Optimizing the Use of Cangrelor in the Real World

Arman Qamar; Deepak L. Bhatt


Am J Cardiovasc Drugs. 2017;17(1):5-16. 

In This Article

Integrating Cangrelor Into Clinical Practice

Cangrelor with its intravenous availability, potent platelet inhibition, and rapid onset and offset of action fulfills an unmet need for an ideal antiplatelet agent in patients receiving PCI. Patients treated with cangrelor require switching to oral P2Y12 inhibitors.[73–75] Consistent with the practice in CHAMPION PHOENIX, clopidogrel 600 mg should be administered immediately after stopping the cangrelor infusion. Pharmacodynamic studies have examined transition strategies from cangrelor to prasugrel or ticagrelor. Accordingly, a 60-mg loading dose of prasugrel should be administered immediately after discontinuing cangrelor. On the other hand, ticagrelor 180 mg can be given before, during, or after cangrelor infusion. To date, clinical trials have only compared cangrelor with clopidogrel. No randomized or observational study has compared clinical outcomes between cangrelor and prasugrel or ticagrelor, though pharmacodynamic data suggest additional antiplatelet effect with cangrelor. Real-world evaluation of cangrelor in comparison to all oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) will provide clinicians with further insights in optimizing the use of cangrelor in reducing ischemic events in routine practice.[76]

There are several clinical scenarios where cangrelor could be advantageous.[77] The intravenous route of administration is ideal for patients who cannot take oral medications because of vomiting, mechanical ventilation, cardiac arrest, shock, therapeutic hypothermia, morphine use, unconsciousness, or sedation. The fast onset and offset of effect with cangrelor mitigates preloading concerns before coronary angiography. Hence, if PCI is indicated, cangrelor immediately achieves maximal platelet inhibition during the procedure. Alternatively, if the coronary anatomy shows surgical disease, CABG can be performed without delay. Cangrelor may also be valuable in clinical situations where patients need to prematurely interrupt oral P2Y12 inhibition, such as before an urgent surgery.