Contemporary Use of Prasugrel in Clinical Practice

Abstract

Background-Prasugrel is a recently approved thienopyridine for use in patients with acute coronary syndromes undergoing percutaneous coronary intervention. There are no data on contemporary use of prasugrel in routine clinical practice. Methods and Results-We assessed the patterns of prasugrel use among 55 821 patients who underwent percutaneous coronary intervention and were discharged alive from January 2010 to December 2011 at 44 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Potential inappropriate therapy was defined as use in patients who had a history of cerebrovascular disease, weighed <60 kg, or were aged ≥75 years old. Clopidogrel was prescribed to 83% (n=46 574) and 17% (n=9247) of patients received prasugrel on hospital discharge. A steady, linear increase in prasugrel use was seen during the study period, with discharge prescription increasing from 8.4% in quarter 1 of 2010 to 22.3% in quarter 4 of 2011. Of the total cohort, 69.1% of patients presented with acute coronary syndrome, and in this group, 17.2% received prasugrel. Among patients prescribed prasugrel, 28.3% (n=2614) received the medication for indications outside of acute coronary syndromes. One or more known contraindications to the drug were present in 6% to 10% of patients discharged on this agent. Conclusions-There has been a steady increase in the use of prasugrel with the drug being used in ≈22% of patients undergoing percutaneous coronary intervention by study end. Prasugrel use in patients with known contraindications is not uncommon and may be a suitable target for focused quality improvement efforts. (Circ Cardiovasc Qual Outcomes. 2013;6:293-298.)

Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST‐Elevation Myocardial Infarction

“…Whether this difference might reflect variations in practice patterns in the United States versus Europe (as suggested, for example, by considerable differences in the use of bare‐metal stent versus DES in the 2 studies) or relate to more contemporary treatment patterns in the present analysis (enrollment extended up to 2014 versus 2012 in TRANSLATE‐ACS) cannot be definitively addressed. Of note, real‐world observations indicate greater acceptance rates and a steady increase in the use of prasugrel over time 5, 28. Any thienopyridine cessation was associated with an increased risk of major adverse cardiac events in TRANSLATE ACS,27 which contrast with our present findings in a STEMI cohort as well as the findings of the PARIS registry6 in a broader PCI population.…”

“…Compared with clopidogrel, prasugrel provides rapid‐onset, more potent and consistent inhibition of platelet aggregation,3 and reduces the risk of cardiovascular mortality and stent thrombosis in patients with myocardial infarction (MI) 4. Prasugrel is recommended over clopidogrel following primary PCI1, 2 and is used increasingly in real‐world clinical practice 5…”

Prasugrel

“…In this sense, the article by Sandhu et al 12 (see page 293 of this issue) fills an important gap. This study is a timely and well-designed prospective registry of almost 56 000 consecutive patients with post-percutaneous coronary intervention.…”

“…Furthermore, the authors found a steady increase in prasugrel use, with ≈22% of patients undergoing percutaneous coronary intervention on this therapy by study end. 12 It is disquieting that prasugrel contraindications have been ignored with a surprising frequency. This is not a sign of good clinical care and meticulous handling of potent pharmaceuticals.…”

Bedside stratification of patients according to CYP2C19*2 genotype

“…It was also shown that clopidogrel was effective enough in the carriers of wild-type (*1*1) CYP2C19, which represents a normal metabolism rate of this drug (Reese et al, 2012). In addition, only up to one-fourth of the prasugrel-treated patients are discharged from hospital for antiplatelet treatment at home (Sandhu et al, 2013;Bagai et al, 2014).…”