What are the considerations for using prasugrel in a patient over 70 years old?

From the Guidelines

Prasugrel should be used with caution in patients over 70 years old, and a reduced maintenance dose of 5 mg daily is recommended in this population, as stated in the guidelines 1. The use of prasugrel in patients over 70 years old requires careful consideration of the potential risks and benefits.

• Key factors to consider include:
  • Age: Prasugrel is generally not recommended for patients over 75 years old due to increased bleeding risk, unless they have high-risk conditions such as diabetes or prior myocardial infarction where the benefits may outweigh the risks 1.
  • Body weight: Patients weighing less than 60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once-daily maintenance dose, and consideration should be given to lowering the maintenance dose to 5 mg in these patients 1.
  • History of stroke or transient ischemic attack: Prasugrel is contraindicated in patients with a history of stroke or transient ischemic attack due to the increased risk of bleeding 1.
  • Concomitant use of other medications: The use of medications that increase the risk of bleeding, such as anticoagulants or NSAIDs, should be carefully evaluated in patients taking prasugrel 1. The loading dose of prasugrel remains 60 mg regardless of age, and the duration of therapy should be at least 12 months for patients receiving a drug-eluting stent (DES) and up to 12 months for patients receiving a bare-metal stent (BMS) 1. Regular monitoring for bleeding complications is essential in patients taking prasugrel, particularly in the elderly population. If the bleeding risk is deemed too high, alternative antiplatelet agents like clopidogrel may be more appropriate for this age group. It is also important to note that the increased bleeding risk in elderly patients is due to age-related changes in pharmacokinetics, decreased renal function, and greater vascular fragility. Overall, the decision to use prasugrel in patients over 70 years old should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

From the FDA Drug Label

In patients ≥75 years of age, prasugrel is generally not recommended, except in high-risk patients (diabetes or prior myocardial infarction [MI]), where its use may be considered (8.5).

The use of prasugrel in a patient over 70 years old is approached with caution. Key considerations include:

• The patient's age, as those ≥75 years are generally not recommended for prasugrel, unless they are high-risk.
• High-risk patients with diabetes or prior myocardial infarction (MI) may be considered for prasugrel use. Since the patient is 70 years old, which is close to the 75-year threshold, careful evaluation of the patient's risk factors and benefits is necessary before making a decision about prasugrel use 2.

From the Research

Considerations for Using Prasugrel in Patients Over 70 Years Old

• The use of prasugrel in patients over 70 years old requires careful consideration due to the increased risk of bleeding associated with this medication 3.
• Studies have shown that prasugrel is effective in reducing ischemic events, but it is also associated with a higher risk of bleeding compared to clopidogrel, particularly in older patients 4, 3.
• The POPular AGE trial found that clopidogrel is a favorable alternative to ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (NSTE-ACS), as it leads to fewer bleeding events without an increase in the combined endpoint of all-cause death, myocardial infarction, stroke, and bleeding 4.
• The PROMETHEUS study found that prasugrel use decreases with increasing age, and that older patients have a higher risk of bleeding, but the treatment effect of prasugrel versus clopidogrel did not demonstrate age-related trends for major adverse cardiac events (MACE) or bleeding 5.
• A study on low-dose prasugrel (5 mg) in elderly patients undergoing percutaneous coronary interventions found that high-on treatment residual platelet reactivity (HRPR) is common, and that a greater body mass index (BMI) is an independent predictor of HRPR 6.

Bleeding Risk and Prasugrel Use in Older Patients

• Older patients are at a higher risk of bleeding when taking prasugrel, and this risk increases with age 3, 5.
• The use of prasugrel in patients over 75 years old is associated with a higher risk of bleeding, and a lower dose of prasugrel may be considered to minimize this risk 3.
• The POPular AGE trial found that the primary bleeding outcome was significantly lower in the clopidogrel group compared to the ticagrelor or prasugrel group, suggesting that clopidogrel may be a safer alternative for older patients 4.

Clinical Outcomes and Prasugrel Use in Older Patients

• The PROMETHEUS study found that crude 1-year major adverse cardiac events (MACE) rates were highest in patients over 70 years old, but adjusted risk was similar between age groups 5.
• The study also found that treatment effects with prasugrel versus clopidogrel did not demonstrate age-related trends for MACE or bleeding, suggesting that prasugrel may be effective in reducing ischemic events in older patients, but with a higher risk of bleeding 5.