Ticagrelor Aim: To raise awareness of NICE TA420 on Ticagrelor and upcoming policy within Leeds

1. TicagrelorAim: To raise awareness of NICE TA420 on Ticagrelor and upcoming policy within Leeds

2. Ticagrelor Prescribing https://www.nice.org.uk/guidance/ta420 NICE Technology appraisal guidance (TA420) published in December 2016 stated: • Ticagrelor, in combination with aspirin, is recommended within its marketing authorisation as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event. • Ticagrelor 60 mg twice daily is the recommended dose when extended treatment is needed for patients with a history of myocardial infarction of at least 1 year and a high risk of an atherothrombotic event. • Treatment may be started without interruption (continuation therapy) after the initial 1‑year treatment with ticagrelor 90 mg or other adenosine diphosphate (ADP) receptor inhibitor therapy in patients with acute coronary syndromes and with a high risk of an atherothrombotic event. • Treatment can also be started up to 2 years from the myocardial infarction, or within 1 year after stopping previous ADP receptor inhibitor treatment. • Unless contraindicated, ticagrelor should always be given with a daily low maintenance dose of aspirin 75 mg to 150 mg. • Treatment should be stopped when clinically indicated or at a maximum of 3 years.

3. Ticagrelor Prescribing Cardiologists at LTHT have now agreed guidance on extended duration Ticagrelortherapy following myocardial infarction for new patients. Their recommendations are: Ticagrelor60mg twice daily should be prescribed, in addition to aspirin 75mg daily, for selected patients with history of myocardial infarction within two years who are at high risk of further events. Extended duration ticagrelor therapy 60mg twice daily should be continued for three years. In most cases this will comprise down-titration from 90mg twice daily prescribed for twelve months following myocardial infarction. Because protection from further cardiovascular events is offset by an increased risk of major bleeding, the decision to prescribe extended duration therapy should be made by a clinician familiar with assessing risk following acute coronary syndrome (usually a consultant cardiologist). In most cases, patients who will benefit from extended duration therapy will be identified during their admission with index myocardial infarction, taking into account findings at angiography (where available), risk factors and consideration of bleeding risk.

4. Ticagrelor Prescribing LTHT guidance continued…. One or more of the following risk factors should be taken into consideration when assessing the risk of future events: • Age over 65 years • Diabetes mellitus requiring medication • Previous myocardial infarction in addition to index event • Multivesselcoronary artery disease • Chronic kidney disease (eGFR < 60ml/min) not requiring dialysis The recommendation for extended duration therapy must be clearly documented in the case notes and communicated to the general practitioner on the eDANas follows:“Please continue ticagrelor 90 mg twice daily for 1 year and then downtitrate to 60 mg twice daily for a further 3 years, if tolerated, in view of extent of coronary artery disease and clinical risk factors. Continue aspirin, statin and other secondary prevention medication long term.” Please note: Ticagrelor is contraindicated in patients with active pathological bleeding, a history of intracranial haemorrhage, or moderate-to-severe hepatic impairment. Co-administration of ticagrelor with a strong CYP3A4 inhibitor (for example, ketoconazole, clarithromycin, nefazodone, ritonavir or atazanavir) is also contraindicated.

5. Ticagrelor Prescribing Current issues: When NICE recommends a treatment 'as an option', the NHS must make sure it complies with the recommendations in this appraisal within 3 months of its date of publication. Ticagrelorcosts £54.60 for a 56‑tablet pack (28 days' supply) (Drug Tariff price April 17) so will put a huge cost pressure on the NHS. Lots of these patients have been discharged from secondary care for management in primary care. LTHT do not have capacity for referral of all patients. According to the NICE TA, GPs could initiate in primary care however patients at ‘high risk of a further event’ has not been clearly defined making it hard for GPs to assess the risk/benefitas well as increasing their workload.

6. Ticagrelor Prescribing Recommendations for primary care: Primary care patients who have already discontinued ticagrelor after MI will not be offered extended duration therapy. We are working with LTHT to develop a process to ensure high risk patients are identified who are currently taking ticagrelor 90mg BD. A specialist will then advise which patients require ongoing treatment with 60mg BD. This process should be ratified in a few months and further information will be provided at the next Prescribing Leads Meeting Contact details for further information/queries:- Rani Khatib Consultant Pharmacist Cardiology ranikhatib@nhs.net 07825453873