Use of Prasugrel in a Patient with Clopidogrel Hypersensitivity

Abstract

Objective:

To report a case of successful use of prasugrel following percutaneous coronary intervention with placement of a bare metal stent in a patient with a documented hypersensitivity reaction to clopidogrel.

Case Summary:

A 61-year-old male with a history of coronary artery disease with coronary stent placement presented with ST-elevation myocardial infarction. The patient had developed Stephens-Johnson syndrome 6 years earlier following Clopidogrel administration, characterized by erythematous plaques and subsequent desquamation of the hands and feet; Clopidogrel was discontinued and he was subsequently treated with ticlopidine in addition to aspirin. The third-generation thienopyridine prasugrel was initiated as a therapeutic alternative to Clopidogrel after placement of a bare metal stent; a 60-mg dose was administered after extubation, followed by 10 mg/day. No signs of allergic reaction were observed in the days, weeks, and months following administration.

Discussion:

Thienopyridines, specifically Clopidogrel, are the standard of care for prevention of coronary stent thrombosis; however, there are few data available on cross-hypersensitivity between these agents. One study demonstrated that 27% of patients who developed an allergic or hematologic reaction to Clopidogrel developed a similar reaction to ticlopidine. Other therapeutic options for patients with Clopidogrel hypersensitivity who are undergoing a percutaneous coronary intervention with stent placement include Clopidogrel desensitization, warfarin plus aspirin, cilostazol, ticagrelor, and ticlopidine. However, these options are limited by efficacy and/or toxicity. With its approval in 2009, prasugrel has become a potential treatment option.

Conclusions:

Prasugrel may be considered a therapeutic alternative in some patients allergic or intolerant to Clopidogrel, but additional data are warranted to make a strong conclusion.