A Pharmacodynamic Study of a Personalized Strategy for P2Y12 Inhibition Versus Ticagrelor in Reducing Ischemic and Bleeding Risk

Phase 2

Completed

• Conditions: Acute Coronary Syndrome; Percutaneous Coronary Intervention
• Interventions: Drug: Ticagrelor, Prasugrel, Clopidogrel

• Registration Number: NCT02044146
• Lead Sponsor: Ottawa Heart Institute Research Corporation

Brief Summary

In patients with heart attacks, the treatment of choice is to restore blood flow with percutaneous coronary intervention (PCI) (use of stents (metal meshes) to open blockages). After PCI, the standard drug treatment includes aspirin and clopidogrel. These medications block full function of the platelet cells, which are responsible for clotting. Despite their use, patients after PCI are at risk for heart attacks, sudden clotting of stents or death. A major contributor may be resistance to clopidogrel. New more potent drugs, which can overcome the resistance, are now available; however, they come with an increase chance of severe bleeding and costs. An ideal solution would be to identify at-risk patients and selectively treat them with more potent drugs, while lower-risk patients continue with clopidogrel. This type of strategy (personalized strategy) would decrease heart attacks and death (compared to clopidogrel), while also preventing bleeding complications (compared to treating all patients with the new drugs).

Of resistant patients, many carry genes (inherited units) that prevent proper absorption of clopidogrel. Our group has developed and tested a new bedside genetic test, which identifies carriers of at-risk genes. However, this technique alone does not identify all at-risk patients. Consequently, we have now devised a novel tool, which combines genetics with patient characteristics to identify high-risk patients.

The present study combines this new tool into a strategy for personalized treatment. Patients with heart attacks who undergo PCI will be randomly assigned to 1 of 3 strategies: a) new personalized strategy, b) clopidogrel strategy (previous standard drug) or c) ticagrelor strategy (stronger approved drug). The function of the platelet cells will be measured at 1 month to determine potential benefits. Evaluation of this new personalized strategy is important for improving patient outcomes after PCI. The hypothesis is that patients receiving a personalized strategy will have decrease risk for future heart attacks and bleeding.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2014-01-21
• Study First Submitted QC: 2014-01-22
• Study First Posted: 2014-01-23
• Study Start: 2014-09
• Primary Completion: 2016-10
• Study Completion: 2017-06
• Status Verified: 2018-10
• Last Update Submitted: 2018-10-03
• Last Update Posted: 2018-10-05

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 120

Inclusion Criteria

• Patients: age >18 yrs, < 75yrs

  -> 60 kg ( since March 2015 age >75 and < 60 kg eligible - but prasugrel reduced to 5mg daily if randomized to personalized therapy arm)

• NSTEMI undergoing PCI will be eligible

Exclusion Criteria

• Patients will be excluded if they have: i) a contra-indication for clopidogrel or prasugrel or ticagrelor (as per monograph), ii) have an intolerance to aspirin, iii) have absolute requirement for ticagrelor or prasugrel (e.g. stent thrombosis, allergic reaction to clopidogrel), iv) requirement for anti-coagulation treatment, v) a history of stroke, TIA or intracranial hemorrhage , vi) a platelet count < 100,000/μl, vii) a known bleeding diathesis, viii) hematocrit <30% or >52%, ix) severe liver dysfunction, x) renal insufficiency (creatinine clearance < 30ml/min), xi) adjuvant therapy with a glycoprotein IIbIIIa inhibitor.

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Ticagrelor	Ticagrelor, Prasugrel, Clopidogrel	Patients will be treated with a 90mg twice daily regimen of Ticagrelor
Clopidogrel registry arm	Ticagrelor, Prasugrel, Clopidogrel	A concurrent registry of patients (not randomized) who are receiving clopidogrel only (as decided by treating physician) will be followed as a comparator group.
Personalized Therapy	Ticagrelor, Prasugrel, Clopidogrel	A point-of-care bedside genetic test for CYP2C19\*2 and CYP2C19\*3 using a buccal swab will be conducted.2 P2Y12 inhibitory drug therapy will be then be directed based on a risk algorithm (integrating genotyping and clinical variables). Patients with "high ischemic risk" are defined as having (\*2 or \*3) and/or diabetes and/or (having age\>65 AND BMI\>=28). "High-risk" patients will be switched to prasugrel at 10mg daily, while "low ischemic risk" patients be kept on clopidogrel 75 daily. For patients \>age 75 or wt \< 60 kg, prasugrel will be reduced to 5mg daily.

Primary Outcome Measures

Name	Time	Method
Proportion of Patients in Therapeutic Window	1 month	The primary endpoint is the proportion of patients outside of the "therapeutic window" in the personalized therapy (PN) arm compared to the ticagrelor (TG) arm at 1 month. The "therapeutic window" will be defined by platelet function values (VerifyNow P2Y12 assay - P2Y12 reaction unit (PRU) ≤ 208 (correlated with decreased ischemic outcomes) AND PRU \>= 85 (correlated with decrease bleeding). This is a surrogate of NACE (net adverse clinical events)

Secondary Outcome Measures

Name	Time	Method
P2Y12 Reaction Unit (PRU)	Baseline, Day 1, 1 month	change in PRU from baseline, day 1 to 1 month in each of the groups
Bleeding	1 month, 6 months	the incidence of bleeding (defined by TIMI minor and major bleeds) among groups
MACE	1 month, 6 months	combined clinical endpoint (MACE) including death, myocardial infarction(MI) or urgent target vessel revascularization (TVR)
Stent thrombosis	1 month, 6 month	stent thrombosis (ARC definite/probable)

Trial Locations

Locations (2)

University of Ottawa Heart Institute; 🇨🇦 Ottawa, Ontario, Canada

Montreal Heart Institute; 🇨🇦 Montreal, Quebec, Canada