Study Finds Prasugrel May Offer Better Outcomes Than Ticagrelor for Diabetic Patients After Stent Placement

The effectiveness of two commonly used anti-clotting medications varied significantly in patients with diabetes who underwent stent placement, according to research presented at the American Heart Association's Scientific Sessions 2025. The TUXEDO-2 study found that prasugrel and ticagrelor, both P2Y12 inhibitors prescribed alongside aspirin to prevent blood clots, did not offer the same level of protection against adverse cardiac events in patients with Type 1 or Type 2 diabetes who received drug-eluting stents.

The randomized clinical trial involved 1,800 adults in India with diabetes and multivessel coronary disease who had undergone percutaneous coronary intervention with drug-eluting stent implantation. Patients were randomly assigned to receive either prasugrel or ticagrelor along with aspirin as part of dual antiplatelet therapy. After one year of treatment, researchers found notable differences in outcomes between the two medication groups.

The primary composite outcome of heart attack, stroke, bleeding complications or death occurred at a rate of 16.57% in the ticagrelor group compared to 14.23% in the prasugrel group. More specifically, the rate of non-fatal heart attack was 5.96% with ticagrelor versus 5.21% with prasugrel, while major bleeding occurred in 8.41% of ticagrelor patients compared to 7.14% of prasugrel patients. Mortality rates also differed, with 5.03% of ticagrelor patients dying compared to 3.67% of prasugrel patients.

Lead study author Dr. Sripal Bangalore, a professor of medicine at NYU Grossman School of Medicine, expressed surprise at the findings. "We hypothesized that ticagrelor should be as good or perhaps even better than prasugrel," Bangalore noted. "It's important to choose the right medicine, and at least from our data, we cannot say that ticagrelor and prasugrel are interchangeable." The study suggests that for individuals with Type 1 or Type 2 diabetes and complex coronary disease, there may be an advantage to treatment with prasugrel over ticagrelor.

The implications of these findings are significant for clinical practice, as current guidelines from the American Heart Association and other organizations often treat these medications as interchangeable options for dual antiplatelet therapy. The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes recommends at least one year of dual antiplatelet therapy for all patients after drug-eluting stent implantation, but does not specify preference between these two P2Y12 inhibitors.

The study population consisted of adults with an average age of 60 years, with 71% men and 29% women. Approximately one quarter of participants were taking insulin, 79% had acute coronary artery syndrome, and about 85% had triple vessel disease. The TUXEDO-2 study was conducted at 66 healthcare sites across India, with enrollment occurring between 2020 and 2024. While the medication comparison analysis followed patients for one year, other parts of the TUXEDO trial will continue for five years.

Study limitations include the fact that patients and physicians knew which medication patients were assigned to, and compliance with the assigned treatment wasn't assessed. Additionally, since the study was conducted only in India, the findings may not apply to countries with different healthcare systems or populations. The research is considered preliminary until published as a full manuscript in a peer-reviewed scientific journal, as abstracts presented at American Heart Association scientific meetings are not peer-reviewed.

For the millions of diabetic patients worldwide who undergo stent procedures annually, these findings could influence treatment decisions and potentially improve outcomes by guiding physicians toward the more effective antiplatelet therapy. The study highlights the importance of personalized medicine approaches in cardiovascular care, particularly for high-risk patient populations like those with diabetes and complex coronary disease.