Ticagrelor 60 mg vs. 90 mg in elderly ACS patients with vs. without diabetes undergoing percutaneous coronary intervention.

No data are available on the pharmacodynamic and pharmacokinetic profile of a low dose of ticagrelor as alternative to its standard dose during the early phase after acute coronary syndrome (ACS) according to diabetic status. We reported a post-hoc analysis of a randomized, crossover trial (NCT04739384) comparing ticagrelor 60 vs. 90 mg in elderly patients with ACS according to the presence or absence of diabetes. The primary endpoint was the pre-dose P2Y12 reaction units (PRU) using the VerifyNow-P2Y12 (Accumetrics, San Diego, CA, USA) at 14 days after treatment with ticagrelor 60 or 90 mg twice daily. Out of 50 patients, 24 (48%) had diabetes. Pre-dose PRU was similar between patients with diabetes (Least-squares means, LSM, difference60 vs. 90 -8.80, 95% confidence interval, CI, -26.7 to 9.15; p = 0.33) and those without diabetes (LSM difference60 vs. 90 0.01, 95%CI -16.8 to 16.8; p = 0.99), without significant heterogeneity (p for interaction = 0.48). Consistently, transmittance aggregometry and multiple electrode aggregometry showed a similar pharmacodynamic profile between the two doses of ticagrelor in patients with and without diabetes. Plasma levels of ticagrelor were significantly lower using the 60 mg dose in both patients with diabetes (pre-dose: LSM difference60 vs. 90 -174 ng/mL, 95%CI -370 to 20.3; p = 0.08; post-dose: LSM difference60 vs. 90 -549 ng/mL, 95%CI -781 to -316; p < 0.001) and without diabetes (pre-dose: LSM difference60 vs. 90 -177 ng/mL, 95%CI -350 to -3.53; p = 0.05; post-dose: LSM difference60 vs. 90 -407 ng/mL; 95%CI -613 to -200; p < 0.001). Ticagrelor 60 mg twice daily provided a similar magnitude of platelet inhibition compared with ticagrelor 90 mg twice daily among elderly patients with ACS irrespective of diabetic status.