Practical experience with ticagrelor: an Australian and New Zealand perspective

Abstract

Objective:

Ticagrelor is recommended in local and international guidelines as first-line therapy in combination with aspirin in patients presenting with acute coronary syndromes (ACS). The purpose of this article is to provide practical guidance regarding the use of ticagrelor in this setting.

Methods and results:

Ticagrelor, a direct-acting, reversible P2Y₁₂ receptor antagonist, has a faster onset, and a more potent and predictable antiplatelet effect compared with clopidogrel. The authors recommend considering the use of ticagrelor in moderate-to-high risk ACS patients treated with an invasive approach and those managed non-invasively who have elevated troponin levels. Consistent with outcomes observed in the PLATO trial overall, ticagrelor was superior to clopidogrel treatment in patients with chronic kidney disease, a history of stroke or transient ischemic attack, the elderly, and patients requiring surgical revascularization.

Conclusions:

When switching from clopidogrel to ticagrelor, patients established on clopidogrel therapy can be switched directly without loading; patients not loaded with clopidogrel and not taking maintenance dose clopidogrel for at least 5 days should first be loaded with ticagrelor. Guidelines recommend discontinuing ticagrelor 5 days before surgery if antiplatelet effects are not desired and recommencing therapy as soon as safe following surgery. Ticagrelor should be avoided in individuals with a history of intracranial hemorrhage, moderate-to-severe hepatic impairment, high bleeding risk, within 24 hours of thrombolytic therapy, and in those treated with oral anticoagulants.

Local, real-world experience suggests low bleeding rates with ticagrelor therapy. Dyspnoea is a common symptom in patients with ACS and is also a side-effect of ticagrelor therapy. Discontinuation of ticagrelor due to dyspnoea has been uncommon in clinical trials. However, local registry data suggest higher discontinuation rates (2–9%) related to dyspnoea in the real-world setting, indicating that clinicians may need to consider other potential causes of dyspnoea before discontinuing ticagrelor.

Keywords: :

• Acute coronary syndromes
• Myocardial infarction
• Ticagrelor
• Antiplatelet agents
• Percutaneous coronary intervention
• Bleeding

Acknowledgements

Declaration of funding

Administrative and medical writing support was provided by Ms Vasugi Sanjayan (Allori Pty Ltd, Australia) and Dr Anja Becher (Sydney, Australia), and was funded by AstraZeneca Australia. The sponsor was given the opportunity to comment on the article.

Declaration of financial/other relationships

Scott A. Harding: Grant/Research: AstraZeneca; Speakers’ Bureau: AstraZeneca. William J. Van Gaal: Speakers’ Bureau: AstraZeneca. Ryan Schrale: Grant/Research: AstraZeneca. John Amerena: Grant/Research: AstraZeneca; Consultant/Advisor: AstraZeneca; Speakers’ Bureau: AstraZeneca. Philip E. Aylward: Sponsorship: AstraZeneca; Grant/Research: AstraZeneca, CSL, GSK, Merck; Consultant/Advisor: The Medicines Company, AstraZeneca, Sanofi Aventis, Boehringer Ingelheim, Bayer; Speakers’ Bureau: The Medicines Company, AstraZeneca, Pfizer, BMS, Bayer. Athula Gunasekara and Christian J. Mussap have disclosed that they have no relevant financial/other interests. CMRO Peer Reviewers on this manuscript have received an honorarium from CMRO for their review work, but have no other relevant financial relationships to disclose.