Physicians Drug Choices; Evidence-Based Practices, or Pharmaceutical Sales Representative Influenced?
Recently I started working with a facility that chooses Brilinta (ticagrelor) over Plavix (clopidogrel), both P2Y12 receptor inhibitors, in most acute coronary syndrome patients requiring PCI (percutaneous coronary intervention) with stent placement, especially drug-eluding stents. Prior to this new hospital, I had never administered Brilinta post PCI with stent placement; most patients would be discharged home with a combination therapy os aspirin and Plavix, and a handful of times I have administered Effient (prasugrel) and Aggrenox (dipyridamole/aspirin).
Which P2Y12 receptor inhibitor will your physician prescribe? Which does your hospital use? And how is that choice made? Being unfamiliar with Brilinta, which is the preferred choice in the hospital I am in now, I decided to ask around. Is it evidence-based practices? Does Brilinta decrease chances of complications and increase survival rate? Or is it solely physician’s choice, or which drug company “supports” the hospital better?
First, let’s understand the concept of why these drugs are used, to begin with. PCI or coronary angioplasty is one of the most commonly practiced procedures performed today, with millions of people undergoing revascularization after myocardial infarction (MI) and coronary artery disease. PCI is a nonsurgical procedure for diagnosing and treating obstructive coronary artery disease. If necessary, the interventional cardiologist will advance a stent into the diseased artery, to allow the return of blood flow through the arterial branch and to the heart muscles. After the stents are placed within the artery, coronary stent thrombosis is one of the complications that may occur, although uncommon, it is clinically devastating and can result in substantial myocardial infarction or death.
To aid in the prevention of coronary stent thrombosis, patient are prescribed a combination of aspirin and a P2Y12 receptor inhibitor such as Plavix, Effient or Brilinta, and the duration of the dual antiplatelet therapy (DAT), is dependent on type of stent used; bare metal stent or drug-eluting stent, and also patient’s risks for reoccurrence and risks for complications, such as bleeding.
After speaking with a few cardiology nurse practitioners and cardiologists within the hospital, I felt that they mostly leaned towards physician’s choice rather than increased benefits. Also, an answer that was repeated a couple of times was “whichever pharmaceutical company supplies better lunches,” or that it depends which sales rep the physicians are most attracted to (less sensitive words were used). One of the physicians I spoke with was actually interested in teaching and told me new research supports the use of Brilinta over Plavix, and Brilinta is reversible. Also, if a patient had previous stent placements, and stent thrombosis occurs while on one medication, or after treatment with a certain drug, they will switch the drug.
As a nurse, although I love some free lunch, I am very interested in evidence-based practices, and the use of Brilinta (ticagrelor) has shown superiority over clopidogrel, in numerous studies. Ticagrelor relative to clopidogrel shows reduced incidents of stent thrombosis in late, subacute, and acute stent thrombosis. Always keeping up with new studies and new medications is essential in the nursing field of practice.
Generic clopidogrel is a less costly choice, which has also shown to be very effective in the treatment and prevention of coronary artery disease before and after stenting, though research shows better outcome with ticagrelor. Many times P2Y12 receptor inhibitors will be used for a limited time, and Brilinta offers discount cards for patients with new prescriptions, thus making it affordable.
Medicine is always evolving and revolving, and it is our duty to keep up with it. Pharmaceutical companies will hire the best-spoken and physically attractive sales reps, and spend millions in advertising and supplies delicious lunches to hospital and office staff, but we have to rely on actual research studies to direct appropriate care to our patients.
The Dude Nurse
Klaus Campos, BSN-RN