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Drug Class Review: Newer Antiplatelet Agents
Drug Class Reviews
Kathy Ketchum, BPharm, MPA:HA, Kim Peterson, MS, Sujata Thakurta, MPA:HA, Allison Low, BA, and Marian S McDonagh, PharmD.
Structured Abstract
Purpose:
We compared the effectiveness and harms of clopidogrel, ticlopidine, extended-release dipyridamole and aspirin and prasugrel in adults with acute coronary syndromes or coronary revascularization (stenting, bypass grafting), ischemic stroke or transient ischemic attack, or symptomatic peripheral vascular disease.
Data Sources:
We searched Ovid MEDLINE®, the Cochrane Database of Systematic Reviews®, and the Cochrane Central Register of Controlled Trials® and Database of Abstracts of Reviews of Effects through January 2011. We also hand searched reference lists, US Food and Drug Administration medical and statistical reviews, and dossiers submitted by pharmaceutical companies.
Review Methods:
Study selection, data abstraction, validity assessment, grading the strength of the evidence, and data synthesis were all carried out according to standard Drug Effectiveness Review Project review methods.
Results and Conclusions:
High-strength evidence indicated that in coronary revascularization, prasugrel reduces target-vessel revascularization more than clopidogrel at 15 months, while moderate-strength evidence indicated that there was more major bleeding with prasugrel. Evidence was moderate strength that the use of clopidogrel for 6 months after coronary revascularization resulted in lower risk of revascularization compared with 1 month, with no increase in bleeding (moderate strength). The benefit lessened after 8 and 12 months and bleeding risk gradually increased (moderate to low strength). In patients with acute coronary syndrome who are managed medically, there was moderate-strength evidence of no significant difference in reduction of mortality out to at least 12 months, significantly fewer myocardial infarctions, and increased major bleeding between clopidogrel plus aspirin compared with aspirin alone.
Following stroke or transient ischemic attack, high-strength evidence indicated that extended-release dipyridamole plus aspirin did not meet criteria for being noninferior to clopidogrel for the primary outcome of recurrent stroke and had higher risks of major bleeding and withdrawals due to adverse events.
Evidence was insufficient to draw strong conclusions about the benefit-risk ratio of using a proton pump inhibitor for any patients taking clopidogrel.
Contents
- Introduction
- Methods
- Results
- Overview
- Key Question 1. For adults with acute coronary syndromes or coronary revascularization via stenting or bypass grafting, prior ischemic stroke or transient ischemic attack, or symptomatic peripheral vascular disease do antiplatelet agents differ in effectiveness?
- Key Question 2. For adults with acute coronary syndromes or coronary revascularization via stenting or bypass grafting, prior ischemic stroke or transient ischemic attack, or symptomatic peripheral vascular disease do antiplatelet agents differ in harms?
- Key Question 3. For adults with acute coronary syndromes or coronary revascularization via stenting or bypass grafting, prior ischemic stroke or transient ischemic attack, or symptomatic peripheral vascular disease do antiplatelet agents differ in effectiveness and harms based on duration of therapy?
- Key Question 4. Are there subgroups of patients based on demographics (age, racial groups, gender), socioeconomic status, other medications (drug-drug interactions), comorbidities (drug-disease interactions), or pregnancy for which one antiplatelet agent is more effective or associated with fewer harms?
- Summary
- Conclusions
- References
- Appendixes
- Evidence Tables
Update 1: January 2007; Original Report: November 2005
The medical literature relating to this topic is scanned periodically. (See http://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/derp/documents/methods.cfm for description of scanning process). Prior versions of this report can be accessed at the DERP website.
Drug Effectiveness Review Project, Marian McDonagh, PharmD, Principal Investigator.
Oregon Evidence-based Practice Center, Mark Helfand, MD, MPH, Director, Oregon Health & Science University.
Acknowledgments: We thank Leah Williams, our publications editor, for putting this report into its present form for you to read.
Suggested citation:
Ketchum K, Peterson K, Thakurta S, Low A, McDonagh M. Drug class review: Newer antiplatelet agents. Final Update 2 report. Prepared by the Oregon Evidence-based Practice Center for the Drug Effectiveness Review Project. Oregon Health & Science University. Portland, OR. 2011. Available at: http://derp.ohsu.edu/about/final-document-display.cfm
The purpose of Drug Effectiveness Review Project reports is to make available information regarding the comparative clinical effectiveness and harms of different drugs. Reports are not usage guidelines, nor should they be read as an endorsement of or recommendation for any particular drug, use, or approach. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports.
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