Ticagrelor pharmacokinetics and pharmacodynamics in patients with NSTEMI after a 180-mg loading dose

Abstract

The pharmacokinetics after a 180-mg loading dose (LD) of ticagrelor has not been thoroughly investigated in NSTEMI patients. We aimed to compare the ticagrelor uptake and on-treatment platelet reactivity between non-ST-segment elevation myocardial infarction (NSTEMI) patients and a control group of patients with stable coronary artery disease (SCAD) undergoing elective percutaneous coronary intervention. We performed an observational, prospective, single-center study including 40 NSTEMI patients and 20 SCAD controls. Key exclusion criteria included ongoing opioid treatment. Both groups received a 180-mg ticagrelor LD, and blood samples were taken pre-dose and 1, 2, 3, 4, 5, and 6 hours post-LD. Plasma concentrations of ticagrelor and its active metabolite AR-C124910XX were determined by validated methods. Platelet aggregation was tested using ADP-induced multiple electrode aggregometry. The primary endpoint was the time to maximal ticagrelor concentration (T_max). Clinical trial registration identifier number: NCT02292277. None of the pharmacokinetic variables differed significantly between the groups, including the T_max of ticagrelor (2.0h [1.0–3.0] versus 2.0h [2.0–3.0], p = 0.393) and the active metabolite AR-C124910XX (3.0 [2.0–4.0] versus 3.0 [2.5–4.0], p = 0.289). High on-treatment platelet reactivity (HPR) was defined as > 46 aggregation units and was at one hour seen in 15% of the NSTEMI patients versus 10% of the controls (p = 1.0). At two hours post the 180-mg ticagrelor LD, 3% of the NSTEMI patients had HPR compared with none of the controls (p = 1.0). In conclusion, the uptake of ticagrelor was not significantly slower in NSTEMI patients not receiving opioids compared with the SCAD controls, leading to adequate onset of platelet inhibition in both groups.

Keywords:

• Myocardial Infarction
• pharmacokinetics
• platelet inhibitor

Acknowledgments

The authors thank Ellinor Berglund, Robin Hofmann, the interventionists at the coronary angiography laboratory, and the physicians working in the emergency department at Södersjukhuset (Stockholm South General Hospital) for excellent help with the identification of patients eligible for inclusion. We also thank Elias Hasselström and Elias Karlsson for help with inclusion and blood sampling.

Declaration of interest statement

Astra Zeneca provided a non-restricted research grant through the Externally Sponsored Research program (ESR-14-10214). M. Holm has received an honorarium from Roche Diagnostics. J. van der Linden has received an honorarium from Astra Zeneca. M Holm and J. van der Linden have received financial support covering travel and accommodation from Astra Zeneca for a presentation at a company sponsored meeting in Vienna in 2015. Further financial support was provided by Karolinska Institute and the Swedish Heart–Lung Foundation. P. Tornvall, J. Westerberg, and S. Rihan Hye have no disclosures.