Are P2Y12 inhibitors superior to aspirin for long-term secondary prevention of cardiovascular disease?

Figures & data

Table 1. Pharmacology of aspirin and oral P2Y12 inhibitors.

Agent	Mechanism of action	Prodrug	Time to onset	Half-life/time to offset	Notable adverse effects	Specific reversal agent	Cost
Aspirin*	COX-1 inhibitor (irreversible)	No	5 minutes	T1/2: 10–20 minutes Time to offset: 3 days	Hypersensitivity reactions, gastrointestinal upset, tinnitus	No	$
Clopidogrel	P2Y12 inhibitor (irreversible)	Yes (two step hepatic process; primarily CYP2C19)	2–8 hours	T1/2 (parent drug): 6 hours T1/2 (active metabolite): 30 minutes Time to offset: 5–7 days	Type IV hypersensitivity reactions, diarrhea	No	$
Prasugrel	P2Y12 inhibitor (irreversible)	Yes (two step; first via esterases, second via hepatic CYP3A)	30 minutes − 4 hours	T1/2 (parent drug): <5 minutes (rapidly hydrolyzed by esterases) T1/2 (active metabolite): 7 hours Time to offset: 7 days	Colonic neoplasms	No	$$
Ticagrelor	P2Y12 inhibitor (reversible)	No (both parent drug and metabolite are active)	30 minutes − 4 hours	T1/2 (parent drug): 7 hours T1/2 (active metabolite): 9 hours Time to offset: 3–5 days	Dyspnea, ventricular pauses	Bentracimab†	$$

*Can also be administered intravenously or rectally.

†Experimental; not approved for clinical use