Fentanyl reduces effectiveness of ticagrelor for PCI – PACIFY RCT

Fentanyl reduces effectiveness of ticagrelor for PCI – PACIFY RCT

Fentanyl is an opioid which is routinely used for periprocedural relief of during percutaneous coronary intervention (PCI). Intravenous morphine has been shown to reduce the absorption of P2Y12 inhibitors, presumably by delaying gastric emptying [1]. Platelet Aggregation with tiCagrelor Inhibition and FentanYl (PACIFY) trial [2] evaluated the effect of intravenous fentanyl on the efficacy of ticagrelor. Ticagrelor plasma levels, platelet function and troponin levels were compared in a randomized trial with and without the use of fentanyl. There were 70 patients in this study who required PCI. Fentanyl arm had lower ticagrelor concentrations and higher platelet reactivity. High sensitivity troponin levels were also higher in the fentanyl arm. One patient developed stent thrombosis and another developed catheter thrombosis in the fentanyl arm while there were no such events in the no fentanyl arm. Authors recommend larger studies while discouraging the use of fentanyl, specifically when loading doses are given just prior to PCI.

Updated on 1st May 2020

PACIFY trial was in the setting of elective angioplasty in which fentanyl was used prophylactically. Hence it did not include any patient with ST elevation myocardial infarction who would have needed more fentanyl for control of pain, right from the ambulance [3]. Another study will be needed to say how much fentanyl reduces effectiveness of ticagrelor in that situation.

References

1. McCarthy CP, Mullins KV, Sidhu SS, Schulman SP, McEvoy JW. The on- and off-target effects of morphine in acute coronary syndrome: A narrative review. Am Heart J. 2016;176:114-121.
2. McEvoy JW, Ibrahim K, Kickler TS, Clarke WA, Hasan RK, Czarny MJ, Keramati AR, Goli RR, Gratton TP, Brinker JA, Chacko M, Hwang CW, Johnston PV, Miller JM, Trost JC, Herzog WR, Blumenthal RS, Thiemann DR, Resar JR, Schulman SP. Effect of Intravenous Fentanyl on Ticagrelor Absorption and Platelet Inhibition Among Patients Undergoing Percutaneous Coronary Intervention: The PACIFY Randomized Clinical Trial. Circulation. 2018;137:307-309.
3. Ibrahim K, Shah R, McEvoy JW. Response by Ibrahim et al to Letter Regarding Article, “Effect of Intravenous Fentanyl on Ticagrelor Absorption and Platelet Inhibition Among Patients Undergoing Percutaneous Coronary Intervention: The PACIFY Randomized Clinical Trial (Platelet Aggregation With Ticagrelor Inhibition and Fentanyl)”. Circulation. 2018 Jul 10;138(2):216-217.