Neurointervention.  2019 Sep;14(2):125-130. 10.5469/neuroint.2019.00087.

Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single Center Experience

Affiliations
  • 1Division of Stroke and Interventional Neurology, NH Institute of Neurosciences, Bangalore, India. drvikramhuded@gmail.com

Abstract

PURPOSE
A safe and efficacious antiplatelet drug is needed for patients with clopidogrel resistance who undergo neuroendovascular procedures. Ticagrelor is a new reversibly binding, oral, direct-acting P2Y receptor antagonist with no known resistance. We describe our clinical experience using ticagrelor for neuroendovascular procedures in Indian patients with clopidogrel resistance at the NH Institute of Neurosciences, Narayana Health City, Bangalore.
MATERIALS AND METHODS
We retrospectively reviewed our endovascular procedure database for all patients with predefined clopidogrel resistance. Clopidogrel resistance was defined as P2Y12 inhibition <40%. Patients were administered ticagrelor along with aspirin prior to the procedure.
RESULTS
Of 127 patients, 32 (25%) were non-responders to clopidogrel (22 [69%] males, 10 [31%] females; median age, 54 years [range, 20-75]). All patients were treated with a 180-mg loading dose of ticagrelor, followed by 90 mg twice daily. Twenty patients (63%) underwent endovascular intervention for intracranial aneurysm, two (6%) for dissecting aneurysms, nine (28%) for stenotic lesions, and one (3%) for carotico-cavernous fistula. No patient experienced any adverse effects related to the use of Ticagrelor in the postoperative period.
CONCLUSION
Ticagrelor is an effective alternative to clopidogrel for use in conjunction with aspirin in patients with clopidogrel resistance. None of our patients had adverse effects from ticagrelor. Drug cost, twice-daily dosing, and risk of faster platelet aggregation activation after discontinuation should be taken into consideration prior to its use in such patients.

Keyword

Clopidogrel; Ticagrelor; Endovascular procedures; Stents

MeSH Terms

Aneurysm, Dissecting
Aspirin
Drug Costs
Endovascular Procedures
Female
Fistula
Humans
Intracranial Aneurysm
Male
Neurosciences
Platelet Aggregation
Postoperative Period
Retrospective Studies
Stents
Aspirin

Cited by  2 articles

Commentary to: Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single-Center Experience
Harsh Deora, Amit Agrawal, Luis Rafael Moscote-Salazar
Neurointervention. 2020;15(1):46-48.    doi: 10.5469/neuroint.2019.00192.

Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel
Ehsan Dowlati, Kory B. Dylan Pasko, Jiaqi Liu, Charles A. Miller, Daniel R. Felbaum, Samir Sur, Jason J. Chang, Ai-Hsi Liu, Rocco A. Armonda, Jeffrey C. Mai
Neurointervention. 2021;16(3):285-292.    doi: 10.5469/neuroint.2021.00290.


Reference

1. Higo T, Ueda Y, Matsuo K, Nishio M, Hirata A, Asai M, et al. Risk of in-stent thrombus formation at one year after drug-eluting stent implantation. Thromb Res. 2011; 128:431–434.
Article
2. Hara M, Nishino M, Taniike M, Makino N, Kato H, Egami Y, et al. High incidence of thrombus formation at 18 months after paclitaxel-eluting stent implantation: angioscopic comparison with sirolimus-eluting stent. Am Heart J. 2010; 159:905–910.
Article
3. Otake H, Shite J, Ako J, Shinke T, Tanino Y, Ogasawara D, et al. Local determinants of thrombus formation following sirolimus-eluting stent implantation assessed by optical coherence tomography. JACC Cardiovasc Interv. 2009; 2:459–466.
Article
4. Kuijpers MJE, Megens RT, Nikookhesal E, Feijge MA, De Mey JG, oude Egbrink MG, et al. Role of newly formed platelets in thrombus formation in rat after clopidogrel treatment: comparison to the reversible binding P2Y12 antagonist ticagrelor. Thromb Haemost. 2011; 106:1179–1188.
Article
5. Patil SB, Jackman LE, Francis SE, Judge HM, Nylander S, Storey RF. Ticagrelor effectively and reversibly blocks murine platelet P2Y12-mediated thrombosis and demonstrates a requirement for sustained P2Y12 inhibition to prevent subsequent neointima. Arterioscler Thromb Vasc Biol. 2010; 30:2385–2391.
6. Birkeland K, Parra D, Rosenstein R. Antiplatelet therapy in acute coronary syndromes: focus on ticagrelor. J Blood Med. 2010; 1:197–219.
7. Heer T, Juenger C, Gitt AK, Bauer T, Towae F, Zahn R, et al. Efficacy and safety of optimized antithrombotic therapy with aspirin, clopidogrel and enoxaparin in patients with non-ST segment elevation acute coronary syndromes in clinical practice. J Thromb Thrombolysis. 2009; 28:325–332.
Article
8. Sprigg N, Gray LJ, England T, Willmot MR, Zhao L, Sare GM, et al. A randomised controlled trial of triple antiplatelet therapy (aspirin, clopidogrel and dipyridamole) in the secondary prevention of stroke: safety, tolerability and feasibility. PLoS One. 2008; 3:e2852.
Article
9. Bowry AD, Brookhart MA, Choudhry NK. Meta-analysis of the efficacy and safety of clopidogrel plus aspirin as compared to antiplatelet monotherapy for the prevention of vascular events. Am J Cardiol. 2008; 101:960–966.
Article
10. Cooke GE, Goldschmidt-Clermont PJ. The safety and efficacy of aspirin and clopidogrel as a combination treatment in patients with coronary heart disease. Expert Opin Drug Saf. 2006; 5:815–826.
Article
11. Fifi JT, Brockington C, Narang J, Leesch W, Ewing SL, Bennet H, et al. Clopidogrel resistance is associated with thromboembolic complications in patients undergoing neurovascular stenting. AJNR Am J Neuroradiol. 2013; 34:716–720.
Article
12. Goh C, Churilov L, Mitchell P, Dowling R, Yan B. Clopidogrel hyper-response and bleeding risk in neurointerventional procedures. AJNR Am J Neuroradiol. 2013; 34:721–726.
Article
13. Prabhakaran S, Wells KR, Lee VH, Flaherty CA, Lopes DK. Prevalence and risk factors for aspirin and clopidogrel resistance in cerebrovascular stenting. AJNR Am J Neuroradiol. 2008; 29:281–285.
Article
14. Sorkin GC, Dumont TM, Wach MM, Eller JL, Mokin M, Natarajan SK, et al. Carotid artery stenting outcomes: do they correlate with antiplatelet response assays? J Neurointerventional Surg. 2014; 6:373–378.
Article
15. Lee DH, Arat A, Morsi H, Shaltoni H, Harris JR, Mawad ME. Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience. AJNR Am J Neuroradiol. 2008; 29:1389–1394.
Article
16. Müller-Schunk S, Linn J, Peters N, Spannagl M, Deisenberg M, Brückmann H, et al. Monitoring of clopidogrel-related platelet inhibition: correlation of nonresponse with clinical outcome in supra-aortic stenting. AJNR Am J Neuroradiol. 2008; 29:786–791.
Article
17. Drazin D, Choulakian A, Nuño M, Kornbluth P, Alexander MJ. Body weight: a risk factor for subtherapeutic antithrombotic therapy in neurovascular stenting. J Neurointerventional Surg. 2011; 3:177–181.
Article
18. Cannon CP, Harrington RA, James S, Ardissino D, Becker RC, Emanuelsson H, et al. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet. 2010; 375:283–293.
Article
19. Capodanno D, Calvi V, Tamburino C. Effect size of ticagrelor over clopidogrel in the Platelet Inhibition and Patient Outcomes (PLATO) trial: from statistics to clinical judgment. J Cardiovasc Med (Hagerstown). 2012; 13:162–163.
20. Capodanno D, Dharmashankar K, Angiolillo DJ. Mechanism of action and clinical development of ticagrelor, a novel platelet ADP P2Y12 receptor antagonist. Expert Rev Cardiovasc Ther. 2010; 8:151–158.
21. Cattaneo M. Ticagrelor versus clopidogrel in acute coronary syndromes. N Engl J Med. 2009; 361:2386. ; author reply 2387-2388.
Article
22. Cheng JW. Ticagrelor: oral reversible P2Y(12) receptor antagonist for the management of acute coronary syndromes. Clin Ther. 2012; 34:1209–1220.
Article
23. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361:1045–1057.
Article
24. Angiolillo DJ, Fernandez-Ortiz A, Bernardo E, Alfonso F, Macaya C, Bass TA, et al. Variability in individual responsiveness to clopidogrel: clinical implications, management, and future perspectives. J Am Coll Cardiol. 2007; 49:1505–1516.
25. Guha S, Sardar P, Guha P, Roy S, Mookerjee S, Chakrabarti P, et al. Dual antiplatelet drug resistance in patients with acute coronary syndrome. Indian Heart J. 2009; 61:68–73.
26. Kar R, Meena A, Yadav BK, Yadav R, Kar SS, Saxena R. Clopidogrel resistance in North Indian patients of coronary artery disease and lack of its association with platelet ADP receptors P2Y1 and P2Y12 gene polymorphisms. Platelets. 2013; 24:297–302.
Article
27. Bonello L, Tantry US, Marcucci R, Blindt R, Angiolillo DJ, Becker R, et al. Consensus and future directions on the definition of high on-treatment platelet reactivity to adenosine diphosphate. J Am Coll Cardiol. 2010; 56:919–933.
Article
28. Pinto Slottow TL, Bonello L, Gavini R, Beauzile P, Sushinsky SJ, Scheinowitz M, et al. Prevalence of aspirin and clopidogrel resistance among patients with and without drug-eluting stent thrombosis. Am J Cardiol. 2009; 104:525–530.
Article
29. Husted S, Emanuelsson H, Heptinstall S, Sandset PM, Wickens M, Peters G. Pharmacodynamics, pharmacokinetics, and safety of the oral reversible P2Y12 antagonist AZD6140 with aspirin in patients with atherosclerosis: a double-blind comparison to clopidogrel with aspirin. Eur Heart J. 2006; 27:1038–1047.
Article
30. Storey RF, Husted S, Harrington RA, Heptinstall S, Wilcox RG, Peters G, et al. 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.
31. Gurbel PA, Bliden KP, Butler K, Tantry US, Gesheff T, Wei C, et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation. 2009; 120:2577–2585.
32. Husted S, Boersma E. Case study: ticagrelor in PLATO and Prasugrel in TRITON-TIMI 38 and TRILOGY-ACS trials in patients with acute coronary syndromes. Am J Ther. 2016; 23:e1876. –e1889.
Article
33. Becker RC, Bassand JP, Budaj A, Wojdyla DM, James SK, Cornel JH, et al. Bleeding complications with the P2Y12 receptor antagonists clopidogrel and ticagrelor in the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J. 2011; 32:2933–2944.
Article
34. Gurbel PA, Bliden KP, Butler K, Antonino MJ, Wei C, Teng R, et al. Response to ticagrelor in clopidogrel nonresponders and responders and effect of switching therapies: the RESPOND study. Circulation. 2010; 121:1188–1199.
35. Hanel RA, Taussky P, Dixon T, Miller DA, Sapin M, Nordeen JD, et al. Safety and efficacy of ticagrelor for neuroendovascular procedures. A single center initial experience. J Neurointerv Surg. 2014; 6:320–322.
Article
Full Text Links
  • NI
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr