Platelet Inhibition With Ticagrelor 60 mg Versus Ticagrelor 90 mg in Elderly Patients With ACS (PlinytheElder)

July 6, 2022 updated by: Giovanni Esposito, Federico II University

Platelet Inhibition With Ticagrelor 60 mg Versus Ticagrelor 90 mg Twice Daily in Elderly Patients With Acute Coronary Syndrome (ACS)

Elderly individuals are increasingly represented among patients with acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 receptor inhibitor has an established role in the prevention of atherothrombotic events in ACS setting. However, DAPT in older patients is challenged by a concurrent heightened risk of ischemia and bleeding. Although guidelines recommend DAPT with aspirin and ticagrelor for elderly patients with ACS, clopidogrel, a less potent antiplatelet agent, continues to be used in more than one third of ACS patients with elderly status being the strongest predictor of undertreatment. A lower dose of ticagrelor may represent an alternative to the standard dose by conferring a similar efficacy and, potentially, a better safety profile. Our prospective, randomized, double-blind, crossover trial will test the hypothesis that a lower dose of ticagrelor provides similar antiplatelet effects compared with a standard dose among elderly patients with ACS.

The main aim of the trial is to determine the pharmacodynamic and pharmacokinetic profile of ticagrelor 60 mg twice daily versus ticagrelor 90 mg twice daily among elderly patients with ACS undergoing PCI.

This will be a prospective, randomized (1:1 ratio), non-inferiority, open-label, crossover trial to evaluate the level of platelet inhibition achieved with a low-dose of ticagrelor (60 mg twice daily) versus a standard dose of ticagrelor (90 mg twice daily) among elderly patients with ACS undergoing PCI.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Elderly individuals account for an increasing proportion of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) given the aging of the population and the lengthening of life expectancy.1, 2 Dual antiplatelet therapy with aspirin and an oral P2Y12 receptor inhibitor is the cornerstone of antithrombotic therapy in patients with ACS undergoing PCI, yet decision-making in older patients remains challenging because of a concomitantly increased risk of bleeding and ischemic complications burdening this population.3 Elderly status may be considered per se a condition at heightened risk of bleeding since, by applying available risk scores, patients aged 75 years or more who undergo PCI are classified as moderate-to-high risk of bleeding irrespective of other additional features.4 Current guidelines recommend DAPT in the setting of ACS and ticagrelor, an oral, reversible, direct-acting P2Y12 receptor inhibitor, should be preferred to clopidogrel and prasugrel among elderly patients.5 Nevertheless, observational studies have consistently shown that new P2Y12 receptor inhibitors continue to be withheld in more than one third of eligible patients with ACS and that aging is the most powerful predictor of undertreatment with clopidogrel.6 This occurs for several reasons, including adverse bleeding events or nonbleeding events, a perceived too high bleeding risk, and the higher risk profile of elderly patients seen in clinical practice compared with that in randomized trials. Therefore, alternative antithrombotic strategies should be pursued for elderly patients with ACS in order to minimize the harmful effects of more potent antiplatelet inhibition without withholding the established ischemic benefit. At this regard, a standard dose of prasugrel (10 mg daily) resulted in a negative net benefit among elderly patients with ACS and a lower dose of prasugrel (5 mg daily) did not prove safer or more effective than clopidogrel.7 8 Since the risk-benefit profile of a full dose of ticagrelor (90 mg twice daily) seemed more favorable among elderly individuals, a lower dose regimen of ticagrelor (60 mg twice daily) has the potential to improve the safety profile of potent P2Y12 receptor inhibition while providing an equally effective option.

A low-dose of ticagrelor has been evaluated in the PEGASUS-TIMI 54 trial, in which 21,162 patients, who were on aspirin and had a myocardial infarction 1 to 3 years earlier, were randomized to ticagrelor at a dose of 90 mg twice daily, ticagrelor at a dose of 60 mg daily, or placebo. The primary efficacy endpoint of cardiovascular death, myocardial infarction, and stroke through 3 years was significantly reduced by 15% and 16% among patients randomized to standard and low-dose of ticagrelor compared with placebo. Patients randomly allocated to the standard and low dose of ticagrelor had a 169% and 132% relative risk increase in major bleeding compared with placebo. Of interest, ticagrelor 90 mg vs. placebo had the greatest benefit for the primary efficacy endpoint among younger than older patients (20% relative risk reduction vs. 2% relative risk increase, respectively), whereas ticagrelor 60 mg vs. placebo had the greatest benefit for the primary efficacy endpoint among older than younger patients (23% relative risk reduction vs. 14% relative risk reduction, respectively). For the safety profile, elderly patients had roughly a 2-fold higher incidence of bleeding compared with younger patients, with ticagrelor 90 mg being associated with the highest rate of bleeding (4.81%). Conversely, ticagrelor 60 mg was associated with a lower incidence of major bleeding (-0.7% absolute difference) compared with ticagrelor 90 mg, even though major bleeding events were increased compared with placebo (+2.43% absolute difference).9 Taken together, the data from the PEGASUS-TIMI 54 suggest ticagrelor 60 mg twice daily may present the best combination of efficacy and safety for elderly patients.

Although no specific data are available for ticagrelor 60 mg among elderly patients with ACS, a substudy of the PEGASUS- TIMI 54 trial showed that ticagrelor 60 mg twice daily achieved a platelet inhibition similar to that with 90 mg twice daily (PRU values: 59±63 and 47±43 for ticagrelor 60 and 90 mg twice daily, respectively).10 Noteworthy, these data have been observed in a relatively younger population (mean age 64 years) with stable coronary artery disease after nearly 2 years from the index myocardial infarction.10 Consequently, the findings of the PEGASUS-TIMI 54 trial cannot be directly extrapolated to our population with since both elderly status and ACS are associated with higher platelet reactivity.

Primary Objectives: the main aim of the trial is to determine whether the efficacy of ticagrelor 60 mg twice daily is not inferior to that of ticagrelor 90 mg twice daily among elderly patients with ACS undergoing PCI.

Secondary Objectives: To evaluate adverse events in patients treated with ticagrelor 60 mg and ticagrelor 90 mg. To determine the pharmacokinetic profile of ticagrelor 60 mg twice daily versus ticagrelor 90 mg twice daily.

This will be a prospective, randomized (1:1 ratio), non-inferiority, open-label, crossover trial to evaluate the level of platelet inhibition achieved with a low-dose of ticagrelor (60 mg twice daily) versus a standard dose of ticagrelor (90 mg twice daily) among elderly patients with ACS undergoing PCI. The study will have a 2 x 2 crossover design with 2-sequence, 2-period, and 2-treatments.

After signing the informed consent form, patients will be randomized to ticagrelor 60 mg twice daily vs. ticagrelor 90 mg twice daily in a 1:1 ratio through a web-based randomization system.

Each patient will be allocated to the following treatments in a open-label fashion:

  • Ticagrelor 90 mg twice daily, followed by ticagrelor 60 mg twice daily;
  • Ticagrelor 60 mg twice daily, followed by ticagrelor 90 mg twice daily;

The study duration for each individual patient will amount to 28 days consisting of:

  • A 2-week first treatment period (from day 1 to day 14): randomly allocated treatment will be maintained for 14 days;
  • A 2-week second treatment period (from day 15 to day 28): the patients will crossover to the alternative treatment, which is administered for 14 days.

Aspirin 100 mg once daily is maintained throughout all the study phases.

Blood sampling to evaluate adenosine diphosphate (ADP) e non-ADP platelet aggregation will be performed at 3 time points:

  • Time 1 (baseline): before randomization;
  • Time 2 (crossover): 14 days after randomization, including 2 samples, before and 2 hours after the last dose of the initial assigned treatment;
  • Time 3 (end of study): 28 days after randomization, including 2 samples, before and 2 hours after the last dose of the second assigned treatment.

Platelet function will be assessed by using several platelet function tests: (i) VerifyNow P2Y12 (VN-P2Y12); (ii) Light transmittance aggregometry (LTA); (iii) Multiplate electrode aggregometry (MEA).

Study Type

Interventional

Enrollment (Actual)

50

Phase

  • Phase 3

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Italy
      • Naples, Italy, 80131
        • Professor Giovanni Esposito

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  1. Ability to provide written informed consent in a time window 1 to 3 days after successful PCI;
  2. Male or female, age ≥ 75 years at screening;
  3. ACS at the time of the index hospitalization;
  4. Use of a loading dose of 180 mg of ticagrelor administered after diagnosis of ACS or after PCI;
  5. Use of a maintenance dose of 90 mg twice daily of ticagrelor of at least 48 hours after the loading dose;
  6. Successful PCI (Thrombolysis In Myocardial Infarction [TIMI] flow 3 and residual coronary stenosis <30%) for non-ST-segment elevation ACS or ST-segment elevation myocardial infarction

Exclusion Criteria:

  1. Use of glycoprotein IIb/IIIa receptor inhibitors;
  2. Need for chronic oral anticoagulant therapy;
  3. Prior fibrinolysis;
  4. Unstable clinical status (hemodynamic or electrical instability);
  5. Planned surgery requiring DAPT discontinuation during the study;
  6. Prior stroke, transient ischemic attack or intracranial bleeding;
  7. Active bleeding;
  8. Severe anemia (hemoglobin < 8g/dL);
  9. Platelet count ≤80x103/ml;
  10. Renal failure (hemodialysis or creatinine clearance ≤ 30 ml/min calculated with Cockroft-Gault formula);
  11. Severe hepatic dysfunction (baseline alanine aminotransferase ≥ 2.5 times the upper limit of normal);
  12. Known hypersensitivity or contraindication to ticagrelor;
  13. Under judicial protection, tutorship or curatorship;
  14. Unable to understand and follow study-related instructions;
  15. Enrollment in another investigational device or drug study.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: TREATMENT
  • Allocation: RANDOMIZED
  • Interventional Model: CROSSOVER
  • Masking: NONE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
EXPERIMENTAL: Standard dose of ticagrelor (90 mg twice daily).
Standard dose of ticagrelor (90 mg twice daily) followed by lower dose of ticagrelor (60 mg twice daily).
Drug: Ticagrelor 90mg
Ticagrelor 90 mg followed by Ticagrelor 60 mg
Other Names:
  • Ticagrelor 60 mg
Drug: Ticagrelor 60 mg
Ticagrelor 60 mg followed by Ticagrelor 90 mg
Other Names:
  • Ticagrelor 90 mg
EXPERIMENTAL: Low dose of ticagrelor (60 mg twice daily).
Low dose of ticagrelor (60 mg twice daily) followed by standard dose of ticagrelor (90 mg twice daily).
Drug: Ticagrelor 90mg
Ticagrelor 90 mg followed by Ticagrelor 60 mg
Other Names:
  • Ticagrelor 60 mg
Drug: Ticagrelor 60 mg
Ticagrelor 60 mg followed by Ticagrelor 90 mg
Other Names:
  • Ticagrelor 90 mg

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
P2Y12 reaction units (PRU) determined by VerifyNow assay.
Time Frame: 14 days
Comparison of pre-dose P2Y12 reaction units (PRU) determined by VerifyNow- P2Y12 assay at 14 days after treatment with ticagrelor 60 mg or 90 mg.
14 days

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
High platelet reactivity (HPR) and ADP-induced platelet reactivity.
Time Frame: 28 days
High platelet reactivity (HPR) and ADP-induced platelet reactivity evaluated through light transmittance aggregometry (LTA) and Multiplate Analyzer.
28 days
Non ADP-induced platelet reactivity.
Time Frame: 28 days
Non ADP-induced platelet reactivity (arachidonic acid and thrombin receptor-activating test).
28 days
The composite of all-cause death, myocardial infarction, or stroke.
Time Frame: 28 days
28 days
The composite of cardiovascular death, myocardial infarction, urgent target-lesion revascularization.
Time Frame: 28 days
28 days
Frequency of spontaneous myocardial infarction.
Time Frame: 28 days
28 days
Frequency of unstable angina.
Time Frame: 28 days
28 days
Frequency of any revascularization.
Time Frame: 28 days
28 days
Frequency of bleeding events according to the BARC, TIMI and GUSTO classification.
Time Frame: 28 days
28 days
Plasma levels of ticagrelor and its active metabolite AR-C124910XX.
Time Frame: 28 days
28 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Federico II University

Collaborators

AdvicePharma Group

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

April 1, 2021

Primary Completion (ACTUAL)

June 20, 2022

Study Completion (ACTUAL)

June 20, 2022

Study Registration Dates

First Submitted

December 28, 2020

First Submitted That Met QC Criteria

February 1, 2021

First Posted (ACTUAL)

February 4, 2021

Study Record Updates

Last Update Posted (ACTUAL)

July 7, 2022

Last Update Submitted That Met QC Criteria

July 6, 2022

Last Verified

July 1, 2022

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 16520 (Other Identifier: Food and Drug Administration)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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