title: Randomized Comparison of Oral P2Y12-Receptor Inhibitor Loading Strategies for Transitioning From Cangrelor: The ExcelsiorLOAD2 Trial.
abstract: This randomized trial tested whether early loading with prasugrel can provide sufficient platelet inhibition even when given at the start of a 2-h infusion of cangrelor.
  
  
  
  Effective platelet inhibition with intravenous cangrelor reduces the risk of ischemic complications during percutaneous coronary intervention (PCI). Transitioning to oral therapy with clopidogrel or prasugrel is only recommended after discontinuation of cangrelor due to drug interactions. Given the long half-life of prasugrel, this drug could achieve effective platelet inhibition even when given early under cangrelor and thereby prevent a transient gap in platelet inhibition.
  
  
  
  This trial randomized 110 P2Y12-receptor blocker-naive patients undergoing PCI with use of cangrelor to loading with prasugrel 60 mg or ticagrelor 180 mg at the start of cangrelor (n = 45 each) or loading with clopidogrel 600 mg after discontinuation of cangrelor (n = 20). The primary endpoint was the proportion of patients without high on-treatment platelet reactivity 1 h after stopping cangrelor.
  
  
  
  The 3 groups were well balanced with respect to clinical parameters. One hour following discontinuation of cangrelor, the primary endpoint was seen in 65.0% of patients on clopidogrel versus 95.6% with ticagrelor and 93.3% with prasugrel (p for superiority of prasugrel vs. clopidogrel = 0.003; p of prasugrel vs. ticagrelor = 0.65). The 30-day incidence of ischemic and bleeding events was similar in all groups.
  
  
  
  Prasugrel 60 mg given at the start of a 2-h infusion of cangrelor can provide a sufficient platelet inhibition post-cangrelor. This approach prevents the transient gap in platelet inhibition seen with oral loading after discontinuation of cangrelor. (Impact of Extent of Clopidogrel-Induced Platelet Inhibition during Elective Stent Implantation on Clinical Event Rate - Advanced Loading Strategies [ExcelsiorLOAD2]; DRKS00009739).
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany. Electronic address: willibald.hochholzer@universitaets-herzzentrum.de.
authors.forename: Willibald
authors.initials: W
authors.lastname: Hochholzer
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Pascal
authors.initials: P
authors.lastname: Kleiner
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Iris
authors.initials: I
authors.lastname: Younas
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Christian M
authors.initials: CM
authors.lastname: Valina
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Löffelhardt
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Amann
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Timo
authors.initials: T
authors.lastname: Bömicke
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Miroslaw
authors.initials: M
authors.lastname: Ferenc
authors.affiliation: Center for Medical Biometry and Medical Informatics, University of Freiburg, Freiburg, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Hauschke
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Trenk
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Franz-Josef
authors.initials: FJ
authors.lastname: Neumann
authors.affiliation: University Heart Center Freiburg · Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Stratz
mesh_terms: D000241:Adenosine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000249:Adenosine Monophosphate / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000284:Administration, Oral; D000368:Aged; D001792:Blood Platelets / Q000187:drug effects* / Q000378:metabolism; D000077144:Clopidogrel; D003327:Coronary Disease / Q000097:blood / Q000000981:diagnostic imaging / Q000628:therapy*; D057915:Drug Substitution; D005260:Female; D005858:Germany; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation; D010974:Platelet Aggregation / Q000187:drug effects; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D010979:Platelet Function Tests; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage* / Q000009:adverse effects; D011446:Prospective Studies; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D058925:Receptors, Purinergic P2Y12 / Q000097:blood / Q000187:drug effects; D015607:Stents; D000077486:Ticagrelor; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: C548576:P2RY12 protein, human; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D058925:Receptors, Purinergic P2Y12; D000249:Adenosine Monophosphate; C117446:cangrelor; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine
keywords: cangrelor; clopidogrel; percutaneous coronary intervention; platelet reactivity; prasugrel; ticagrelor