(625) A Retrospective Analysis of Factors Affecting Prasugrel Activity in Neurocritical Care Patients

Introduction: Prasugrel is an irreversible inhibitor of the P2Y12 adenosine diphosphate receptor on platelets and is often used to prevent stent thrombosis. Variability in prasugrel concentrations, specifically in critically ill patients, has been observed via VerifyNow P2Y12 Platelet Reactivity Unit (PRU) monitoring. The objective of this study was to characterize prasugrel requirements in neurocritical care patients requiring intra- or extracranial stenting and to identify patient specific factors that may contribute to varying dose requirements.

Methods: This study was a single center, retrospective chart review of adult, neurocritical care patients who received at least one dose of prasugrel for intra- or extracranial stenting from April 1, 2022 - March 31, 2023. Patient’s presenting for emergent intervention were categorized as critically ill, and patients with pre-planned procedures were categorized as non-critically ill.

Results: A total of 27 patients were included in the final analysis: 9 in the critically ill cohort and 18 in the non-critically ill cohort. The median prasugrel dose required during hospital admission was 10 mg in both groups, whereas the mean prasugrel dose required during hospital admission, excluding outlier loading doses in critically ill patients, was 12.4 mg in the critically ill group and 11.6 mg in the non-critically ill group. The median prasugrel dose required at hospital discharge was 10 mg in both groups. At the time of data collection, 2/9 (22.2%) critically ill patients and 7/18 (38.9%) non-critically ill patients had their outpatient dose decreased within six months of discharge. Of the 9 critically ill patients, 4/9 (44.4%) had a median prasugrel dose requirement higher than the standard 10 mg daily during ICU admission. These patients received a combination of enteral tube feeding, mechanical ventilation, and vasopressors during this time.

Conclusions: A trend towards higher prasugrel dose requirements was observed in critically ill patients. It is hypothesized that tube feeding, mechanical ventilation, and vasopressor use are potential factors that may contribute to these increased requirements. More research is warranted to better characterize prasugrel dosing requirements in neurocritical care patients and the patient-specific factors affecting them.