Trends in Platelet Adenosine Diphosphate P2Y₁₂ Receptor Inhibitor Use and Adherence Among Antiplatelet-Naive Patients After Percutaneous Coronary Intervention, 2008-2016

Abstract

IMPORTANCE Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y 12 receptor (P2Y 12) inhibitors. OBJECTIVES To determine trends in use of the different P2Y 12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y 12 inhibitors. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y 12 inhibitor for 90 days preceding PCI. The P2Y 12 inhibitor filled within 30 days of discharge was identified from pharmacy claims. MAIN OUTCOMES AND MEASURES Proportion of patients filling prescriptions for P2Y 12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y 12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents. RESULTS A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y 12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y 12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79

Frequency and clinical outcomes of CYP2C19 genotype-guided escalation and de-escalation of antiplatelet therapy in a real-world clinical setting

“…7,8 However, these alternative therapies have higher bleeding risk, discontinuation rates, and cost compared to clopidogrel. 5,6,9,10 In clinical practice, switching between P2Y 12 inhibitors has become increasingly common and is driven by clinical and socioeconomic factors. 11,12 Understanding the frequency and reasons for switching from clopidogrel to prasugrel or ticagrelor (termed "escalation") or from prasugrel or ticagrelor to clopidogrel (termed "de-escalation") has emerged as a major area of investigation.…”

<p><em>CYP2C19*17</em> May Increase the Risk of Death Among Patients with an Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Who Receive Clopidogrel and Rivaroxaban</p>

“…21,22 Nevertheless, the problem of the variability of the response to clopidogrel is still relevant as the therapy with ticagrelor and prasugrel is connected to the higher number of bleeding complications; it is more expensive, which leads to lower compliance among patients and, finally, is not the treatment of choice when used as part of a combined antithrombotic treatment. 23,24 According to the current guidelines and expert opinions, patients with an acute coronary syndrome (ACS) with atrial fibrillation (AF) need to be treated with combined antithrombotic therapy: antiplatelet therapy plus oral anticoagulants. 24 Although the prescription of anticoagulant therapy is regulated by the guidelines for treatment of AF aimed to prevent cardioembolic complications, a combined antithrombotic therapy is connected to an increase in the bleeding events risk.…”

Influence of CYP2C19 genotype on antiplatelet treatment outcomes after percutaneous coronary intervention in patients with coronary heart disease

“…Patients with fast metabolizing CYP2C19 genotype had the least number of MACE while patients with very slow CYP2C19 genotype experienced the highest number of MACE in the present study. In terms of the CYP2C19 genotype, when comparing very slow with fast metabolizers, the concentration of effective active drugs in plasma was significantly reduced in the latter, so the anti-platelet aggregation effect was low (3,10). Therefore, we selected clopidogrel as a PCI antiplatelet therapy.…”