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Prasugrel use after PCI less likely in CKD
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Patients with chronic kidney disease had increased risk for ischemic events and were less likely to receive prasugrel than clopidogrel after undergoing PCI for ACS, according to data from the PROMETHEUS study.
The multicenter, observational, prospective study included 19,832 patients with ACS undergoing PCI and treated with dual antiplatelet therapy using aspirin plus prasugrel (Effient, Daiichi Sankyo) or clopidogrel from 2010 to 2013. Of these patients, 28.3% had chronic kidney disease (CKD), defined as glomerular filtration rate less than 60 mL/min/1.73 m2, and 71.7% did not have CKD.
CKD confers poor outcomes
At 1 year, the adjusted risk for MACE — a composite of death, MI, stroke or unplanned revascularization — was higher in patients with CKD vs. those without CKD (adjusted HR = 1.27; 95% CI, 1.18-1.37), Usman Baber, MD, MS, assistant professor of medicine at Icahn School of Medicine at Mount Sinai and a Cardiology Today Next Gen Innovator, and colleagues wrote.
The risks for bleeding (aHR = 1.46; 95% CI, 1.24-1.73) and MI (aHR = 1.36; 95% CI, 1.17-1.58) at 1 year were also higher in the presence of CKD, but the researchers noted no differences in incidence of revascularization or stent thrombosis.
Additionally, compared with those without CKD, patients with CKD were about half as likely to be prescribed prasugrel, compared with clopidogrel, after PCI (11% vs. 24%; P < .001) and use was uniformly lower across various subgroups, including those with high thrombotic risk indications.
Prasugrel, compared with clopidogrel, was associated with lower unadjusted rates of MACE at 1 year in patients with CKD (18.3% vs. 26.5%; P < .001) and those without CKD (10.9% vs. 17.9%; P < .001). However, on propensity score-stratified analysis, this relationship was not significant in patients with CKD (aHR = 1; 95% CI, 0.8-1.25) and was attenuated in patients without CKD (aHR = 0.84; 95% CI, 0.74-0.95).
Similarly, unadjusted bleeding rates with prasugrel vs. clopidogrel were lower in both patient groups, but the associations were not significant on propensity score-stratified analysis in patients with CKD (aHR = 1.04; 95% CI, 0.7-1.53) or those without CKD (aHR = 0.95; 95% CI, 0.72-1.24).
Patients with CKD were older, more often women and had more comorbidities, including diabetes, anemia and prior revascularization. They were also more likely to have multivessel disease and to receive bare-metal stents and bivalirudin than patients without CKD.
“These data suggest the need for randomized trial evidence to guide therapy in CKD patients with ACS undergoing PCI,” Baber and colleagues wrote.
More study needed
“The low use of prasugrel among patients with CKD in this study is notable and mirrors prior reports,” Hitinder S. Gurm, MD, from the University of Michigan and the VA Medical Center in Ann Arbor, wrote in an accompanying editorial comment. “The study also attempts to explore the comparative efficacy and safety of prasugrel and clopidogrel in patients with CKD, but it may be premature to use the results of this study to guide clinical care.”
He also noted that the data should be viewed in the context of existing randomized data from trials such as TRITON-TIMI-38, which showed the benefit of prasugrel vs. clopidogrel in patients with CKD, and PLATO, which showed the benefit of ticagrelor (Brilinta, AstraZeneca) vs. clopidogrel in patients with CKD.
Despite these data, however, Gurm wrote that “in our collective practice, the ideal P2Y12 inhibitor in patients with CKD remains unknown.” – by Melissa Foster
Disclosures: The PROMETHEUS study was sponsored and funded by Daiichi Sankyo and Eli Lilly. Baber reports no relevant financial disclosures. Please see the study for the other authors’ relevant financial disclosures. Gurm reports receiving research funding from Blue Cross Blue Shield of Michigan and the NIH and serving as a consultant for Osprey Medical.
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