Pharmacokinetics and pharmacodynamics of ticagrelor in patients with stable coronary artery disease: Results from the ONSET-OFFSET and RESPOND studies

Background and Objectives: Ticagrelor, the first reversibly binding oral P2Y12 receptor antagonist, improves outcomes in patients with acute coronary syndromes (ACS) compared with clopidogrel. In the ONSETOFFSET study (parallel group trial) and the RESPOND study (crossover trial), the pharmacodynamic effects of ticagrelor were compared with clopidogrel in patients with coronary artery disease (CAD).Wenow report the pharmacokinetic analyses of ticagrelor, and the exposure-inhibition of platelet aggregation (IPA) relationships from these studies. Patients and Methods: Patients were treated with ticagrelor (180 mg loading dose, 90mg twice daily maintenance dose) or clopidogrel (600 mg loading dose, 75 mg once daily maintenance dose) in addition to aspirin (acetylsalicylic acid) [75-100 mg once daily]. Ticagrelor administration was for 6 weeks in ONSETOFFSET. In RESPOND, ticagrelor was given for 14 days before or after 2 weeks of clopidogrel in patients classified as clopidogrel responders or non-responders. Pharmacokinetics and IPA were evaluated following the loading and last maintenance doses. Exposure-IPA relationships were evaluated using a sigmoid maximum effect (Emax) model. Outcome Measures: The outcome measures were ticagrelor and AR-C124910XX (active metabolite) pharmacokinetics and exposure-IPA relationships in both trials, including the effect of prior clopidogrel exposure, and effects in clopidogrel responders and non-responders in RESPOND. Results: In ONSET-OFFSET, maximum (peak) plasma concentration (Cmax), time to Cmax (tmax) and area under the plasma concentration-time curve from time 0 to 8 hours (AUC8) for ticagrelor were 733 ng/mL, 2.0 hours and 4130 ng•h/mL, respectively; and for AR-C124910XX were 210 ng/mL, 2.1 hours and 1325 ng•h/mL, respectively. Emax estimates were IPA >97%. Trough plasma ticagrelor (305 ng/mL) and AR-C124910XX (121 ng/mL) concentrations were 5.2 and 7.7 times higher than respective concentration producing 50% of maximum effect (EC50) estimates. In RESPOND, ticagrelor mean C_max and AUC8 following 2-week dosing were comparable between clopidogrel responders (724 ng/mL and 3983 ng•h/mL, respectively) and non-responders (764 ng/mL and 3986 ng•h/mL, respectively). Pharmacokinetics of ticagrelor were unaffected by prior clopidogrel dosing. Emax estimates were IPA >96%for both responders and non-responders. Trough plasma concentrations were sufficient to achieve high IPA. Conclusions: Ticagrelor pharmacokinetics in stable CAD patients were comparable to previous findings in stable atherosclerotic and ACS patients, and were not affected by prior clopidogrel exposure or clopidogrel responsiveness. Ticagrelor effectively inhibited platelet aggregation, and trough plasma concentrations of ticagrelor and AR-C124910XX were sufficient to result in high IPA in stable CAD patients.