Ticagrelor Administered as Standard Tablet or Orodispersible Formulation

Azienda Ospedaliero Universitaria di Sassari130 enrolled

Overview

Randomized clinical study evaluating superiority in platelet inhibition after administration of Ticagrelor 180 mg loading dose as an orodispersible formulation versus traditional coated tablets in patients admitted for ST elevation myocardial infarction or very high-risk non-ST elevation myocardial infarction.

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for patients with acute ST-segment elevation myocardial infarction (STEMI). Additional antithrombotic therapy prior or during intervention plays an important role in the short- and long-term outcomes after PPCI. Oral antiplatelet therapy including a platelet P2Y12 receptor inhibitors is a cornerstone of antithrombotic treatment in patients with acute coronary syndromes. Prasugrel and Ticagrelor have been shown to be superior to Clopidogrel in patients with STEMI in reduction of ischemic complication without any increase in the bleeding risk and with a significant reduction in the stent thrombosis rate. Nevertheless, in STEMI patients, pharmacodynamic studies showed prasugrel and ticagrelor oral loading dose (LD) provided a suboptimal platelet inhibition in the first hours after LD, and at least 4 hours are required to achieve and effective platelet aggregation inhibition in the majority of patients, in part due to slowed gut motility caused by morphine use. Orodispersible tablet (ODT) is a different tablet formulation that disperses upon contact with the moist mucosal surfaces of the oral cavity and quickly release its components before swallowing; thus local drug dissolution and absorption as well as onset of clinical effect can be obtained conveniently easily and quickly by bypassing gastrointestinal tract. Recently, Ticagrelor 90 mg ODT has become available and bioequivalence studies on healthy volunteers documented its effectiveness with consequent approval by European Medicine Agency of this formulation which is currently available on the market. Thus, the aim of the present study is to evaluate the superiority in platelet inhibition with 180 mg Ticagrelor loading dose (LD) administered as ODTs as compared with standard formulation, among patients with STEMI or very high-risk NSTEMI undergoing immediate PCI. Primary objective consists in evaluating platelet reactivity 1 hour after Ticagrelor loading dose by VerifyNow test.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

SINGLE

Enrollment

130

Conditions

ST Elevation Myocardial Infarction NSTEMI - Non-ST Segment Elevation MI

Interventions

Ticagrelor orodispersible tabletsDRUG

Ticagrelor loading dose (180 mg) given as two orodispersible tablets (each of 90 mg), to be dispersed in saliva.

Ticagrelor standard tabletsDRUG

Ticagrelor loading dose (180 mg) given as two standard coated tablets (each of 90 mg) to be swallowed with water.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Patients presenting within 12 hours from the onset of symptoms with STEMI or very high-risk NSTEMI referred for immediate (\< 2 hours) angiography. Very high-risk NSTEMI patients include patients with haemodynamic instability or cardiogenic shock, heart failure, life-threatening arrhythmias or resuscitated cardiac arrest, intermittent ST-segment elevation, or ongoing chest pain. 2. Informed, written consent 3. Male or female patients, aged ≥ 18 years old Exclusion Criteria: 1. Age \< 18 years 2. Active bleeding; bleeding diathesis; coagulopathy 3. History of gastrointestinal or genitourinary bleeding \<2 months 4. Major surgery in the last 6 weeks 5. History of intracranial bleeding or structural abnormalities 6. Suspected aortic dissection 7. Administration in the week before the index event of clopidogrel, ticlopidine, prasugrel, ticagrelor, thrombolytics, bivalirudin, low-molecular weight heparin or fondaparinux. 8. Concomitant oral or IV therapy with strong CYP3A inhibitors or strong CYP3A inducers, CYP3A with narrow therapeutic window 9. Known relevant hematological deviations: Hb \<10 g/dl, Thromb. \<100x10\^9/l 10. Use of warfarin or new oral anticoagulant derivatives within the last 7 days 11. Known severe liver disease, severe renal failure 12. Allergy or hypersensitivity to ticagrelor or any of the excipients. 13. Pregnancy or lactation

Locations (1)

Cardiologia Clinica e Interventistica - AOU Sassari

Sassari, Italy

Outcomes

Primary Outcomes

Evaluation of Platelet Inhibition

Platelet reactivity will be measured by VerifyNow test 1 hour after Ticagrelor loading dose (LD) administered as orodispersible tablets as compared with standard formulation in 130 patients with STEMI or very high-risk NSTEMI undergoing immediate PCI. The VerifyNow PRU Test is designed to measure P2Y12 receptor blockade. Results of the PRU Tests are reported as P2Y12 Reaction Units (PRU). PRU measures the extent of platelet aggregation in the presence of a P2Y12 inhibitor. Lower PRU levels are associated with expected antiplatelet effect.

Time frame: 1 hour

Secondary Outcomes

Percent of Patients With Insufficient Antiaggregation

The percent of patients with a high residual platelet reactivity (PRU \> 208 by VerifyNow test), thus not adequately antiaggregated, 1 hour after Ticagrelor LD.

Time frame: 1 hour

Number of Participants With Residual Platelet Reactivity at Various Timepoints

Residual platelet reactivity (PRU) at 2, 4 and 6 hours measured by VerifyNow test to assess antiplatelet effect of P2Y12 inhibitors

Time frame: 2, 4 and 6 hours

Number of Participants With Clinically Relevant Bleeding Events

Actionable bleeding events across the two different regimens of Ticagrelor administration, requiring diagnostic studies, hospitalization, or treatment by a health care professional (BARC type 2 or higher)

Time frame: 30 days

Data from ClinicalTrials.gov

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