Effectiveness of switching hyper responders from prasugrel to clopidogrel after acute coronary syndrome: the POBA SWITCH study

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Background: As a consequence of the more potent antiplatelet properties of new P2Y12 blockers, an increased bleeding risk has been reported in clinical trials. We studied the biological impact of the switch from Prasugrel to Clopidogrel in patients identified as hyper-responders to Prasugrel. Methods: 387 consecutive patients admitted for ACS and discharged on prasugrel 10 mg daily were included in the present study. Prasugrel response was assessed one month after discharge by PRI VASP. 16% patients (61/387) suffered from bleeding complications during 6 month follow-up. ROC analysis was performed to define the best PRI VASP value for prediction of bleeding complications (AUC=0.71, p<0.0001). We identified a threshold value of PRI VASP ≤10% defining Very Low on-Treatment Platelet Reactivity (VLTPR) to predict bleeding complications. Among these patients, 20 patients still on prasugrel were switched to Clopidogrel 75 mg daily and tested one month later. Results: 20 patients were analyzed with a mean PRI VASP of 7±2%. One month after switching, we observed significant increase in PRI VASP at 36±12% (p<0.001). Importantly, 90% (n=18) patients were identified as good responders to clopidogrel (PRI VASP between 10 and 50%), 2 as low responders (PRI VASP>50%) and none remained with VLTPR. No bleeding or ischemic events were reported after switching, while six patients suffered from BARC bleeding complications with prasugrel (p=0.008). Figure 1 Conclusion: Switch to Clopidogrel in prasugrel "hyper responders" was effective and lead to an adequate platelet inhibition in a large majority of patients. Therefore, this tailored therapy could be useful for bleeding prevention with new P2Y12 blockers.

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