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Hemorrhagic stroke
Original research
Half-dose ticagrelor versus standard-dose clopidogrel in a dual antiplatelet regimen for stent-assisted coiling or flow diversion of unruptured intracranial aneurysms: a cohort study
  1. Yi-Chen Li1,2,
  2. Man-Man Yi1,3,
  3. Rong Wang4,
  4. Man-Man Xu4,
  5. Tao Liu4,
  6. Shi-Jie Na4,
  7. Teng-Fei Shao2,5,
  8. Lan-Ping Ding6,
  9. Wei-Hong Ge2,
  10. Yu-Zhu Peng1,
  11. Zong Zhuang4
    1. 1Pharmacy, Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, Jiangsu, China
    2. 2Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
    3. 3Pharmacy, Beijing An Zhen Hospital, Capital Medical University, Beijing, Beijing, China
    4. 4Neurosurgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
    5. 5Pharmacy, Macau University of Science and Technology, Taipa, Macau, Macao
    6. 6Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
    1. Correspondence to Dr Zong Zhuang; zhuangzong{at}126.com; Professor Yu-Zhu Peng; pyz1131{at}163.com

    Abstract

    Background Intracranial hemorrhage is the major safety concern of standard-dose ticagrelor (90 mg twice daily) based dual antiplatelet therapy (DAPT). The bleeding avoidance strategy through dose de-escalation has been investigated in interventional cardiology. However, the preserved antithrombotic efficacy and better safety of half-dose (45 mg twice daily) ticagrelor remains unverified in patients undergoing stent-assist coiling (SAC) or flow diversion (FD) treating unruptured intracranial aneurysms (UIA).

    Methods A single-center, prospective, cohort study was conducted to compare DAPT with aspirin 100 mg daily plus half-dose ticagrelor vs standard-dose clopidogrel (75 mg daily) in UIA patients. The adenosine diphosphate inhibition (ADPi) rate was utilized to quantify the antagonization of adenosine diphosphate (ADP)-induced platelet aggregation. The patients were followed-up at 6 month after discharge. The primary efficacy outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), and the primary safety outcome was major bleeding. The secondary outcome was minor hemorrhage.

    Results Our study included 322 UIA patients, of which 254 patients were eventually enrolled after propensity score matching. The ADPi of half-dose ticagrelor (51.56%±31.46%) was comparable (P=0.089) to that of clopidogrel (57.44%±22.76%). The outcomes were also comparable. Five (3.94%) patients in the ticagrelor group and eight (6.30%) patients in the clopidogrel group reported MACCE (P=0.393). One patient in the ticagrelor group was diagnosed with asymptomatic intracranial hemorrhage 1 month after stenting. There were 36 (28.35%) minor hemorrhagic events in the ticagrelor group and 35 (27.56%) in the clopidogrel group, (P=0.889).

    Conclusion Half-dose ticagrelor was effective and safe as a potential alternative to clopidogrel in the DAPT regimen for patients undergoing SAC/FD for UIA.

    • Aneurysm
    • Platelets
    • Stent
    • Flow Diverter
    • Drug

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnis-2024-021792

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • Contributors Conception and design: YCL, MMY, RW, TFS, YZP, ZZ. Data collection and analysis: YCL, MMY, RW, MMX, TL, SJN, ZZ. Drafting the article: YCL, MMY, RW, TFS, ZZ. Critical revision of the manuscript: MMX, TL, SJN, LPD, WHG, YZP. Responsible for the overall content: YCL, MMY, YZP, ZZ. Final approval of the manuscript: all authors. Guarantor: ZZ.

      • Funding This work was supported by the Project of Nanjing University Hospital Management Institution and the Aid Project of Nanjing Drum Tower Hospital Health, Education & Research Foundation (NDYG2020032), the Jiangsu Research Hospital Association for Precision Medication (JY202008), Jiangsu Pharmaceutical Association-Tianqing Hospital Pharmacy Research Program (Q202005) and Jiangsu Pharmaceutical Association-Aosaikang Hospital Pharmacy Research Program (A202308).

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.