Which Antiplatelet Works Better in Impaired Renal Function?

TOPLINE:

Prasugrel provided a more rapid reduction in platelet aggregation than clopidogrel in patients with stable coronary artery disease on dual antiplatelet therapy and an impaired renal function, specifically within initial days of treatment initiation.

METHODOLOGY:

• Chronic kidney disease often coexists with coronary artery disease and is known to impair drug metabolism. Whether renal function affects platelet aggregation induced by commonly used antiplatelet drugs remains unclear.
• Researchers conducted a substudy of a previous prospective trial involving 164 patients with stable coronary artery disease (median age, 67 years; 82.9% men) who were receiving dual antiplatelet therapy with aspirin and clopidogrel.
• Patients were randomly assigned to either continue 75 mg of clopidogrel daily or switch to 3.75 mg of prasugrel daily.
• The analysis stratified the patients into two groups: those with an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m² (n = 20) and those with an eGFR ≥ 45 mL/min/1.73 m² (n = 144).
• The primary endpoint was inhibition of platelet aggregation, measured as P2Y₁₂ reaction units (PRU), at days 5 and 30 post-randomization.

TAKEAWAY:

• In patients with an eGFR < 45 mL/min/1.73 m², prasugrel induced a faster decline in platelet aggregation than clopidogrel at both days 5 and 30; however, the difference in mean PRU values was statistically significant only on day 5 (mean PRU, 157.9 vs 214.2; P = .036).
• The effects of the drugs varied by eGFR only during the early phase of initiating treatment, with a significant interaction observed only at day 5 (P for interaction = .028).
• Both treatments had a favorable safety profile with regard to the risk for bleeding, regardless of renal function.

IN PRACTICE:

“The significant reduction in platelet aggregation observed with prasugrel in the eGFR < 45 group highlights its potential benefit in the early management of platelet reactivity in patients with renal impairment,” the researchers reported.

SOURCE:

This study was led by Ayane Miyagi, University of the Ryukyus, Okinawa, Japan. It was published online on August 1, 2025, in Heart.

LIMITATIONS:

This study had a relatively small sample size, especially in patients with lower eGFR, limiting generalizability. The open-label design may have introduced bias. Long-term outcomes and safety profiles could not be assessed with only a 30-day follow-up.

DISCLOSURES:

The researchers received funding from Daiichi Sankyo. The evaluation target of this study was a pharmaceutical product manufactured by the funding company.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.