Prasugrel in the Elderly
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Article, see p 2435
Elderly patients are at increased risk of bleeding events as well as ischemic (such as myocardial infarction, stent thrombosis) events. As such, the balance between reducing ischemic events with potent antiplatelet agents while minimizing the risk of bleeding is critical in the elderly. The 2016 American College of Cardiology/American Heart Association Dual Antiplatelet Therapy update recommends prasugrel over clopidogrel (class IIa recommendations) in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) except for those who are at high risk for bleeding (such as the elderly) and who have a history of stroke or transient ischemic attack.1 The 2017 European Society of Cardiology ST-elevation myocardial infarction guidelines recommends a potent P2Y12 inhibitor (prasugrel or ticagrelor) in patients with ST-elevation myocardial infarction (class I) who underwent PCI unless contraindicated.2 The guidelines go on to state that it is generally not recommended to use prasugrel in the elderly (patients ≥75 years of age) or in patients with lower body weight, but if used, a reduced dose of 5 mg is recommended.2 The US Food and Drug Administration-approved label does not recommend prasugrel in the elderly except in high-risk patients (those with diabetes mellitus or prior myocardial infarction [MI]) and recommends a reduced dose (5 mg) only in those with lower body weight (<60 kg). Much of these recommendations stems from a concern for increased risk of bleeding and uncertain benefit for ischemic end points resulting in no net clinical benefit in the elderly. In the TRITON TIMI 38 trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel Thrombolysis in Myocardial Infarction 38) of prasugrel (10 mg) versus clopidogrel in patients with ACS with planned PCI, prasugrel was associated with significantly reduced rates of ischemic events (including stent thrombosis) …