{"id":28941,"date":"2012-05-11T12:21:03","date_gmt":"2012-05-11T16:21:03","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=28941"},"modified":"2012-05-14T14:59:15","modified_gmt":"2012-05-14T18:59:15","slug":"a-brilinta-theory-on-why-ticagrelor-doesnt-work-as-well-in-the-u-s","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/05\/11\/a-brilinta-theory-on-why-ticagrelor-doesnt-work-as-well-in-the-u-s\/","title":{"rendered":"A ‘Brilinta’ Theory on Why Ticagrelor Doesn\u2019t Work as Well in the U.S."},"content":{"rendered":"

In July 2011, the FDA approved ticagrelor<\/a> (Brilinta) as a blood-thinner for acute coronary syndrome patients. Both before and since then, experts and frontline clinicians have been discussing why this selective P2Y12-receptor antagonist did not show, in the PLATO randomized comparison<\/a> with clopidogrel,\u00a0a significant advantage in North American participants<\/a> \u2014\u00a0even though it showed a benefit in the overall trial and in non-U.S. participants. Some have wondered whether relatively higher doses of aspirin used in the U.S. might be the problem<\/a> and, therefore, that such doses should be \u201cavoided\u201d by users of ticagrelor.\u00a0However, there is a very simple alternative\u00a0theory:<\/p>\n

Intermediate-dose\u00a0aspirin is just plain more effective than low-dose\u00a0aspirin.<\/strong> Therefore, ticagrelor provides no additional benefit when intermediate-dose aspirin is being used.<\/p>\n

Take a look at the \u201cancient\u201d aspirin trials, in which relatively higher doses of aspirin were often associated with outcome benefits despite more gastrointestinal bleeding. Many\u00a0physicians do not know\u00a0\u2014 or maybe just forgot \u2014 that some early trials showing a significant benefit of aspirin were done with 1300 mg daily<\/a>!\u00a0I\u2019m not suggesting doses on that scale, but rather 162 mg to 325 mg daily, which also showed benefits in early studies<\/a>.<\/p>\n

Anecdotally, we seem to see\u00a0a lot less GI bleeding nowadays, as the\u00a0early studies were conducted before\u00a0routine use of H2-receptor antagonists and proton-pump inhibitors.\u00a0Given that some patients have aspirin resistance and there is a dose-response curve\u00a0(albeit nonlinear), it\u00a0makes sense that some subgroups may benefit from intermediate-dose\u00a0aspirin (just as we explore whether some patients benefit from higher doses of clopidogrel).<\/p>\n

The proper message may not be to \u201cavoid tigacrelor\u201d\u00a0if you take intermediate-dose\u00a0aspirin. Perhaps\u00a0you just\u00a0don\u2019t need ticagrelor in the first place because aspirin\u2019s already doing the job.\u00a0Yes, this goes against the ACCF\/AHA guidelines<\/a>, but\u00a0that\u2019s what blog posts are for.<\/p>\n

What do you think about my intermediate-dose aspirin theory? Please chime in.<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Harry Peled wonders whether intermediate-dose aspirin may simply be so effective that it obviates the need for a P2Y12-receptor antagonist.<\/p>\n","protected":false},"author":421,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[495,7],"tags":[239,1267,364,255,1266,240],"class_list":["post-28941","post","type-post","status-publish","format-standard","hentry","category-anticoagulation-2","category-prevention","tag-acs","tag-acute-coronary-syndromes","tag-aspirin","tag-brilinta","tag-p2y12-receptor-antagonists","tag-ticagrelor"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28941","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/421"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=28941"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28941\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=28941"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=28941"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=28941"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}