What is the preferred choice between Efient (prasugrel) and Plavix (clopidogrel) for antiplatelet therapy?

Efient (Prasugrel) vs Plavix (Clopidogrel) for Antiplatelet Therapy

Ticagrelor is recommended over both prasugrel and clopidogrel for most patients with acute coronary syndrome (ACS), unless bleeding risk outweighs ischemic benefit. 1

General Comparison of P2Y12 Inhibitors

• Prasugrel (Efient) provides more potent platelet inhibition than clopidogrel, with significantly reduced rates of ischemic events, but carries an increased risk of major bleeding, including fatal bleeding 2
• Clopidogrel (Plavix) has a more favorable bleeding profile but less effective platelet inhibition compared to prasugrel 3, 2
• In real-world settings, prasugrel shows better balance between ischemic and bleeding events compared to both clopidogrel and ticagrelor 4

Patient-Specific Selection Algorithm

For ACS Patients Undergoing PCI:

1. First-line option: Ticagrelor (unless contraindicated)

   • Recommended over clopidogrel in ACS patients 1
   • More effective in reducing ischemic events than clopidogrel 1

2. Second-line options:

   • Prasugrel for patients:

     • Without history of stroke/TIA
     • Age <75 years
     • Weight ≥60 kg
     • At high ischemic risk but low bleeding risk 1, 5

   • Clopidogrel for patients:

     • With history of stroke/TIA
     • Age ≥75 years
     • Weight <60 kg
     • At high bleeding risk
     • Requiring oral anticoagulation 1, 6

Specific Clinical Scenarios:

• NSTE-ACS with unknown coronary anatomy: Prasugrel is not recommended 1
• STEMI patients receiving thrombolysis: Clopidogrel is recommended (300 mg loading dose in patients <75 years, 75 mg daily maintenance) 1
• Medically managed ACS patients: Prasugrel is not recommended 1
• Patients with stent thrombosis while on clopidogrel: Switch to prasugrel 1

Evidence for Prasugrel vs Clopidogrel

• The TRITON-TIMI 38 trial showed prasugrel reduced the combined endpoint of cardiovascular death, nonfatal MI, and nonfatal stroke by 19% compared to clopidogrel (9.9% vs 12.1%, HR 0.81) 5, 2
• Prasugrel significantly reduced myocardial infarction (7.4% vs 9.7%) and stent thrombosis (1.1% vs 2.4%) compared to clopidogrel 2
• However, prasugrel increased major bleeding (2.4% vs 1.8%), life-threatening bleeding (1.4% vs 0.9%), and fatal bleeding (0.4% vs 0.1%) 2

Special Populations

• Elderly patients (≥75 years): Clopidogrel is preferred due to lower bleeding risk

  • The POPular AGE trial showed clopidogrel led to fewer bleeding events without increasing ischemic outcomes compared to ticagrelor in patients ≥70 years 6
  • Prasugrel is not recommended for patients ≥75 years due to increased bleeding risk without clear benefit 5

• Diabetic patients: Prasugrel offers significant benefit over clopidogrel without increased bleeding 1

• Patients with high bleeding risk:

  • Consider clopidogrel as the safest option 6
  • Use proton pump inhibitor (PPI) in combination with DAPT to reduce gastrointestinal bleeding risk 1

Duration of Therapy

• For ACS patients treated with coronary stent implantation, DAPT with a P2Y12 inhibitor plus aspirin is recommended for 12 months unless there are contraindications such as excessive bleeding risk 1
• For medically managed ACS patients, DAPT is recommended for 12 months 1

Common Pitfalls to Avoid

• Never use prasugrel in patients with prior stroke or TIA - this is a contraindication due to significantly increased bleeding risk 1, 5
• Avoid prasugrel in patients ≥75 years unless benefits clearly outweigh risks (e.g., diabetic patients or those with prior MI) 5
• Do not administer prasugrel before knowing coronary anatomy in NSTE-ACS patients 1
• Avoid prasugrel in patients <60 kg due to increased bleeding risk 5
• Do not use prasugrel in medically managed ACS patients (without PCI) 1