Practical experience with ticagrelor: An Australian and New Zealand perspective

Scott A. Harding, William J. Van Gaal, Ryan Schrale, Athula Gunasekara, John Amerena, Christian J. Mussap, Philip E. Aylward

Research output: Contribution to journalReview article

6 Citations (Scopus)

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.

LanguageEnglish
Pages1469-1477
Number of pages9
JournalCurrent Medical Research and Opinion
Volume31
Issue number8
DOIs
Publication statusPublished - 3 Aug 2015

Keywords

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

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Harding, S. A., Van Gaal, W. J., Schrale, R., Gunasekara, A., Amerena, J., Mussap, C. J., & Aylward, P. E. (2015). Practical experience with ticagrelor: An Australian and New Zealand perspective. Current Medical Research and Opinion, 31(8), 1469-1477. https://doi.org/10.1185/03007995.2015.1058247
Harding, Scott A. ; Van Gaal, William J. ; Schrale, Ryan ; Gunasekara, Athula ; Amerena, John ; Mussap, Christian J. ; Aylward, Philip E. / Practical experience with ticagrelor : An Australian and New Zealand perspective. In: Current Medical Research and Opinion. 2015 ; Vol. 31, No. 8. pp. 1469-1477.
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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.",
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Harding, SA, Van Gaal, WJ, Schrale, R, Gunasekara, A, Amerena, J, Mussap, CJ & Aylward, PE 2015, 'Practical experience with ticagrelor: An Australian and New Zealand perspective', Current Medical Research and Opinion, vol. 31, no. 8, pp. 1469-1477. https://doi.org/10.1185/03007995.2015.1058247

Practical experience with ticagrelor : An Australian and New Zealand perspective. / Harding, Scott A.; Van Gaal, William J.; Schrale, Ryan; Gunasekara, Athula; Amerena, John; Mussap, Christian J.; Aylward, Philip E.

In: Current Medical Research and Opinion, Vol. 31, No. 8, 03.08.2015, p. 1469-1477.

Research output: Contribution to journalReview article

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T1 - Practical experience with ticagrelor

T2 - Current Medical Research and Opinion

AU - Harding, Scott A.

AU - Van Gaal, William J.

AU - Schrale, Ryan

AU - Gunasekara, Athula

AU - Amerena, John

AU - Mussap, Christian J.

AU - Aylward, Philip E.

PY - 2015/8/3

Y1 - 2015/8/3

N2 - 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.

AB - 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.

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KW - Antiplatelet agents

KW - Bleeding

KW - Myocardial infarction

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Harding SA, Van Gaal WJ, Schrale R, Gunasekara A, Amerena J, Mussap CJ et al. Practical experience with ticagrelor: An Australian and New Zealand perspective. Current Medical Research and Opinion. 2015 Aug 3;31(8):1469-1477. https://doi.org/10.1185/03007995.2015.1058247