Alternatives to clopidogrel for acute coronary syndromes: Prasugrel or ticagrelor?

Table 1 Alternatives to clopidogrel for patients with acute coronary syndromes

Drug	Main features	Pros	Cons
Cilostazol	Phosphodiesterase inhibitor with antiplatelet and antirestenotic effects, also indicated for the medical treatment of claudication	Different mechanism of action translates into increased antithrombotic efficacy when used in combination with aspirin and a thienopyridine	Tolerability limited by gastro-intestinal side effects in up to 20% of patients
Oral anticoagulants	Several agents directly or indirectly inhibiting the coagulation process, including warfarin and dabigatran	Different mechanism of action translates into increased antithrombotic efficacy when used in combination with aspirin	Specificity for the coagulation process translates into lower efficacy on thrombotic processes largely dependent on platelets (such as stent thrombosis). Narrow therapeutic window and need for frequent monitoring (warfarin) translates in higher incidence of bleeding complications
Prasugrel	Third-generation thienopyridine irreversibly inhibiting the P2Y12 receptor, with quicker, more consistent and more potent action than clopidogrel	Potency and consistency of effect enable homogeneous and nearly complete platelet aggregation inhibition in most patients, with ensuing benefits on myocardial infarction and stent thrombosis	Greater potency may translate into bleeding risk overcoming ischemic benefits in those at moderate or high bleeding risk, such as the elderly and those with previous stroke or transient ischemic attack
Ticagrelor	Non-thienopyridine agent reversibly inhibiting the P2Y12 receptor, with quicker, more consistent, and more potent action, but shorter half-life than clopidogrel	Direct action translates into quicker onset of action and lack of interaction with drugs metabolized by cytochrome P450, such as proton pump inhibitors	Shorter half-life may translate into greater risk of thrombotic recurrences in case of non-compliance
Ticlopidine	First-generation thienopyridine irreversibly inhibiting the P2Y12 receptor, with longer half-life than clopidogrel	Limited cross-unresponsiveness translates into potential role in those lacking complete response to clopidogrel. Off-patent status translates into low cost	Lower tolerability with frequent gastro-intestinal adverse effects. Rarely but significantly associated with life-threatening agranulocytosis and thrombotic thrombocytopenic purpura