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Contemporary Time Trends in Use of Antiplatelet Agents Among Patients with Acute Coronary Syndrome and Comorbid Diabetes Mellitus or Chronic Kidney Disease
Author(s) -
Desai Rishi J.,
Spoendlin Julia,
Mogun Helen,
Gagne Joshua J.
Publication year - 2017
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1002/phar.2018
Subject(s) - prasugrel , ticagrelor , clopidogrel , medicine , acute coronary syndrome , kidney disease , odds ratio , p2y12 , diabetes mellitus , cardiology , myocardial infarction , endocrinology
Study Objective To describe contemporary trends of P2Y12 inhibitor use in patients with acute coronary syndrome ( ACS ) and comorbid diabetes mellitus ( DM ) and/or chronic kidney disease ( CKD ) who have a higher risk of recurring ACS and may benefit from treatment with higher efficacy third‐generation agents (prasugrel and ticagrelor). Design Observational cohort study. Setting A large U.S. commercial insurance program (2009–2015). Patients P2Y12 inhibitor initiated within 2 weeks after an ACS event. Measurements and Main Results We identified 98,649 P2Y12 inhibitor initiators, of whom 24.5% had comorbid DM (no CKD ), 10.5% had CKD (no DM ), and 12.6% had DM and CKD . Overall, 85.2% of patients initiated clopidogrel, followed by prasugrel (11.6%) and ticagrelor (3.2%). Prasugrel use decreased over time irrespective of preexisting DM and/or CKD ; ticagrelor use increased. In logistic regression models accounting for patient demographics and clinical covariates, preexisting DM alone was not associated with prasugrel or ticagrelor versus clopidogrel treatment initiation; however, having CKD with or without DM significantly reduced the likelihood of receiving prasugrel versus clopidogrel (odds ratio [ OR] 0.81, 95% confidence interval [ CI] 0.74–0.88 for CKD alone; OR 0.91, 95% CI 0.83–0.98 for DM and CKD ). Comorbid DM and CKD reduced the odds of initiating ticagrelor versus clopidogrel ( OR 0.80, 95% CI 0.70–0.92). Principal Conclusions We observed lower or similar use of prasugrel and ticagrelor compared with clopidogrel in patients with ACS and comorbid DM and/or CKD . Given the potential for worse clinical outcomes with clopidogrel in these patients, our findings highlight the need to investigate the implications of these trends on recurrent ACS and bleeding events.