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11 November 2011
NICE recommends ticagrelor (Brilique▼) in combination with low-dose aspirin for up to 12 months as a treatment option for adults with acute coronary syndromes (ACS), i.e. people: with ST-segment-elevation myocardial infarction (STEMI) that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or with non-ST-segment-elevation myocardial infarction (NSTEMI), or admitted to hospital with unstable angina – defined as ST or T wave changes on the ECG suggestive of ischaemia plus one of the characteristics defined below. Before ticagrelor is continued beyond the initial treatment the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.
Action
Local decision making bodies should familiarise themselves with this guidance and be making arrangements to implement the recommendations.
What does the NICE guidance say?
Ticagrelor plus low-dose aspirin is recommended for up to 12 months as a treatment option in adults with ACS, that is, people:
- with STEMI, defined as ST elevation or new left bundle branch block on ECG, that cardiologists intend to treat with primary PCI or
- with NSTEMI or
- admitted to hospital with unstable angina, defined as ST or T wave changes on ECG suggestive of ischaemia plus one of the characteristics defined in the paragraph below. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.
The characteristics to be used in defining treatment with ticagrelor for unstable angina are: age 60 years or older; previous myocardial infarction or previous coronary artery bypass grafting (CABG); coronary artery disease with stenosis of 50% or more in at least two vessels; previous ischaemic stroke; previous transient ischaemic attack, carotid stenosis of at least 50% or cerebral revascularisation; diabetes mellitus; peripheral arterial disease; or chronic renal dysfunction, defined as a creatinine clearance of less than 60ml per minute per 1.73m2 of body-surface area.
Background information
The major source of data on which this guidance is based is the PLATO trial, where ticagrelor plus aspirin was compared with clopidogrel plus aspirin in preventing vascular events in patients with ACS. Further details of the trial can be found in a previous NPC rapid review of the trial and in an NPC Rapid Review of a pre-planned analysis of patients undergoing early invasive intervention for ACS.
Ticagrelor is licensed in combination with low-dose aspirin for the prevention of atherothrombotic events in adult patients with ACS, including patients managed medically, and those requiring PCI or CABG. Treatment should be initiated with a single 180mg loading dose (two tablets of 90mg each) and then continued at 90mg twice daily. Treatment is recommended for up to twelve months.
The cost of a pack of 56 x 90 mg tablets of ticagrelor (28 days supply) is £54.60.
The NICE Clinical Guideline on unstable angina and NSTEMI recommends clopidogrel in addition to aspirin for patients with ACS and a predicted 6-month mortality of more than 1.5% and no contraindications (for example, an excessive bleeding risk). Treatment with clopidogrel in combination with low-dose aspirin should be continued for 12 months after the most recent acute episode of non-ST-segment-elevation ACS.
NICE guidance on prasugrel states that prasugrel in combination with aspirin is an option for preventing atherothrombotic events in people with ACS having PCI only when:
- immediate PCI for STEMI is necessary or
- stent thrombosis has occurred during clopidogrel treatment or
- the patient has diabetes mellitus.
Further information on the management of ACS can be found on NHS Evidence and the NPC’s website contains e-learning covering the topic of antiplatelet agents.
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