Switching between ticagrelor and clopidogrel in patients who underwent percutaneous coronary intervention: insight into contemporary practice in Chinese patients

Abstract

Ticagrelor has been proved to be more effective than clopidogrel; however, little is known about the switching between ticagrelor and clopidogrel in real-world clinical practice. We assessed the prevalence, related factors, dose bridging, compliance, and short-term outcomes of in-hospital switching between ticagrelor and clopidogrel in consecutively recruited patients treated by ticagrelor after percutaneous coronary intervention (PCI). A total of 417 eligible patients administrated with ticagrelor in-hospital after PCI were recruited. Switching between ticagrelor and clopidogrel occurred in 362 (86.8%) patients, with 318 (76.3%) from clopidogrel to ticagrelor occurring mainly after PCI and 44 (10.6%) from ticagrelor to clopidogrel primarily at discharge. History of cerebrovascular disease, final diagnosis of acute coronary syndrome, left main disease, ostial lesion, co-administration with warfarin, CYP2C19 loss-of-function alleles' carriage status, and ticagrelor-related dyspnoea emerged as related factors for the switching between clopidogrel and ticagrelor. Dose bridging between clopidogrel loading dose and ticagrelor maintenance dose (MD) was more frequent in patients switching from clopidogrel to ticagrelor, while the bridging between ticagrelor MD and clopidogrel MD was more likely to occur in patients switched from ticagrelor to clopidogrel. At 6 month follow-up, poor compliance was observed in patients from clopidogrel to ticagrelor (64.8%) or treated only by ticagrelor (50.9%), but perfect compliance in patients from ticagrelor to clopidogrel (100%). After excluding the cases with incompliance, patients switching from ticagrelor to clopidogrel had a relatively lower bleeding risk in comparison with patients with constant ticagrelor treatment and those switching from clopidogrel to ticagrelor (29.5% vs. 50.0% vs. 46.6%, adjusted = 0.02). In-hospital switching between ticagrelor and clopidogrel is frequent in patients undergoing PCI. In comparison with constant ticagrelor treatment, switching from clopidogrel to ticagrelor in ischaemic high-risk patients confers similar antiplatelet efficacy and safety, while switching from ticagrelor to clopidogrel in ischaemic low-risk patients relates to lower hazard for bleeding events.

Switching from ticagrelor to clopidogrel in patients with ST‐segment elevation myocardial infarction undergoing successful percutaneous coronary intervention in real‐world China: Occurrences, reasons, and long‐term clinical outcomes

“…Previous studies showed that the rate of nonloading dose was low in patients switching from ticagrelor to clopidogrel . Our study also showed that more than half of the patients (55.3%) with STEMI switched to clopidogrel without loading dose.…”

“…In China, switching from ticagrelor to clopidogrel, which is defined as de‐escalation, after PCI is more common. Financial burden, unavailability, and concerns about increased risk of bleeding with ticagrelor are the most important reasons for de‐escalation . In China, most of the patients with ACS who switched from ticagrelor to clopidogrel did not use loading dose .…”

“…ticagrelor are the most important reasons for de-escalation. 8,12 In China, most of the patients with ACS who switched from ticagrelor to clopidogrel did not use loading dose. 12 However, different studies addressing de-escalation in recent years showed contradictory efficacy and safety of switching.…”

“…12 However, different studies addressing de-escalation in recent years showed contradictory efficacy and safety of switching. 8,[13][14][15] Although some studies assessed the pharmacodynamic effects of loading dose during de-escalation to clopidogrel, [3][4][5]16 the best strategy of switching remains unclear because of the lack of long-term study of clinical outcomes.…”

Actual Problems of Antitombotic Therapy in Acute Coronary Syndrome (Following the Material Presented at the European Society of Cardiology Congress 2017)

“…Большинство этих исследований не показали увели-чения ишемических событий или кровотечений у пациен-тов после «переключения» с прасугрела или тикагрелора на клопидогрел [23,24], однако по результатам анализа регистра SCOPE исследователи сообщали о возможном увеличении риска возникновения кардиоваскулярных событий (ишемических событий + кровотечений) (Отно-шение шансов (ОШ) 5,3; 95% доверительный интервал (ДИ) 2,1-18,2, p = 0,04), преимущественно за счет повы-шения частоты ИМ при краткосрочном наблюдении (42 дня после выписки из стационара) в группе с переключе-нием на клопидогрел [25].…”