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The proportion of patients receiving clopidogrel (Plavix) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) fell from 2008 to 2016, not only because of the rise of other P2Y12 receptor inhibitors, but also because of a trend of more patients skipping them completely, a study suggested.

During this period, the proportion of patients not getting their P2Y12-inhibitor prescriptions filled within 30 days of discharge rose from 6.4% to 19.1% (P<0.001), according to researchers led by Elias Dayoub, MD, MPP, of the Hospital of the University of Pennsylvania in Philadelphia, reporting online in .

Among those who received a drug-eluting stent during PCI, medication possession ratios at 6 months averaged 0.85 for clopidogrel users, 0.79 for recipients of prasugrel (Effient), and 0.76 for those who started taking ticagrelor (Brilinta; P<0.001). Copayments for a 6-month supply of each drug were $132, $287, and $265, respectively (P<0.001).

By 12 months, the medication possession ratio dropped to 0.76, 0.71, and 0.68 for clopidogrel, prasugrel, and ticagrelor (P<0.001), respectively. The mean total copayment for these drugs had reached $251, $556, and $557 by then (P<0.001).

This all suggests that the higher out-of-pocket costs of prasugrel and ticagrelor may be contributing to increasing nonadherence to P2Y12 inhibitors after PCI, Dayoub's group concluded, noting that patients who did not adhere to these drugs in turn were at higher risk of recurrent ACS and hospitalization for bleeding.

"In the world of medical errors, we learned to stop blaming individual healthcare professionals; in the world of nonadherence, we should stop blaming patients," said Julie Lauffenburger, PharmD, PhD, and Niteesh Choudhry, MD, PhD, both of Brigham and Women's Hospital in Boston, writing in an accompanying .

"This is not to say that patients should be left out of this process -- it is ultimately patients who must put pills in their mouths and swallow them. But the system, of course including physicians, needs to acknowledge the importance of barriers, such as unmet social needs and work, to help patients address them."

Dayoub and colleagues performed their retrospective analysis using administrative claims from UnitedHealthCare gathered from the OptumInsight Clinformatics Data Mart database. Commercially insured patients included in the study were adults ages 18-64 who had not gotten a P2Y12 inhibitor for 90 days preceding PCI for ACS (n=55,340). Mean age was 54.4, with 23.0% of participants being women.

Patients found to be less likely to be adherent to P2Y12-inhibition therapy were younger, non-white, and women, and to be residents of the southern U.S.

The investigators acknowledged that the medication-possession ratio tends to overestimate medication adherence as it does not indicate how many days people took their medication.

Lauffenburger and Choudhry said that ultimately, clinicians need to choose optimal medications based on patients' ability to afford them: "In this context, this could mean prescribing clopidogrel rather than prasugrel or ticagrelor, even if the efficacy may be lower. After all, higher long-term adherence to a slightly less-effective therapy might ultimately be more beneficial than short-term adherence to the best available therapy."