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Martínez-Quintana E, Tugores A. Clopidogrel: A multifaceted affair. J Clin Pharmacol 2014; 55:1-9. [DOI: 10.1002/jcph.413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/14/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Efrén Martínez-Quintana
- Cardiology Department; Complejo Hospitalario Universitario Insular Materno Infantil; Las Palmas de Gran Canaria Spain
| | - Antonio Tugores
- Research Unit; Complejo Hospitalario Universitario Insular Materno Infantil; Las Palmas de Gran Canaria Spain
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Ismail S, Lee YM, Patel M, Duarte JD, Ardati AK. Genotype- and phenotype-directed antiplatelet therapy selection in patients with acute coronary syndromes. Expert Rev Cardiovasc Ther 2014; 12:1289-303. [PMID: 25340283 DOI: 10.1586/14779072.2014.970180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Although dual antiplatelet therapy (DAPT) has been a standard treatment in patients with acute coronary syndrome (ACS) for over a decade, only recently have therapeutic options beyond aspirin and clopidogrel become available. Additional treatment options are particularly useful because of the documented history of variability in antiplatelet response. This article reviews the current treatment options for DAPT in ACS, and reviews both genotype- and phenotype-guided methods for determining optimal antiplatelet therapy for patients with ACS. Additionally, recommendations from current guidelines as well as expert commentary are provided for the use of available testing methods to determine optimal DAPT for ACS patients.
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Affiliation(s)
- Sahar Ismail
- Department of Medicine, University of Illinois, Chicago, IL, USA
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53
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Tresukosol D, Suktitipat B, Hunnangkul S, Kamkaew R, Poldee S, Tassaneetrithep B, Likidlilid A. Effects of cytochrome P450 2C19 and paraoxonase 1 polymorphisms on antiplatelet response to clopidogrel therapy in patients with coronary artery disease. PLoS One 2014; 9:e110188. [PMID: 25329996 PMCID: PMC4199712 DOI: 10.1371/journal.pone.0110188] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 09/08/2014] [Indexed: 12/20/2022] Open
Abstract
Clopidogrel is an antiplatelet prodrug that is recommended to reduce the risk of recurrent thrombosis in coronary artery disease (CAD) patients. Paraoxonase 1 (PON1) is suggested to be a rate-limiting enzyme in the conversion of 2-oxo-clopidogrel to active thiol metabolite with inconsistent results. Here, we sought to determine the associations of CYP2C19 and PON1 gene polymorphisms with clopidogrel response and their role in ADP-induced platelet aggregation. Clopidogrel response and platelet aggregation were determined using Multiplate aggregometer in 211 patients with established CAD who received 75 mg clopidogrel and 75–325 mg aspirin daily for at least 14 days. Polymorphisms in CYP2C19 and PON1 were genotyped and tested for association with clopidogrel resistance. Linkage disequilibrium (LD) and their epistatic interaction effects on ADP-induced platelet aggregation were analysed. The prevalence of clopidogrel resistance in this population was approximately 33.2% (n = 70). The frequencies of CYP2C19*2 and *3 were significantly higher in non-responder than those in responders. After adjusting for established risk factors, CYP2C19*2 and *3 alleles independently increased the risk of clopidogrel resistance with adjusted ORs 2.94 (95%CI, 1.65–5.26; p<0.001) and 11.26 (95%CI, 2.47–51.41; p = 0.002, respectively). Patients with *2 or *3 allele and combined with smoking, diabetes and increased platelet count had markedly increased risk of clopidogrel resistance. No association was observed between PON1 Q192R and clopidogrel resistance (adjusted OR = 1.13, 95%CI, 0.70–1.82; p = 0.622). Significantly higher platelet aggregation values were found in CYP2C19*2 and *3 patients when compared with *1/*1 allele carriers (p = 1.98×10−6). For PON1 Q192R genotypes, aggregation values were similar across all genotype groups (p = 0.359). There was no evidence of gene-gene interaction or LD between CYP2C19 and PON1 polymorphisms on ADP-induced platelet aggregation. Our findings indicated that only CYP2C19*2 and *3 alleles had an influence on clopidogrel resistance. The risk of clopidogrel resistance increased further with smoking, diabetes, and increased platelet count.
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Affiliation(s)
- Damrus Tresukosol
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
| | - Bhoom Suktitipat
- Department of Biochemistry, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
- Integrative Computation BioScience Center (ICBS), Mahidol University, Salaya, Nakhon Prathom, Thailand
| | - Saowalak Hunnangkul
- Department of Health Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
| | - Ruttakarn Kamkaew
- Department of Biochemistry, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
| | - Saiphon Poldee
- Department of Biochemistry, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
| | - Boonrat Tassaneetrithep
- Department of Health Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
| | - Atip Likidlilid
- Department of Biochemistry, Faculty of Medicine, Siriraj Hospital, Mahidol University, Siriraj, Bangkoknoi, Bangkok, Thailand
- * E-mail:
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Sorich MJ, Rowland A, McKinnon RA, Wiese MD. CYP2C19 genotype has a greater effect on adverse cardiovascular outcomes following percutaneous coronary intervention and in Asian populations treated with clopidogrel: a meta-analysis. ACTA ACUST UNITED AC 2014; 7:895-902. [PMID: 25258374 DOI: 10.1161/circgenetics.114.000669] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The degree to which cytochrome P450 (CYP) 2C19 genotype influences the effectiveness of clopidogrel remains uncertain because of considerable heterogeneity in results between studies and potential publication bias. Clopidogrel indication and ethnic population have been proposed to influence the effect of CYP2C19 genotype. METHODS AND RESULTS A systematic review was undertaken up to 14 November 2013. Meta-analysis of the CYP2C19 genotype effect was stratified by the predominant clopidogrel indication (percutaneous coronary intervention [PCI] versus non-PCI) and ethnic population (white versus Asian) of each primary study. The primary analysis was restricted to studies with ≥500 participants, which comprised 24 studies and a total of 36 076 participants. The association between carriage of ≥1 CYP2C19 loss-of-function (LoF) allele and major cardiovascular outcomes differed significantly (P<0.001) between studies of whites not undergoing PCI (relative risk 0.99 [95% confidence interval, 0.84-1.17]; n=7043), whites undergoing PCI (1.20 [1.10-1.31]; n=19,016), and Asians undergoing PCI (1.91 [1.61-2.27]; n=10,017). Similar differences were identified in secondary analyses of 2 CYP2C19 LoF alleles, stent thrombosis outcomes, and studies with ≥200 participants. Minimal heterogeneity was apparent between studies of Asian populations. CONCLUSIONS The reported association between CYP2C19 LoF allele carriage and major cardiovascular outcomes differs based on the ethnic population of the study and, to a lesser extent, the clopidogrel indication. This is potentially of major importance given that over 50% of Asians carry ≥1 CYP2C19 LoF alleles.
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Affiliation(s)
- Michael J Sorich
- From the School of Medicine, Flinders University (M.J.S., A.R., R.A.M.); and School of Pharmacy and Medical Sciences, University of South Australia (M.D.W.), Adelaide, SA, Australia.
| | - Andrew Rowland
- From the School of Medicine, Flinders University (M.J.S., A.R., R.A.M.); and School of Pharmacy and Medical Sciences, University of South Australia (M.D.W.), Adelaide, SA, Australia
| | - Ross A McKinnon
- From the School of Medicine, Flinders University (M.J.S., A.R., R.A.M.); and School of Pharmacy and Medical Sciences, University of South Australia (M.D.W.), Adelaide, SA, Australia
| | - Michael D Wiese
- From the School of Medicine, Flinders University (M.J.S., A.R., R.A.M.); and School of Pharmacy and Medical Sciences, University of South Australia (M.D.W.), Adelaide, SA, Australia
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55
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Bounafaa A, Berrougui H, Ikhlef S, Essamadi A, Nasser B, Bennis A, Yamoul N, Ghalim N, Khalil A. Alteration of HDL functionality and PON1 activities in acute coronary syndrome patients. Clin Biochem 2014; 47:318-25. [PMID: 25218815 DOI: 10.1016/j.clinbiochem.2014.09.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/29/2014] [Accepted: 08/16/2014] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The functionality of HDL has been suggested as an important factor in the prevention of cardiovascular and coronary artery diseases. The objective of the present study was to investigate the functionality of HDL and the factors that may affect the anti-atherogenic properties of HDL in ACS patients. METHODS AND RESULTS One hundred healthy subjects and 205 ACS patients were recruited. HDL functionality was evaluated by measuring their capacity to mediate cholesterol efflux from J774 macrophages. Oxidative stress status was determined by measuring plasma malondialdehyde (MDA), protein carbonyl, and vitamin E levels by HPLC. The PON1 Q192R polymorphism status and PON1 paraoxonase and arylesterase activities of the healthy subjects and ACS patients were also determined. The HDL of ACS patients displayed a limited capacity to mediate cholesterol efflux, especially via the ABCA1-pathway. MDA (7.06±0.29 μM) and protein carbonyl (9.29±0.26 μM) levels were significantly higher in ACS patients than in healthy subjects (2.29±0.21 μM and 3.07±0.17 μM, respectively, p<0.0001), while α- and γ-tocopherol (vitamin E) levels in ACS patients were 8-fold (p<0.001) and 2-fold (p<0.05) lower than in healthy subjects. Paraoxonase, arylesterase and HDL-corrected PON1 activities (PON1 activity/HDL ratio) were significantly lower in ACS patients. Logistic regression analyses showed that high PON1 paraoxonase and arylesterase activities had a significant protective effect (OR=0.413, CI 0.289-0.590, p<0.001; OR=0.232 CI 0.107-0.499, p<0.001, respectively) even when adjusted for HDL level, age, BMI, and PON1 polymorphism. CONCLUSION The results of the present study showed that the functionality of HDL is impaired in ACS patients and that the impairment may be due to oxidative stress and an alteration of PON1 activities.
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Affiliation(s)
- Abdelghani Bounafaa
- Laboratory of Biochemistry & Neuroscience, Applied Biochemistry and Toxicology Team, Hassan I University, Faculty of Sciences and Technology, Settat, Morocco; Department of Biology, Polydisciplinary Faculty, Sultan Moulay Sliman University, Beni-Mellal, Morocco; Laboratory of Biochemistry, Pasteur Institute of Morocco, Casablanca, Morocco; Department of Medicine, Geriatrics Service, Faculty of Medicine and Biological Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Hicham Berrougui
- Department of Biology, Polydisciplinary Faculty, Sultan Moulay Sliman University, Beni-Mellal, Morocco; Department of Medicine, Geriatrics Service, Faculty of Medicine and Biological Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Souade Ikhlef
- Department of Medicine, Geriatrics Service, Faculty of Medicine and Biological Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Abdelkhalid Essamadi
- Laboratory of Biochemistry & Neuroscience, Applied Biochemistry and Toxicology Team, Hassan I University, Faculty of Sciences and Technology, Settat, Morocco
| | - Boubker Nasser
- Laboratory of Biochemistry & Neuroscience, Applied Biochemistry and Toxicology Team, Hassan I University, Faculty of Sciences and Technology, Settat, Morocco
| | - Ahmed Bennis
- Cardiology Service, Ibn Rochd University Hospital Center, Casablanca, Morocco
| | - Najoua Yamoul
- Cardiology Service, Ibn Rochd University Hospital Center, Casablanca, Morocco
| | - Noreddine Ghalim
- Laboratory of Biochemistry, Pasteur Institute of Morocco, Casablanca, Morocco
| | - Abdelouahed Khalil
- Department of Medicine, Geriatrics Service, Faculty of Medicine and Biological Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada.
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Polasek TM, Doogue MP, Miners JO. Metabolic activation of clopidogrel: in vitro data provide conflicting evidence for the contributions of CYP2C19 and PON1. Ther Adv Drug Saf 2014; 2:253-61. [PMID: 25083217 DOI: 10.1177/2042098611422559] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The recent report that clopidogrel efficacy may be more dependent on paraoxonase-1 (PON1) than on cytochrome P450 2C19 (CYP2C19) activity raises questions about the roles of these and other enzymes in clopidogrel activation. To provide insight into the emerging PON1 versus CYP2C19 debate, this commentary summarizes the clinical evidence on the pharmacokinetic determinants of clopidogrel efficacy. We then review the in vitro studies investigating the enzymes involved in clopidogrel activation, and comment on their strengths and limitations. There is agreement amongst in vitro studies regarding the involvement of CYP1A2 and CYP2B6 in the metabolism of clopidogrel to 2-oxo-clopidogrel. However, the evidence for other CYP enzymes in the first activation step (e.g. CYP2C19 and CYP3A4) is inconsistent and dependent on the in vitro test system and laboratory. All major drug metabolizing CYP enzymes are capable of converting 2-oxo-clopidogrel to sulfenic acid intermediates that subsequently form the active thiol metabolite. However, the extent of CYP involvement in this second step has been challenged, and new evidence suggests that CYP-independent hydrolytic cleavage of the thioester bond may be more important than oxidative metabolism.
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Affiliation(s)
- Thomas M Polasek
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Sturt Road, Bedford Park, Adelaide, SA 5042, Australia
| | - Matthew P Doogue
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - John O Miners
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Adelaide, Australia
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Siller-Matula JM, Lang IM, Neunteufl T, Kozinski M, Maurer G, Linkowska K, Grzybowski T, Kubica J, Jilma B. Interplay between genetic and clinical variables affecting platelet reactivity and cardiac adverse events in patients undergoing percutaneous coronary intervention. PLoS One 2014; 9:e102701. [PMID: 25051347 PMCID: PMC4106864 DOI: 10.1371/journal.pone.0102701] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/23/2014] [Indexed: 12/30/2022] Open
Abstract
Several clinical and genetic variables are associated with influencing high on treatment platelet reactivity (HTPR). The aim of the study was to propose a path model explaining a concurrent impact among variables influencing HTPR and ischemic events. In this prospective cohort study polymorphisms of CYP2C19*2, CYP2C19*17, ABCB1, PON1 alleles and platelet function assessed by Multiple Electrode Aggregometry were assessed in 416 patients undergoing percutaneous coronary intervention treated with clopidogrel and aspirin. The rates of major adverse cardiac events (MACE) were recorded during a 12-month follow up. The path model was calculated by a structural equation modelling. Paths from two clinical characteristics (diabetes mellitus and acute coronary syndrome (ACS)) and two genetic variants (CYP2C19*2 and CYP2C19*17) independently predicted HTPR (path coefficients: 0.11 0.10, 0.17, and -0.10, respectively; p<0.05 for all). By use of those four variables a novel score for prediction of HTPR was built: in a factor-weighted model the risk for HTPR was calculated with an OR of 3.8 (95%CI: 3.1–6.8, p<0.001) for a score level of ≥1 compared with a score of <1. While MACE was independently predicted by HTPR and age in the multivariate model (path coefficient: 0.14 and 0.13, respectively; p<0.05), the coexistence of HTPR and age ≥75 years emerged as the strongest predictor of MACE. Our study suggests a pathway, which might explain indirect and direct impact of variables on clinical outcome: ACS, diabetes mellitus, CYP2C19*2 and CYP2C19*17 genetic variants independently predicted HTPR. In turn, age ≥75 years and HTPR were the strongest predictors of MACE.
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Affiliation(s)
| | - Irene M. Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Thomas Neunteufl
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Marek Kozinski
- Department of Cardiology and Internal Medicine, Collegium Medicum of the Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gerald Maurer
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Katarzyna Linkowska
- Institute of Molecular and Forensic Genetics, Collegium Medicum of the Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Tomasz Grzybowski
- Institute of Molecular and Forensic Genetics, Collegium Medicum of the Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum of the Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- * E-mail: (JS-M); (BJ)
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58
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Li P, Bu SH, Lu XT, Li LX, Xu AJ, Tang YN, Zhang J. Relationships between PON1 Q192R polymorphism and clinical outcome of antiplatelet treatment after percutaneous coronary intervention: a meta-analysis. Mol Biol Rep 2014; 41:6263-73. [PMID: 24981930 DOI: 10.1007/s11033-014-3509-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 06/19/2014] [Indexed: 01/11/2023]
Abstract
This meta-analysis was performed to assess the relationships between the PON1 Q192R (rs662 T>C) polymorphism and the clinical outcome of antiplatelet treatment after percutaneous coronary intervention (PCI). A range of electronic databases were searched: Web of Science (1945-2013), the Cochrane Library Database (Issue 12, 2013), PubMed (1966-2013), EMBASE (1980-2013), CINAHL (1982-2013) and the Chinese Biomedical Database (CBM) (1982-2013) without language restrictions. Meta-analysis was conducted using the STATA 12.0 software. The crude odds ratio (OR) with their 95 % confidence interval (CI) were calculated. Six clinical cohort studies with a total number of 5,189 patients undergoing PCI for coronary heart disease were included. Our meta-analysis revealed that the PON1 Q192R polymorphism was correlated with an increased risk of major adverse cardiovascular events (MACE) in patients receiving antiplatelet treatment after PCI (C allele vs. T allele: OR = 1.22, 95 % CI 1.04-1.43, P = 0.014; CT+CC vs. TT: OR = 1.38, 95 % CI 1.03-1.86, P = 0.029; CC vs. TT: OR = 1.45, 95 % CI 1.05-1.99, P = 0.024; respectively), especially among Asians. Furthermore, we found significantly positive correlations between the PON1 Q192R polymorphism and the incidence of stent thrombosis in patients receiving antiplatelet treatment after PCI (C allele vs. T allele: OR = 1.42, 95 % CI 1.08-1.87, P = 0.011; CT+CC vs. TT: OR = 1.93, 95 % CI 1.01-3.67, P = 0.046; CC vs. TT: OR = 2.18, 95 % CI 1.09-4.35, P = 0.027; respectively). Our meta-analysis of clinical cohort studies provides evidence that the PON1 Q192R polymorphism may increase the risk of MACE and stent thrombosis in patients receiving antiplatelet treatment after PCI.
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Affiliation(s)
- Ping Li
- Department of Pharmacy, The Affiliated Xinhua Hospital of Shanghai Jiaotong University, Kongjiang Road No. 1665, Yangpu District, Shanghai, 200082, People's Republic China
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Martínez-Quintana E, Medina-Gil JM, Rodríguez-González F, Garay-Sánchez P, Limiñana JM, Saavedra P, Tugores A. Positive clinical response to clopidogrel is independent of paraoxonase 1 Q192R and CYP2C19 genetic variants. J Clin Pharmacol 2014; 54:843-9. [DOI: 10.1002/jcph.275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 02/03/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Efrén Martínez-Quintana
- Cardiology Department; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
| | - José M Medina-Gil
- Cardiology Department; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
| | - Fayna Rodríguez-González
- Intensive Care Unit; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
| | - Paloma Garay-Sánchez
- Research Unit; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
| | - José M Limiñana
- Research Unit; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
| | - Pedro Saavedra
- Department of Mathematics; Universidad de Las Palmas de Gran; Canaria
| | - Antonio Tugores
- Research Unit; Complejo Hospitalario Universitario Insular Materno-Infantil; Las Palmas de Gran Canaria Spain
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Tantry US, Jeong YH, Navarese EP, Kubica J, Gurbel PA. Influence of genetic polymorphisms on platelet function, response to antiplatelet drugs and clinical outcomes in patients with coronary artery disease. Expert Rev Cardiovasc Ther 2014; 11:447-62. [DOI: 10.1586/erc.13.20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kalantzi KI, Tsoumani ME, Goudevenos IA, Tselepis AD. Pharmacodynamic properties of antiplatelet agents: current knowledge and future perspectives. Expert Rev Clin Pharmacol 2014; 5:319-36. [PMID: 22697594 DOI: 10.1586/ecp.12.19] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Thomas MR, Storey RF. Genetics of Response to Antiplatelet Therapy. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2014; 124:123-53. [DOI: 10.1016/b978-0-12-386930-2.00006-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Dorfman R, Khayat Z, Sieminowski T, Golden B, Lyons R. Application of personalized medicine to chronic disease: a feasibility assessment. Clin Transl Med 2013; 2:16. [PMID: 24351097 PMCID: PMC3878365 DOI: 10.1186/2001-1326-2-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 09/25/2013] [Indexed: 02/04/2023] Open
Abstract
Personalized Medicine has the potential to improve health outcomes and reduce the cost of care; however its adoption has been slow in Canada. Bridgepoint Health is a complex continuous care provider striving to reduce the burden of polypharmacy in chronic patients. The main goal of the study was to explore the feasibility of utilizing personalized medicine in the treatment of chronic complex patients as a preliminary institutional health technology assessment. We analyzed stroke treatment optimization as a clinical indication that could serve as a "proof of concept" for the widespread implementation of pharmacogenetics. The objectives of the study were three-fold:1. Review current practice in medication administration for stroke treatment at Bridgepoint Health2. Critically analyze evidence that pharmacogenetic testing could (or could not) enhance drug selection and treatment efficacy for stroke patients;3. Assess the cost-benefit potential of a pharmacogenetic intervention for stroke.Review current practice in medication administration for stroke treatment at Bridgepoint HealthCritically analyze evidence that pharmacogenetic testing could (or could not) enhance drug selection and treatment efficacy for stroke patients;Assess the cost-benefit potential of a pharmacogenetic intervention for stroke.We conducted a review of stroke treatment practices at Bridgepoint Health, scanned the literature for drug-gene and drug-outcome interactions, and evaluated the potential consequences of pharmacogenetic testing using the ACCE model.There is a substantial body of evidence suggesting that pharmacogenetic stratification of stroke treatment can improve patient outcomes in the long-term, and provide substantial efficiencies for the healthcare system in the short-term. Specifically, pharmacogenetic stratification of antiplatelet and anticoagulant therapies for stroke patients may have a major impact on the risk of disease recurrence, and thus should be explored further for clinical application. Bridgepoint Health, and other healthcare institutions taking this path, should consider launching pilot projects to assess the practical impact of pharmacogenetics to optimize treatment for chronic continuous care.
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Affiliation(s)
- Ruslan Dorfman
- Present Address: Geneyouin Inc, Maple, ON, Canada
- The Rotman School of Management, The University of Toronto, Toronto, ON, Canada
| | - Zayna Khayat
- The Rotman School of Management, The University of Toronto, Toronto, ON, Canada
- International Centre for Health Innovation, Richard Ivey School of Business, University of Western Ontario, London, ON, Canada
| | | | - Brian Golden
- International Centre for Health Innovation, Richard Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Renee Lyons
- Bridgepoint Chair in Complex Chronic Disease Research, TD Scientific Director, Bridgepoint Collaboratory for Research and Innovation, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, The University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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64
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Karathanos A, Geisler T. Monitoring aspirin and clopidogrel response: testing controversies and recommendations. Mol Diagn Ther 2013; 17:123-37. [PMID: 23588781 DOI: 10.1007/s40291-013-0022-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antiplatelet therapy is the cornerstone of the treatment for patients with coronary artery disease (CAD). Dual therapy with clopidogrel and aspirin is currently the standard treatment after percutaneous coronary interventions. However, despite the use of clopidogrel, a considerable number of patients continue to suffer major adverse cardiac events. There is a growing degree of evidence supporting high on-treatment platelet reactivity (HPR) as a predictive factor for recurrent ischemic complications. Numerous studies have shown an interindividual variability of responsiveness to clopidogrel and aspirin, which is one of the reasons for HPR. There is yet to be established an assay for antiplatelet drug response as the gold standard. This paper provides a background to the current controversies surrounding the issue of testing for the effectiveness of antiplatelet therapy and reviews the various genetic and phenotype-based laboratory tests to measure aspirin and clopidogrel response and their correlation with clinical outcomes. On the basis of the current evidence and trying to be cost-effective, testing should be considered on a case-by-case basis, especially in patients who present with an acute coronary syndrome or stent thrombosis. In the case of stable CAD, we think that testing might be helpful in particular risk groups of patients to avoid ischemic or bleeding complications.
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Affiliation(s)
- Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Ottfried-Müller-Straße 10, 72076, Tübingen, Germany
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Kim HS, Cho DY, Park BM, Bae SK, Yoon YJ, Oh M, Ghim JL, Kim EY, Kim DH, Shin JG. The effect of CYP2C19 genotype on the time course of platelet aggregation inhibition after clopidogrel administration. J Clin Pharmacol 2013; 54:850-7. [DOI: 10.1002/jcph.225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/01/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Ho-Sook Kim
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Doo-Yeoun Cho
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Bo-Min Park
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Soo-Kyoung Bae
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Yune-Jung Yoon
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Minkyung Oh
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
| | - Jong-lyul Ghim
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Eun-Young Kim
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
| | - Dong-Hyun Kim
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
| | - Jae-Gook Shin
- Department of Pharmacology and PharmacoGenomics Research Center; Inje University College of Medicine; Busan Republic of Korea
- Department of Clinical Pharmacology; Inje University Busan Paik Hospital; Busan Republic of Korea
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Nishio R, Shinke T, Otake H, Nakagawa M, Inoue T, Hariki H, Osue T, Taniguchi Y, Iwasaki M, Hiranuma N, Konishi A, Kinutani H, Kuroda M, Hirata KI. Paraoxonase-1 activity affects the clopidogrel response in CYP2C19 loss-of-function carriers. Thromb Res 2013; 132:558-64. [DOI: 10.1016/j.thromres.2013.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 07/26/2013] [Accepted: 09/09/2013] [Indexed: 10/26/2022]
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Hurst N, Nooney V, Raman B, Chirkov Y, De Caterina R, Horowitz J. Clopidogrel “resistance”: Pre- vs post-receptor determinants. Vascul Pharmacol 2013; 59:152-61. [DOI: 10.1016/j.vph.2013.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 01/01/2023]
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Siller-Matula JM, Trenk D, Schrör K, Gawaz M, Kristensen SD, Storey RF, Huber K. Response Variability to P2Y12 Receptor Inhibitors. JACC Cardiovasc Interv 2013; 6:1111-28. [DOI: 10.1016/j.jcin.2013.06.011] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 06/20/2013] [Indexed: 12/19/2022]
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Abstract
Variability in drug responsiveness is a sine qua non of modern therapeutics, and the contribution of genomic variation is increasingly recognized. Investigating the genomic basis for variable responses to cardiovascular therapies has been a model for pharmacogenomics in general and has established critical pathways and specific loci modulating therapeutic responses to commonly used drugs such as clopidogrel, warfarin, and statins. In addition, genomic approaches have defined mechanisms and genetic variants underlying important toxicities with these and other drugs. These findings have not only resulted in changes to the product labels but also have led to development of initial clinical guidelines that consider how to facilitate incorporating genetic information to the bedside. This review summarizes the state of knowledge in cardiovascular pharmacogenomics and considers how variants described to date might be deployed in clinical decision making.
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Fisch AS, Perry CG, Stephens SH, Horenstein RB, Shuldiner AR. Pharmacogenomics of anti-platelet and anti-coagulation therapy. Curr Cardiol Rep 2013; 15:381. [PMID: 23797323 DOI: 10.1007/s11886-013-0381-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Arterial thrombosis is a major component of vascular disease, especially myocardial infarction (MI) and stroke. Current anti-thrombotic therapies such as warfarin and clopidogrel are effective in inhibiting cardiovascular events; however, there is great inter-individual variability in response to these medications. In recent years, it has been recognized that genetic factors play a significant role in drug response, and, subsequently, common variants in genes responsible for metabolism and drug action have been identified. These discoveries along with new diagnostic targets and therapeutic strategies hold promise for more effective individualized anti-coagulation and anti-platelet therapy.
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Affiliation(s)
- Adam S Fisch
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, and the Program in Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Barrett PM, Price MJ. Pharmacogenomics in Interventional Pharmacology: Present Status and Future Directions. Interv Cardiol Clin 2013; 2:615-625. [PMID: 28582188 DOI: 10.1016/j.iccl.2013.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pharmacogenomics offers the possibility of tailoring a drug to a patient's unique genetic signature, improving the likelihood of clinical efficacy while minimizing risks. Clopidogrel, a platelet P2Y12 receptor inhibitor that forms the cornerstone of dual antiplatelet therapy in patients with unstable coronary artery disease and those undergoing percutaneous coronary intervention, is the first broadly used drug in cardiovascular medicine in which genotyping may help optimize outcomes. This article describes techniques to identify the genetic determinants of drug response, their application (ie, clopidogrel), and the challenges to integration of pharmacogenomics into the practice of interventional cardiology.
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Affiliation(s)
- Paddy M Barrett
- Scripps Translational Science Institute, 3344 North Torrey Pines Court, Suite 300, La Jolla, CA 92037, USA
| | - Matthew J Price
- Scripps Translational Science Institute, 3344 North Torrey Pines Court, Suite 300, La Jolla, CA 92037, USA; Cardiac Catheterization Laboratory, Scripps Green Hospital, 10666 North Torrey Pines Road, Maildrop S1056, La Jolla, CA 92037, USA.
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Laine M, Frere C, Ronsin O, Gaubert M, Toesca R, Bessereau J, Michelet P, Gramond C, Helal O, Paganelli F, Bonello L. Assessing post-treatment platelet reactivity: a focus on patient selection and setting. Expert Rev Cardiovasc Ther 2013; 11:1557-66. [PMID: 23992465 DOI: 10.1586/14779072.2013.820440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dual antiplatelet therapy is critical to inhibit platelet reactivity in order to prevent ischemic recurrences in stented patients. However, studies have observed a variable blockade of the P2Y12 adenosine diphosphate receptor between patients following clopidogrel intake. This interindividual variability in the biological response is not uncommon with clopidogrel (about 50%) and even prasugrel (20%). High on-treatment platelet reactivity (HTPR) is correlated with thrombotic events following percutaneous coronary intervention. Several studies suggested that tailoring of antiplatelet therapy based on platelet reactivity (PR) monitoring could safely reduce the rate of major adverse cardiovascular events in HTPR patients. In addition, low on-treatment PR was recently associated with bleeding events both in patients treated with prasugrel and clopidogrel. Of importance, bleedings are associated with a poor prognosis in stented patients. Overall, the potential of PR monitoring to individualize antiplatelet therapy might benefit stented patients by reducing both ischemic and bleeding risks. However, such strategies remain to be evaluated in adequately designed large-scale randomized clinical trials.
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Affiliation(s)
- Marc Laine
- Département de Cardiologie, Hôpital Universitaire Nord, Marseille, France
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Würtz M, Lordkipanidzé M, Grove EL. Pharmacogenomics in cardiovascular disease: focus on aspirin and ADP receptor antagonists. J Thromb Haemost 2013; 11:1627-39. [PMID: 23809178 DOI: 10.1111/jth.12318] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Indexed: 11/27/2022]
Abstract
Antiplatelet agents like aspirin and adenosine diphosphate receptor antagonists are effective in reducing recurrent ischemic events. Considerable inter-individual variability in the platelet inhibition obtained with these drugs has initiated a search for explanatory mechanisms and ways to improve treatment. In recent years, numerous genetic polymorphisms have been linked with reduced platelet inhibition and lack of clinical efficacy of antiplatelet drugs, particularly clopidogrel and aspirin. Consequently, attempts to adjust antiplatelet treatment according to genotype have been made, but the clinical benefit has been modest in studies performed so far. The progress in genome science over the last decade and the declining cost of sequencing technologies hold the promise of enabling genetically tailored antiplatelet therapy. However, more evidence is needed to clarify which polymorphisms may serve as targets to improve treatment. The present review outlines the panel of polymorphisms affecting the benefit of aspirin and adenosine diphosphate receptor antagonists, including novel and ongoing studies evaluating whether genotyping may be beneficial in tailoring antiplatelet therapy.
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Affiliation(s)
- M Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Li X, Zhang L, Chen X, Qu F, Li J, Ma C, Yang J, Xu B, Wang H, Xu Q, Zhang Y, Li Y, Lu C, Yin T. PON1 Q192R genotype influences clopidogrel responsiveness by relative platelet inhibition instead of on-treatment platelet reactivity. Thromb Res 2013; 132:444-9. [PMID: 23993903 DOI: 10.1016/j.thromres.2013.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/26/2013] [Accepted: 08/05/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND paraoxonase-1 (PON1) was recently identified as the crucial enzyme for clopidogrel bioactivation, with PON1 Q192R (rs662) polymorphism determining the clopidogel antiplatelet efficacy. However, subsequent studies showed controversies over the findings. This study aimed to evaluate the impact of PON1 Q192R in parallel to that of CYP2C19*2 (rs4244285) on clopidogrel responsiveness in a cohort of Chinese patients with unstable angina pectoris. MATERIAL AND METHODS One hundred and eighty Chinese-Han patients diagnosed with unstable angina pectoris and treated with clopidogrel were consecutively recruited. Clopidogrel responsiveness, measured by relative platelet inhibition {RI=[(pretreatment aggregation-posttreatment aggregation at 5days)/(pretreatment aggregation)] x100%}, was assessed in relation to PON1 Q192R and CYP2C19*2 genotypes. RI values were stratified into four quartiles, with patients in quartile 1 defined as individuals of clopidogrel non-responsiveness. The contributions of PON1 Q192R and CYP2C19*2 to on-treatment platelet reactivity (OTPR) at 5days maintenance dose of clopidogrel were also evaluated. RESULTS For PON1 Q192R genotypes, RI values were significantly lower in patients with QR and RR alleles than in patients with QQ alleles (p=0.01). OTPR values at 5days maintenance dose of clopidogrel were similar across all the PON1 Q192R genotypes (p=0.41). PON1 192 QR and RR conferred increased risks for clopidogrel non-responsiveness [OR 3.64; 95% CI (1.21-10.92), p=0.02]. For CYP2C19*2 genotypes, compared to CYP2C19*1/*1 wild type carriers, CYP2C19*2 carriers showed a significantly higher OTPR (p=0.009), and a trend for lower RI values (p=0.06). An increased risk for clopidogrel non-responsiveness was found in patients with CYP2C19*2 genotype [OR 2.02; 95% CI (1.03-3.96), p=0.04]. CONCLUSIONS Both PON1 Q192R and CYP2C19*2 genotypes influence clopidogrel responsiveness, with the impact of PON1 Q192R mainly on relative platelet inhibition instead of OTPR of clopidogrel.
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Affiliation(s)
- Xiaoqi Li
- Institute of Geriatric Cardiology, General Hospital of Chinese People's Liberation Army, Beijing 100853, China
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CYP2C19 Genetic Polymorphism, Rabeprazole and Esomeprazole Have no Effect on the Antiplatelet Action of Clopidogrel. J Cardiovasc Pharmacol 2013; 62:41-9. [PMID: 23474843 DOI: 10.1097/fjc.0b013e31828ecf44] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Perry CG, Shuldiner AR. Pharmacogenomics of anti-platelet therapy: how much evidence is enough for clinical implementation? J Hum Genet 2013; 58:339-45. [PMID: 23697979 PMCID: PMC3715315 DOI: 10.1038/jhg.2013.41] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pharmacogenomics, the study of the genomics of drug response and adverse effects, holds great promise for more effective individualized (personalized) medicine. Recent evidence supports a role of loss-of-function (LOF) variants in the cytochrome P450 enzyme CYP2C19 as a determinant of clopidogrel response. Patients given clopidogrel after percutaneous coronary intervention who carry LOF variants do not metabolize clopidogrel, a prodrug, into its active form resulting in decreased inhibition of platelet function and a higher likelihood of recurrent cardiovascular events. Despite a large body of evidence supporting clinical utility, adoption of anti-platelet pharmacogenetics into clinical practice has been slow. In this review, we summarize the pharmacokinetic, pharmacodynamic and clinical evidence, identify gaps in knowledge and other barriers that appear to be slowing adoption, and describe CYP2C19 pharmacogenetics implementation projects currently underway. Only when we surmount these barriers will clinicians be able to use pharmacogenetic information in conjunction with the history, physical examination and other medical tests and information to choose the most efficacious anti-platelet therapy for each individual patient.
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Affiliation(s)
- Christina G. Perry
- Program in Personalized and Genomic Medicine, and the Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland USA
| | - Alan R. Shuldiner
- Program in Personalized and Genomic Medicine, and the Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland USA
- Geriatric Research and Education Clinical Center, Veterans Administration Medical Center, Baltimore, Maryland USA
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Zhang L, Chen Y, Jin Y, Qu F, Li J, Ma C, Yang J, Xu B, Wang H, Li X, Li Y, Zhang Y, Lu C, Yin T. Genetic determinants of high on-treatment platelet reactivity in clopidogrel treated Chinese patients. Thromb Res 2013; 132:81-7. [PMID: 23726091 DOI: 10.1016/j.thromres.2013.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 03/22/2013] [Accepted: 05/05/2013] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Cytochrome P450 (CYP), ATP-binding cassette transporters (ABCB1), and paraoxonase-1 (PON1) play crucial roles in clopidogel absorption and bioactivation. Genetic polymorphisms in these genes have been associated with the variability of the response to clopidogrel, however their contribution to high on-treatment platelet reactivity (HPR) in clopidogrel treated Chinese patients is less known. MATERIALS AND METHODS Five-hundred Chinese-Han patients treated with clopidogrel for acute coronary syndrome (ACS) were consecutively recruited from the Department of Geriatric Cardiology, General Hospital of Chinese People's Liberation Army, from September 2010 to September 2012. We assessed the relations of CYP2C19*2 (rs4244285), CYP2C19*3 (rs4986893), CYP2C19*17 (rs12248560), PON1Q129R (rs662) and ABCB1C3435T (rs1045642) to the platelet aggregation after 5 days maintenance dose of clopidogrel administration, and the risk for HPR. The cutoff of HPR was defined as 20 μmol/L adenosine diphosphate (ADP)-induced platelet aggregation>50%. RESULTS Both CYP2C19*2 and *3 alleles were significantly associated with higher platelet aggregation after 5 days maintenance dose of clopidogrel administration (P<0.00001 and P=0.042, respectively). The platelet aggregation in carriers of at least one CYP2C19 loss-of-function allele (*2 or *3, accounted for 58% of the study population) was obviously higher than that in non-carriers (P<0.00001). Patients with the CYP2C19*2 allele had a higher risk of HPR than those with the CYP2C19 wild-type genotype [adjusted hazard ratio (HR), 1.56; 95% confidence interval(CI), 1.04-2.33, P=0.03]. The carriers of at least one CYP2C19 loss-of-function allele could also predict significantly greater risk of HPR compared with non-carriers (adjusted HR1.79,95% CI: 1.33-2.4,P=0.003). However, the carriage of CYP2C19*3 alone could not predict the risk of HPR significantly (adjusted HR, 1.5; 95% CI: 0.83-3, P=0.16). Significant relation of CYP2C19*17, PON1Q129R and ABCB1C3435T to the platelet aggregation was not found. CONCLUSION In clopidogrel treated Chinese patients with ACS, carriers of at least one CYP2C19 loss-of-function allele could predict greater risk of HPR, with the impact mainly attributing to CYP2C19*2. Neither ABCB1 nor PON1 genotype could influence the antiplatelet response of clopidogrel in the cohort of Chinese patients.
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Affiliation(s)
- Lanning Zhang
- Institute of Geriatric Cardiology, General Hospital of Chinese People's Liberation Army, Beijing 100853, China
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Martinelli N, Consoli L, Girelli D, Grison E, Corrocher R, Olivieri O. Paraoxonases: ancient substrate hunters and their evolving role in ischemic heart disease. Adv Clin Chem 2013; 59:65-100. [PMID: 23461133 DOI: 10.1016/b978-0-12-405211-6.00003-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Interest in the role of paraoxonases (PON) in cardiovascular research has increased substantially over the past two decades. These multifaceted and pleiotropic enzymes are encoded by three highly conserved genes (PON1, PON2, and PON3) located on chromosome 7q21.3-22.1. Phylogenetic analysis suggests that PON2 is the ancient gene from which PON1 and PON3 arose via gene duplication. Although PON are primarily lactonases with overlapping, but distinct specificities, their physiologic substrates remain poorly characterized. The most interesting characteristic of PON, however, is their multifunctional roles in various biochemical pathways. These include protection against oxidative damage and lipid peroxidation, contribution to innate immunity, detoxification of reactive molecules, bioactivation of drugs, modulation of endoplasmic reticulum stress, and regulation of cell proliferation/apoptosis. In general, PON appear as "hunters" of old and new substrates often involved in athero- and thrombogenesis. Although reduced PON activity appears associated with increased cardiovascular risk, the correlation between PON genotype and ischemic heart disease remains controversial. In this review, we examine the biochemical pathways impacted by these unique enzymes and investigate the potential use of PON as diagnostic tools and their impact on development of future therapeutic strategies.
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Affiliation(s)
- Nicola Martinelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Verona, Italy.
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Gorog DA, Fuster V. Platelet function tests in clinical cardiology: unfulfilled expectations. J Am Coll Cardiol 2013; 61:2115-29. [PMID: 23541972 DOI: 10.1016/j.jacc.2012.11.080] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 11/20/2012] [Accepted: 11/26/2012] [Indexed: 01/04/2023]
Abstract
This review is a critical evaluation of publications in the past decade on the usefulness of platelet function tests (PFTs) in clinical cardiology, in aiding diagnosis, predicting risk, and monitoring therapy. The ideal PFT should: 1) detect baseline platelet hyperreactivity; 2) allow individualization of antiplatelet medication; 3) predict thrombotic risk; and 4) predict bleeding risk. The practicalities of clinical cardiology demand rapid, accurate, and reliable tests that are simple to operate at the bedside and available 24 h a day, 7 days a week. Point-of-care PFTs most widely evaluated clinically include PFA-100 and VerifyNow. None of these tests can reliably detect platelet hyperreactivity and thus identify a prothrombotic state. Identification of antiplatelet nonresponsiveness or hyporesponsiveness is highly test specific, and does not allow individualization of therapy. The power of PFTs in predicting thrombotic events for a given individual is variable and often modest, and alteration of antithrombotic treatment on the basis of the results of PFTs has not been shown to alter clinical outcome. PFTs in current mainstream use cannot reliably assess bleeding risk. These tests have been in use for over a decade, but the hopes raised by PFTs in clinical practice remain unfulfilled. Although physiologically relevant measurement of platelet function now is more important than ever, a critical reappraisal of available techniques in light of clinical requirements is needed. The use of native blood, global stimulus instead of individual agonists, contribution of thrombin generation by activated platelets to the test results, and establishment of a PFT therapeutic range for each antiplatelet drug should be considered and is discussed.
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Affiliation(s)
- Diana A Gorog
- National Heart & Lung Institute, Imperial College, London, United Kingdom.
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P2Y12 Receptor Inhibitors in Acute Coronary Syndromes: What Is New on the Horizon? Cardiol Res Pract 2013; 2013:195456. [PMID: 23533940 PMCID: PMC3590496 DOI: 10.1155/2013/195456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 12/21/2012] [Indexed: 01/31/2023] Open
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor represents the cornerstone therapy for patients with acute coronary syndromes or undergoing percutaneous interventions, leading to a reduction of subsequent ischemic events. Variable response to clopidogrel has received close attention, and pharmacokinetic, pharmacodynamic, and pharmacogenomic factors have been identified as culprits. This led to the introduction of newer, potentially safer, and more effective antiplatelet agents (prasugrel and ticagrelor). Additionally, several point-of-care assays of platelet function have been developed in recent years to rapidly screen individuals on antiplatelet therapy. While the routine use of platelet function testing is uncertain and not currently recommended, it may be useful in instances when the degree of platelet inhibition may be uncertain such as high-risk patients undergoing percutaneous coronary intervention or when there may be a suspected pharmacodynamic interaction with other drugs. The current paper focuses on the P2Y12 receptor inhibitors and their pharmacogenetics and indications in patients with acute coronary syndromes or receiving percutaneous coronary interventions as well as the applicability of platelet function testing in this clinical context.
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Park KW, Park JJ, Kang J, Jeon KH, Kang SH, Han JK, Lee SE, Yang HM, Lee HY, Kang HJ, Koo BK, Oh BH, Park YB, Kim HS. Paraoxonase 1 gene polymorphism does not affect clopidogrel response variability but is associated with clinical outcome after PCI. PLoS One 2013; 8:e52779. [PMID: 23418418 PMCID: PMC3572125 DOI: 10.1371/journal.pone.0052779] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 11/20/2012] [Indexed: 12/04/2022] Open
Abstract
Background Paraoxonase (PON) is a high-density-lipoprotein (HDL) associated enzyme with antioxidative and anti-atherogenic property. Its function is associated with coronary artery disease and its activity genetically controlled. We evaluated whether genetic variation of PON-1 is associated with clinical outcome in a large cohort of Korean patients with drug-eluting stents implantation. Methods A total of 1676 patients with drug-eluting stent implantation were enrolled in the prospective CROSS-VERIFY cohort from June 2006 to June 2010. We genotyped the PON1-Q192R gene, measured clopidogrel on-treatment platelet reactivity (OPR), and analyzed lipid profiles. The primary endpoint was the composite of cardiac death, myocardial infarction, and stent thrombosis at 12 months. Results PON-1 genotyping data were available in 1336 patients. Since the Q-allele is associated with decreased PON-activity, we analyzed the outcome between patients with QQ/QR (815 patients, 61%) and those with RR-genotype (521 patients, 39%). After adjustment for common cardiac risk factors, the QQ/QR-genotype was an independent predictor of the primary thrombotic endpoint with an 11-fold increased risk (HR 11.6, 95% CI: 1.55–87.0), but not repeat revascularization (HR 1.12, 95% CI: 0.78–1.61). The QQ/QR-genotype was not associated with OPR (QQ/QR: 231±86 PRU vs. RR 236±82 PRU, p = 0.342) but higher small-dense LDL levels (1.20±0.12 mg/dL vs. 0.76±0.15 mg/dL, p = 0.027). The increased risk of thrombotic outcomes was more profound in acute coronary syndrome (ACS) patients compared with non-ACS patients. Conclusion PON1 Q-allele is an independent predictor of worse cardiovascular outcome independent of platelet function and is associated with significantly higher levels of small dense LDL-C.
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Affiliation(s)
- Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Ki-Hyun Jeon
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Si-Hyuck Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang Eun Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hae-Young Lee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Byung-Hee Oh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Young-Bae Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
- * E-mail:
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Ford NF, Taubert D. Clopidogrel, CYP2C19, and a Black Box. J Clin Pharmacol 2013; 53:241-8. [DOI: 10.1002/jcph.17] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/09/2012] [Indexed: 11/09/2022]
Affiliation(s)
| | - Dirk Taubert
- Department of Pharmacology; University Hospital of Cologne; Cologne; Germany
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Clopidogrel pharmacokinetics and pharmacodynamics vary widely despite exclusion or control of polymorphisms (CYP2C19, ABCB1, PON1), noncompliance, diet, smoking, co-medications (including proton pump inhibitors), and pre-existent variability in platelet function. J Am Coll Cardiol 2013; 61:872-9. [PMID: 23333143 DOI: 10.1016/j.jacc.2012.11.040] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 10/26/2012] [Accepted: 11/27/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study sought to determine whether known genetic, drug, dietary, compliance, and lifestyle factors affecting clopidogrel absorption and metabolism fully account for the variability in clopidogrel pharmacokinetics and pharmacodynamics. BACKGROUND Platelet inhibition by clopidogrel is highly variable. Patients with reduced inhibition have increased risk for major adverse cardiovascular events. Identification of factors contributing to clopidogrel's variable response is needed to improve platelet inhibition and reduce risk for cardiovascular events. METHODS Healthy subjects (n = 160; ages 20 to 53 years; homozygous CYP2C19 extensive metabolizer genotype; no nicotine for 6 weeks, prescription drugs for 4 weeks, over-the-counter drugs for 2 weeks, and no caffeine or alcohol for 72 h; confined; restricted diet) received clopidogrel 75 mg/day for 9 days, at which time clopidogrel pharmacokinetic and pharmacodynamic endpoints were measured. RESULTS At steady-state, clopidogrel active metabolite (clopidogrel(AM)) pharmacokinetics varied widely between subjects (coefficients of variation [CVs] 33.8% and 40.2% for clopidogrel(AM) area under the time-concentration curve and peak plasma concentration, respectively). On-treatment vasodilator stimulated phosphoprotein P2Y(12) platelet reactivity index (PRI), maximal platelet aggregation (MPA) to adenosine phosphate, and VerifyNow P2Y12 platelet response units (PRU) also varied widely (CVs 32% to 53%). All identified factors together accounted for only 18% of intersubject variation in pharmacokinetic parameters and 32% to 64% of intersubject variation in PRI, MPA, and PRU. High on-treatment platelet reactivity was present in 45% of subjects. CONCLUSIONS Clopidogrel pharmacokinetics and pharmacodynamics vary widely despite rigorous exclusion or control of known disease, polymorphisms (CYP2C19, CYP3A5, ABCB1, PON1), noncompliance, co-medications, diet, smoking, alcohol, demographics, and pre-treatment platelet hyperreactivity. Thus, as yet unidentified factors contribute to high on-treatment platelet reactivity with its known increased risk of major adverse cardiovascular events. (A Study of the Effects of Multiple Doses of Dexiansoprazole, Lansoprazole, Omeprazole or Esomeprazole on the Pharmacokinetics and Pharmacodynamics of Clopidogrel in Healthy Participants: NCT00942175).
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Park JJ, Park KW, Kang J, Jeon KH, Kang SH, Ahn HS, Han JK, Koh JS, Lee SE, Yang HM, Lee HY, Kang HJ, Koo BK, Oh BH, Park YB, Kim HS. Genetic determinants of clopidogrel responsiveness in Koreans treated with drug-eluting stents. Int J Cardiol 2012; 163:79-86. [PMID: 23260377 DOI: 10.1016/j.ijcard.2012.09.075] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 06/28/2012] [Accepted: 09/14/2012] [Indexed: 01/25/2023]
Abstract
BACKGROUND Variations of genes encoding cytochrome enzymes, drug transporters, and paraoxonase have recently been reported to be associated with clopidogrel response variability besides the well-known CYP2C19 loss-of-function (LOF) alleles. We determined whether newly reported genetic variations are associated with clopidogrel on-treatment platelet reactivity (OPR) in Korean patients. METHODS OPR was measured in 1264 consecutive patients who underwent percutaneous coronary intervention using the VerifyNowP2Y12 assay system and genotyping of PON-1 Q192R, ABCB1 C3435T, CYP1A2*1F, CYP2B6*6, CYP2C19*2, CYP2C19*3, CYP2C19*17, CYP3A4 (IVS10+12G>A), and CYP3A5*3 was performed. We applied two different cutoffs, i.e. 240 P2Y12 reaction units (PRU) and 253 PRU, to define high OPR. RESULTS Mean OPR of the entire population was 231±83 PRU. Genetic variations of ABCB1 and PON-1 genes as well as that of CYP1A2, 2B6, 3A4, and 3A5 were not associated with clopidogrel response variability. As for CYP2C19, patients were classified into 4 metabolism genotypes: 0.6% ultrarapid (UM), 40.3% extensive (EM), 48.8% intermediate (IM), and 10.3% poor metabolizers (PM). After adjustment for possible confounders, CYP2C19 metabolism genotype was associated with a significant increase in OPR: effect on OPR-difference: +27 PRU, p=0.015 for EM, +53 PRU, p<0.001 for IM, and +74 PRU, p=0.006 for PM compared with UM. In multivariable analysis, the CYP2C19 genotype was the only independent predictor of high-OPR among genetic variations using two different cutoffs. CONCLUSIONS Among genes postulated to be involved in clopidogrel metabolism, only the CYP2C19 genotype is associated with response variability and emerged as an independent predictor of high-OPR using two different cutoffs. PON-1 and ABCB1 genetic variants do not affect clopidogrel OPR in Korean patients.
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Affiliation(s)
- Jin Joo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
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Chan MY, Tan K, Tan HC, Huan PT, Li B, Phua QH, Lee HK, Lee CH, Low A, Becker RC, Ong WC, Richards MA, Salim A, Tai ES, Koay E. CYP2C19 and PON1 polymorphisms regulating clopidogrel bioactivation in Chinese, Malay and Indian subjects. Pharmacogenomics 2012; 13:533-42. [PMID: 22462746 DOI: 10.2217/pgs.12.24] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
UNLABELLED AIM, MATERIALS & METHODS: We investigated the functional significance of CYP2C19*2, *3, *17 and PON1 Q192R SNPs in 89 consecutive Asian patients on clopidogrel treatment and the prevalence of functionally significant polymorphisms among 300 Chinese, Malays and Asian Indians. RESULTS Both CYP2C19 loss-of-function alleles (*2 or *3) were associated with higher platelet reactivity while the CYP2C19 gain-of-function allele (*17) had lower platelet reactivity. For PON1, the median PRI was not significantly different between the QQ, QR and RR groups. The allele frequencies of CYP2C19*2, CYP2C19*3 and CYP2C19*17 were 0.280, 0.065 and 0.010 (rare) for Chinese, 0.310, 0.050 and 0.025 for Malays, and 0.375, 0.010 (rare) and 0.165 for Indians, respectively. CONCLUSION Our data suggest that genotyping studies to investigate clopidogrel response should include CYP2C19*2 and *3 but not *17 polymorphisms in Chinese, and CYP2C19*2 and *17 polymorphisms but not *3 in Indians. All three polymorphisms should preferably be genotyped in Malays.
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Affiliation(s)
- Mark Y Chan
- National University Heart Centre, 1E Kent Ridge Road, Singapore 119228, Singapore.
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Trenk D, Kristensen SD, Hochholzer W, Neumann FJ. High on-treatment platelet reactivity and P2Y12 antagonists in clinical trials. Thromb Haemost 2012; 109:834-45. [PMID: 23238773 DOI: 10.1160/th12-08-0588] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/07/2012] [Indexed: 12/18/2022]
Abstract
Dual antiplatelet therapy with aspirin and clopidogrel in patients undergoing percutaneous coronary intervention (PCI) and in patients with acute coronary syndromes (ACS) has substantially decreased the rate of cardiovascular events. Within the past decade, the variability in pharmacodynamic response as well as the moderate antiplatelet efficacy of clopidogrel has raised major concerns, since high on-clopidogrel platelet reactivity has consistently been associated with increased risk for ischaemic events in PCI patients. The variability in response could be linked to genetic polymorphisms impacting on activity of cytochrome P450 enzymes as well as clinical and demographic variables, but, taken together, factors identified so far can explain only up to approximately 12% of this variability in adenosine diphosphate-induced platelet aggregation on clopidogrel. Regulatory agencies as well as major cardiac societies suggest the use of other anti-platelet medications or alternative dosing strategies for clopidogrel in patients with reduced effectiveness of clopidogrel. This review will focus on the current status of alternate strategies for more sufficient suppression of high platelet reactivity.
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Affiliation(s)
- D Trenk
- Universitaets-Herzzentrum Freiburg-Bad Krozingen, Klinik für Kardiologie und Angiologie II, Bad Krozingen, Suedring 15, Bad Krozingen, Germany.
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Ancrenaz V, Desmeules J, James R, Fontana P, Reny JL, Dayer P, Daali Y. The paraoxonase-1 pathway is not a major bioactivation pathway of clopidogrel in vitro. Br J Pharmacol 2012; 166:2362-70. [PMID: 22428615 DOI: 10.1111/j.1476-5381.2012.01946.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Clopidogrel is a prodrug bioactivated by cytochrome P450s (CYPs). More recently, paraoxonase-1 (PON1) has been proposed as a major contributor to clopidogrel metabolism. The purpose of this study was to assess the relative contribution of CYPs and PON1 to clopidogrel metabolism in vitro. EXPERIMENTAL APPROACH Clopidogrel metabolism was studied in human serum, recombinant PON1 enzyme (rePON1), pooled human liver microsomes (HLMs), HLMs with the CYP2C19*1/*1 genotype and HLMs with the CYP2C19*2/*2 genotype. Inhibition studies were also performed using specific CYP inhibitors and antibodies. Clopidogrel and its metabolites were measured using LC/MS/MS method. KEY RESULTS PON1 activity was highest in the human serum and there was no difference in PON1 activity between any of the HLM groups. The production of clopidogrel's active metabolite (clopidogrel-AM) from 2-oxo-clopidogrel in pooled HLMs was approximately 500 times that in serum. When 2-oxo-clopidogrel was incubated with rePON1, clopidogrel-AM was not detected. Clopidogrel-AM production from 2-oxo-clopidogrel was lower in CYP2C19*2/*2 HLMs compared with CYP2C19*1/*1 HLMs, while PON1 activity in HLMs with both genotypes was similar. Moreover, incubation with inhibitors of CYP3A, CYP2B6 and CYP2C19 significantly reduced clopidogrel bioactivation while a PON1 inhibitor, EDTA, had only a weak inhibitory effect. CONCLUSION AND IMPLICATIONS This in vitro study shows that the contribution of PON1 to clopidogrel metabolism is limited at clinically relevant concentrations. Moreover, CYP2C19, CYP2B6 and CYP3A play important roles in the bioactivation of clopidogrel.
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Affiliation(s)
- V Ancrenaz
- Clinical Pharmacology and Toxicology Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Tang XF, Wang J, Zhang JH, Meng XM, Xu B, Qiao SB, Wu YJ, Chen J, Wu Y, Chen JL, Gao RL, Yuan JQ, Yang YJ. Effect of the CYP2C19*2 and *3 genotypes, ABCB1 C3435T and PON1 Q192R alleles on the pharmacodynamics and adverse clinical events of clopidogrel in Chinese people after percutaneous coronary intervention. Eur J Clin Pharmacol 2012; 69:1103-12. [DOI: 10.1007/s00228-012-1446-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/25/2012] [Indexed: 10/27/2022]
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Clinical Impact of Genetically Determined Platelet Reactivity. J Cardiovasc Transl Res 2012; 6:398-403. [DOI: 10.1007/s12265-012-9421-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 10/30/2012] [Indexed: 01/04/2023]
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Sim SC, Kacevska M, Ingelman-Sundberg M. Pharmacogenomics of drug-metabolizing enzymes: a recent update on clinical implications and endogenous effects. THE PHARMACOGENOMICS JOURNAL 2012; 13:1-11. [PMID: 23089672 DOI: 10.1038/tpj.2012.45] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Interindividual differences in drug disposition are important causes for adverse drug reactions and lack of drug response. The majority of phase I and phase II drug-metabolizing enzymes (DMEs) are polymorphic and constitute essential factors for the outcome of drug therapy. Recently, both genome-wide association (GWA) studies with a focus on drug response, as well as more targeted studies of genes encoding DMEs have revealed in-depth information and provided additional information for variation in drug metabolism and drug response, resulting in increased knowledge that aids drug development and clinical practice. In addition, an increasing number of meta-analyses have been published based on several original and often conflicting pharmacogenetic studies. Here, we review data regarding the pharmacogenomics of DMEs, with particular emphasis on novelties. We conclude that recent studies have emphasized the importance of CYP2C19 polymorphism for the effects of clopidogrel, whereas the CYP2C9 polymorphism appears to have a role in anticoagulant treatment, although inferior to VKORC1. Furthermore, the analgesic and side effects of codeine in relation to CYP2D6 polymorphism are supported and the influence of CYP2D6 genotype on breast cancer recurrence during tamoxifen treatment appears relevant as based on three large studies. The influence of CYP2D6 polymorphism on the effect of antidepressants in a clinical setting is yet without any firm evidence, and the relation between CYP2D6 ultrarapid metabolizers and suicide behavior warrants further studies. There is evidence for the influence of CYP3A5 polymorphism on tacrolimus dose, although the influence on response is less studied. Recent large GWA studies support a link between CYP1A2 polymorphism and blood pressure as well as coffee consumption, and between CYP2A6 polymorphism and cigarette consumption, which in turn appears to influence the lung cancer incidence. Regarding phase II enzyme polymorphism, the anticancer treatment with mercaptopurines and irinotecan is still considered important in relation to the polymorphism of TPMT and UGT1A1, respectively. There is a need for further clarification of the clinical importance and use of all these findings, but the recent research in the field that encompasses larger studies and a whole genome perspective, improves the possibilities be able to make firm and cost-effective recommendations for drug treatment in the future.
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Affiliation(s)
- S C Sim
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Personalized cardiovascular medicine: status in 2012. Can J Cardiol 2012; 28:693-9. [PMID: 23036280 DOI: 10.1016/j.cjca.2012.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 08/27/2012] [Accepted: 08/27/2012] [Indexed: 12/12/2022] Open
Abstract
Personalized medicine is the tailoring of the diagnosis, prevention, and treatment to the characteristics of each individual patient. In this review, we provide a status report on genetic variants that influence therapy with antiplatelet agents, warfarin, and statins. Resistance to clopidogrel, an antiplatelet therapy, has been shown to be present in 25% to 30% of Caucasians and an even higher percentage in Asians. Part of this resistance is because of the CYP2C19*2 allele. Administering clopidogrel on the basis of previous genetic testing remains controversial. A recent breakthrough in point-of-care genetic testing for clopidogrel might be significant, not only for genetic testing for clopidogrel, but for the whole of personalized medicine. Genetic testing for aspirin resistance is not yet recommended because of incomplete genetic data. Studies to determine the value of genetic testing before the administration of warfarin are ongoing. Testing for SLCO1B1 allele for individuals with muscle cramps who are taking statins could be very helpful but is not yet recommended as routine. Pharmacogenetics has the potential to customize therapy and move away from the current model of 1 drug fits all.
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Fuster V, Bhatt DL, Califf RM, Michelson AD, Sabatine MS, Angiolillo DJ, Bates ER, Cohen DJ, Coller BS, Furie B, Hulot JS, Mann KG, Mega JL, Musunuru K, O'Donnell CJ, Price MJ, Schneider DJ, Simon DI, Weitz JI, Williams MS, Hoots WK, Rosenberg YD, Hasan AAK. Guided antithrombotic therapy: current status and future research direction: report on a National Heart, Lung and Blood Institute working group. Circulation 2012; 126:1645-62. [PMID: 23008471 PMCID: PMC4086864 DOI: 10.1161/circulationaha.112.105908] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Valentin Fuster
- Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574, USA.
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Wu H, Qian J, Xu J, Sun A, Sun W, Wang Q, Ge J. Besides CYP2C19, PON1 genetic variant influences post-clopidogrel platelet reactivity in Chinese patients. Int J Cardiol 2012; 165:204-6. [PMID: 22974728 DOI: 10.1016/j.ijcard.2012.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 08/22/2012] [Indexed: 11/27/2022]
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Trenk D, Zolk O, Fromm MF, Neumann FJ, Hochholzer W. Personalizing antiplatelet therapy with clopidogrel. Clin Pharmacol Ther 2012; 92:476-85. [PMID: 22948893 DOI: 10.1038/clpt.2012.133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dual antiplatelet therapy with aspirin and clopidogrel is the accepted standard for prevention of ischemic complications after percutaneous coronary intervention and has been shown to reduce cardiovascular events in patients with acute coronary syndromes (ACSs). There is substantial interindividual variability in antiplatelet response to clopidogrel. Various clinical studies have demonstrated that patients with high on-clopidogrel platelet reactivity incur an increased risk for ischemic events. In recent years, several clinical and demographic variables as well as multiple genetic factors contributing to the variability in antiplatelet response to clopidogrel have been identified. We discuss strategies based on platelet function testing or genotyping for improvement of antiplatelet effects of clopidogrel and thereby clinical outcome.
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Affiliation(s)
- D Trenk
- Universitäts-Herzzentrum Freiburg-Bad Krozingen, Klinik für Kardiologie und Angiologie II, Bad Krozingen, Germany.
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Value of platelet pharmacogenetics in common clinical practice of patients with ST-segment elevation myocardial infarction. Int J Cardiol 2012; 167:2882-8. [PMID: 22940005 DOI: 10.1016/j.ijcard.2012.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/13/2012] [Accepted: 07/21/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Antiplatelet drug resistance is a well-known problem, causing recurrent cardiovascular events. Multiple genetic polymorphisms have been related to antiplatelet resistance by several large trials, however data from common clinical practice is limited. We examined the influence of previously described polymorphisms, related to aspirin and clopidogrel resistance, on treatment outcome in a real life unselected population of patients presenting with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention. METHODS AND RESULTS This cohort study consisted of 1327 patients with STEMI. Patients were treated according to a standardized guideline-based protocol. Nine polymorphisms, COX1 (-842A>G), P2Y1 (893C>T), GPIa (807C>T), GPIIIa (PlA1/A2), CYP2C19 (*2, *3 and *17), ABCB1 (3435T>C) and PON1 (576A>G), were genotyped. During 1 year of follow up the primary endpoint, a composite of cardiac death or recurrent myocardial infarction, was reached in 86 patients. The COX1 and CYP2C19*2 polymorphisms were associated with the primary endpoint, HR 2.55 (95% CI 1.48-4.40), P=0.001 and HR 2.03 (1.34-3.09) P=0.001, respectively. The combined analysis demonstrated a 2.5-fold increased risk for individuals with ≥ 2 risk alleles, P=6.9 × 10(-9). The association of COX1 was driven by mortality related events whereas that of CYP2C19*2 was mainly attributed to myocardial infarction and stent thrombosis. CONCLUSION In this unselected, real life population of STEMI patient on dual-antiplatelet therapy, the polymorphisms COX1 -842A>G and CYP2C19*2 were determinants of thrombotic complications during follow-up. We show that in a clinical setting, testing for these polymorphisms could be of value in the identification of STEMI patients at risk for recurrent cardiovascular events.
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Abstract
PURPOSE OF REVIEW To survey genetic variation contributing to variable responsiveness and toxicity to important cardiovascular drugs and highlight recent developments in the field of cardiovascular pharmacogenomics and personalized medicine. RECENT FINDINGS Previously recognized pharmacogenomic associations with drug efficacy have been further validated (e.g. with clopidogrel and warfarin) and shown to influence clinically important outcomes. The clinical significance of variants modulating toxicity (e.g. SLCO1B1 with simvastatin) has also been confirmed. The genetic contribution to variable efficacy and toxicity of other important classes of cardiovascular drugs, such as beta-blockers, is becoming increasingly recognized. Prospective trials testing whether the use of genomic information improves clinical care are underway. Guidance based on the most well-established pharmacogenomic findings has appeared in prescribing labeling and is in the early stages of being implemented into routine clinical care. SUMMARY Clinically validated gene variants that modulate responsiveness to cardiovascular drugs continue to be discovered and validated. Early steps are underway to translate these discoveries into clinical care.
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Antonino MJ, Jeong YH, Tantry US, Bliden KP, Gurbel PA. Role of genotype-based personalized antiplatelet therapy in the era of potent P2Y 12receptor inhibitors. Expert Rev Cardiovasc Ther 2012; 10:1011-22. [DOI: 10.1586/erc.12.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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The story of clopidogrel and its predecessor, ticlopidine: Could these major antiplatelet and antithrombotic drugs be discovered and developed today? CR CHIM 2012. [DOI: 10.1016/j.crci.2012.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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