Antiplatelet drug

1. Moderator
Dr. Tariq Ahmed
Chowdhury
Assistant professor
Cardiology,NICVD
Presenter
Dr. Swapan Kumar Ray
MD(Neurology), Phase-A
National institute of
Neurosciences &
Hospital

2. PRASUGREL
NEWER ANTIPLATELET

3.  Process of thrombus formation:
1. Subendothelial tissue factor exposed to
circulating blood following
atherosclerotic plaque rupture.
2. Activation of coagulation cascade.
3. Platelet adhesion, activation and
aggregation.
4. Formation of thrombus.

4.  Injury to the endothelium, exposes the
subendothelial matrix
 Platelets adhere to exposed collagen & von
Willebrand factor
 Platelet activation occur under the influence
of thrombin

5.  Platelet activation changes its shape &
liberate more thrombin, thromboxane A2 &
ADP
 These substances bind to their respective
platelets receptors & promote further
activation
 Activated platelets bind each other & to
vessel wall forming platelet plug. These
aggregated platelet combine with fibrin
polymer form thrombus.

6. Role of platelets in thrombus
formation

7. 1. COX1 Inhibitor:
Aspirin
2. P2Y12Inhibitors :
a. Thienopyridine: Ticlopidine,
Clopidogrel, Prasugrel
b. Nonthienopyridine: Ticagrelor,
Cangrelor
3. GP IIb/IIIa antagonists:
Abciximab, Tirofiban, Eftifibatid
4. Dipyridamol

8.  It is a newer generation thienopyridin.
 It is a prodrug.
 Irreversibly and noncompetitively inhibit the
P2Y12 receptor.
 Prasugrel mediated inhibition of platelet
aggregation is approximately 5 to 9 times
more potent than that of clopidogrel.

9.  It blocks the binding of adenosine diphosphate
(ADP) to the receptor P2Y12 on platelet thus
inhibiting-
-platelet activation and
aggregation

11.  Absorption:
Absorption: >79%
Peak plasma concentration: 30 min
 Metabolism:
Rapidly hydrolyzes in intestine to a
thiolactone which is then converted in
the liver to active metabolite via
CYP3A4 and CYP2B6.

12.  Distribution:
Volume of distribution: 44-48 L
 Elimination:
Half life: 7hrs (2-15 hr)
Excretion: Urine(68%), feces(27%)

13.  Reduction of thrombotic cardiovascular
events (including stent thrombosis) in
patients with ACS who are to be managed
with PCI for –
a. Unstable angina or non-ST-elevation MI
b. ST-elevation-MI (STEMI) when managed
with primary or delayed PCI.

14. COR LOE Recommendations
IIa B-R In patients with ACS (NSTE-ACS or STEMI) treated
with DAPT after coronary stent implantation who
are not at high risk for bleeding complications and
who do not have a history of stroke or TIA, it is
reasonable to choose prasugrel over clopidogrel
for maintenance of P2Y12 inhibitor therapy.
III:
Harm
B-R Prasugrel should not be administered to patients
with a prior history of stroke or TIA.
2016 ACC/AHA Guideline

15.  60mg PO once as loading dose, then 10mg
orally once daily.
 If patient<60kg , consider 5mg orally once
daily due to potentially increased bleeding
risk(efficacy and safety not established).

16. 1. Active bleeding such as peptic ulcer or
intracranial hemorrhage.
2. Prior transient ischemic attack or stroke.
3. Hypersensitivity.

17.  Common:
Bleeding
Thrombotic thrombocytopenic purpura
 Others:
Abnormal hepatic function
Allergic reaction
Angioedema
Hyperlipidemia
Headache
Back pain

18. 1. With warfarin:
increases the risk of bleeding.
2. With NSAIDs(used chronically):
may increase the risk of bleeding.
3. Other concomitant medications:
It can be administered with
cytochrome P450 enzymes inducers
or inhibitors.

19.  It can also be administered with-
Aspirin
Statin
Digoxin and
Drugs that elevate gastric PH,
including PPI and H2 blockers.

20. 1.Renal impairment:
a. mild to moderate renal impairment
(CrCL=30-50ml/min):
-No dosage adjustment require.
b. End stage renal disease:
-Limited experience.

21. 2.Hepatic impairment:
a. Mild to moderate(Child-Pugh Class A
and B):
-No dosages adjustment.
b. Severe hepatic disease:
-No study done but chance of
higher risk of bleeding.

22. 3.Pregnancy:
-Category B
4.Geriatric use:
-Patients >75 years of age increase
risk of fatal bleeding
5.Low body weight:
-Individual with body weight <60kg
increase risk of bleeding

23. 1. TRITON–TIMI 38 study: To compare
prasugrel with clopidogrel in ACS with
scheduled PCI.
2. TRILOGY-ACS: To compare clopidogrel and
prasugrel in high risk NSTEMI and UA patients
without revascularisation .
3. PRAGUE-18 Study: To compare the efficacy
and safety of prasugrel and ticagrelor in ST
elevation MI treated with primary PCI.

24.  TRITON-TIMI 38: Trial to Asses Improvement
in Therapeutic Outcomes by Optimizing
platelet inhibition with prasugrel
Thrombolysis In MI).
 To compare prasugrel with clopidogrel in ACS
with scheduled PCI.
 Randomized, double blind, parallel group
study.
 13,608 patients with moderate-to-high-risk
acute coronary syndromes with scheduled PCI

25.  Prasugrel (60mg loading dose and 10mg
daily maintenance dose) or clopidogrel
(300mg loading dose and 75mg daily
maintenance dose) for 6 to 15 months.
 Primary end point was death from
cardiovascular causes, nonfatal myocardial
infarction, or nonfatal stroke.
 The key safety end point was major bleeding.

26.  Prasugrel significantly reduced the primary
efficacy end point (Prasugrel 9.9% vs
clopidogrel 12.1%).
 There were significant reductions in the
prasugrel group in the rates of myocardial
infarction (prasugrel 7.4% vs. clopidogrel
9.7%).
 It also reduce the risk of urgent target vessel
revascularization (Prasugrel 2.5% vs
clopidogrel 3.7%%) & stent thrombosis(1.1%
vs 2.4%)

27.  Non CABG related major bleeding was
observed in 2.4% of patients receiving
prasugrel and in 1.8% of patients receiving
clopidogrel.
 CABG-related major bleeding rates were
13.4% with prasugrel vs. 3.2% with
clopidogrel.

28.  The TRILOGY trial - The Targeted platelet
Inhibition to cLarify the Optimal strateGY to
medically manage acute coronary
syndromes trial
 Studied clopidogrel and prasugrel in high-
risk NSTEMI and unstable angina (UA)
patients selected for medical management
without revascularisation.

29.  It was a randomised, double-blind trial with
a sample size (n=9326)
 Primary analysis involving 7243 patients
age< 75 years receiving aspirin, treatment
with prasugrel (10 mg/day) vs clopidogrel (75
mg/day) up to 30 months .
 In a secondary analysis involving 2083
patients age 75 years or older, with 5 mg of
prasugrel vs 75 mg of clopidogrel.

30.  At a median follow-up of 17 months, the
primary end point of death from
cardiovascular causes, myocardial infarction,
or stroke among patients <75 years occurred
in 13.9% of the prasugrel group and 16.0% of
the clopidogrel group.
 Similar results were observed in the overall
population

31.  Rates of severe and intracranial bleeding were
similar in the two groups in all age groups.
 Among patients with unstable angina or
myocardial infarction without ST-segment
elevation, prasugrel did not significantly
reduce the frequency of the primary end
point, as compared with clopidogrel, and
similar risks of bleeding were observed.

32.  It was designed to compare the efficacy and
safety of prasugrel and ticagrelor in ST
elevation MI treated with primary PCI.
 A total of 1230 patients were randomly
assigned, across 14 sites.
 Primary end-point was defined as death, re-
infarction, urgent target vessel
revascularization, stroke, serious bleeding
requiring transfusion or prolonging
hospitalization at 7 days.

33.  The occurrence of the primary endpoint did
not differ between groups receiving prasugrel
and ticagrelor (4.0% and 4.1%, respectively).
 The occurrence of key secondary end-point
within 30 days, composed of cardiovascular
death, non-fatal MI, or stroke did not show
any significant difference between prasugrel
and ticagrelor (2.7% and 2.5%, respectively).

34.  Among patients with STEMI undergoing
primary PCI, similar efficacy and bleeding was
observed for either prasugrel or ticagrelor.
 Among such patients, the use of either agent
is acceptable.

35.  Prasugrel inhibits ADP induced platelet
aggregation more rapidly, more consistently,
and to a greater extent than standard doses
of clopidogrel.
 In ACS (NSTE-ACS or STEMI) patient,after
coronary stent implantation who are not at
high risk for bleeding complications,
prasugrel is preferable to clopidogrel.

36.  Prasugrel should not use in patient with
previous TIA/stroke.
 Patients with STEMI undergoing primary PCI,
similar efficacy and bleeding was observed for
either prasugrel or ticagrelor
 In UA or NSTEMI without revuscularisation,
prasugrel did not show any superiority over
clopidogrel.