Magazine article Drug Topics

Dual Antiplatelet Therapy Lowers Risk of CV Death in MI Secondary Prevention

Magazine article Drug Topics

Dual Antiplatelet Therapy Lowers Risk of CV Death in MI Secondary Prevention

Article excerpt

ANTICOAGULATION THERAPIES

A recently published study showed that patients who received dual antiplatelet therapy two years postmyocardial infarction (MI) had a 15% lower risk of MI, stroke, or CV death compared with patients who received placebo plus aspirin during a median 33 months follow-up.

Study patients were randomized to low-dose ticagrelor (60 mg twice daily), high-dose ticagrelor (90 mg twice daily), or placebo plus aspirin. The efficacy end point was virtually the same with low-dose or high-dose ticagrelor. However, patients had a 2.3-fold and 2.6-fold higher risk of clinically significant bleeding and a 3.0-fold and 3.7-fold higher risk of transfusion with low-dose and high-dose ticagrelor, respectively, compared with patients in the placebo group. The drug was also associated with an approximately 3-fold greater risk of dyspnea. Roughly 30% of patients discontinued the study drug.

Secondary prevention of MI still remains a careful balancing act between risks and benefits. These results suggest that low-dose ticagrelor plus aspirin may be a viable alternative for secondary MI prevention in patients for whom the benefits outweigh the risks of bleeding.

Source: Bonaca MP, Bhatt DL, Cohen M. Long-term use of ticagrelor in patients with prior myocardial infarction. NEJM 2015. http://bit.ly/Ltuticag. Published online March 14, 2015.

Pharmacogenetic testing worthwhile for newer anticoagulants

Polymorphisms in two genes, CYP2C9 and VKORC1, account for about 40% of the variability in patients' responses to warfarin. Use of FDA-approved initial-dosing recommendations based on these genetic tests increases time in the therapeutic range, but genotype-based dosing hasn't been shown to improve clinical outcomes. Testing is not reimbursed by Medicare.

In a previous trial (ENGAGE AF-TIMI 48), 21,105 adults with nonvalvular atrial fibrillation were randomized to receive warfarin (INR of 2.0-3.0) or daily edoxaban (30 or 60 mg) for a median 2.8 years. Genotyping was done for more than 14,000 of these patients, who were then stratified as having a normal, sensitive, or highly sensitive response to warfarin (62%, 35%, and 3%, respectively).

In the first 90 days of treatment, those patients with a highly sensitive or sensitive response had supratherapeutic warfarin levels a greater proportion of time (18.3% and 8.4%, respectively) than did those with a normal response (2. …

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