Antiplatelets and Antithrombotics

Posted by Jeff Berk, BOLT International

Oops Haiku:

Stoned in parent’s car…

Drops joint, OH SHIT IT’S ON FIRE…

Pretty orange sky.







Arizona’s State Weed






So we finally straightened up enough to finish publishing our latest report on antiplatelets and antithrombotics (anticoagulants).  Conveniently, the ever-cooperative FDA finally straightened up enough to approve Brilinta (I have a tantrum from a couple of days back touching on the “wisdom” of the Agency).  Thus, the report is actually kind of relevant.  If you want more than the teaser below, and have a credit card that’s not maxed out, go to the “buy now” link on BOLT’s website ( and ka-ching it, and you’ll be swamped with knowledge about:

  • Burgeoning competition between Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban) and pipeline competitors Lixiana (edoxaban) and betrixaban; in SPAF, ACS, cancer, VTE/PE, mechanical valves.  Formulary considerations / SPAF pharmacoeconomics.


  • Competition between Brilinta (ticagrelor), Effient (prasugrel), Plavix (clopidogrel) and pipeline competitors elinogrel, vorapaxar, atopaxar and cangrelor.  Formulary considerations.


  • Acute and chronic treatment of ACS patients; with antiplatelet +/- antithrombotics.


Drugs discussed in this report include:






Okay, so now that the sales pitch is done (Okay, not quite:  Buy the report.  Springsteen albums aren’t free, you know.  Now it’s done) here’s a nibble from BOLT’s Thought Leaders on where Effient, Brilinta and Plavix will tier on the formulary:


  • The decision as to which antiplatelets will be on formulary will be driven by the interventional cardiologists, not by the emergency meds.  EDs are not going to start patients on any antiplatelet unless they have prior buy-in from the staff cardiologists; so that strategic decision is going to be made ahead of time.  Everybody says that clopidogrel will remain on formulary, as it is (or soon will be) generic.  Our Panel also feels strongly that ticagrelor should be on formulary based on the survival data.  The disagreement is on whether or not there is a place for prasugrel.  Some believe that prasugrel provides a meaningful reduction in events in STEMIs and in diabetics.  Most of our Panelists are dubious about prasugrel’s diabetes claim that it is better than ticagrelor. Physicians are going to use prasugrel exactly where they are using it now, which is in the STEMI patient who is young, doesn’t have a prior history of stroke, is a pretty robust person, weighs more than 60 kg, those are all the exclusions on the labeling, and they come in during the day (when there is enough hospital staff to properly monitor the patient for bleeding).  Clopidogrel will be used in patients who are at enhanced bleeding risk (contraindicating prasugrel and ticagrelor), can’t afford ticagrelor, and in those who are not going to be compliant with twice-daily dosing.


“As an interventionalist at the end of the day when you are dealing with these new drugs, ticagrelor or prasugrel, people who are really dictating how they are going to be used are the interventionalists”.


“I think the physicians will have different allegiance to the drugs and some people will seek to preserve a role for prasugrel.  But in reality the data that we have at the moment, the mortality data and safety data, is so much better for ticagrelor than prasugrel.  So inevitably that will be the agent of choice as it crosses a broad range of the acute coronary syndrome patients assuming people can afford to pay for it.  Are both agents on your formulary; Prasugrel and ticagrelor?  They are, yes, although we haven’t been able to start using ticagrelor yet because NICE haven’t released their final guidance.  Due to the cost implications the commission has it on hold until that final guidance is available.  And when do you expect that to happen?  In October NICE will release its final guidance, but the draft guidance has been very positive and it is unlikely to change.  It is reasonable to assume that their guidance will be supportive”


“In your hospital will both prasugrel and ticagrelor be put on formulary?  Yeah, absolutely.  In fact, prasugrel is already on formulary and ticagrelor will be on formulary.  And our conversations right now we are trying to decide what to do because my guess is ticagrelor is going to be the preferred agent.  So take me through the kinds of patients in whom you are going to be making the decision on do I reach for clopidogrel, do I reach for ticagrelor, do I reach for prasugrel?  In each of those patient populations I am really interested in understanding which patients are going to be, in your opinion, the best candidates for which of these agents to start and then where do you go from there?  That is a great question.  Obviously, we want to make protocols as…


Oops.  The free-meter just expired.

Categories: acute coronary syndrome, antiplatelets, Antithrombotics, Cardiovascular, DVT/PE, SPAF
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