Ticagrelor and prasugrel may have altered efficacy for the treatment of acute coronary syndrome (ACS) in patients with diabetes mellitus (DM), according to study results published in the Journal of the American College of Cardiologists: Cardiovascular interventions.

These findings were from a pre-specified analysis of data from the Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5 trial in which patients (N=4016) who were hospitalized for ACS were randomly assigned to receive 180 mg ticagrelor followed by a 90 mg maintenance dose twice daily (n=2011) or 60 mg prasugrel followed by a maintenance dose of 10 mg once daily (n=2005). Patients were followed through for 1 year. The study’s primary endpoint was a composite of stroke, myocardial infarction (MI), or death.

In this cohort, 22.2% of participants had DM, 463 of whom were assigned to receive ticagrelor and 429 to receive prasugrel. Among patients without DM, 1548 received ticagrelor and 1576 prasugrel.

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Baseline characteristics were comparable between treatment groups in patients with DM, except for previous coronary artery bypass surgery which was more prevalent in participants receiving prasugrel vs ticagrelor. Characteristics of patients without DM did not differ at baseline between drug treatment groups. Patients with and without DM did not have significantly different angiography results.

After a median follow-up of 365.2 days, the primary endpoint was observed in 11.2% and 13.0% of patients with DM treated with ticagrelor and prasugrel, respectively (hazard ratio [HR], 0.84; 95% CI, 0.58-1.24; P =.383) and in 8.6% and 5.2% of patients without DM treated with ticagrelor and prasugrel, respectively (HR, 1.70; 95% CI, 1.29-2.24; P <.001). Both drugs had similar efficacy in patients with DM, but ticagrelor was found to be less efficacious than prasugrel in patients without DM (P =.0035).

Fewer deaths (3.0% vs 4.1%; P =.077), MIs (2.1% vs 4.6%; P <.001), and definite stent thromboses (0.3% vs 1.0%; P =.020) were observed among patients without DM receiving prasugrel vs ticagrelor, respectively.

Risk for Bleeding Academic Research Consortium types 3 to 5 bleeding events were observed in 6.9% and 5.5% of patients with DM receiving ticagrelor and prasugrel, respectively (HR, 1.27; 95% CI, 0.70-2.29; P =.425) and in 5.2% and 4.6% of patients without DM receiving ticagrelor and prasugrel, respectively (HR, 1.13; 95% CI, 0.80-1.60; P =.500).

Study limitations include the fact, because fewer patients with vs without diabetes were enrolled, the study did not have sufficient power to examine differences in the primary endpoint between those 2 groups.

The study authors concluded that these observations indicate that ticagrelor and prasugrel were not as effective for treatment of ACS in patients with comorbid DM. Among patients without DM, prasugrel was more efficacious than ticagrelor.


Ndrepepa G, Kastrati A, Menichelli M, et al. Ticagrelor or prasugrel in patients with acute coronary syndromes and diabetes mellitus. JACC Cardiovasc Interv. 2020;13(19):2238-2247. doi:10.1016/j.jcin.2020.07.032