Clopidogrel Versus Ticagrelor in Dual Antiplatelet Therapy for Intracranial Aneurysm Patients Undergoing Neuroendovascular Treatment: A Systematic Review and Meta-analysis
Mostafa Hossam El Din Moawad1, Ibraheem Alkhawaldeh2, Abdulrahman Sharaf3, Sumaya Alsalah4, Mohamed Smail Aissani5, Mona Mahmoud Elsakka6, Ibrahim Serag7, Osama Bisht8, Ahmed Negida9
11. Faculty of Pharmacy Clinical department Alexandria University, Alexandria, Egypt., 2Faculty of Medicine, Mutah University, 3Department of Clinical Pharmacy, Salmaniya Medical Complex, Government Hospital, Manama, Bahrain., 4Ministry of Health, Primary Care, governmental health centers., 5Blida University 01, Algeria., 6Faculty of pharmacy damanhour university., 7Faculty of medicine mansoura University, 8Kliikum Coburg, Klinik, für Innere Medizin I, Ketschendorfer Str. 33, 96450 Coburg., 9Virginia Commonwealth University
Objective:
We aimed to investigate the safety and effectiveness of administering clopidogrel versus ticagrelor in addition to aspirin as a part of dual antiplatlete therapy (DAPT) regimen for unanticipated or planned neuroendovascular operations.
Background:
Patients with cerebral aneurysms often undergo neurointerventional treatments involving stent implantation or flow diversion. These treatment options are associated with high risk of thromboembolic complications which shows the importance of the use of DAPT. However, there is some conflict regarding the use of ticagrelor or clopidogrel in addition to aspirin in DAPT.
Design/Methods:
We searched PubMed, Web of Science, and Scopus for comparative studies that fit the eligibility criteria including observational studies and randomized controlled trials up to August 2023. We excluded reviews, case reports, and meta-analyses. The analysis was performed using a fixed effect model since no or minimal heterogeneity was present. We conducted pooled analysis of odds ratio (OR) at confidence interval 95% and p-value of 0.05.
Results:
The search strategy and screening yielded a total of 13 eligible articles. There was no difference between clopidogrel and ticagrelor in thromboembolic complications, hemorrhagic complications, stroke, ischemic stroke, stent thrombosis, modified Rankin scale (mRs) 0-2 and all-cause mortality (OR= 0.92, 95% CI [0.73, 1.16], p=0.46), (OR= 1.06 .95% CI : 0.82–1.36), (OR= 1.06 ,95% CI [0.72, 1.57], p=0.76), (OR= 1.06, 95% CI [0.67, 1.69], p=0.79), (OR= 0.88 ,95% CI [0.46, 1.71], p=0.71),(OR=0.86, 95% CI 0.51 to 1.45; P=0.56), and (OR= 1.01 with 95% CI [0.59, 1.73], p=0.97), respectively. The overall odds ratio between the clopidogrel and ticagrelor in mRs worsening favored ticagrelor (OR= 0.52, 95% CI [0.32, 0.83], p=0.007).
Conclusions:
Comparable results were obtained regarding safety and efficacy outcomes between both drugs as used in DAPT regimens. Therefore, clopidogrel can be used as first-line according to the recommended guidelines, with the use of ticagrelor as an alternative for patients with inadequate response to clopidogrel due to the presence of polymorphism in CYP450 enzymes that activate clopidogrel to prevent the risk of thrombosis.