Anticoagulation module 2: antiplatelet

therapy
Introduction

Module 1 introduced the physiology and pathology of thrombosis: how platelets and soluble
coagulation proteins come together to minimise blood loss in the formation of a clot. Ideally,
this process (haemostasis) is highly regulated to ensure that clots develop only under defined
circumstances and only in appropriate anatomical locations. However, failure to correctly
regulate haemostasis can lead to inappropriate thrombus formation.

According the National Institute for Health and Care Excellence (NICE), each year in the UK
almost a quarter of a million people have a first ischaemic stroke or myocardial infarction (MI).
In the UK, over 1.4 million people have had a heart attack, and 900,000 are living with the
effect of stroke. About 20% of the UK population aged 5575 years (850,000 people) have
lower extremity peripheral artery disease, while 16% of people with cardiovascular disease
have multi-vascular disease. We have seen in module 1 that when thrombosis occurs in an
artery, it usually does so at a point where the vessel is affected by atherosclerosis, and under
conditions of high shear. This means that platelets take a lead role in the initiation of arterial
thrombosis, and therefore that inhibition of platelet function is central to the treatment and
prevention of arterial thrombotic events. It is worth noting that each of the four major risk
factors for cardiovascular disease (smoking, dyslipidaemia, diabetes and hypertension) has
been independently associated with increased platelet activity.

The platelet

An understanding of platelet structure and the process of platelet activation is helpful when
considering the various ways in which platelets can be suppressed pharmacologically. We have
looked at these in some detail in module 1 a summary, with an emphasis on the main
pharmacological targets, is presented below.

At present, inhibitors of platelet function can be broadly grouped into three according to their
mechanism of action:

Inhibitors of the metabolism of the cell

Adenosine diphosphate (ADP) receptor blockers.

 Inhibitors of plateletplatelet interactions.

Metabolic inhibitors

There are two major drugs in this class, aspirin and dipyridamole, and both are taken orally.
Aspirin is actually three drugs for the price of one, with analgesic, antipyrexial and anti-
inflammatory activity, the latter accounting for its effect on the platelet.

Aspirin

Aspirin passively crosses the membrane and irreversibly inhibits cyclooxygenase by acetylation
of the amino acids adjacent to the active site. The cyclooxygenase enzyme performs the rate-
limiting step in synthesis of thromboxane A2 from arachidonic acid (see figure 1).

Figure 1. Key
elements of platelet function, showing current pharmacological targets

Without a nucleus, platelets are unable to produce more cyclooxygenase and, therefore, the
effect of aspirin will last until the platelet reaches the end of its lifespan and is replaced,
generally in the region of seven to 10 days. Restoration of normal haemostasis does not seem
to require all platelets to be replaced, and can be assumed five to seven days after stopping
aspirin according to UK guidelines.1 It should be noted that cessation of aspirin is often not
necessary prior to operative procedures it carries a risk of thrombosis; specialist advice
should be sought.
Thromboxane A2 production by cyclooxygenase is only one of numerous mechanisms of
platelet activation, so while aspirin can be shown to reduce aggregation in response to a
number of agonists in vitro, it does not abolish all platelet function.2

Antithrombotic doses used in clinical trials3 for the reduction of cardiovascular disease have
varied widely from less than 50 mg to over 1,200 mg per day, with no evidence of any
difference in clinical efficacy, although standard doses now vary between 75 and 300 mg daily.
The major risk of aspirin treatment is that of gastrointestinal ulceration and haemorrhage.

Aspirin resistance

One subject which continues to receive much attention is the concept of so called aspirin
resistance. This is defined in the laboratory as higher than expected platelet reactivity despite
aspirin treatment. Causes are likely to be multifactorial and range from poor medication
compliance, to genetic polymorphisms, to reduced platelet recovery time. There is some
evidence that patients with responses to aspirin, which are lower than expected by laboratory
testing, have a higher risk of cardiovascular events. However, there is, as yet, no consensus on
which platelet function tests perform best in this setting and, perhaps more importantly, any
indication of how the results of such testing should alter management. 4 Certainly, increasing
aspirin dose, or adding other antiplatelets, does not seem to alter outcomes. 5 Tests for aspirin
resistance are therefore not yet routinely recommended outside the context of clinical trials. 5

Aspirin in secondary prevention of cardiovascular disease

NICE recommends a dose of 75 mg aspirin daily as secondary prevention in all patients

without a contraindication a dose which is felt to provide the optimum balance between
efficacy and gastrointestinal side effects.6

Aspirin in primary prevention of cardiovascular disease

The role of aspirin in primary prophylaxis against arterial thrombosis in those at risk is more
controversial. Evidence for benefit is weak, and largely based on subgroup analyses of larger
trials. On the whole, primary prophylaxis with aspirin is NOT recommended, as the small
benefit is probably outweighed by the small risk of gastrointestinal bleeding. NICE guidance,
drawing on position statements from the European Society for Cardiology (ESC), suggest
considering primary prophylaxis only in the highest risk patients (hypertensive patients with
renal impairment (eGFR <45 mls/min) and/or 10-year cardiovascular risk estimation of >20%) 7.
The POPADAD (Prevention of Progression of Arterial Disease and Diabetes) trial 8 found no
beneficial effect of aspirin in diabetic patients with asymptomatic peripheral artery disease.

Aspirin in atrial fibrillation

As discussed in module 1, thrombus formation in atrial fibrillation (AF) occurs under

conditions of low shear and thus has more in common with venous thrombosis than arterial
thrombosis. One might expect that aspirin would have limited efficacy in prevention of
thrombosis and stroke in AF and, this does seem to be the case. Recent guidelines from
NICE9 and the ESC10 do not recommend aspirin for stroke prevention in AF, as accumulating
evidence suggests it is substantially less effective than anticoagulants at preventing stroke,
while carrying a similar risk of bleeding.10 This will be discussed again in module 3.

Dipyridamole

Dipyridamole has a number of actions: as an inhibitor of phosphodiesterase it prevents the

inactivation of cyclic adenosine monophosphate (cAMP). Hence, intra-platelet levels of cAMP
are increased, resulting in reduced activation of second messengers within the cytoplasm. A
second action is in the inhibition of thromboxane synthase, thus reducing platelet activation. A
corollary of this is that more endoperoxides are available as a substrate for prostacyclin
synthase, so that levels of prostacyclin rise, leading to vasodilation as well as platelet inhibition.
Its effect is relatively short-lived and repeated dosing, or slow-release preparations are
required in order to achieve 24-hour inhibition of platelet function.

Dipyridamole can be used along with aspirin in the secondary prevention of stroke and
transient ischaemic attack, although recent NICE and Royal College of Physicians guidelines
recommend clopidogrel monotherapy as the more cost-effective option, with aspirin plus
dipyridamole reserved for patients with a contraindictation to clopidogrel. 11,12

Side effects relate to its vasodilatory properties: gastrointestinal symptoms, dizziness, rash,
tachycardia and worsening symptoms of coronary artery disease. Cautions include rapidly
worsening angina, recent MI, heart failure, hypotension, and left ventricular outflow
obstruction.
ADP-receptor blockage

ADP is a powerful stimulant of the platelet and acts via a specific purinoreceptor on the
platelet surface. Release of ADP from dense granules is an important mechanism for positive
feedback activation and recruitment of further platelets, so blockade of this pathway causes a
reduction in platelet activity in response to a wide variety of stimuli. Ticlopidine, an earlier ADP
inhibitor, is no longer used due to its haematological side effects. Three other drugs are
currently available.

Clopidogrel

Clopidogrel is a thienopyridine derivative that is metabolised through cytochrome P450 in the

liver. It dramatically inhibits platelet aggregation induced by the binding of ADP to its
P2Y12 purinoreceptor on the platelet surface, a mechanism which appears to be independent of
cyclooxygenase. The peak action on platelet function occurs after several days of oral dosing,
and adverse effects include evidence of bone marrow suppression, in particular leucopenia.

Early trials of clopidogrel in cardiovascular disease, such as CAPRIE (Clopidogrel Versus Aspirin
in Patients with Atherothombosis) and CURE (Clopidogrel in Unstable Angina to Prevent
Recurrent Events),13,14 showed better outcomes in combination with aspirin compared with
aspirin alone, a result widely confirmed in other settings (see figure 2). However, the CASPAR
(Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Artery Disease)
trial15 found no benefit of the addition of clopidogrel to aspirin in below-knee bypass grafting.
Following the results of trials, such as the CURRENTOASIS 7 (Clopidogrel and Aspirin Optimal
Dose Usage to Reduce Recurrent Events Seventh Organization to Assess Strategies in
Ischemic Syndromes)16 this dual therapy is now recommended by NICE for post-acute coronary
syndrome non-ST-elevation MI (NSTEMI) for 12 months, and post ST-elevation MI (STEMI) for at
least four weeks after the infarction. A loading dose of 300600 mg is generally followed by 75
mg daily.
 Figure 2.
Kaplan-Meier curves from the CURE study the effect of long-term clopidogrel

A problem with clopidogrel follows from its prodrug status. It needs to be activated in the liver
by cytochrome P450 enzymes, including CYP2C19. There are several isoforms of this enzyme:
some confer loss of function (of which the most common is CYP2C19*2, possibly leading to
clopidogrel resistance), while others (such as CYP2C19*17) cause a gain of function. Patients
who carry one or two reduced function polymorphisms in this enzyme have been shown to be
at risk of adverse cardiovascular outcomes, including stent thrombosis, leading to a Food and
Drugs Administration (FDA) warning. However, a meta-analysis concluded that there is no
consistent influence of CYP2C19 gene polymorphisms on the clinical efficacy of clopidogrel,
and that the current evidence does not support the use of individualised antiplatelet regimens
guided by CYP2C19 genotype.17 This may be because CYP2C19 genotype is only one of a
number of factors which influence risk for further events in patients treated with clopidogrel. 18

Another issue is that there is evidence that the use of proton-pump inhibitors (PPIs) (to reduce
dyspepsia and gastrointestinal bleeding, which can be a significant problem in patients taking
antiplatelet agents) reduces the antiplatelet effects of clopidogrel, most likely by inhibition of
the CYP2C19 enzyme. Many local guidelines will thus advise avoidance of PPIs especially
omeprazole and esomeprazole in patients taking clopidogrel. However, a recent meta-
analysis concluded that the clinical impact of this interaction is probably not significant,
pointing out that PPIs offer significant protection from gastrointestinal bleeding. 19Pending a
definitive answer to this question, local policies should be followed.
Prasugrel

Prasugrel, like clopidogrel, is a thienopyridine prodrug that is metabolised partly in the plasma
by an esterase and partly via the liver cytochrome P450 system to its active metabolite, which
irreversibly inhibits the platelet P2Y12 receptor. The CYP2C19 enzyme appears to have a minor
role in prasugrel metabolism and the drugs onset of action is more rapid (within 30 minutes)
and consistent than that of clopidogrel.20

Given this, one would expect that prasugrel would exert greater inhibition on platelet function
that clopidogrel; this does seem to be the case, and this seems to be reflected in clinical
outcomes, with fewer thrombotic events but more bleeding complications in patients on
prasugrel. TRITON-TIMI (Trial to Assess Improvement in Therapeutic Outcomes by Optimising
Platelet Inhibition with Prasugrel Thrombolysis in Myocardial Infarction) 21 compared
prasugrel and clopidogrel in over 13,000 patients, finding prasugrel to be associated with
reduced cardiovascular death, non-fatal MI and stent thrombosis (HR 0.81), but more bleeding
(HR 1.32). As the number of bleeds was smaller than the number of ischaemic events, there
was felt to be an overall clinical benefit, although no significant mortality benefit was
demonstrated.

By contrast, a second major trial, the phase III TRILOGY ACS (Targeted Platelet Inhibition to
Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) study compared
the effect of prasugrel (10 mg daily, or 5 mg daily in patients >75 years) with that of clopidogrel
(75 mg daily)22 Over 7,000 acute coronary syndrome patients under 75 years with unstable
angina or NSTEMI, managed without revascularisation and taking aspirin, were followed for up
to 30 months. The primary end point of the trial was cardiovascular death, MI or stroke. The
study was performed at 966 sites in 52 countries.

Results showed that, through a median follow-up period of 17 months, the primary end point
occurred in 13.9% of those treated with prasugrel and 16.0% of those treated with clopidogrel
(hazard ratio 0.91; 95% confidence interval [CI] 0.791.05; p=0.21). Thus, the first trial to study
the effect of platelet inhibition in patients with acute coronary syndrome managed medically
without revascularisation found no significant difference between prasugrel and clopidogrel in
the prevention of death, MI or stroke. However, the pre-specified analysis of multiple recurrent
ischaemic events (all components of the primary end point) suggested a lower risk for
prasugrel among patients under the age of 75 years (hazard ratio 0.85; 95% CI 0.721.00;
p=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age
groups.
Ticagrelor

Figure 3. Processing of ADP-receptor blockers.

Ticagrelor is absorbed as an active drug and binds reversibly to the ADP
receptor. Prasugrel is part-metabolised by a plasma esterase and partly by
hepatic cytochrome enzymes. Clopidogrel also needs to be modified by
passage through the liver. Both prasugrel and clopidogrel bind irreversibly to
the receptor

Ticagrelor is a cyclo-pentyl-triazolo-pyrimidine and is a direct and reversible P2Y 12 antagonist,

with a short half-life that requires twice-daily dosing, generally with a 90 mg tablet. Unlike
clopidogrel and prasugrel, it is not a prodrug but acts directly and rapidly. The PLATO (Platelet
Inhibition and Patient Outcomes) trial23 compared ticagrelor with clopidogrel in patients with
STEMI, or moderate to high risk NSTEMI. Ticagrelor reduced the risk of a composite outcome
of death from vascular causes, MI, or stroke (HR 0.84). There was no significant increase in
major bleeding rates with ticagrelor overall, but there was a small increase in the risk of non-
procedure related bleeding, including intracranial haemorrhage.

Apart from bleeding, side effects associated with ticagrelor include elevated creatinine
concentrations, increased ventricular pauses, and dyspnoea (11.8% in PLATO study).

Cangrelor

Cangrelor is an intravenous ATP analogue, which provides reversible P2Y12 inhibition with
rapid onset and offset (within one to two hours) of action. A recent meta-analysis of the three
CHAMPION trials of cangrelor initiated at the beginning of percutaneous coronary intervention
(PCI) versus clopidogrel, showed a 19% relative risk reduction in the primary end point of
periprocedural death, MI, ischaemia-driven revascularisation and stent thrombosis, with a
small increase in bleeding.24 It received marketing authorisation in the EU in 2015.

The differences in the metabolism of the three oral ADP-receptor blockers are summarised
in figure 3.

Choosing an ADP-receptor blocker: a role for platelet function

testing?

Prasugrel and ticagrelor both seem more effective than clopidogrel at preventing
cardiovascular events but at a cost of increased bleeding risk. They are also considerably more
expensive than clopidogrel, which is now off patent. Are there any laboratory tests which help
us to decide which agent to prescribe for an individual patient?

We have seen that testing for CYP2C19 status has not yet gained universal acceptance as
helpful in this context. Another approach has been to measure the reactivity of platelets
following antiplatelet administration, with a view to switching therapy for those patients whose
platelets do not seem adequately suppressed.

Platelet reactivity tests

View details

ADP receptor blockers current guidelines

In the absence of agreement on the place of platelet testing, guidelines on ADP-receptor

blocker choice are largely based on the available trial evidence.

NICE guidance on prasugrel (TA18227) is based on a detailed analysis of the TRITON-TIMI trial.
Prasugrel is recommended as an option, in addition to aspirin, in acute coronary syndromes
requiring PCI, only when: (i) immediate PCI for STEMI is required; or (ii) there is stent
thrombosis in patients on clopidogrel; or (iii) in patients with diabetes.

For ticagrelor, NICE guidance (TA23628) recommends its use for up to 12 months, alongside low-
dose aspirin, after an acute coronary syndrome (STEMI plus primary PCI, NSTEMI, or admission
with unstable angina).
Recent ESC Guidelines recommend ticagrelor or prasugrel first line along with aspirin in
patients with STEMI. For NSTEMI, ticagrelor is recommended for all patients at moderate to
high risk of ischaemic events, with prasugrel as an option for those undergoing PCI.
Clopidogrel is relegated to second line, for patients who can not receive either of the other
agents, or who also require oral anticoagulation (where the bleeding risk with prasugrel or
ticagrelor is felt to be unacceptably high).29,30

Clearly this has significant cost implications local guidelines should be followed.

Preventing plateletplatelet interactions

GpIIb/IIIa, also known as integrin IIb3 is the most important platelet surface receptor in
achieving stable platelet aggregation. It binds fibrinogen, and other platelets via fibrinogen. It is
the most abundant glycoprotein on the platelet surface, and its numbers and adhesive
properties are increased by platelet activation of any cause (inside-out signalling). Binding to
GpIIb/IIIa also contributes to platelet activation (outside-in signalling). The central importance
of GpIIb/IIIa to platelet function is demonstrated by the severe bleeding phenotype associated
with its congenital absence (Glanzmanns thrombasthenia).

For all these reasons GpIIb/IIIa is an attractive target for critical occasions when profound
platelet inhibition is required.Three GpIIb/IIIa inhibiting agents are available, each of which
must be given by injection or infusion. They are NICE approved for the early management of
high-risk patients with acute coronary syndromes for whom early PCI is planned; their use
should be by specialists only.31

Abciximab

Abciximab has a long history, being first in its class, not only in GpIIa/IIIb blockage but also as a
therapeutic monoclonal antibody. It is an established agent in the prevention of aggregation in
acute coronary settings (alongside heparin and aspirin) and inhibits aggregation by 90% within
two hours of its infusion. Platelet function then recovers over the course of two days but it has
a major adverse effect of haemorrhage. There should be caution in its use in severe renal
impairment. Abciximab can cause thrombocytopaenia within two to four hours of
commencement. This can rarely be severe (<20 x 109/L).
Eptifibatide

Eptifibatide is a cyclic heptapeptide that mimics the part of the structure of fibrinogen that
interacts with GpIIb/IIIa. Thus, it is a fraction of the size of abciximab and is targeted at the
same structure on the platelet surface. It is licensed for the prevention of early MI in patients
with unstable angina or NSTEMI. There is again caution in renal impairment, with a reduction
in dose if estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m 2, and should be
avoided if eGFR <30 ml/min/1.73 m2.

Tirofiban

The third agent, tirofiban has a similar licence and contraindications as eptifibatide, including
abnormal bleeding, severe hypertension (as this is a risk factor for haemorrhagic stroke), use
of oral anticoagulants and hepatic impairment. However, the level of caution in renal disease is
eGFR <60 ml/min/1.73 m2, with the use of half the dose when eGFR <30 ml/min/1.73 m 2.

Other agents

Vorapaxar

Vorapaxar is a first in class oral inhibitor of the platelet thrombin receptor PAR-1. Its place in
therapy is currently uncertain as trials to date have showed modest benefits in reducing
ischaemic events, with substantial risks of haemorrhage, especially intracranial haemorrhage. 29

Figure 4. Mode of action of receptor blockers.

Targets of antithrombotic therapy include ADP and GpIIb/IIIa receptors.
Blockage of these receptors prevents the activation of the second messengers
crucial for initiation of thrombosis
Iloprost

Iloprost is a prostacyclin analogue that exerts its effects by promoting vasodilatation and
inhibiting ADP-induced platelet aggregation, thereby opposing the effects of thromboxane A 2.
It may also increase the rate of metabolism of tissue plasminogen activator by the liver, but
must be continuously infused.

Cilostazol

Cilostazol, like dipyridamole, is a phosphodiesterase inhibitor and so reduces platelet

aggregation but also increases arterial vasodilation. Its use is restricted to those with
intermittent claudication, in peripheral arterial disease patients.

Summary

Established antiplatelet agents are summarised in table 1, while figure 4 illustrates how our
knowledge of platelet physiology has enabled us to inhibit its activity.

Table 1. Mechanism for suppressing platelet function

Haemorrhage

The British Committee for Standards in Haematology (BCSH) issued recent guidelines on the
management of bleeding in patients taking antithrombotic agents. 1 Simply stopping the agent
may not be sufficient if bleeding is severe, as it may take several days for platelet function to
return to normal (see table 2).
 Table 2.
Times to normal platelet function after cessation of antiplatelet agents

Options to stop bleeding range from basic haemostatic measures (pressure, surgical opinion)
to platelet transfusion. Decisions regarding stopping/reversing antithrombotic agents have
clear implications for thrombotic risk; specialist advice should be sought.