Comparative Long-Term Effect of Three Anti-P2Y12 Drugs after Percutaneous Angioplasty: An Observational Study Based on Electronic Drug Adherence Monitoring

A Review of the Role of the Antiplatelet Drug Ticagrelor in the Management of Acute Coronary Syndrome, Acute Thrombotic Disease, and Other Diseases

P2Y12 inhibitors, including aspirin, are key components of dual-antiplatelet therapy (DAPT), which is the optimal therapeutic strategy for preventing arterial thrombosis in patients with acute coronary syndromes (ACS) who underwent stent implantation. Ticagrelor is a cyclopentyl-triazole pyrimidine antiplatelet drug that was the first reversible oral P2Y12 receptor antagonist. Compared with clopidogrel, ticagrelor exerts a faster onset and offset of function by reversible and selective inhibition of platelet aggregation in ACS patients, including those with coronary artery blood revascularization. Despite improvement in stent materials, stent thrombosis (ST) due to high on-treatment platelet reactivity (HPR) to clopidogrel continues to occur. In addition to antiplatelet aggregation, ticagrelor displays pleiotropic cardioprotective effects, including improving coronary blood flow, reducing myocardial necrosis after an ischemic event, and anti-inflammatory effects. The benefits of ticagrelor over clopidogrel were consistent in the PLATO results, with lower incidence of the primary endpoint. Also, in 2020, the findings from the phase 3 THALES trial (NCT03354429) showed that aspirin combined with 90 mg of ticagrelor significantly reduced the rates of stroke and death compared with aspirin alone in patients with AIS or TIA. Here, we review recent research on the superiority of ticagrelor over clopidogrel, discuss the pharmacological mechanism, and present future perspectives. This review aims to present the roles of ticagrelor in the management of acute coronary syndrome, acute thrombotic disease, and other diseases.

Is There a Threshold for Medication Adherence? Lessons Learnt From Electronic Monitoring of Drug Adherence

Medication adherence is a well-recognized problem in the management of patients with chronic diseases needing a long-term pharmacotherapy. While fighting against non-adherence, an important question frequently arises, i.e., how much adherence is enough to obtain the full treatment benefits? Most studies having attempted to answer this question have used large pharmacy records and health care databases to quantify the percentage of days covered by the prescribed treatment and hence deduce a threshold below which there appears to be fewer benefits from therapy. In the present paper, the use of data obtained using electronic monitoring of adherence is discussed as another means to assess adherence thresholds with a particular emphasis on hypertension. The data show that even with the use of electronic monitoring of adherence, which provides a comprehensive dosing history, it is extremely difficult to define an adherence threshold in hypertension. This is due to many factors that need to be taken into account, including not only the pattern of patients’ adherence and their clinical and environmental characteristics, but also the pharmacological characteristics of the prescribed drugs, the severity of the disease and many others. To determine adherence cut-offs more precisely, specific protocols should be designed to answer the question in various clinical conditions. These protocols should be conducted in well-defined patients’ groups, they should use the most reliable methods to measure adherence providing if possible a detailed dosing history perhaps combined with drugs levels in blood or urine. These studies should also choose the best methods to measure clinical endpoints, such as ambulatory blood pressure monitoring or home blood pressure in the case of hypertension. One important aspect is that datasets should be solid and large enough to be able to analyze adherence data as a continuous variable using newly developed mathematical models including new metrics catching the complexity of adherence. The rapid development of new technologies like devices, connectivity, and analytics, will probably provide new solutions to improve our ability to define valid and clinically useful adherence thresholds in various therapeutic areas.