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466 Cardio Diabetes Medicine 2017

Ticlopidine • Increased platelet activation/aggregation in
diabetic patient contributes to their increased
• Thioenopyridine platelet inhibitor
rate of ischemic events. Clear role for aspirin in
• Prodrug. Requires activation by cytochrome secondary prevention, ? “primary” prevention.
P450 in liver Dual antiplatelet therapy indicated for at least
• Irreversibly modifies platelet ADP receptor 1 year after ACS or PCI. More potent P2Y12
and thus blocks pro-aggregatory effects of ADP receptor antagonists likely of greater benefit
in diabetics, if bleeding risk not too high.
Clinical uses
. Dual antiplatelet therapy with aspirin and
Unclear. Appears to be more effective than aspirin in clopidogrel has been the mainstay of
preventing stroke in patients who have already had secondary prevention of atherothrombotic
a stroke or a TIA. However aspirin remain treatment events in patients with ACS or those
of choice because of ticlopidine’s bone marrow undergoing PCI. However, despite the benefit
suppressant effects. of this combination, atherothrombotic events
continue to occur.
Ticlopidine plus aspirin is more effective than aspirin
alone or aspirin plus anticoagulants in preventing
thromboembolic complications related to coronary Conclusion:
stenting, but it is not licensed for this use. In practice, a favourable balance between the
beneficial and harmful effects of antiplatelet therapy
Adverse effects is achieved by treating patients whose thrombotic risk

• Neutropaenia in 2.4%, severe in 0.8% clearly outweighs their risk of bleeding complications.
• TTP in 0.02% References
• Nausea, diarrhoea. 1. Jennings LK. Role of platelets in atherothrombosis. Am J
Cardiol 2009;103:4A–10A
• Rashes
2. Bhatt DL. Role of antiplatelet therapy across the spectrum of
• Abnormal liver function tests rarely. patients with coronary artery disease. Am J Cardiol 2009;103:11A–9A
Cholestatic jaundice has been reported 3. Hirsh J, Guyatt G, Albers GW, Harrington R, Schunemann HJ.
Executive summary: American College of Chest Physicians Evidence-Based
• Rashes and diarrhoea are more common than Clinical Practice Guidelines (8th Edition). Chest 2008;133:71S–109S
with aspirin but other GI effects, including 4. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic
peptic ulceration are less common. and thrombolytic therapy for ischemic stroke: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest
Contraindications 2008;133:630S–9S
5. Hankey GJ, Sudlow CL, Dunbabin DW. Thienopyridine derivatives
• history of leucopaenia, thrombocytopaenia (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other
or agranulocytosis serious vascular events in high vascular risk patients. Cochrane Database
• blood diseases that prolong bleeding time Syst Rev 2000;2:CD001246
• lesions likely to bleed (eg active peptic ulcer,
acute haemorrhagic stroke)
• caution in patients with impaired liver function.
Should be discontinued if hepatitis or jaundice
develops. There is little experience of its use in
patients with renal impairment.

Dual Antiplatelet Therapy:
• Often a combination of aspirin plus an ADP/
P2Y inhibitor (such as clopidogrel, prasugrel,
ticagrelor, or another) is used in order to obtain
greater effectiveness than with either agent
alone.

GCDC 2017