PLATO: Is bigger, better, faster really our greatest priority?

I thought that nothing multiplied faster than rabbits, except maybe the number of ace inhibitors available on the world market.  Now, platelet inhibitors are following suit and the race is more intense than ever for bigger, better, faster, and safer. Ticagrelor plus aspirin is out front today as reported by Lisa Nainggolan in heartwire. The new drug produced a significant reduction in death, MI and stent thromboses in ACS patients in a head to head comparison with clopidigrel plus aspirin. Amazingly, there was no increase in major bleeds.   PLATO could have only been more interesting if it had included a prasugrel arm as well.    

Things are moving very quickly in the business of divorcing platelets from one another.   As a practicing cardiologist, I’m just getting accustomed to having Prasugrel as an option.   Only 2 weeks ago, a pharmaceutical rep came to detail me on it.  Because of my “other life” as a medical blogger, I was already aware that small elderly women and patients with renal impairment need a lower dose due to increased bleed rates. I was thrilled to learn that all of my clopidogrel allergic patients could try it. I was proudly building a comfort zone with Prasugrel, but now, I’ll hardly have time to enjoy my new found anti- platelet toy until I’ll have another option to consider.

Though the PLATO results are exciting, there are still some cautionary issues with Ticagrelor; as happy as I am about the lower risk of bleeding, I’m equally concerned about the nagging issue of dyspnea. Since everyone in Kentucky smokes (some starting as young as 6), sorting out the  “is it COPD or Ticagrelor” question will be a challenge( and about as much fun as trying to sort out whether someone has big legs because of Actos or heart failure). The “asymptomatic” pauses are also a concern. In my experience, wherever there has been even the slightest hint of smoke from rhythm issues, it will for some, turn into a fire. 

In the race for bigger, better, faster and safer, I hope someone will add the attribute of “affordability”. We hurt a lot of patients in the infancy of our addiction to metal coils by not making certain our patients could also afford or comply with the “grease” that kept them open.  It would be refreshing if this medication could undercut the cost of prasugrel and name brand clopidogrel. As attractive as any other attribute in the race for the ultimate platelet inhibitor is the ability to actually get it into the mouths of those who need it. 

Lastly, there is the issue of how much money we are spending in the development of these medications when the world of prevention goes lacking.  We are now up to our third marketable compound that kind of does the same thing as the others, only a little bit better.  Do we really need “a little bit better” right now?  Is it really millions upon millions of dollars worth "better" to find the best platelet inhibitor in the world or should we spend the same money and prevent millions upon millions of patients from ever needing one?

If we put the same question to the great philosopher Plato who shares his name with this study’s acronym, he might have answered with one of his best known quotes: “The beginning is the most important part of the work”. 

Sometimes the question is whether to begin at all.

Your comments

	PLATO: Is bigger, better, faster really our greatest priority?
	# 1 of 3	September 2, 2009 01:26 (EDT)
	Dr Makkar	What drives the search for better therapies is the degree of unmet need and the extent of dissatisfaction with current options. I agree that the once you have decently safe & effective drugs that save most (if not all) lives, the subsequent dollars should be better spent on research on preventive issues that would obviate the need for such drugs in the first place. The search for the 'Ultimate Perfect Drug' only drains the resources and is not a rationale approach atleast from the Health economists' point of view.
	# 2 of 3	September 7, 2009 09:10 (EDT)
	suresh vijan	This is another me too drug with minor benefits. What needs to be answered is whether these me too drugs are cost effective?. Compare the results of Current OASIS -7. Do we really need new drugs? and that to for how long?. That issue is not addresed in these trials.
	# 3 of 3	September 10, 2009 06:51 (EDT)
	golftee	Suresh, My question is whether it's prasugrel or ticagrelor that is the "me too" drug.  Ticagrelor looks to be more safe and a little more easily dealt with.  I'm a bit concerns about the side effect profile with the dyspnea which I don't understand.  It might be a signal or an artifact of the survey.  Subjective symptoms are often a toublesome area for trials.  I hope it's the best thing since buttered bread,.....er....bread dipped in olive oil, so we can end the search for bigger, better, faster in this drug class. Melissa

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