News Release

Reduced dose of prasugrel associated with reduced risk for bleeding in low-weight or elderly patient

Embargoed news from Annals of Internal Medicine

Peer-Reviewed Publication

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. Reduced dose of prasugrel associated with reduced risk for bleeding in low-weight or elderly patients with acute coronary syndrome

Abstract: https://www.acpjournals.org/doi/10.7326/M20-1806

Editorial: https://www.acpjournals.org/doi/10.7326/M20-4770

URL goes live when the embargo lifts

A head-to-head comparison of two antiplatelet therapies found that a reduced dose of prasugrel was as effective and associated with a reduced risk for bleeding compared with a standard dose of tricagrelor for elderly or low-weight patients with acute coronary syndrome (ACS). Findings from a randomized trial are published in Annals of Internal Medicine.

Two large randomized trials showed that prasugrel and ticagrelor are superior to clopidogrel and aspirin for older patients with ACS, but the dosing algorithm of prasugrel was adjusted after the initial trial because of safety concerns. However, the efficacy and safety of this adjusted treatment strategy have not been widely tested in large randomized trials.

The ISAR-REACT 5 (Intracoronary Stenting and AntiThrombotic Regimen: Rapid Early Action for Coro-nary Treatment 5) trial showed that prasugrel was superior to ticagrelor in reducing the composite end point of death, myocardial infarction, or stroke without increasing the risk for major bleeding in patients with ACS who were managed invasively. In this secondary analysis, researchers from the Deutsches Herzzentrum München (Technische Universität München) and German Center for Cardiovascular Research assessed efficacy and bleeding in nearly 4,000 elderly or underweight patients with ACS planned for invasive management at one of 23 medical centers who were randomly assigned to receive either a reduced dose of prasurgrel or a standard dose of ticagrelor. They found that the lower dose of prasugrel maintained anti-ischemic efficacy while protecting this patient population against the excess risk for bleeding.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Adnan Kastrati, MD, can be reached through Lisa Pietrzyk at lisa.pietrzyk@tum.de or Christine Vollgraf at christine.vollgraf@dzhk.de.

2. Canada sees recent dramatic increase in off-label use of synthetic cannabinoids among older adults

Abstract: https://www.acpjournals.org/doi/10.7326/M20-0598

URL goes live when the embargo lifts

Use of synthetic cannabinoids has increased dramatically among Canadian older adults in recent years, with nearly all (92.8 percent) of prescriptions being written for off-label use. This is potentially concerning, as older adults may be particularly susceptible to the adverse effects of these drugs, including psychomotor, cognitive, mental health, and cardiovascular complications. A brief research report is published in Annals of Internal Medicine.

Synthetic cannabinoids have been on the Canadian formulary for more than 20 years and are approved to treat chemotherapy-induced nausea and vomiting. Providers may also choose to prescribe these drugs for off-label use to treat conditions such as chronic pain, sleep disturbances, and the behavioral and psychological symptoms of dementia. How much they are prescribed has not been widely known.

Researchers from the University of Toronto studied linked health care databases in Ontario, Canada to describe yearly trends in synthetic cannabinoid prescriptions between 1997 and 2017, and the characteristics of persons to whom these drugs were dispensed in 2017. The data showed a 3.7-fold increase in use between 2012 and 2017. Persons prescribed the drugs were older adults with a median of 4 chronic conditions who were concurrently receiving a median of 7 drugs, including several other psychoactive medications. According to the study authors, these drugs are being prescribed with limited evidence for benefit and largely unknown harms. The authors suggest that increasing use may reflect a broader societal acceptance of cannabis, especially in jurisdictions, such as Canada, where recreational cannabis was recently legalized.

Media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. The lead author, Nathan Stall, MD, can be reached directly at nathan.stall@mail.utoronto.ca.

Also in this issue:

Institutional Review Board Quality, Private Equity, and Promoting Ethical Human Subjects Research
Holly Fernandez Lynch, JD, MBE, and Stephen Rosenfeld, MD, MBA
Medicine and Public Issues
Abstract: https://www.acpjournals.org/doi/10.7326/M20-1674

How Hospital Stays Resemble Enhanced Interrogation
Kenneth J. Mishark, MD; Holly Geyer, MD; and Peter A. Ubel, MD
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M19-3874

Point-of-Care Ultrasonography, Primary Care, and Prudence
Michael Tanael, MD, USAF
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M20-1840

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