1. JOURNAL REVIEW Dr RAJESH K F
NEWER ANTIPLATELETS
JOURNAL REVIEW
Dr RAJESH K F

2. Adenosine diphosphate (ADP) plays a key role in the genesis of physiological platelet-rich hemostatic plugs and of pathological arterial thrombi

3. Gq-coupled P2Y1 receptor and Gi-coupled P2Y12 receptor
Transduction of ADP signal involves interaction with 2 platelet receptors
Gq-coupled P2Y1 receptor and Gi-coupled P2Y12 receptor
Concomitant activation of both Gq and Gi pathways by ADP elicit normal platelet aggregation
P2Y1

4. Prasugrel
Rapid and consistent inhibitory effects on platelet aggregation than clopidogrel
Distinct chemical structure permits conversion to its active metabolite with less dependence on CYP enzymes than clopidogrel

5. Different metabolism
Appearance of active metabolite in circulation within 15 min
Reaches max plasma concentration at 30 min
Higher mean area under concentration-time curve of active metabolite of prasugrel 60 mg than that of clopidogrel 600 mg

6. Faster and greater mean inhibition of P2Y12-dependent platelet function after 60-mg LD and 10-mg maintenance dose than after a 300- or 600-mg LD and 75- or 150-mg maintenance dose of clopidogrel
No influence of CYP genotype on its pharmacokinetics and pharmacodynamics
Lower interindividual variability in inhibition of P2Y12
Low prevalence of subjects who display resistance to prasugrel

7. TRITON TIMI 38
Randomized, double-blind, parallel-group, multinational trial
Evaluated high-risk patients with ACS who required PCI
Patients randomized to receive 60-mg prasugrel followed by 10 mg/d or a 300-mg clopidogrel followed by 75 mg/d for 6 to 15 months

8. Prasugrel associated with
Fewer ischemic events (HR, 0.81; 95% CI, 0.73 to 0.90; P<0.001)
Significant reductions in
Rates of MI (9.7% for clopidogrel vs. 7.4% for prasugrel; P<0.001),
Urgent TVR(3.7% vs. 2.5%; P<0.001)
Stent thrombosis (2.4% vs. 1.1%; P<0.001)

9. Major bleeding observed in 2. 4% of prasugrel and in 1
Major bleeding observed in 2.4% of prasugrel and in 1.8% of clopidogrel (hazard ratio, 1.32; 95% CI, 1.03 to 1.68; P = 0.03)
Rate of life-threatening bleeding (1.4% vs. 0.9%;P= 0.01)
Nonfatal bleeding (1.1% vs. 0.9%; HR, 1.25; P = 0.23)
Fatal bleeding (0.4% vs. 0.1%; P = 0.002)

10. Posthoc analysis
3 subgroups appeared to have less net clinical benefit(≥75 yrs and <60 kg) or greater harm(previous CVA)
More effective antithrombotic drug than clopidogrel in patients with diabetes mellitus, STEMI, coronary stents, or recurrent cardiovascular events on treatment
DIABETIC SUBGROUP

11. TRILOGY ACS
Trial design: NSTE-ACS patients <75 years of age selected for medical management without PCI (n = 7,243) were randomized to prasugrel 10 mg daily vs. clopidogrel 75 mg daily. Patients ≥75 years of age (n = 2,083) were randomized to prasugrel 5 mg daily vs. clopidogrel 75 mg daily.
Results
(p = 0.21)
At 30 months, among patients <75 years of age:
CV death, MI, or stroke: 13.9% of the prasugrel group vs. 16.0% of the clopidogrel group (HR = 0.91, p = 0.21)
All-cause death: 7.8% vs. 8.1% (HR = 0.96, p = 0.63 )
Non-CABG TIMI major bleeding: 2.1% vs. 1.5% (HR = 1.31, p = 0.27)
Outcomes were similar in the overall population, including the elderly
16.0
13.9 %
Conclusions
Among medically treated patients with NSTE-ACS, prasugrel did not reduce adverse outcomes compared with clopidogrel
Major bleeding was similar between groups
Prasugrel
Clopidogrel
Roe MT, et al. N Engl J Med 2012;367:

13. Comparison with Higher Dose Clopidogrel
IPA (%; 20 mM ADP)
IPA (%; 20 mM ADP)
N=201
P< for each
P<0.0001
Prasugrel 60 mg
Clopidogrel 600 mg
Clopidogrel 150 mg
Prasugrel 10 mg
Hours
14 Days
Wiviott et al Circ 2007 (In Press) 13

14. CANGRELOR Belongs to family of analogs of ATP
Display high affinity for P2Y12 receptor
Potent inhibitor of ADP-induced aggregation of human washed platelets (PIC509.4 with 30 mol/L ADP)
Does not require conversion to an active metabolite
Immediately active after IV infusion
Half-life of 3 to 6 minutes

15. Clinical Pharmacology
IV infusion well tolerated in healthy volunteers
Result in dose-dependent inhibition of ADP-induced platelet aggregation at doses up to 4 microg/kg/min
At highest dose 3.2- and 2.9-fold increase in bleeding time in men and women, respectively
Short half-life result in rapid reversal of both platelet-inhibitory effect and effect on bleeding time
Reverse within 20 minutes after cessation of infusion

17. Double-blind randomized trial in PCI 2-part phase II study
Assessed safety and pharmacodynamics in PCI
First part of study enrolled 200 patients undergoing PCI
Randomized to 18- to 24-hour IV infusion of placebo or to 1, 2, or 4 microg/kg/min cangrelor in addition to aspirin and heparin before procedure
Greenbaum AB, Grines CL, Bittl JA, Becker RC, Kereiakes DJ, Gilchrist IC, Clegg J, Stankowski JE, Grogan DR, Harrington RA, Emanuelsson H,Weaver WD. Initial experience with an intravenous P2Y12 platelet receptor antagonist in patients undergoing percutaneous coronary intervention:results from a 2-part, phase II, multicenter, randomized, placeboand active-controlled trial. Am Heart J. 006;151:689.e1– 689.e10.

18. Second part of study 199 patients
Randomized to receive either cangrelor (4 microg / kg/ min1) or abciximab before PCI
Incidence of combined major and minor bleeding - not significant difference
After termination of infusion platelet aggregation returned to baseline values much faster in cangrelor treated group
10 DAY EVENTS

19. STEP-AMI Safety, Tolerability and Effect on Patency in Acute MI
Angiographic trial
Assessed safety and efficacy of cangrelor as an adjunct to tpa in 92 patients with AMI
All patients were treated with aspirin and heparin
Randomized to cangrelor alone (280micro g/min), full-dose tpa alone, or cangrelor 35, 140, or 280micro g/min in conjunction with half-dose tpa
Combination of cangrelor and half-dose tpa resulted in 60-min coronary patency similar to that of full-dose tpa alone (55% versus 50%; PNS) and greater patency than with cangrelor alone (55% versus 18%; P0.05)
Bleeding and adverse clinical events were comparable across groups

20. 4 to 7 days of clopidogrel treatment resulted in only 60% inhibition
Study directly compared effects of clopidogrel and cangrelor administration in patients with IHD
Cangrelor (2 and 4micro g/mL/min) almost completely inhibited 10 mol/L ADP induced platelet aggregation
4 to 7 days of clopidogrel treatment resulted in only 60% inhibition
Storey RF, Wilcox RG, Heptinstall S. Comparison of the pharmacodynamic effects of the platelet ADP receptor antagonists clopidogrel and AR-C69931MX in patients with ischaemic heart disease. Platelets. 2002;13:407– 413.

21. CHAMPION PCI
Comparing Treatment With Cangrelor (With Usual Care) to Usual Care, in Subjects Who Require PCI
N=8877

22. + + Subjects Index Procedure Endpoints
Subjects who require PCI (with or without stent)
1:1 randomization to main treatment groups Double blind, double dummy
Placebo capsules (to match)
Cangrelor bolus (30 µg/kg) & infusion (4 µg/kg/min)
Clopidogrel capsules (600 mg)
Placebo bolus & infusion (to match) + +
Subjects who require PCI Study drug infusion: for at least 2 hours or the duration of the procedure, whichever is longer
Index Procedure
Clopidogrel capsules (600 mg)
Placebo capsules (to match)
Clopidogrel maintenance (at the discretion of the physician)
Endpoints
At 48 hours after randomization—
1° efficacy endpoint: composite incidence of all-cause mortality, MI, and IDR
2° efficacy endpoint: incidence of individual components, stroke & abrupt vessel closure
Safety endpoints: hemorrhage and transfusion
Safety: AEs/SAEs

23. Cangrelor not superior to 600 mg clopidogrel in moderate to high risk patients undergoing PCI
Using standard methods cangrelor appears to be non-inferior to 600 mg clopidogrel
Platelet function testing - cangrelor provides very rapid ADP blockade and did not interfere with post PCI clopidogrel effect

24. Efficacy Endpoints at 48 hours
Cangrelor Clopidogrel Efficacy mITT* (N=3897) (N=3871) OR (95% CI) P Value
Death/MI/IDR 7.5% 7.1% 1.05 (0.88, 1.24) (primary endpoint)
MI 7.1% 6.6% 1.09 (0.91, 1.29) 0.36
IDR 0.3% 0.6% 0.56 (0.28, 1.11) 0.10
All-cause mortality 0.2% 0.1% 1.59 (0.52, 4.87) 0.42
Stent thrombosis 0.2% 0.3% 0.63 (0.25, 1.63) 0.34
Stroke 0.2% 0.2% 0.85 (0.29, 2.54) 0.77
Q-wave MI 0.1% 0.3% 0.40 (0.12, 1.27) 0.12
Death/Q-wave MI/ 0.6% 0.9% 0.67 (0.39, 1.14) 0.14 IDR
Death/Q-wave MI/ 0.5% 0.6% 0.78 (0.42, 1.44) 0.42 Stent thrombosis
*mITT= modified intent to treat population (patients with PCI and study drug)

25. Increase in ACUITY minor and GUSTO mild bleeding with cangrelor though no increase in the need for blood transfusion

26. CHAMPION PLATFORM

27. Efficacy Endpoints at 48 Hours
Efficacy mITT*
(SA/UA/NSTEMI)
Cangrelor
N=2654
Comparator
N=2641
OR [95% CI]
P value
Death/MI/IDR**
7.0%
8.0%
0.87 (0.71,1.07)
0.17 MI
6.7%
7.2%
0.92 (0.74,1.13)
0.42
Non QMI**
6.5%
6.9%
0.94 (0.76,1.16)
0.55
QMI
0.2%
0.3%
0.50 (0.15,1.65)
0.25
IDR
0.7%
0.9%
0.79 (0.43,1.44)
0.44
Stent Thrombosis
0.6%
0.31 (0.11,0.85)
0.02
Death
0.33 (0.13,0.83)
Death/QMI/IDR
1.6%
0.55 (0.33,0.93)
0.2
0.5
1.0
2.0
5.0
Cangrelor Better
Comparator (placebo) Better
* *Primary Analysis
** mITT= modified intent to treat population (patients with PCI and study drug), QMI= Q-wave myocardial infarction

28. Difference in primary endpoint not statistically significant
Lower rates of stent thrombosis, mortality

29. No significant effect on transfusions, even in high risk subgroups
Groin hematomas increased, not unexpected versus placebo

30. CHAMPION PHOENIX Randomized, double-blind, double-dummy, superiority
Primary efficacy endpoint: Death/MI/IDR/ST at 48 hours
Key secondary endpoint: Stent Thrombosis at 48 hours
Efficacy endpoints also examined at 30 days
Primary safety endpoint: GUSTO Severe Bleeding at 48 hours

31. Primary Efficacy Outcomes at 48 Hours, MITT
Cangrelor (N=5472)
Clopidogrel
(N=5470)
OR (95% CI)
P-value
Primary Analysis Adjusted1
Death/MI/IDR/ST
257/5470 (4.7%)
322/5469 (5.9%)
(0.66, 0.93)
0.005
Secondary Efficacy Outcomes at 48 Hours, MITT
Stent thrombosis (key secondary endpoint)
46/5470
(0.8%)
74/5469
(1.4%)
0.62 (0.43,0.90)
0.01 MI
207/5470 (3.8)
255/5469 (4.7)
0.80 (0.67,0.97)
0.02
Q-wave MI
11/5470 (0.2)
18/5469 (0.3)
0.61 (0.29,1.29)
0.19
IDR
28/5470 (0.5)
38/5469 ( 0.7)
0.74 (0.45,1.20)
0.22
Death
18/5470 (0.3)
1.00 (0.52,1.92)
>0.99
CV Death
1. The logistic model was adjusted for baseline status and clopidogrel dose. P value of shown on the KM curve is log rank p value.
Bhatt DL, Stone GW, Mahaffey KW, et al…. Harrington RA. NEJM 2013 at

32. IV cangrelor significantly (p=0
IV cangrelor significantly (p=0.005) reduced composite of death, MI, ischemia-driven revascularization, or stent thrombosis at 48 hours, with a 22% odds reduction
key secondary endpoint of stent thrombosis significantly reduced with 38% odds reduction
Benefit sustained through 30 days

33. No excess in severe bleeding or transfusions
Intravenous cangrelor may be an attractive option across the full spectrum of PCI, including stable angina, NSTEMI, and STEMI.

34. BRIDGE STUDY
To evaluate the use of cangrelor, an IV, reversible P2Y12 platelet inhibitor, for bridging thienopyridine-treated patients to CABG
Stage II Randomized, Double-Blind, Placebo-Controlled

35. Bridging strategy to CABG after thienopyridine discontinuation
Cangrelor (at 0.75 µg/kg/min) achieves levels of platelet inhibition known to be associated with a low risk of thrombotic events
Without increased risk of bleeding before or during CABG, although with a numerical increase in minor pre-CABG bleeding
Independent of prior thienopyridine dose & time of discontinuation
Consistent pharmaocdynamic effect during IV infusion
Rapid offset after IV discontinuation prior to surgery
No increased incidence of adverse events (e.g. dyspnea) or laboratory abnormalities despite extended dosing

36. TICAGRELOR Not a prodrug; does not require metabolic activation
Rapid onset of inhibitory effect on P2Y12 receptor
Greater inhibition of platelet aggregation than clopidogrel
Degree of inhibition reflects plasma concentration
Faster offset of effect than clopidogrel
Functional recovery of all circulating platelets
Displays no significant affinity for other P2 receptors
P2Y12 receptor is targeted by ticagrelor via noncompetitive mechanism suggesting existence of an independent receptor binding site

37. DISPERSE TRIAL
Dose-Finding Investigative Study to Assess the Pharmakodynamic Effects in Atherosclerotic Disease
Comparison of Ticagrelor With Clopidogrel
Randomized, double-blind, parallel-group dose-finding study
200 stable atherosclerotic outpatients on treatment with aspirin 75 to 100 mg once daily
Received ticagrelor (50, 100, or 200 mg BID or 400 mg QD) or clopidogrel 75 mg once daily for 28 days

38. Ticagrelor (100 or 200 mg BID or 400 mg QD) inhibited platelet aggregation more rapidly and effectively and with less variability than clopidogrel after both first dose and 28 days of therapy
Only 1 major, nonfatal hemorrhage occurred in ticagrelor 400 mg QD group
Moderate and minor bleeding events - dose related (from 29% to 51%) in ticagrelor and 32% in clopidogrel
Other adverse events- dyspnea,dizziness, headache, and hematuria
Dyspnea-dose related(10%-50mg BID, 16% mg BID and 20% mg QD)
None of dyspnea was serious
None associated with congestive heart failure or bronchospasm.

39. DISPERSE-2 study Compared safety of ticagrelor with clopidogrel
990 patients
NSTEMI treated with aspirin and standard therapy for ACS
Randomly assigned ticagrelor 90 mg BID or 180 mg BID and clopidogrel (300-mg LD 75-mg QD MD) for up to 12 weeks
Statistically significant difference in major bleedings

40. Posthoc analysis
Continuous ECG- asymptomatic ventricular pauses 2.5 seconds were more common with ticagrelor 180 mg BID
Dyspnea frequently with ticagrelor
Clinical impact appeared low, with few cases being considered serious or leading to discontinuation of treatment
Pathogenesis of dyspnea is unclear
Hypothesis - may be mediated by adenosine

41. SUBSTUDY OF DISPERSE-2
Ticagrelor inhibition of platelet aggregation-dose dependent
Both doses achieved greater inhibition than clopidogrel
Ticagrelor produced further suppression of platelet aggregation in patients who were currently receiving clopidogrel
Storey RF, Husted S, Harrington RA, Heptinstall S, Wilcox RG, Peters G,Wickens M, Emanuelsson H, Gurbel P, Grande P, Cannon CP. Inhibition of platelet aggregation by AZD6140, a reversible oral P2Y12 receptor antagonist, compared with clopidogrel in patients with acute coronary syndromes. J Am Coll Cardiol. 2007;50:1852–1856.

42. PLATO Platelet Inhibition and Patient Outcomes
Phase III randomized, double-blind, parallel group efficacy and safety study
Ticagrelor (180-mg LD 90-mg BID MD) compared with clopidogrel (300- to 600-mg LD 75-mg daily MD) for prevention of MACEs in patients with NSTEMI or STEMI
65% of enrolled patients underwent PCI

43. After 12 months of follow-up primary end point (a composite of vascular death,MI or stroke) - 9.8% in ticagrelor compared with 11.7% in patients receiving clopidogrel

44. Major efficacy endpoints
All patients*
Ticagrelor
(n=9,333)
Clopidogrel
(n=9,291)
HR for (95% CI)
p value†
Primary objective, n (%)
CV death + MI + stroke
864 (9.8)
1,014 (11.7)
0.84 (0.77–0.92)
<0.001
Secondary objectives, n (%)
Total death + MI + stroke
CV death + MI + stroke +
ischaemia + TIA + arterial
thrombotic events
Myocardial infarction
CV death
Stroke
901 (10.2)
1,290 (14.6)
504 (5.8)
353 (4.0)
125 (1.5)
1,065 (12.3)
1,456 (16.7)
593 (6.9)
442 (5.1)
106 (1.3)
0.88 (0.81–0.95)
0.84 (0.75–0.95)
0.79 (0.69–0.91)
1.17 (0.91–1.52)
0.005
0.001
0.22
Total death
399 (4.5)
506 (5.9)
0.78 (0.69–0.89)
The percentages are K-M estimates of the rate of the endpoint at 12 months.

45. Stent thrombosis
(evaluated in patients with any stent during the study)
Ticagrelor (n=5,640)
Clopidogrel
(n=5,649) HR
(95% CI)
p value
Stent thrombosis, n (%)
Definite
Probable or definite
Possible, probable, definite
71 (1.3)
118 (2.1) (2.8)
106 (1.9)
158 (2.8)
202 (3.6)
0.67 (0.50–0.91)
0.75 (0.59–0.95)
0.77 (0.62–0.95)
0.009
0.02
0.01
*Time-at-risk is calculated from first stent insertion in the study or date of randomisation

46. Higher incidence of TIMI major non–CABG related bleeding in ticagrelor (2.8%)compared with clopidogrel (2.2%;P0.03)
Incidence of TIMI major CABG related bleeding - similar
High incidence of CABG-related bleeding in both groups (446 of 931 [47.9%] in ticagrelor versus 476 of 968 [49.2%] in clopidogrel) incidence of total bleeding not significantly different

47. PLATO - Dyspnoea *p values were calculated using Fischer’s exact test
All patients
Ticagrelor
(n=9,235)
Clopidogrel
(n=9,186)
p value*
Dyspnoea, %
Any
With discontinuation of study treatment
13.8
0.9
7.8
0.1
<0.001
*p values were calculated using Fischer’s exact test

48. ELINOGREL Direct-acting, reversible P2Y12 inhibitor
Can be administered both intravenously and orally
Terminal half-life of 12 hours
Complete inhibition of P2Y12-dependent ADP induced platelet aggregation was observed at the 20-mg dose.

49. ERASE-MI
Early Rapid Reversal of Platelet Thrombosis With Intravenous PRT Before PCI to Optimize Reperfusion in Acute MI
Phase II clinical trial
Randomized trial evaluating the safety and tolerability of adjunctive antiplatelet therapy with intravenous elinogrel (10, 20, 40, and 60 mg) before PCI in patients with STEMI
Results showed that incidence of bleeding events was infrequent and appeared to be similar in patients treated with all doses of elinogrel and in placebo
ERASE-MI, published in the December 2009 issue of the American Heart JournalDr Jeffrey Berger (Duke Clinical Research Institute, Durham, NC).

50. INNOVATE-PCI Phase 2 Safety and Efficacy Study
Evaluate use of both intravenous and oral formulations
Multicenter, randomized, double-blind, triple-dummy,clopidogrel-controlled study of intravenous and oral elinogrel compared with clopidogrel in non urgent (including elective) PCI
After CAG randomized to clopidogrel or 1 of 3 doses of elinogrel
Study designed to understand clinical efficacy, biological activity, tolerability, and safety nonurgent PCI

51. Death, MI, stroke, or revascularization
INNOVATE PCI
Trial design: Patients undergoing nonurgent PCI were randomized to one of four groups prior to PCI: 1) elinogrel 80 mg IV, then 150 mg oral twice daily (n = 207); 2) elinogrel 80 mg IV, then 100 mg oral twice daily (n = 201); 3) elinogrel 80 mg IV, then 50 mg oral twice daily; or 4) clopidogrel mg, then 75 mg daily (n = 208).
Results
No TIMI major bleeds in any group
Numerical increase in access bleeds requiring medical attention with higher doses of elinogrel compared with clopidogrel
Death, MI, stroke, or revascularization: approximately 2.8% of the elinogrel 150 mg group, 4% of the elinogrel 100 mg group, and 1.5% of the clopidogrel group (p = NS)
Dyspnea: 12.1%, 15.4%, and 4.3%
(p = NS) %
4.0
2.8
1.5
Conclusions
Among patients undergoing nonurgent PCI, the use of elinogrel is feasible
Access site bleeds were numerically higher with increasing doses of elinogrel
Similar to ticagrelor, dyspnea was more common with study drug
Death, MI, stroke, or revascularization
Elinogrel 150 mg
Elinogrel 100 mg
Clopidogrel
Presented by Dr. Sunil Raul at ESC 2010

52. THANK U