BRILINTA Monotherapy in High-Bleeding Risk Patients Who Underwent PCI had Reduced Risk of Clinically Relevant Bleeding Than With Dual Antiplatelet Therapy in the TWILIGHT Trial
Secondary endpoint of non-inferiority achieved for the risk of composite of MI, death or stroke. Results presented at TCT 2019 conference and published in the New England Journal of Medicine
New data from TWILIGHT, a Phase IV independent trial (funded by AstraZeneca), showed that in patients at high-bleeding risk who underwent PCI and completed three months of dual antiplatelet therapy, BRILINTA (ticagrelor) monotherapy (90 mg twice daily) reduced the risk of BARC (Bleeding Academic Research Consortium) type 2, 3 or 5 bleeding compared to BRILINTA plus low-dose aspirin after 12 months.
In the trial, 9,006 patients received open-label ticagrelor (90 mg twice daily) and aspirin (81-100 mg daily) for three months after a PCI. The 7,119 patients that remained event-free of major bleeding or an ischemic event during the three months of treatment with ticagrelor and aspirin were randomized to either double-blinded aspirin or placebo for an additional 12 months, with continuation of open-label ticagrelor.
Ticagrelor monotherapy was associated with a 44% lower risk of BARC 2, 3 or 5 bleeding over one year, with an absolute risk reduction of 3.1%, compared to ticagrelor plus aspirin. The incidence of the primary endpoint, time to first occurrence of BARC type 2, 3 or 5 bleeding between month 3 and 15, was 4.0% in patients treated with ticagrelor plus placebo compared to 7.1% in patients treated with ticagrelor plus aspirin (HR 0.56; 95% CI 0.45 to 0.68; p<0.001).
The incidence of BARC 3 or 5 bleeding was also lower (1.0% vs 2.0%, HR 0.49; 95% CI 0.33 to 0.74) with ticagrelor plus placebo versus ticagrelor plus aspirin. Rates of the composite of all-cause death, myocardial infarction (MI) or stroke, a key secondary endpoint, were similar between the two groups, 3.9% and 3.9%, respectively for ticagrelor plus placebo and ticagrelor plus aspirin (HR 0.99; 95% CI 0.78 to 1.25; non-inferiority p<0.001).
Roxana Mehran, TWILIGHT's Global Principal Investigator and Director of the Center for Interventional Cardiovascular Research and Clinical Trials at Mount Sinai Heart and Professor of Cardiology, and Population Health Science and Policy, at Icahn School of Medicine at Mount Sinai, said “In high-risk PCI patients, further ischemic events remain a life-threatening concern. As seen in TWILIGHT, in patients who tolerated three months of dual antiplatelet therapy, lowering the risk of major bleeding while preserving the ischemic benefit using ticagrelor monotherapy is an important clinical advance for these patients.”
Danilo Verge, Vice President, Global Medical Affairs, Cardiovascular, Renal and Metabolism said: “The benefit of BRILINTA in reducing thrombosis following the placement of a stent is well established and recommended in guidelines in patients with acute coronary syndromes. The results from the TWILIGHT trial show that following percutaneous coronary intervention in high-risk patients, the withdrawal of aspirin while continuing ticagrelor monotherapy resulted in a lower bleeding rate, while showing non-inferiority for the risk of composite of death, MI, or stroke versus dual antiplatelet therapy.”
Results from TWILIGHT were presented on Thursday, September 26, 2019 at Transcatheter Cardiovascular Therapeutics (TCT) 2019, the annual scientific conference of the Cardiovascular Research Foundation, in San Francisco, and published simultaneously in the New England Journal of Medicine.
BRILINTA is not indicated for use without aspirin or in patients undergoing PCI who have not had an acute coronary syndrome (ACS) event.
BRILINTA is indicated to reduce the rate of cardiovascular (CV) death, MI, and stroke in patients with ACS or a history of MI. For at least the first 12 months following ACS, it is superior to clopidogrel.
BRILINTA also reduces the rate of stent thrombosis in patients who have been stented for treatment of ACS.
Dosing: In the management of ACS, initiate BRILINTA treatment with a 180-mg loading dose. Administer 90 mg twice daily during the first year after an ACS event. After one year administer 60 mg twice daily. Use BRILINTA with a daily maintenance dose of aspirin of 75-100 mg.
