Posts Tagged ‘prasugrel’

Caution : Non-Academic stuff

Anti hypertensives, lipid-lowering drugs along with antiplatelet drugs always find a proud place in most cardiac prescriptions. The toxic rivalry between various drugs and their creators is a well-known secret. However, the current fight among the antiplatelet agents is reaching comical proportions. The punches and reverse punchs on and off the podium is there for everybody to see.

It all started with clopidogrel two decades ago which was crowned after conquering then-popular Ticlopidine. It was followed by Prasugrel and Ticagrelor. Ticagrelor seems to taste its own medicine from Prasugrel, which brought back memories of the same knock out punches both of them gave to clopidogrel in the past. I guess the ISAR bruised Ticagrelor is just taking a time out, expected to REACT with fresh vigor in the next bout vs Prasugrel.

While these financial heavyweights struggle to keep the bull run, in the multi-billion-dollar stent maintenance market . Aspirin, the aged warrior is enjoying the theatrics silently. While Aspirin is repeatedly shown ( shown literally means shown: Mind you, It is not a synonym for a proven fact ) that it is inferior in stented patients.For stable CAD Aspirin still in the very much in the reckoning. Let the Twilight shine soon. Don’t get a shock of your life, if Aspirin regains the championship one day.


Final message

Let us hope the fight gets over till another Grelor  crash lands from nowhere. Meanwhile, we shall strive hard as professional physicians to increase the per-capita antiplatelet drug consumption in  every acute and chronic coronary syndrome (with or without PCI). This will help keep Homosapien’s coronary artery eternally patent.


For pure Academics  (Conclusions in science is a misnomer . . . )




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Platelets  are the major culprits in initiating arterial thrombus.Platelet  inhibition is  the key  modality  to treat /prevent  acute and chronic coronary syndromes. It is  an approved indication for primary and secondary prevention of CAD.

Anti platelet  agents are the biggest drug  market among the cardiac drugs. It is  a billion dollar  medical game  played  with two  million  human  platelets !

Aspirin is the best anti-platelet agent known .It is not only most effective but also  available at a fraction of the cost other  drugs. Unfortunately  it is  a generic and not a patented one .Being cheap  ,   good safety profile  is the biggest  disadvantage of aspirin  !  So ,  consistent efforts were made to make this drug appear weaker. Hence came many new anti-platelet agents .

After analyzing  the available literature ,  I have compiled the following conclusions ( Mostly biased observation ! but I strongly believe the  bias is more  towards truth . . . )

All of the following statements can be termed either  true ,were true , believed to be true may  be  true ,  at some point of time  (Between the  last decade and today !)

  1. Aspirin alone is good enough in both  ACS and chronic CAD
  2. Clopidogrel is   equally effective like aspirin in ACS.
  3. Aspirin alone is dangerous in ACS.
  4. Clopidogrel alone is more  dangerous than aspirin alone in ACS,
  5. Aspirin + Clopidogrel  provides the best anti-platelet  action.
  6. Aspirin + Clopidogrel combination is still dangerous .
  7. Prasugrel is more effective than clopidogrel
  8. Prasugrel can never be as effective as aspirin *
  9. Never use clopidogrel alone in DES patient.
  10. Aspirin can be safe in most stented patients
  11. Mono platelet inhibition is a crime !
  12. Risk of  sudden death continues to be significant in spite of dual antiplatelet agents in many with DES.
  13. For prasugrel to be  really useful  it should always be prescribed with aspirin.
  14. Prasugrel alone can be dangerous in stented patients.
  15. If the patient is  getting heparin  simultaneously none of the above seems to be  really  important (Of course all patients with ACS will be getting this )

Above are my inferences in all those trials on platelets in the last three decades

What do you infer  ?

To  a discerned reader all of the above statements  may appear wrong   !

*Finally , it looks to me  both clopidogrel and prasugrel ride  a fake  ride on the shoulders of trusted war horse called Aspirin . There is  a strong basis for this  suspicion  as none of the researchers are ready to do a one to one direct comparison between aspirin and prasugrel  or clopidogrel !

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The funny thing in medicine is  ,   simpler the  question ,   greater the  difficulty to answer ! f  Clopidogrel  is   an  irreversible blocker of platelet aggregation . It  probably ,  is one  of the top  cardiovascular  drugs  used currently .It came into human domain as an aspirin killer and failed miserably , and currently piggy packing on the ageless aspirin for it ‘s action. The concept of dual antiplatelet agent is a classical example . The fact  that , Clopidogrel can rarely be used as a successful  mono anti platelet agent while aspirin can do this job with flying colors will unmask the secrets of  antiplatelet drug industry .

Do you know ,  this drug which  is considered  as a   great  antiplatelet drug , does  not even, pass the  basic test of   prolonging  the bleeding time  in a consistent fashion  ?

Still , we are not clear why it  does  or does not increase the bleeding time in vitro or vivo in linear  fashion.We have  confirmed this  in simple bedside experiments. (More dogmatic conclusions   can be drawn  in bed side , than those  double-blind studies) . In many patients 300 mg of clopidogrel failed to prolong the bleeding time even by  few seconds ! Surgeons who operate on clopdogelised patients differ  widely in their  experience  when they do emergency surgeries on them .

The issue is very vital  ,  Questions raised  are  critical  !

  • If clopidgorel  has a  notoriously unpredictable impact on prolonging  bleeding  time , Then ,  is it not  dangerous ? ,  for those millions of patients with DES(Drug eluting stents )  who live at at the  mercy of clopidogrel’s   erratic behavior.
  • Cardiology community  never got shocked  ,  even as  in this era of evidence based cardiology , a drug  which is being used for over 10 years without even a basic monitoring strategy for it’s efficacy.
  • Such is the scenario ,  it is not at all a surprise ,   to find a huge population  of DES patients   who  dial 911 or 108  with   sub-acute sent thrombosis  due to  clopidogrel failure and resistance.

Read this article published in one of the prestigious cardio thoracic  journal and comprehend  yourself   about clopidogrel’s controversy .

Final message

End of life , is  looming large on Clopidogrel , but it has done it’ s intended mission : Increasing the basic cost of cardiovascular   care in general population  .

A costly and a   dubious equivalent to  Aspirin   wrote a  phenomenal    success story in the narrow lanes of  medical wall street !

No doubt , it   will face the same fate as Ticlopidine ,   Prasugrel has just landed to repeat the same old story !

The easiest   job  to do  in   this wold is to fooling around   the public

and  it is an  irony medical professionals  and their patients  are  often

the   victims

Read also the herd mentality in  medical science

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