Chewed or Crushed Administration of Adenosine Diphosphate Receptor Inhibitors in Acute Coronary Syndromes: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration

INTRODUCTION

Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption.

AREAS COVERED

This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023.

EXPERT OPINION

Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.

Negative Impact of ST-Segment Elevation Myocardial Infarction and Morphine Dose on Ticagrelor Uptake and Pharmacodynamics: A Population PK/PD Analysis of Pooled Individual Participant Data

BACKGROUND

Ticagrelor is widely used in patients with stable and acute coronary artery disease. Understanding the factors that influence its pharmacokinetics (PK) and pharmacodynamics (PD) could improve therapeutic outcomes. We therefore performed a pooled population PK/PD analysis using individual patient data from two studies. We focused on the impact of morphine administration and ST-segment elevation myocardial infarction (STEMI) on the risk of high platelet reactivity (HPR) and dyspnea.

METHODS

A parent-metabolite population PK/PD model was developed based on data from 63 STEMI, 50 non-STEMI, and 25 chronic coronary syndrome (CCS) patients. Simulations were then run to evaluate the risk of non-response and adverse events associated with the identified variability factors.

RESULTS

The final PK model consisted of first-order absorption with transit compartments, distribution with two compartments for ticagrelor and one compartment for AR-C124910XX (active metabolite of ticagrelor), and linear elimination for both drugs. The final PK/PD model was an indirect turnover model with production inhibition. Morphine dose and STEMI, independently, had a significant negative effect on the absorption rate (reduction of log([Formula: see text]) by 0.21×morphine dose (mg) and by 2.37 in STEMI patients, both p < 0.001), and the presence of STEMI significantly impacted both efficacy and potency (both p < 0.001). The simulations run with the validated model showed a high rate of non-response in patients with those covariates (RR 1.19 for morphine, 4.11 for STEMI and 5.73 for morphine and STEMI, all three p < 0.001). By increasing ticagrelor dosage, the negative morphine effect was reversible in patients without STEMI and just limited in patients with STEMI.

CONCLUSION

The developed population PK/PD model confirmed the negative impact of morphine administration and presence of STEMI on ticagrelor PK and antiplatelet effect. Increasing ticagrelor doses seems effective in morphine users without STEMI, whereas the STEMI effect is not entirely reversible.

Crushed/chewed administration of potent P2Y12 inhibitors in ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Systematic review and meta-analysis

Crushed or chewed potent P2Y₁₂ inhibitors are commonly used in the hope of bridging the gap of platelet inhibition in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The study aimed to investigate the efficacy and safety of this alternative oral administration strategy by performing a meta-analysis of available randomized clinical trials (RCTs). PubMed, Embase, the Cochrane Library and Web of Science medical literature databases were searched for RCTs comparing crushed/chewed vs. integral administration of loading dose potent P2Y₁₂ inhibitors in patients with STEMI undergoing pPCI with no language restrictions from inception to January 20th, 2021. The primary efficacy endpoints of high on treatment platelet reactivity (HPR) and P2Y₁₂ reaction units (PRU) at 1 hour together with safety and additional clinical endpoints were evaluated by pooled odds ratio (OR) or mean differences (MD) with 95% confidence intervals (95% CI). A total of 973 patents in six RCTs were eligible for analysis, while 876 patients present baseline and procedural characteristics. HPR and PRU at 1 hour were significantly reduced in the group receiving crushed/chewed P2Y₁₂ inhibitors compared with integral tablets (OR 0.28, 95% CI 0.16 to 0.49, P < .0001; MD -60.62, 95% CI -97.06 to -24.19, P = .001, respectively). Safety endpoints of major bleeding (OR 0.54, 95% CI 0.11 to 2.73, P = .46) and any bleeding (OR 0.84, 95% CI 0.43 to 1.64, P = .61), as well as additional clinical endpoints of cardiovascular death, myocardial infarction, and stroke were not affected by the oral administration strategy. In STEMI patients undergoing pPCI, crushed or chewed administration of potent P2Y₁₂ inhibitors are associated with enhanced early platelet inhibition and appear to be safe. The clinical profile transformed from this pharmacodynamic benefit need to be determined by further researches.

Antithrombotic treatment in primary percutaneous coronary intervention

INTRODUCTION

Despite a timely mechanical reperfusion with primary percutaneous coronary intervention (pPCI) patients presenting with ST-elevation myocardial infarction (STEMI) display an increased risk of adverse cardiovascular events. Several studies have demonstrated that guideline-directed antithrombotic therapy is effective to reduce this risk. However, there is still much to be accomplished to improve antithrombotic therapies in this clinical setting.

AREAS COVERED

This paper reviews current data on antithrombotic therapy in STEMI patients undergoing pPCI.

EXPERT OPINION

Antithrombotic therapy for STEMI patients undergoing pPCI should take into account the variability of thrombotic and bleeding risk in the short and long term. Patients with STEMI profit from the administration of early onset antiplatelet agents and anticoagulation to achieve sufficient and predictable antithrombotic effect at the time of pPCI. Thereafter, antithrombotic therapies should be tailored to individual risk of recurrence over the long term, to avoid excess bleeding, while ensuring adequate secondary ischemic prevention.