Crushed ticagrelor in comatose patients treated with primary percutaneous coronary intervention

Oral trans-mucosal administration of ticagrelor: is this really the future?

“…The origin of this delayed onset of antiplatelet effect in high-risk ACS settings is likely multifactorial and affects the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of any drug, including ticagrelor, and translate into delayed absorp-tion (11)(12)(13)(14). These observations underscore the need to identify strategies associated with improved drug absorption.…”

“…A common limitation to both studies is the use of a single platelet function assay, whereas the use of additional tests would have allowed to corroborate the study findings (18,19). In addition, the clinical setting where the absorption of oral P2Y12 receptor inhibitors is known to be mostly impaired (and thus where faster onset of ticagrelor PD effects needed) is STEMI (8)(9)(10)(11)(12)(13)(14)(15)(16). Therefore, performing the study in primary PCI patients would have been the best approach, and whether these results can be reproduced in patients with STEMI is unknown.…”

“…However, this might be related to the different methods of administration: in CHEERS, ticagrelor tablets were actively chewed by patients, whereas in the study by Niezgoda et al tablets were crushed in advance and then administered sublingually to the patients. The oral transmucosal system allows for a more rapid absorption into the blood stream as compared with oral administration to the gastrointestinal tract and consequently offers an alternative means of drug administration, which therefore could be more effective in settings, such as STEMI, where gastrointestinal absorption is impaired (8)(9)(10)(11)(12)(13)(14)(15)(16). Of note, the oral cavity comprises the lips, cheeks, tongue, hard palate, soft palate and the floor of the mouth and the lining of the oral cavity is referred to as the oral mucosa, which includes the buccal, sublingual, gingival, palatal and labial mucosae (20).…”