Coming safely to a stop: a review of platelet activity after cessation of antiplatelet drugs

Isobel Ford

Research output: Contribution to journalArticle

5 Citations (Scopus)
3 Downloads (Pure)

Abstract

The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes, during PCI and after placement of arterial stents.
Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed.

The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding.
Fear of a “rebound” of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in stable patients. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel.

Recent RCTs confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping DAPT before surgery or in individuals at highest bleeding or thrombotic risk.
Original languageEnglish
Pages (from-to)141-150
Number of pages10
JournalTherapeutic Advances in Drug Safety
Volume6
Issue number4
Early online date1 Jun 2015
DOIs
Publication statusPublished - Aug 2015

Fingerprint

clopidogrel
Platelet Aggregation Inhibitors
Blood Platelets
Aspirin
Guidelines
Hemorrhage
Hemostatics
Therapeutics
Acute Coronary Syndrome
Pharmaceutical Preparations
Fear
Stents
Blood Vessels
Mortality

Keywords

  • antiplatelet therapy
  • cessation
  • clopidogrel
  • P2Y12 inhibitors
  • platelet activation
  • rebound

Cite this

Coming safely to a stop : a review of platelet activity after cessation of antiplatelet drugs. / Ford, Isobel.

In: Therapeutic Advances in Drug Safety, Vol. 6, No. 4, 08.2015, p. 141-150.

Research output: Contribution to journalArticle

@article{fa85afbca91a4d77b60a5f5cb9e253a2,
title = "Coming safely to a stop: a review of platelet activity after cessation of antiplatelet drugs",
abstract = "The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes, during PCI and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed.The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding.Fear of a “rebound” of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in stable patients. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent RCTs confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping DAPT before surgery or in individuals at highest bleeding or thrombotic risk.",
keywords = "antiplatelet therapy, cessation, clopidogrel, P2Y12 inhibitors, platelet activation, rebound",
author = "Isobel Ford",
note = "Funding Isobel Ford is an employee of the University of Aberdeen. The research for the writing of this review received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors",
year = "2015",
month = "8",
doi = "10.1177/2042098615588085",
language = "English",
volume = "6",
pages = "141--150",
journal = "Therapeutic Advances in Drug Safety",
issn = "2042-0986",
publisher = "SAGE Publications Ltd",
number = "4",

}

TY - JOUR

T1 - Coming safely to a stop

T2 - a review of platelet activity after cessation of antiplatelet drugs

AU - Ford, Isobel

N1 - Funding Isobel Ford is an employee of the University of Aberdeen. The research for the writing of this review received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors

PY - 2015/8

Y1 - 2015/8

N2 - The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes, during PCI and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed.The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding.Fear of a “rebound” of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in stable patients. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent RCTs confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping DAPT before surgery or in individuals at highest bleeding or thrombotic risk.

AB - The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes, during PCI and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed.The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding.Fear of a “rebound” of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in stable patients. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent RCTs confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping DAPT before surgery or in individuals at highest bleeding or thrombotic risk.

KW - antiplatelet therapy

KW - cessation

KW - clopidogrel

KW - P2Y12 inhibitors

KW - platelet activation

KW - rebound

U2 - 10.1177/2042098615588085

DO - 10.1177/2042098615588085

M3 - Article

VL - 6

SP - 141

EP - 150

JO - Therapeutic Advances in Drug Safety

JF - Therapeutic Advances in Drug Safety

SN - 2042-0986

IS - 4

ER -