Pharmacotherapy 2019;39(9):912-920)

Comparative effectiveness and safety of prasugrel versus ticagrelor following percutaneous coronary intervention: An observational study

“…The observational literature evaluating outcomes of antiplatelet use in patients with ACS undergoing PCI has shown conflicting results 5–9,18,28 . Differences in how study designs address variability in follow‐up time, inclusion, and exclusion criteria, approaches for addressing covariates may lead to divergent conclusions.…”

“…Using a conventional ITT analytic approach that fails to address censoring events that are imbalanced between treatment groups, as well as differential censoring, can lead to different interpretations of the estimates. Dawwas et al evaluated the comparative effectiveness and safety of ticagrelor versus prasugrel in patients with ACS in a retrospective cohort analysis 28 . Their results indicated that ticagrelor was associated with a decreased risk of recurrent nonfatal cardiovascular events (HR: 0.80, 95% CI: 0.70–0.92) and major bleeding events (HR: 0.54, 95% CI: 0.41–0.70).…”

Diurnal Variability of Platelet Aggregation in Patients with Myocardial Infarction Treated with Prasugrel and Ticagrelor

“…In the majority of patients, prasugrel and ticagrelor are preferred over clopidogrel due to improved cardiovascular outcomes [5]. The clinical superiority of prasugrel or ticagrelor above each other is debatable, as reports on this matter are not consistent [6][7][8][9][10][11]. The ISAR-REACT 5 trial, the only available randomized, clinical, head-to-head study, showed a reduction of composite ischemic endpoint (death, AMI, stroke) with prasugrel vs. ticagrelor in ACS patients [6].…”

“…However, the study had limitations that impede interpretation of its results and applicability [10]. On the other hand, data from registries and observational studies are neutral [11] or show ischemic benefit when ticagrelor is used instead of prasugrel in patients with ACS or AMI [7,8].…”

“…) history of ischemic stroke or transient ischemic attack;(7) history of intracranial hemorrhage; (8) history of gastrointestinal bleeding within last 30 days; (9) history of moderate or severe hepatic impairment; (10) history of major surgery or severe trauma (within 3 months); (11) patient on dialysis; (12) infection or inflammatory state; (13) therapy with strong CYP3A inhibitors or inducers; (…”