From the Guidelines
Prasugrel is indicated for patients with acute coronary syndrome (ACS) who are undergoing percutaneous coronary intervention (PCI) to reduce the risk of thrombotic cardiovascular events, including stent thrombosis. It is specifically used in patients with unstable angina, non-ST elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI). The standard dosing regimen consists of a 60 mg loading dose followed by a 10 mg daily maintenance dose, taken with aspirin (75-325 mg daily) 1. For patients weighing less than 60 kg, a reduced maintenance dose of 5 mg daily should be considered 1. Prasugrel is contraindicated in patients with active pathological bleeding, history of stroke or transient ischemic attack, and generally not recommended for patients aged 75 or older unless high-risk situations exist (such as diabetes or prior MI) 1. Some key points to consider when using prasugrel include:
- Prasugrel provides more potent and consistent platelet inhibition compared to clopidogrel, which translates to better clinical outcomes in ACS-PCI patients, though with an increased bleeding risk 1.
- The use of prasugrel in patients undergoing PCI is addressed in the guidelines, and it is recommended to administer prasugrel at the time of PCI, rather than before PCI 1.
- Prasugrel is not recommended for "upfront" therapy in patients with NSTE-ACS, and its use should be guided by the patient's coronary anatomy and the planned treatment strategy 1.
- Patients with a history of cerebrovascular events, those over 75 years of age, and those with low body weight (<60 kg) are at increased risk of bleeding with prasugrel and should be carefully evaluated before initiating therapy 1.
From the FDA Drug Label
Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
Prasugrel is indicated to reduce the rate of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI), specifically:
- Unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI)
- ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI 2.
From the Research
Indications for Prasugrel
Prasugrel is indicated for the prevention of atherothrombotic events in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) 3. This includes patients with:
- Unstable angina pectoris/non-ST-segment-elevation myocardial infarction (unstable angina/NSTEMI)
- ST-segment-elevation myocardial infarction (STEMI)
Patient Subgroups
Prasugrel has been shown to be effective in specific subgroups of patients, including:
- Patients with diabetes mellitus 3
- Patients with STEMI, NSTEMI, or unstable angina (UA) undergoing PCI 4
- Patients at high risk of ischemic events, such as those with cardiogenic shock or ST-segment elevation myocardial infarction presentation 5
Contraindications and Precautions
Prasugrel is contraindicated in patients with a history of stroke or transient ischaemic attack 3. Additionally, patients aged ≥75 years, those weighing <60 kg, and those with a history of bleeding complications should be carefully assessed for the risk-benefit ratio of prasugrel therapy 3, 6, 5.
Comparison to Clopidogrel
Prasugrel has been shown to be superior to clopidogrel in reducing the risk of ischemic events in patients with ACS undergoing PCI, but is associated with an increased risk of bleeding complications 3, 4, 6, 7. The choice between prasugrel and clopidogrel should be based on individual patient characteristics and risk factors.