Fentanyl is a potent opiate commonly administered in the cath lab. Recently, questions on its safety have been raised by research demonstrating that intravenous morphine significantly delays the absorption of oral P2Y12 platelet inhibitors. The mechanism might be slowed gastric emptying.

The Platelet Aggregation with tiCagrelor Inhibition and FentanYl (PACIFY) trial enrolled 212 patients undergoing indicated angioplasty and randomized them to receive the procedure with or without fentanyl. Furthermore, all participants received subcutaneous lidocaine and intravenous midazolam besides 180 mg of ticagrelor as antiplatelet agent.

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Blood samples were taken in order to analyze the plasmatic concentration of ticagrelor 0.5, 1, 2, 4, and 24 hours after the load. Platelet function was also measured at 2 hours with the VerifyNow system.

The group receiving fentanyl presented significantly lower plasmatic concentrations of ticagrelor and higher platelet reactivity with the addition of ADP 2 hours after the load.

No differences in ticagrelor concentration were observed at 4 hours.

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In a pain survey with a 1-10 scale, patients who received fentanyl reported a 1.5 maximum pain vs. 2.3 reported by patients who did not receive the drug (p = 0.14).

One patient who received fentanyl experienced acute stent thrombosis and another presented catheter thrombosis. There were no thrombotic events in patients who did not receive fentanyl.

The post-procedural levels of ultra-sensitive troponin were significantly higher in the group receiving fentanyl, which raises questions on the clinical importance of the interaction between these drugs.

Conclusion

Routine use of fentanyl as part of sedation in coronary angioplasty reduces the absorption of ticagrelor and delays platelet inhibition, without comfort improvement as a counterpart.

Editorial

These results are added to the list of prior reports on how morphine delays the absorption of clopidogrel, prasugrel, and ticagrelor.

The prophylactic administration of fentanyl at the start of catheterization should be reconsidered.

Original title: Effect of Intravenous Fentanyl on Ticagrelor Absorption and Platelet Inhibition Among Patients Undergoing Percutaneous Coronary Intervention: The PACIFY Randomized Clinical Trial.

Reference: John W. McEvoy et al. Circulation. 2017 Oct 18. Epub ahead of print.

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