Study Finds Prasugrel Superior to Ticagrelor for Diabetic Patients with Coronary Artery Disease

The TUXEDO-2 study, a randomized clinical trial involving 1,800 adults in India with Type 1 or Type 2 diabetes and multivessel disease, found significant differences in outcomes between two commonly used antiplatelet medications. Patients who received prasugrel showed lower rates of heart attack, stroke, bleeding complications and death compared to those taking ticagrelor, despite both medications being frequently used interchangeably in clinical practice. According to the research presented at the American Heart Association's Scientific Sessions 2025, 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.

The study specifically examined patients who had undergone percutaneous coronary intervention with drug-eluting stent implantation, a procedure to restore blood flow in narrowed or blocked arteries. Lead study author Sripal Bangalore, M.D., M.H.A., FAHA, a professor of medicine at NYU Grossman School of Medicine in New York City, expressed surprise at the findings. "We were surprised by the results because we hypothesized that ticagrelor should be as good or perhaps even better than prasugrel," Bangalore said. "It's important to choose the right medicine, and at least from our data, we cannot say that ticagrelor and prasugrel are interchangeable."

The detailed results showed consistent advantages for prasugrel across multiple measures. The rate of non-fatal heart attack was 5.96% in the ticagrelor group versus 5.21% in the prasugrel group. Major bleeding occurred in 8.41% of ticagrelor patients compared to 7.14% of prasugrel patients. Mortality rates also differed significantly, with 5.03% of ticagrelor patients dying compared to 3.67% of prasugrel patients during the one-year study period. All patients in the study received dual antiplatelet therapy, which combines aspirin with a P2Y12 inhibitor like ticagrelor or prasugrel. This approach is standard practice following stent implantation and aligns with the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes, which recommends at least one year of dual antiplatelet therapy after drug-eluting stent placement.

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 research was conducted at 66 health care sites across India from 2020 to 2024. Bangalore emphasized the clinical implications of these findings. "For individuals with Type 1 or Type 2 diabetes and complex coronary disease, there may be an advantage to treatment with prasugrel over ticagrelor, and importantly, the two should not be used interchangeably," he stated. The study abstract is available through the American Heart Association Scientific Sessions 2025 Online Program Planner.

Researchers noted several limitations to the study, including that both patients and physicians knew which medication was assigned, and compliance with the prescribed treatment wasn't formally assessed. Additionally, since the study was conducted exclusively in India, the findings may not necessarily apply to populations in countries with different health systems or demographic characteristics. The TUXEDO-2 study represents an important contribution to understanding medication selection for diabetic patients requiring stent procedures, a population at particularly high risk for cardiovascular complications. The full findings await publication in a peer-reviewed scientific journal, as the current results are considered preliminary until that process is complete.