P2Y₁₂-inhibitor monotherapy after coronary stenting: are all P2Y₁₂-inhibitors equal?

ABSTRACT

Introduction

P2Y₁₂-inhibitor monotherapy following 1–3 months of dual antiplatelet therapy (DAPT) reduces (major) bleeding without an apparent increase in ischemic events and has therefore emerged as an alternative to 6–12 months of DAPT following percutaneous coronary intervention (PCI). However, there are important differences between the available P2Y₁₂-inhibitors (clopidogrel, prasugrel, and ticagrelor) as agents of choice for P2Y₁₂-inhibitor monotherapy.

Areas covered

This review critically appraises the evidence for P2Y₁₂-inhibitor monotherapy after PCI using either clopidogrel, prasugrel, or ticagrelor. Furthermore, we discuss ongoing trials and future directions for research.

Expert opinion

P2Y₁₂-inhibitor monotherapy following 1–3 months of DAPT is an alternative to 6–12 months of DAPT following PCI. Ticagrelor may be considered the current preferred option due to its reliable effect on platelet reactivity and its predominant use in clinical trials. Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but more research into prasugrel monotherapy is warranted. Alternatively, clopidogrel can be used, although there are concerns of high platelet reactivity, especially when genotyping and/or platelet function testing are not used. Future research will need to address the minimal duration of DAPT before switching to P2Y₁₂-inhibitor monotherapy and what the optimal antithrombotic therapy beyond 12 months is.

KEYWORDS:

• Dual antiplatelet therapy
• P2Y₁₂-inhibitor monotherapy
• clopidogrel
• prasugrel
• ticagrelor
• percutaneous coronary intervention

Article highlights

• P2Y₁₂-inhibitor monotherapy following 1–3 months of DAPT has emerged as an alternative to 6–12 months of DAPT following PCI, but there are important differences between clopidogrel, prasugrel, and ticagrelor as agents of choice for P2Y₁₂-inhibitor monotherapy.

• Ticagrelor has a reliable effect on platelet reactivity and has been predominantly used in clinical trials evaluating P2Y₁₂-inhibitor monotherapy.

• Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but prasugrel has so far been vastly underrepresented in clinical trials evaluating P2Y₁₂-inhibitor monotherapy.

• Clopidogrel might be less suitable as agent of choice for P2Y₁₂-inhibitor monotherapy in patients undergoing PCI for ACS, especially if patients do not undergo CYP2C19 genotyping prior to aspirin withdrawal

• Future research will need to address the minimal duration of DAPT before switching to P2Y₁₂-inhibitor monotherapy and what the optimal antithrombotic therapy is beyond 12 months.

Declaration of Interest

JM ten Berg has received research grants from AstraZeneca and ZonMw and personal fees from AstraZeneca, Accu-Metrics, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Ferrer, Idorsia, Pfizer and The Medicines Company. MAM Beijk has received a research grant from Actelion (Johnson & Johnson). Y Appelman has received a research grant from the Dutch Heart Foundation. WJ Kikkert has received a research grant from AstraZeneca. JPS Henriques has received research grants from Abbott Vascular, AstraZeneca, B. Braun, Getinge, Ferrer, Infraredx and ZonMw. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.