Chewing—not just swallowing—ticagrelor helps the blood thinner work faster

Chewing the blood thinner ticagrelor rather than simply swallowing the pill could yield more effective results in patients suffering from ST-segment elevation myocardial infarction (STEMI), research published in JAMA Cardiology this week suggests.

Dual antiplatelet therapy is the standard of care in STEMI cases, Elad Asher, MD, MHA, and colleagues wrote in the study, and ticagrelor is a direct-acting P2Y12 inhibitor that doesn’t require metabolic activation like other popular drugs.

STEMI patients undergoing primary percutaneous coronary intervention (PPCI) are especially prone to periprocedural thrombotic events, Asher and co-authors explained, resulting in a need to achieve inhibition of platelet aggregation (IPA) in these individuals quickly. However, it often takes several hours for P2Y12 inhibitors to start working for these patients.

Ticagrelor has been increased in dosage and crushed in previous studies, which have shown that breaking down the tablets can be efficient in acute coronary syndrome patients with IPA. Still, the authors wrote, those trials haven’t included STEMI patients, who often require a different course of treatment.

“The aim of this study was to investigate whether chewing ticagrelor is associated with more favorable platelet inhibitory effects compared with the conventional way of swallowing whole tablets in patients with STEMI undergoing PPCI,” they said in the paper.

The researchers randomized 50 STEMI patients to either chewing a loading dose—180 mg—of ticagrelor or swallowing an equal dose of the pill. Subjects’ P2Y12 reaction units were analyzed at baseline, then 30 minutes, an hour and four hours after taking the medication.

Asher et al. found that platelet reactivity in the chewing group was reduced by 24 percent 30 minutes after the loading dose, and relative inhibition of platelet aggregation in the chewing vs. swallowing group were 51 percent versus 10 percent at one hour and 81 percent versus 76 percent at four hours. One patient in each group experienced an uncommon major adverse cardiac or cardiovascular event during a 30-day follow-up period.

For the most part, chewing the tablets seemed to be the quickest, most effective method of ingesting ticagrelor. This method, Asher and colleagues said, suggest that chewing the drug results in a faster absorption via the mucosa or stomach.

“To our knowledge, this is the first investigation to show that, in patients with STEMI undergoing PPCI, chewing a lower dose of ticagrelor was associated with enhanced platelet inhibitory effects compared with standard ticagrelor administration, particularly in the early hours after drug administration,” the authors wrote. “Chewing ticagrelor could overcome the disadvantages of drug absorption via the gastrointestinal tract, particularly during the first crucial hours of STEMI.”