Bad Korzingen, Germany—A reduced dose of the antiplatelet prasugrel might be a good option for elderly or low-weight patients with acute coronary syndrome, according to a new study.

An article in the Annals of Internal Medicine reports the results of a head-to-head comparison of a reduced dose of prasugrel against tricagrelor, another antiplatelet medication, for those patient groups. University Heart Center Freiburg–Bad Krozingen–led researchers determined that, in patients with ACS, a reduced dose of prasugrel was as effective and associated with a reduced risk for bleeding compared to a standard dose of tricagrelor.

The authors note that two large, randomized trials found that prasugrel and ticagrelor are superior to clopidogrel and aspirin for older patients with ACS, but the dosing algorithm of prasugrel had to be adjusted after the initial trial because of safety concerns. Their study focused on the efficacy and safety of this adjusted treatment strategy, which had not been widely tested in large randomized trials.

The trial, ISAR-REACT 5 (Intracoronary Stenting and AntiThrombotic Regimen: Rapid Early Action for Coronary Treatment) indicates that prasugrel is superior to ticagrelor in reducing the composite end point of death, myocardial infarction, or stroke without increasing the risk for major bleeding in patients with ACS who were managed invasively. In this secondary analysis of cases at 23 medical centers, the study team assessed efficacy and bleeding in nearly 4,000 elderly or underweight patients with ACS planned for invasive management who were randomly assigned to receive either a reduced dose of prasugrel or a standard dose of ticagrelor.

Researchers report that, in the elderly or low-weight group, the efficacy end point occurred in 12.7% of patients assigned to receive prasugrel and 14.6% of those assigned to receive ticagrelor (hazard ratio [HR], 0.82; 95% CI, 0.60-1.14). By comparison, in the neither elderly nor low-weight group, the efficacy end point occurred in 4.8% of patients assigned to receive prasugrel and 7.3% of those assigned to receive ticagrelor (HR, 0.65; CI, 0.48-0.88; P for interaction >0.2).

The authors also advise that, in the elderly or low-weight group, Bleeding Academic Research Consortium type 3 to 5 bleeding occurred in 8.1% of patients assigned to receive prasugrel and 10.6% of those assigned to receive ticagrelor (HR, 0.72; [0.46-1.12]), and in 3.7% and 3.8%, respectively, of patients in the neither elderly nor low-weight group (HR, 0.98; [CI, 0.65-1.47]; P for interaction >0.2).

“In elderly or low-weight patients with ACS, a reduced dose of prasugrel compared with the standard dose of ticagrelor is associated with maintained anti-ischemic efficacy while protecting these patients against the excess risk for bleeding,” the authors conclude.

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