P2Y12 Antagonists: Pharmacology, Efficacy and Patient Considerations

Abstract Today atherothrombotic disease accounts for up to 40% of deaths in Western countries. The role of platelets in the pathogenesis of atherothrombosis disease is well known. Anti-platelet drugs have been shown to prevent formation and progression of thrombosis and are used to prevent complications in acute coronary syndrome. Aspirin and clopidogrel have been the conventional anti-platelet therapy for many years. Despite this, clopidogrel has well known disadvantages that include bleeding, delayed onset, and inter-patient response variability that may equate to negative ischemic outcomes. This has led to the development of alternative oral P2Y12 antagonists such a prasugrel and ticagrelor that have undergone large randomized controlled trials. In these trials, clopidogrel has been compared to the newer oral P2Y12 antagonists in terms of efficacy and safety. Lack of experience with the newer agents, combined with fears about higher rates of bleeding compared with clopidogrel and cost, may have slowed the rate of prasugrel and ticagrelor adoption. In this article we review the pharmacology and individual patient considerations that affect the decision of which P2Y12 antagonist to use.