Brilinta: Is It Really Better than Plavix?

Headline:  Brilinta Reduces Death Rates vs. Plavix in Acute Coronary Syndrome!

Tagline:  But Not By Much, and at a High Cost.

July 20, 2011 AstraZenica received FDA approval for their new antiplatelet agent Brilinta (ticagrelor) for use in acute coronary syndrome.  Brilinta joins an increasingly crowded market of antiplatelet agents that includes the longstanding leader in the class Plavix and Effient, which came to market July 10, 2009.  Effient has not become terribly popular, likely due to its higher rate of bleeding complications including life threatening bleeding and an increased incidence of stroke in patients with previous stroke.  These risks seem to have held sway over the modestly reduce rate of restenosis of coronary artery stents seen in Effient vs. Plavix patients when used post coronar artery stent placement.

The primary selling point of Brilinta is that in the PLATO clinical trial the mortality rate in patients with acute coronary syndrome was stastically significantly lower in patient using Brilinta (9.8%) vs. Plavix (11.7%) P<0.001.  Patients on Brilinta had lower death rates from heart attack and stroke, but had higher rates of non-fatal bleeding complications. The reversible mechanism of action of Brilinta has its drawbacks though, requiring twice daily dosing vs. daily dosing with Plavix.

The primary issue with Brilinta is whether this statistically significant reduction in death rates in acute coronary syndrome is practically significant, and whether the potential drawbacks of twice daily dosing and the non-compliance issues this may engender will erode those benefits when used for longer periods of time.  When the Plavix patent expires soon and generic clopidogrel becomes available the benefits of Brilinta and its current high cost of $7.24/day will need to be enough to make that cost difference palatable.  Plavix has been an effective, well tolerated and extremely popular drug. It is the third highest gross sales drug in the US  (2009 data) and is anticipated to be available as an inexpensive generic in about May 2012.

These are some of the pros and cons that patients and physicians will need to consider when making a decision between Plavix and Brilinta


Plavix Brilinta
Pros: Pros:
Long track record and well understood Slightly lower death rate in acute coronary syndrome
Currently less expensive than Brilinta, soon to be much less expensive after generic Plavix is available May 2012. No hepatic metabolism needed
Once Daily Dosing Can be used with proton pump inhibitors
Cons: Cons:
Slightly less effective in acute coronary syndrome Higher cost, soon to be much higher
Loses efficacy used with Proton Pump Inhibitors Twice daily dosing may reduce compliance
New drug, after market side effects to be determined
Efficacy reduced with aspirin doses >100 mg daily


Brilinta, like Plavix and Effient works as a platelet aggregation inhibitor, but acts with a slightly different mechanism of action, binding at a site different from the ADP receptor it blocks.  It is a reversible receptor inhibitor, and Brilinta, unlike Plavix does not require hepatic activation which may be a potential advantage in some patients. The importance of the hepatic metabolism issue in overall efficacy is unclear, and this may be just a theoretic issue of little clinical significance.

Brilinta currently has a black box warning similar to that with Plavix warning against use in patients with active bleeding, a history of intracranial hemorrhage, and tha bleeding should be suspected in any patient with hypotension who has had a recent procedure like CABG, coronary angiography or any other surgery.  Unlike Plavix the black box warning also includes an increased risk of cardiovascular events if Brilinta is discontinued, making the twice daily dosing and compliance an even larger concern.  The black box warning also noted the reduced effectiveness of Brilinta if aspirin at doses higher than 100 mg daily are used.  This could easily be done inadvertently in patients taking OTC aspirin products.  If you do not personally have a history with Aspirin usage, consider this resource about aspirin side effects.

An unexpected issue with Brilinta is a much higher incidence of dyspnea (13%) vs Plavix (7%).

In summary I expect Brilinta to be a niche product used in uncommon circumstances once clopidogrel becomes available as an inexpensive generic.

15 Responses to Brilinta: Is It Really Better than Plavix?

  1. I was given Brilinta after a second stent was installed inside of the first and had most of the side affects beathing problems, terrible brusing, capulary broke left small pool of blood, under skin, light headed standing up to quick, dizzy at times, and I would get very, very weak at times for a few minutes. But, the weakness could on some days follow me all day lightly. I found that if I push myself through the weakness it would get better as strange as that sounds. But for those of you who have used Brilinta it is hard to do all of the time. The eakness, light head and breathing is the worst until you see your cap spill a little pool of blood then you really worry. My friend takes cumadin sorry for spelling and said there is something wrong. I looked up Brilinta and all these symptomes say see the Dr right away so I did and I am on Plavix. I feel great no bruses or bleeding but look up Plavix you need to be TESTED. Youv body has to have the right cemisrty sorry to have Plavix work. Depending on the amount of the cemical you need depends a on how well Plavix will work for you. I hope the doctor tested you if you went to plavix or you need to think about using another doctor. Look it up if you have a little of the cem you need it works a little, more works better, and more is even better how much of the cem do you have in your body did the doctor test you? Look it up Please

  2. please be honest with me.dec 2005 had heart. 4 stents inplanted. given Plavix 75 mil. once a day. 2007 had 2nd attack. 2 more stents. stiil stayed on Plavix. 2009 2 implanted stents closed. replaced and still on Plavix 2011 2 more stents implanted. still on Plavix. YESTERDAY May 24th a severe attack rushed to hospital and 2 stents replaced. prescribed. BRILINTA .was prescribed and this evening may 25th when I read testimonies aboutBRILINTA its not very encouraging. im 66 years old. Any feed back. thanks Ray

  3. Very confused – Brilinta vs Plavix. Brilinta costs me 250 per moth and I’m paying but Plavix would cost me 7 bucks per month.
    I had a heart attack 8 months ago and had 2 stents put in my lowere left (100% blockage). Lifestyle was my problem. I weighed 270 pounds and got very little excercise. I’m 53 years old. Since my heart attack I’ve lost 90 pounds, reduced my waist from 44 to 34. I excercise daily – hiking, canoeing, tennis etc. I’ve cut out red meat, most meats alcohol and am on about a 90% vegan diet.
    My cardiologist is very surprised and pleased with my lifestyle change but wants me on Brilinta for life. My blood work looks great and I tend to agree with using a blood thinner I just am torn about the price. Honestly the difference in price is not a huge issue for me but I don’t want to throw money away. Help appreciated.

  4. Paul: I cannot help. Bleeding is a known complication of any of the antiplatelet products, aspirin, Plavix and Brilinta. Sorry to hear about his/your poor outcome. DrP.

  5. Hello Sir,
    how can we fight or stop AstraZeneca, the drug Brilinta was prescribe to my father 3 days after having 3 stints put in and on the 8th day of Brilinta he had to be flown to the local Trauma center because he had a stroke loss use of his right side & could no longer speak and was bleeding on his brain, two day later he had emergency brain surgery to take out a massive blood clot and to stop the bleeding before it broke his brain stem, after 6 months or so of being in the hospital he has had seizure’s and is still on a feeding tube. I have written and called every law firm and even the FDA and filed complaints with them to. can you please help

  6. After a stent was placed I was prescribed Brilinta. I took 2 pills a day for 3 days as instructed. Three hours after my 6th pill I was rushed to the hospital and diagnosed as being in acute respiratory failure. The RX was not suspected as the cause until the next day after everything else was eliminated. Once the drug was totally flushed from my system and replaced with Plavix I could breathe normally. Scariest night of my life.

  7. I had a heart attack 7 years ago. I was taking Plavix and had no problems. I stopped taking this drug because of the cost and seeing all of the kick backs my Doctor’s office staff was receiving from the drug reps. (Gift cards, free food ect.) They had no problems having discussion with the drug reps. at the Dr. office sign in counter. Sometimes there would be 2 – 5 drug reps. in the office each time I went.

    I had a second heart attack last week because of not taking the meds. My doctor gave me Brilinta instead of Plavix. The cost without insurance at Costco is $300 per month vs $30 for Plavix.

    I feel the reason is that the Patent has expired on Plavix and the drug reps are telling the Doctors to switch everyone to the new money maker drugs. I’m not going for it and the doctors office nurse is fighting against me. I think their should be some laws to stop this type of practice.

  8. I know my previous description of the side effects I experienced with the 3 wk. use of Brilinta sounds unusual, but, unfortunately my statement is completely truthful. I continue with mild hematuria and very annoying itching after 10 days no longer taking it. I question how long the medicine stays in the system. I have no kidney or liver problems. I am 70 years old. I sincerely wish I had never taken Brilinta.

  9. Brilinta gave me extreme fatigue, weakness, shortness of breath, small amount blood in my urine, backpain, itching, stomach sore inside, heartburn even with dry toast, low blood pressure, irregular pulse and this happened in the 3 weeks I took it. I am allergic to Plavix–bad rash and itching, so I started coated aspirin 325 mg. Worked for me before. After 11 years my first stint is patent. I feel Brilinta is a very dangerous drug.Never will take it again. Be careful, folks, this drug can really harm you.

  10. I was on Brilinta for almost 2 years.. A drug diluted stent at Barnes Hospital in St. Louis 2/2012. I told the doctor I could NOT pay the huge amount monthly for the Brilinta when Plavix is only $6 a month.. they said NO..! I had to be on Brilinta for life.
    From the start I was so tired, lifeless, dizzy etc… The worse was the lung side effect.. I just could not get a deep Breath. I lived like this (like a heavy cement in my lungs)… for almost 2 years.. I decided to go through a dangerous recheck of my stent (doctors felt I needed another stent placed inside my first)… it was the Brilinta all along.
    Since I have been put on Plavix I am still some tired but can at last BREATH… I walk more so I lost 15 lbs… before I could not get out of bed, even though the doctors complained..”you have to walk more..get more exercise”. I would say over and over I am just to tired.. I cant breath..
    So now I take one Plavix a day, feel so much better.
    I really think Brilinta is very dangerous.. Way too expensive.
    It took 2 years of my life from me..

  11. I had an adverse reaction to it immediately (fast breathing) which became insupportable after 5 days. I have fibromyalgia so I just thought it was much worse than usual, before I realized it was the drug that was causing severe joint and muscle stiffness and also extreme, rather violent irritability. I could not get hold of any of my doctors to ask what to do, so I took myself off it that night and substituted Plavix then another in the morning and things went better right away. I now take one Plavix a day which is what was agreed to by all the doctors who eventually called back the next day.

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