From the Guidelines
Transitioning from Cangrelor to Clopidogrel
Transition should be facilitated by administering 600 mg of clopidogrel at the end of the cangrelor infusion, as cangrelor's interaction with P2Y12 prevents the binding of the active metabolites of clopidogrel or prasugrel until cangrelor dissociates from P2Y12 1.
- The half-life of cangrelor is 3 to 5 min, and there is recovery of platelet function within 60 min 1, which allows for a relatively quick transition to clopidogrel.
- The CHAMPION-PCI trial demonstrated that transitioning from IV cangrelor to clopidogrel by administering 600 mg of clopidogrel at the end of the infusion is a viable strategy 1.
- It is essential to note that cangrelor has a fast onset and offset of action, making it a valuable option for patients undergoing PCI, and its use may be considered an alternative to pretreatment with other antiplatelet drugs 1.
- The CHAMPION-PHOENIX trial further supported the use of cangrelor in patients undergoing PCI, showing a significant reduction in the primary composite ischemic endpoint at 48 hours compared with clopidogrel 1.
From the FDA Drug Label
As shown in Figure 3, discontinuation of cangrelor infusion, followed by administration of the irreversible P2Y12 platelet inhibitors clopidogrel or prasugrel led to a 1-hour decrease in IPA followed by an increase in inhibition of platelet aggregation beginning at about one hour The expected antiplatelet effect of a 600 mg loading dose of clopidogrel or a 60 mg loading dose of prasugrel was blocked when clopidogrel or prasugrel was administered during a cangrelor infusion In the CHAMPION PHOENIX trial, Clopidogrel 600 mg was administered immediately at the end of the KENGREAL infusion in patients randomized to KENGREAL.
To transition from cangrelor to clopidogrel, administer a 600 mg loading dose of clopidogrel immediately at the end of the cangrelor infusion 2.
From the Research
Transitioning from Cangrelor to Clopidogrel
- The CHAMPION trials demonstrated the safety of transitioning from cangrelor to clopidogrel in patients who underwent percutaneous coronary intervention (PCI) 3.
- A study published in The American Journal of Cardiology found that transitioning from cangrelor to clopidogrel resulted in low rates of stent thrombosis and severe bleeding, comparable to those identified in the CHAMPION program 3.
- The ExcelsiorLOAD2 trial tested the effectiveness of loading with prasugrel at the start of a 2-h infusion of cangrelor and found that it can provide sufficient platelet inhibition post-cangrelor, preventing a transient gap in platelet inhibition 4.
- However, the study also found that loading with clopidogrel after discontinuation of cangrelor resulted in a lower proportion of patients without high on-treatment platelet reactivity compared to prasugrel and ticagrelor 4.
- A review published in Expert Opinion on Drug Metabolism & Toxicology highlighted the importance of understanding the pharmacology of cangrelor and oral P2Y12 inhibitors to define the optimal approach to transition to oral P2Y12 inhibitors without incurring the risk of drug-drug interactions 5.
- The ARCANGELO study found that transitioning from cangrelor to oral P2Y12 inhibitors, including clopidogrel, was safe and effective in patients undergoing PCI, with low rates of bleeding and major adverse cardiac events 6.
Key Considerations
- The timing of transition from cangrelor to oral P2Y12 inhibitors plays a crucial role in the occurrence of drug-drug interactions, especially with clopidogrel and prasugrel 5.
- Adhering to product labels and guideline recommendations is crucial for optimizing safety and efficacy of cangrelor 5.
- The CHAMPION PHOENIX trial demonstrated that cangrelor consistently reduced periprocedural ischemic events in patients with stable angina and acute coronary syndrome undergoing PCI, with a modest increase in mild and moderate bleeding 7.