|Pharmacotherapeutic group: Platelet aggregation inhibitors excluding heparin. ATC code: B01AC22.|
PharmacodynamicsPrasugrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the P2Y12 class of ADP receptors on platelets. Since platelets participate in the initiation and/or evolution of thrombotic complications of atherosclerotic disease, inhibition of platelet function can result in the reduction of the rate of cardiovascular events such as death, myocardial infarction, or stroke.Following a 60 mg loading dose of prasugrel, inhibition of ADP-induced platelet aggregation occurs at 15 minutes with 5 µM ADP and 30 minutes with 20 µM ADP. The maximum inhibition by prasugrel of ADP-induced platelet aggregation is 83% with 5 µM ADP and 79% with 20 µM ADP, in both cases with 89% of healthy subjects and patients with stable atherosclerosis achieving at least 50% inhibition of platelet aggregation by 1 hour. Prasugrel-mediated inhibition of platelet aggregation exhibits low between-subject (9%) and within-subject (12%) variability with both 5 µM and 20 µM ADP. Mean steady-state inhibition of platelet aggregation was 74% and 69% respectively for 5 µM ADP and 20 µM ADP, and was achieved following 3 to 5 days of administration of the 10 mg prasugrel maintenance dose preceded by a 60 mg loading dose. More than 98% of subjects had ≥20% inhibition of platelet aggregation during maintenance dosing.Platelet aggregation gradually returned to baseline values after treatment in 7 to 9 days after administration of a single 60 mg loading dose of prasugrel, and in 5 days following discontinuation of maintenance dosing at steady-state.Switching data: Following administration of 75 mg clopidogrel once daily for 10 days, 40 healthy subjects were switched to prasugrel 10 mg once daily with or without a loading dose of 60 mg. Similar or higher inhibition of platelet aggregation was observed with prasugrel. Switching directly to prasugrel 60 mg loading dose resulted in the most rapid onset of higher platelet inhibition. Following administration of a 900 mg loading dose of clopidogrel (with ASA), 56 subjects with ACS were treated for 14 days with either prasugrel 10 mg once daily or clopidogrel 150 mg once daily, and then switched to either clopidogrel 150 mg or prasugrel 10 mg for another 14 days. Higher inhibition of platelet aggregation was observed in patients switched to prasugrel 10 mg compared with those treated with clopidogrel 150 mg. In a study of 276 ACS patients managed with PCI, switching from an initial loading dose of 600 mg clopidogrel or placebo administered upon presentation to the hospital prior to coronary angiography to a 60 mg loading dose of prasugrel administered at the time of percutaneous coronary intervention, resulted in a similar increased inhibition of platelet aggregation for the 72 hour duration of the study.
Efficacy and Safety in Acute Coronary Syndrome (ACS)The phase 3 TRITON study compared Efient (prasugrel) with clopidogrel, both co-administered with ASA and other standard therapy. TRITON was a 13,608 patient, multi-centre international, randomised, double-blind, parallel group study. Patients had ACS with moderate to high risk UA, NSTEMI, or STEMI and were managed with PCI.Patients with UA/NSTEMI within 72 hours of symptoms or STEMI between 12 hours to 14 days of symptoms were randomised after knowledge of coronary anatomy. Patients with STEMI within 12 hours of symptoms and planned for primary PCI could be randomised without knowledge of coronary anatomy. For all patients, the loading dose could be administered any time between randomisation and 1 hour after the patient left the catheterisation lab. Patients randomised to receive prasugrel (60 mg loading dose followed by 10 mg once daily) or clopidogrel (300 mg loading dose followed by 75 mg once daily) were treated for a median of 14.5 months (maximum of 15 months with a minimum of 6 months follow-up). Patients also received ASA (75 mg to 325 mg once daily). Use of any thienopyridine within 5 days before enrolment was an exclusion criterion. Other therapies, such as heparin and GPIIb/IIIa inhibitors, were administered at the discretion of the physician. Approximately 40% of patients (in each of the treatment groups) received GPIIb/IIIa inhibitors in support of PCI (no information available regarding the type of GPIIb/IIIa inhibitor used). Approximately 98% of patients (in each of the treatment groups) received antithrombins (heparin, low molecular weight heparin, bivalirudin, or other agent) directly in support of PCI.The trial's primary outcome measure was the time to first occurrence of cardiovascular (CV) death, non-fatal myocardial infarction (MI), or non-fatal stroke. Analysis of the composite endpoint in the All ACS population (combined UA/NSTEMI and STEMI cohorts) was contingent on showing statistical superiority of prasugrel versus clopidogrel in the UA/NSTEMI cohort (p<0.05).All ACS population: Efient showed superior efficacy compared to clopidogrel in reducing the primary composite outcome events as well as the pre-specified secondary outcome events, including stent thrombosis (see Table 3). The benefit of prasugrel was apparent within the first 3 days and it persisted to the end of study. The superior efficacy was accompanied by an increase in major bleeding (see sections 4.4 and 4.8). The patient population was 92% Caucasian, 26% female, and 39% ≥65 years of age. The benefits associated with prasugrel were independent of the use of other acute and long-term cardiovascular therapies, including heparin/low molecular weight heparin, bivalirudin, intravenous GPIIb/IIIa inhibitors, lipid-lowering medicinal products, beta-blockers, and angiotensin converting enzyme inhibitors. The efficacy of prasugrel was independent of the ASA dose (75 mg to 325 mg once daily). The use of oral anticoagulants, non-study antiplatelet medicinal products and chronic NSAIDs was not allowed in TRITON. In the All ACS population, prasugrel was associated with a lower incidence of CV death, non-fatal MI, or non-fatal stroke compared to clopidogrel, regardless of baseline characteristics such as age, sex, body weight, geographical region, use of GPIIb/IIIa inhibitors, and stent type. The benefit was primarily due to a significant decrease in non-fatal MI (see Table 3). Subjects with diabetes had significant reductions in the primary, and all secondary composite endpoints.The observed benefit of prasugrel in patients ≥ 75 years was less than that observed in patients <75 years. Patients ≥ 75 years were at increased risk of bleeding, including fatal (see sections 4.2, 4.4, and 4.8). Patients ≥ 75 years in whom the benefit with prasugrel was more evident included those with diabetes, STEMI, higher risk of stent thrombosis, or recurrent events.Patients with a history of TIA or a history of ischaemic stroke more than 3 months prior to prasugrel therapy had no reduction in the primary composite endpoint.
Table 3: Patients with Outcome Events in TRITON Primary Analysis
In the All ACS population, analysis of each of the secondary endpoints showed a significant benefit (p<0.001) for prasugrel versus clopidogrel. These included definite or probable stent thrombosis at study end (0.9% vs. 1.8%; HR 0.498; CI 0.364, 0.683); CV death, non-fatal MI, or urgent target vessel revascularisation through 30 days (5.9% vs. 7.4%; HR 0.784; CI 0.688,0.894); all cause death, non-fatal MI, or non-fatal stroke through study end (10.2% vs. 12.1%; HR 0.831; CI 0.751, 0.919); CV death, non-fatal MI, non-fatal stroke or rehospitalisation for cardiac ischaemic event through study end (11.7% vs. 13.8%; HR 0.838; CI 0.762, 0.921). Analysis of all cause death did not show any significant difference between prasugrel and clopidogrel in the All ACS population (2.76% vs. 2.90%), in the UA/NSTEMI population (2.58% vs. 2.41%), and in the STEMI population (3.28% vs. 4.31%).Prasugrel was associated with a 50% reduction in stent thrombosis through the 15-month follow-up period. The reduction in stent thrombosis with Efient was observed both early and beyond 30 days for both bare metal and drug eluting stents.In an analysis of patients who survived an ischaemic event, prasugrel was associated with a reduction in the incidence of subsequent primary endpoint events (7.8% for prasugrel vs. 11.9% for clopidogrel).Although bleeding was increased with prasugrel, an analysis of the composite endpoint of death from any cause, non-fatal myocardial infarction, non-fatal stroke, and Non-CABG-related TIMI major haemorrhage favoured Efient compared to clopidogrel (Hazard Ratio, 0.87; 95% CI, 0.79 to 0.95; p=0.004). In TRITON, for every 1000 patients treated with Efient, there were 22 fewer patients with myocardial infarction, and 5 more with NonCABG-related TIMI major haemorrhages, compared with patients treated with clopidogrel.Results of a pharmacodynamic/pharmacogenomic study in 720 Asian ACS PCI patients demonstrated that higher levels of platelet inhibition are achieved with prasugrel compared to clopidogrel, and that prasugrel 60-mg loading dose/10-mg maintenance dose is an appropriate dose regimen in Asian subjects who weigh at least 60 kg and are less than 75 years of age (see section 4.2).In a 30 month study (TRILOGYACS) in 9326 patients with UA/NSTEMI ACS medically managed without revascularisation (non-licensed indication), prasugrel did not significantly reduce the frequency of the composite endpoint of CV death, MI or stroke compared to clopidogrel. Rates of TIMI major bleeding (including life threatening, fatal and ICH) were similar in prasugrel and clopidogrel treated patients. Patients ≥75 years old or those below 60 kg (N=3022) were randomized to 5 mg prasugrel. As in the < 75 years old and ≥60 kg patients treated with 10 mg prasugrel, there was no difference between 5 mg prasugrel and 75 mg clopidogrel in CV outcomes. Rates of major bleeding were similar in patients treated with 5 mg prasugrel and those treated with 75 mg clopidogrel. Prasugrel 5 mg provided greater antiplatelet effect than clopidogrel 75 mg. Prasugrel should be used with caution in patients ≥ 75 years old and in patients weighing <60 kg (see sections 4.2, 4.4 and 4.8).
|Outcome Events||Prasugrel + ASA||Clopidogrel +ASA||Hazard Ratio (HR) (95% CI)||p-value|
|All ACS||(N=6813)%||(N=6795)%||0.812 (0.732, 0.902)
|Primary Composite Outcome EventsCardiovascular (CV) death, non-fatal MI, or non-fatal stroke
|Primary Individual Outcome Events|
||0.886 (0.701, 1.118)
||0.757 (0.672, 0.853)
||1.016 (0.712, 1.451)
|UA/NSTEMI Primary Composite Outcome Events||(N= 5044)%||(N=5030)%|| || |
|CV death, non-fatal MI, or non-fatal stroke
||0.820 (0.726, 0.927)
|STEMIPrimary Composite Outcome Events||(N= 1769)%||(N=1765)%|| || |
|CV death, non-fatal MI, or non-fatal stroke
||0.793 (0.649, 0.968)