DAPT Regimens for Elderly and Patients with Respiratory Conditions a Scoping Review

Background: Although ticagrelor is more potent than clopidogrel, it is associated with higher risk of bleeding and dyspnea. Since elderly patients are at higher risk of bleeding there is a concern of whether they should be prescribed clopidogrel instead of ticagrelor and a shorter duration of DAPT or even a monotherapy antiplatelet. Additionally, guidelines recommend being cautious when prescribing ticagrelor to COPD and asthmatic patients, yet, it is unclear whether patients with respiratory conditions are at higher risk of dyspnea from ticagrelor. This scooping review is conducted to assess the safety and efficacy of ticagrelor versus clopidogrel in elderly ≥75 years and patients with respiratory conditions. Also, to investigate the most suitable antiplatelet duration for elderly patients ≥75 years. Method: EMBASE, MEDLINE, and Cochran library were systemically searched. Studies were included if they were published in English; included adult patients diagnosed with ACS; are ≥75 years old or diagnosed with respiratory disease (asthma, COPD); treated with DAPT including clopidogrel or ticagrelor or monotherapy antiplatelet; reported quantitative data regarding bleeding or dyspnea. Studies were excluded if they were published prior to 2006. Outcome of interest were cardiovascular events, bleeding, and dyspnea. Results: 13 articles met the inclusion criteria and were included: 5 RCTs, 1 non-RCT, and 7 subgroup analyses. Two studies compared the safety and efficacy of ticagrelor versus clopidogrel in COPD patients (one of the studies included asthmatic patients), 3 studies compared safety and efficacy of ticagrelor versus clopidogrel in elderly, and 8 studies compared the duration of DAPT in elderly. Conclusions: Available data suggests that COPD and asthmatic patients are not at higher risk of dyspnea from ticagrelor and might benefit more from ticagrelor since they are at higher risk of ischemic events, yet, it is associated with higher discontinuation rate. Additionally, there was no difference between clopidogrel and ticagrelor in elderly patients in regard to cardiovascular endpoint while clopidogrel might lower the risk of bleeding. Shorter duration of DAPT might also minimize the risk of bleeding in elderly. However, data regarding DAPT in elderly and respiratory disease patients is limited, and evidence regarding the most appropriate regimen remains inconclusive.