HelixTalk Episode #105 - Unraveling the Mystery of P2Y12 Inhibitors: Clinical Pearls and Comparative Evidence

Date posted: December 3, 2019, 6:00 am

In this episode, we review the three oral P2Y12 inhibitors on the market (clopidogrel, prasugrel, ticagrelor) and discuss each agent’s clinical pearls, comparative effectiveness, and unique precautions.

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Key Concepts

1. P2Y12 inhibitors are commonly added to aspirin in patients with an acute coronary syndrome, especially when percutaneous coronary intervention (PCI) is done.  These drugs (mostly clopidogrel) may also be used in other indications.
2. Clopidogrel (Plavix) has variable efficacy due to genomic variations; it generally has a lower efficacy benefit but also a lower bleeding risk than the other P2Y12 inhibitors.
3. Prasugrel (Effient) is only used in patients who receive PCI and is either avoided or contraindicated in several patient populations (age >= 75 years, body weight < 60 kg, and history of TIA or stroke).
4. Ticagrelor (Brilinta) causes dyspnea and ventricular pauses (which are not typically seen with other P2Y12 inhibitors) and should be used with aspirin doses less than 100 mg per day for optimal efficacy.

References

• Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-e228. doi: 10.1016/j.jacc.2014.09.017.
• O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019.