The role of prasugrel in prevention of CV events

Prasugrel is a potent antiplatelet inhibitor with a rapid onset of activity and reduced inter-patient variability. Clinical trial data from TRITON TIMI-38 demonstrated significantly fewer cardiovascular events in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) who were treated with prasugrel compared with clopidogrel (all patients also received low-dose aspirin). However, prasugrel is also associated with a significantly greater risk of bleeding, including major, life-threatening and fatal bleeds. As a result prasugrel is contraindicated in patients with prior stroke or transient ischaemic attack (TIA); and should only be used cautiously and at a lower maintenance dose in older patients (>75 years) and those of low bodyweight (<60kg). NICE guidance recommends that prasugrel is considered for patients presenting with ACS and scheduled for PCI in three specific groups: patients undergoing primary PCI following an ST-elevation myocardial infarction, patients that experienced re-infarction or stent thrombosis while taking aspirin and clopidogrel, and patients with diabetes mellitus. Since launch, the adoption of prasugrel into routine clinical practice has been slow, probably because clinicians are unsure of the benefit-to-risk ratio, particularly with respect to the risk of bleeding. Patients prescribed prasugrel should be carefully counselled on the importance of adherence to therapy for the prescribed period and should be encouraged to seek specialist advice should side effects or other issues arise during treatment.