Combining the $P2Y_{12}$ antagonist cangrelor with energy metabolism inhibitors has a synergistic antiaggregatory effect

Antiplatelet therapy represents a key strategy to reduce cardiovascular events related to thrombosis. This study aimed to test whether inhibiting platelet energy metabolism would enhance the antiaggregatory action of cangrelor. Washed platelets isolated from healthy volunteers were exposed to carbon monoxide-releasing molecule A1 (CORM-A1; mitochondrial respiration and glycolysis inhibitor) or a mixture of 2-deoxy-D-glucose (2DG; hexokinase inhibitor) and oligomycin (ATP synthase inhibitor), individually and in combinations with cangrelor (a purinergic receptor $P2Y_{12}$ antagonist). Platelet function and energy metabolism were assessed using light transmission aggregometry, the Seahorse technique, and liquid chromatography-tandem mass spectrometry. Adenosine triphosphate (ATP) release and intraplatelet metabolic ATP levels were measured using the luciferin-luciferase-based luminescence assays. Reactive oxygen species generation by platelets was measured using the dichlorodihydrofluorescein diacetate-based fluorescent assay. Alone, CORM-A1 and cangrelor inhibited platelet aggregation, but only CORM-A1 attenuated platelet energy metabolism and thromboxane $A_{2}$ release. Administered together, cangrelor and CORM-A1 synergistically inhibited platelet aggregation. Combining oligomycin and 2DG at low concentrations also synergistically enhanced the antiaggregatory effect of cangrelor. In conclusion, combining the purinergic receptor $P2Y_{12}$ antagonist cangrelor with energy metabolism inhibitors that affect both ATP production pathways in platelets synergistically inhibits platelet aggregation. Therefore, the downregulation of energy metabolism pathways in platelets provides an attractive strategy to increase the efficacy of antiplatelet drugs.