AstraZeneca announced that the US Food and Drug Administration (FDA) has approved Brilinta (ticagrelor) tablets to reduce the rate of heart attack (Myocardial Infarction [MI]) and cardiovascular (CV) death in adult patients with ACS, compared to clopidogrel.
Brilinta, a new oral antiplatelet medicine, is indicated to reduce the rate of thrombotic cardiovascular events in patients with ACS (unstable angina [UA] Non-ST-Elevation Myocardial Infarction [NSTEMI], or ST-Elevation Myocardial Infarction [STEMI]). Brilinta has been shown to reduce the rate of a combined endpoint of CV death, MI or stroke compared to clopidogrel. The difference between treatments was driven by CV death and MI with no difference in stroke. In patients treated with an artery-opening procedure known as Percutaneous Coronary Intervention (PCI), Brilinta reduces the rate of stent thrombosis. Brilinta has been studied in ACS in combination with aspirin. Maintenance doses of aspirin above 100 mg decreased the effectiveness of Brilinta. Avoid maintenance doses of aspirin above 100 mg daily.
David Brennan, chief executive officer, AstraZeneca said: “The FDA approval of Brilinta is good news for patients in the United States and represents a significant milestone as we seek to help ensure ACS patients around the world have access to this innovative medicine. With over one million people affected by ACS in the US each year, the fact that physicians have a new and more effective treatment option than clopidogrel to help reduce the rate of heart attack and cardiovascular death in these patients is an important advance.”
Now that Brilinta is approved in the US, AstraZeneca will begin the process of working with hospital formularies, protocol committees, government and managed care reimbursement bodies to bring this medicine to patients. Navigating these steps, which are necessary before Brilinta will be available to a substantial number of incident ACS patients, will be a key focus for the next 12 months.
The FDA approval is based upon data from the landmark PLATO (A Study of PLATelet Inhibition and Patient Outcomes) study, a superiority trial that compared treatment with Brilinta to clopidogrel in 18,624 ACS patients worldwide.
Brilinta, like other antiplatelet agents, can cause significant, sometimes fatal, bleeding. In PLATO, there was no statistical difference in patients treated with Brilinta compared to patients treated with clopidogrel in total major bleeding events (11.6% vs. 11.2%), including fatal and fatal/life-threatening bleeding events. Non-CABG (Coronary Artery Bypass Graft) major + minor bleeding events (8.7% vs. 7%) were more common with Brilinta versus clopidogrel.
The most commonly observed adverse reactions associated with the use of Brilinta vs. clopidogrel were bleeding (11.6% vs.11.2%) and a feeling of breathlessness called dyspnea (14% vs. 8%).
As with all AstraZeneca products, the company will work to ensure that physicians and patients understand both the benefits and risks associated with Brilinta. For Brilinta, one of the ways AstraZeneca will help ensure physicians and patients are appropriately informed about bleeding risk and the impact of aspirin dose on the effectiveness of Brilinta is through a Risk Evaluation Mitigation Strategy (REMS).
According to the American Heart Association, over one million Americans are hospitalised with ACS every year. It is estimated that up to one in three patients could have a recurrent heart attack, or die within one year of their first CV event.
Brilinta is now approved in 39 countries, including the US, Brazil, Australia, and Canada under the trade name Brilinta and in the European Union under the trade name Brilique. Brilinta is currently under regulatory review in an additional 45 countries, including Russia, India and China. PLATO was a large (18,624 patients in 43 countries) head-to-head patient outcomes study of ticagrelor versus clopidogrel, both given in combination with aspirin and other standard therapy, designed to establish whether ticagrelor could achieve a clinically meaningful reduction in cardiovascular end points in ACS patients, above and beyond those afforded by clopidogrel.
The study demonstrated that treatment with Brilinta led to a greater reduction in the primary end point – a composite of CV death, MI, or stroke – compared to patients who received clopidogrel (9.8% vs. 11.7% at 12 months; 1.9% Absolute Risk Reduction [ARR]; 16% Relative Risk Reduction [RRR]; 95% CI, 0.77 to 0.92; P<0.001). The difference in treatments was driven by CV death and MI with no difference in stroke. In PLATO, the absolute difference in treatment benefit versus clopidogrel was seen at 30 days and the Kaplan-Meier survival curves continue to diverge throughout the 12 month treatment period.
The study also demonstrated that treatment with Brilinta for 12 months was associated with a 21 percent RRR in CV death (4% vs. 5.1%; 1.1% ARR; P=0.001) and a 16 percent RRR in MI compared to clopidogrel at 12 months (5.8% vs. 6.9%; 1.1% ARR; P<0.005).
In a post hoc analysis of PLATO, it was determined that more than 80 percent of patients worldwide, including more than 40 percent of patients in the US, received low maintenance doses of aspirin (100 mg or less). Results for US and non-US patients taking Brilinta with these low maintenance doses of aspirin were similar. Maintenance doses of aspirin above 100 mg reduced the effectiveness of Brilinta, and should be avoided. After any initial dose, Brilinta should be used with maintenance aspirin doses of 75-100 mg per day. As with any unplanned subset analysis, the post hoc analysis should be treated with caution.
Brilinta is an oral antiplatelet treatment for ACS in a new chemical class called cyclopentyltriazolopyrimidines (CPTPs). Brilinta works by preventing the formation of new blood clots and maintaining blood flow in the body to help reduce a patient’s risk of another cardiovascular event (called atherothrombotic events) such as a heart attack or cardiovascular death. Brilinta is a reversibly-binding oral Adenosine Diphosphate (ADP) receptor antagonist.
Brilinta will be available in 90 mg tablets to be administered with a single 180 mg oral loading dose (two 90 mg tablets) followed by a twice daily, 90 mg maintenance dose. Following an initial loading dose of aspirin, Brilinta should be used with a maintenance dose of 75-100 mg aspirin once daily; for most patients an 81 mg aspirin dose is likely to be used.
Brilinta and Brilique are trademarks of the AstraZeneca group of companies.
ACS is an umbrella term for conditions that result from insufficient blood supply to the heart muscle. These conditions range from unstable angina (unremitting chest pain that threatens a heart attack) to heart attack.
AstraZeneca is a global, innovation-driven biopharmaceutical business with a primary focus on the discovery, development and commercialisation of prescription medicines for gastrointestinal, cardiovascular, neuroscience, respiratory and inflammation, oncology and infectious disease.