Ticagrelor Versus Prasugrel for the Treatment of Patients with Type 2 Diabetes Mellitus Following Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Introduction

Antiplatelet therapy is very important following percutaneous coronary intervention (PCI) to reduce the risk of post-interventional complications. However, bleeding risk might be a limiting factor of these blood thinners [1]. New generation P2Y₁₂ inhibitors (ticagrelor and prasugrel) might soon replace clopidogrel for the post-interventional treatment of patients with acute coronary syndrome (ACS) [2]. This was indicated in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI 38) and the PLATelet inhibition and patient Outcomes (PLATO) trials [3, 4].

The newer antiplatelet agents ticagrelor and prasugrel have faster and stronger platelet inhibition in comparison to the commonly used clopidogrel [5] following coronary angioplasty and hence the European guidelines now recommend both antiplatelet drugs as first-line choice for the post-interventional treatment of patients with ACS [6].

Recently, a few meta-analyses based on the general population comparing the efficacy and safety of ticagrelor versus prasugrel were published. However, controversial issues were observed. For example, a head-to-head comparison by Bundhun et al. showed comparable outcomes between ticagrelor and prasugrel for the treatment of patients with ACS [7]. Bleeding events were also similarly observed. Nevertheless, another head-to-head comparison by Sakurai et al. showed prasugrel to be associated with lower risk of bleeding events in comparison to ticagrelor [8].

Patients with type 2 diabetes mellitus (T2DM) are at higher risk of thrombosis due to platelet dysfunctions [9]. Clopidogrel hyporesponsiveness was also observed in this subgroup of patients following PCI [10]. However, those newer potent antiplatelet agents were not systematically compared in a subgroup of patients with T2DM.

In this analysis, we aimed to systematically compare the post-interventional clinical outcomes and bleeding events observed with ticagrelor versus prasugrel in patients with T2DM.

Methods

Search Strategies (Data Sources, Search Terms, Inclusion and Exclusion Criteria)

The database of EMBASE (www.sciencedirect.com), MEDLINE including its subset PubMed, the Cochrane Central Register of Controlled Trials, and www.ClinicalTrials.gov were carefully searched for publications comparing the post-coronary interventional outcomes following ticagrelor versus prasugrel use in patients with T2DM. Articles which were published in English were considered relevant to this analysis.

“Ticagrelor, prasugrel and percutaneous coronary intervention”, “ticagrelor, prasugrel, percutaneous coronary intervention and diabetes mellitus”, “ticagrelor, prasugrel, diabetes mellitus”, “ticagrelor, prasugrel, coronary artery diseases”, “prasugrel, ticagrelor, acute coronary syndrome”,...