The Drug & Therapeutics Bulletin has featured a review of the place of ticagrelor in the management of patients with acute coronary syndrome (ACS).

The article summarises the available evidence comparing ticagrelor with clopidogrel. No published trials have directly compared ticagrelor and prasugrel.

The authors conclude that “Data, predominantly from one large randomised controlled trial, suggest that, when added to aspirin, ticagrelor reduces the composite endpoint of vascular death, myocardial infarction or stroke compared with clopidogrel in patients with acute coronary syndrome (ACS). With such use, ticagrelor does not appear more likely than clopidogrel to increase the rate of major bleeding, including coronary artery bypass grafting-related bleeding, but may be associated with an increased risk of intracranial haemorrhage. Ticagrelor has some important common unwanted effects which mean it is unsuitable for many patients with ACS (including those with co-existing chronic obstructive pulmonary disease, hyperuricaemia, or on beta-blockers). Although ticagrelor appears to offer some benefits over clopidogrel in ACS, it is much more expensive, requires twice-daily dosing and has unknown long-term safety. Consequently, we cannot currently recommend ticagrelor as first-line therapy in the management of patients with ACS.”