Diabetes Could Decide between Ticagrelor and Prasugrel

Diabetes has an impact on the relative effect of ticagrelor and prasugrel in patients undergoing acute coronary syndrome (ACS) according to a recent analysis of the ISAR-REACT 5 published in JACC Intv.

diabetes

Similarly to the main study outcomes, this sub-analysis of the ISAR-REACT 5 has shown that the combined end point of death, MI or stroke at one year is higher in patients treated with ticagrelor vs prasugrel (8.6% ticagrelor vs 5.2% prasugrel: HR 1.70; CI 95% 1.29-2.24). What is new is that this is true only for the NON-diabetic population.

Diabetic patients have higher events rate, but there are no differences between the two drugs (11.2% ticagrelor vs 13.0% prasugrel; HR 0.84; CI 95% 0.58-1.24). Diabetes had a significant impact on antiaggregation effect (p=0.0035 for the interaction).

Bleeding was not affected by diabetes both with ticagrelor and prasugrel.


Read also: Virtual ACC 2020 | COMPASS Sub-Analysis: Diabetes Increases the Benefit of Rivaroxaban Combined with AAS.


The ISAR-REACT 5 outcomes came as a surprise even for researchers, who expected ticagrelor superiority. There are many questions and few answers. 

Why does the advantage of prasugrel lessens in the context of diabetes? 

This might be explained by platelet hyperactivity in diabetic patients and by reduced active metabolites with prasugrel. Ticagrelor, which does not require metabolic activation, could his way compensate for lost ground and show similar results to prasugrel’s in the diabetic population.


Read also: Coronary Disease in Diabetes: Diabetic Patients Have Much Greater Plaque Progression.


The separate components of the primary end point showed no difference between the drugs in the diabetic population. This included stent thrombosis rate. 

On the other hand, in the NON-diabetic cohort, prasugrel showed a numerical benefit in mortality (3.0% vs 4.1%; p=0.077), a significant benefit in MI (2.1% vs 4.6%; p<0.001) and a significant benefit in stent thrombosis (0.3% vs 1.0%; p= 0.020).

The safety end point (3 to 5 BARC bleeding in one year) resulted similar between the drugs, both for diabetics (6.9% vs 5.5%; p=0.425) and non-diabetics (5.2% vs 4.6%; p=0.500).


Read also: Silent Diabetes Is the New Stealthy Enemy.


This might be the time to question the antiaggregation strategy bearing in mind that the studies that found ticagrelor (PLATO) and prasugrel (TRITON-TIMI 38) superiority vs. clopidogrel were published more than 10 years ago. 

Patients with acute coronary syndrome in these studies received first generation bare metal and drug eluting stents, which do not exist anymore. 

If these studies were carried out today, we should expect at least one significant difference in terms of stent thrombosis compared against the original outcomes.

2238-full

Original title: Ticagrelor and prasugrel in patients with acute coronary syndromes and diabetes mellitus.

Reference: Ndrepepa G et al. J Am Coll Cardiol Intv. 2020;13:2238-2247.


Subscribe to our weekly newsletter

Get the latest scientific articles on interventional cardiology

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.

More articles by this author

TCT 2024 | FAVOR III EUROPA

The study FAVOR III EUROPA, a randomized trial, included 2,000 patients with chronic coronary syndrome, or stabilized acute coronary syndrome, and intermediate lesions. 1,008...

TCT 2024 – ECLIPSE: Randomized Study of Orbital Atherectomy vs Conventional PCI in Severely Calcified Lesions

Coronary calcification is associated with stent under-expansion and increased risk of both early and late adverse events. Atherectomy is an essential tool for uncrossable...

TCT 2024 | Use of Drug-Coated Balloons for Side Branch Treatment in Provisional Stenting

In some cases, treating coronary bifurcations with provisional stenting requires side branch stenting, which may lead to suboptimal outcomes. Drug-coated balloons (DCBs) have emerged...

TCT 2024 | Use of Artificial Intelligence for Patients with Suspected Coronary Artery Disease

The current approach to chest pain mainly focuses on symptom characteristics, conducting functional tests for ischemia assessment. However, several randomized clinical trials have shown...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

Related Articles

SOLACI Sessionsspot_img

Recent Articles

TCT 2024 | FAVOR III EUROPA

The study FAVOR III EUROPA, a randomized trial, included 2,000 patients with chronic coronary syndrome, or stabilized acute coronary syndrome, and intermediate lesions. 1,008...

TCT 2024 | TRISCEND II

This randomized study included 400 patients; 267 were treated with EVOQUE valve and 133 with optimal medical treatment (OMT). After one-year follow-up, there were no...

TCT 2024 – ACCESS-TAVI: Comparing Percutaneous Access Closure Strategies After TAVI

Vascular access complications following transcatheter aortic valve implantation (TAVI) remain common. However, few studies compare vascular access closure methods.  Based on the CHOICE-CLOSURE and MASH...