Tastes Like Ticagrelor: Mouth-Dissolving Pills Match Standard Ones in ACS

(UPDATED) Ticagrelor tablets that dissolve in the mouth are not superior to pills with standard coatings in ACS patients undergoing PCI, based on platelet reactivity, according to the small, randomized TASTER study. The trial did, however, show that orodispersible tablets (ODT) are equally safe and effective and, as such, may hold particular appeal in this setting.  

“In critically ill patients, such as a relevant proportion of those with an ACS, the use of oral pharmacological agents needing water for pill swallowing might not represent an ideal drug administration route,” write Guido Parodi, MD, PhD (Sassari University Hospital, Italy), and colleagues. “In particular, in the ambulance, emergency department, or catheterization laboratory, where the speed of action is pivotal for patient management, drinking water might not be promptly available or may be technically difficult.”

Calling the study “revolutionary,” co-author Filippo Dossi, MD (Sassari University Hospital), told TCTMD in an email that ODT ticagrelor is “a definite drug for a definite situation. This is exactly how modern technology helps us: to develop a precise solution for any given situation.”

Specifically, “the use of ODT ticagrelor makes the difference in two different scenarios: the first one involves all patients lying in a supine position (ie, ambulance, emergency room, cath lab) because ODT ticagrelor represents an easy and faster way of administration (remember that ‘time is muscle!’),” he explained. “The second one concerns all patients that are old, with a previous stroke, or those sedated, unconscious, or intubated patients [who have] consequent difficulties in swallowing.”

Commenting on the study for TCTMD, Malcolm Bell, MD (Mayo Clinic, Rochester, MN), agreed that it clearly shows mouth-dissolving ticagrelor “works as effectively as the tablet form and that if you cannot use a tablet for whatever reason, it seems reasonable to use.”

However, he cautioned, “I don’t think we'd be using it routinely, as it’s not going to work any faster.” Bell pointed out that other forms of antiplatelet therapy also can be given, either at the time or in a delayed fashion.

However, Dossi noted that using IV antiplatelet agents is more expensive and often linked to greater bleeding versus ticagrelor. “Furthermore, both GP IIb/IIIa inhibitors and cangrelor must be used in continuous infusion and so not easy handle in an out-of-hospital and urgent settings. Moreover, most recent guidelines consider IV antiplatelet drugs as a second-line treatment. As a first-line treatment, for its strong platelet inhibitor power and relatively safety profile, we thus suggest the use of ticagrelor in its most-convenient form.”

To show the advantage of ODT over standard tablets would “require a really big trial and I don’t think it would be feasible or worth it,” Bell said. “The bottom line here is this just provides us with an alternative mode of giving this drug if you felt that the patient couldn’t swallow a tablet and you really wanted to give this drug rather than anything else.”

Although it didn’t show a clear win for ODT ticagrelor over standard tablets, the TASTER study shows “a convenient alternative way of ticagrelor administration,” Dossi said. “Real-world data are playing an increasing role in healthcare decisions nowadays, and they will add further evidence to current knowledge.”

TASTER Trial

For the study, published as a research letter in the July 20, 2021, issue of the Journal of the American College of Cardiology, Parodi and colleagued randomized 126 STEMI patients presenting within 12 hours of symptom onset to receive a 180-mg loading dose of ticagrelor as an ODT or a standard coated tablet, with the former generally administered without water. More than half of patients (58.7%) presented with STEMI and one-quarter of patients were also administered morphine. The study drug was given to 90% of patients in the cath lab.

Platelet reactivity units (PRU) at 1 hour, the primary endpoint, was measured using the point-of-care VerifyNow assay.

Mean time from drug prescription to preparation and administration was shorter in the ODT group than in those receiving standard tablets (34 vs 55 seconds; P = 0.001), but the 1-hour median PRU value was similar (92 vs 140; P = 0.656). Also, a similar percentage of patients reported high residual platelet reactivity (> 208 PRU) 1 hour after receiving the loading dose regardless of pill type (18% vs 19%; P = 0.935), and residual platelet reactivity was similar between the study groups at 1, 2, 4, and 6 hours after administration.

In addition, there were no differences in median 1-hour PRU between ODT or standard tablets for the subgroups of STEMI patients (147 vs 151; P = 0.813) or those who received morphine (192 vs 173; P = 0.372).

On multivariate analysis, both morphine use (OR 4.30; 95% CI 1.33-13.88) and baseline PRU value (OR 1.021; 95% CI 1.009-1.033) predicted high residual platelet reactivity at 1 hour.

Lastly, there was no difference observed in clinical events between the study arms, and no patients reported BARC > 2 bleeding.

As for cost, Dossi said he does not expect ODT ticagrelor's to be higher than for swallowable pills. Also, after having been asked by many patients about the flavor, he tried one and described it as “not bitter at all and dissolves in few seconds! I would say it taste like a wafer!”