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Batta A, Kalra BS, Khirasaria R. Critical Issues and Recent Advances in Anticoagulant Therapy: A Review. Neurol India 2019; 67:1200-1212. [PMID: 31744944 DOI: 10.4103/0028-3886.271256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
As the population is aging, clinicians are coming across more patients with atrial fibrillation and venous thromboembolism requiring anticoagulation to prevent stroke and systemic embolisms. Due to a high prevalence and unfavorable consequences, managing thromboembolic diseases have become areas of clinical concern. Traditional anticoagulants like heparin, low molecular weight heparin and warfarin have been used for the prevention and treatment of venous and arterial thromboses. But, issues of bleeding, parenteral route of administration, or the need for frequent monitoring due to variability in response respectively limit their use. The article gives an overview of coagulation along with existing therapy available for anticoagulation and to present an update on utility and recent advances of new oral anticoagulants (NOACs) beginning from their nomenclature, advantages, disadvantages, precautions and contraindications compared with those of vitamin K antagonists (VKAs) based on a large number of recent studies and clinical trials.
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Affiliation(s)
- Angelika Batta
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Bhupinder S Kalra
- Department of Pharmacology, Maulana Azad Medical College, New Delhi, India
| | - Raj Khirasaria
- Department of Pharmacology, Baroda Medical College and SSG Hospital, Vadodara, Gujarat, India
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Shen H, Yao M, Sinz M, Marathe P, Rodrigues AD, Zhu M. Renal Excretion of Dabigatran: The Potential Role of Multidrug and Toxin Extrusion (MATE) Proteins. Mol Pharm 2019; 16:4065-4076. [PMID: 31335150 DOI: 10.1021/acs.molpharmaceut.9b00472] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Following oral administration, dabigatran etexilate (DABE) is rapidly hydrolyzed to its active form, dabigatran. DABE, but not dabigatran, presents as a P-glycoprotein (P-gp) substrate and has increasingly been used as a probe drug. Therefore, although dosed as DABE, a P-gp drug-drug interaction (DDI) is reported as a dabigatran plasma concentration ratio (perpetrator versus placebo). Because the majority of a DABE dose (80 to 85%) is recovered in urine as unchanged dabigatran (renal active secretion is ∼25% of total clearance), dabigatran was evaluated in vitro as a substrate of various human renal transporters. Active (pyrimethamine-sensitive) dabigatran uptake was observed with human embryonic kidney (HEK) 293 cells expressing multidrug and toxin extrusion protein 1 (MATE1) and 2K (MATE2K), with Michaelis-Menten constant (Km) values of 4.0 and 8.0 μM, respectively. By comparison, no uptake of 2 μM dabigatran (versus mock-transfected HEK293 cells) was evident with HEK293 cells transfected with organic cation transporters (OCT1 and OCT2) and organic anion transporters (OAT1, 2, 3, and 4). The efflux ratios of dabigatran across P-gp- and BCRP (breast cancer resistance protein)-MDCK (Madin-Darby canine kidney) cell monolayers were 1.5 and 2.0 (versus mock-MDCK cell monolayers), suggesting dabigatran is a relatively poor P-gp and BCRP substrate. Three of five drugs (verapamil, ketoconazole, and quinidine) known to interact clinically with dabigatran, as P-gp inhibitors, presented as MATE inhibitors in vitro (IC50 = 1.0 to 25.2 μM). Taken together, although no basolateral transporter was identified for dabigatran, the results suggest that apical MATE1 and MATE2K could play an important role in its renal clearance. MATE-mediated renal secretion of dabigatran needs to be considered when interpreting the results of P-gp DDI studies following DABE administration.
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Affiliation(s)
- Hong Shen
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
| | - Ming Yao
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
| | - Michael Sinz
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
| | - Punit Marathe
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
| | - A David Rodrigues
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
| | - Mingshe Zhu
- Department of Metabolism and Pharmacokinetics , Bristol-Myers Squibb Research and Development , Princeton , New Jersey 08543 , United States
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Shimizu M, Natori T, Tsuda K, Yoshida M, Kamada A, Oi K, Ishigaku Y, Oura K, Narumi S, Yamamoto M, Terayama Y. Thrombin-induced platelet aggregation −effect of dabigatran using automated platelet aggregometry−. Platelets 2019; 31:360-364. [DOI: 10.1080/09537104.2019.1624707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Mie Shimizu
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
- Department of Clinical Research, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Tatsunori Natori
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Keisuke Tsuda
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Makiko Yoshida
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Asami Kamada
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kiyotaka Oi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoko Ishigaku
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kazumasa Oura
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shinsuke Narumi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masahiro Yamamoto
- Department of Clinical Research, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yasuo Terayama
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
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Lee JH, Oh YM, Lee SD, Lee JS. Rivaroxaban versus Low-Molecular-Weight Heparin for Venous Thromboembolism in Gastrointestinal and Pancreatobiliary Cancer. J Korean Med Sci 2019; 34:e160. [PMID: 31144482 PMCID: PMC6543062 DOI: 10.3346/jkms.2019.34.e160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) is the standard treatment for venous thromboembolism (VTE) in patients with active cancer. However, use of factor Xa inhibitors, such as rivaroxaban, is increasing on the basis of limited clinical evidence. The present single-center study compared the incidence of bleeding and other treatment outcomes in gastrointestinal and pancreatobiliary cancer (GI tract cancer) patients administered rivaroxaban or LMWH for the treatment of VTE. METHODS Retrospective data from 281 GI tract cancer patients who were treated for VTE with rivaroxaban (n = 78) or LMWH (n = 203) between 1 January 2012 and 31 December 2016, were analyzed. Primary end-point was the incidence of major and clinically relevant bleeding. Secondary outcomes included the incidence of recurrent VTE and mortality. RESULTS Clinically relevant bleeding occurred in 19 patients (24.4%) in the rivaroxaban group and 31 (15.3%) in the LMWH group (P = 0.074). No inter-group difference was observed for rate of VTE recurrence (3.8% with rivaroxaban vs. 3.9% with LMWH; P > 0.999) or incidence of major bleeding (5.1% with rivaroxaban vs. 8.9% with LMWH; P = 0.296). Multivariate Cox proportional hazards analysis for age, cancer type, metastasis, history of chemotherapy or recent surgery, and Eastern Cooperative Oncology Group performance status revealed a 1.904-fold higher risk of bleeding with rivaroxaban than LMWH (1.031-3.516; P = 0.040). No significant inter-group difference was found in terms of hazard ratio for all-cause mortality. CONCLUSION Compared to LMWH, rivaroxaban was associated with a higher incidence of clinically relevant bleeding in GI tract cancer patients presenting with VTE.
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Affiliation(s)
- Jang Ho Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Moj D, Maas H, Schaeftlein A, Hanke N, Gómez-Mantilla JD, Lehr T. A Comprehensive Whole-Body Physiologically Based Pharmacokinetic Model of Dabigatran Etexilate, Dabigatran and Dabigatran Glucuronide in Healthy Adults and Renally Impaired Patients. Clin Pharmacokinet 2019; 58:1577-1593. [DOI: 10.1007/s40262-019-00776-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fawzy AM, Lip GYH. Pharmacokinetics and pharmacodynamics of oral anticoagulants used in atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:381-398. [PMID: 30951640 DOI: 10.1080/17425255.2019.1604686] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The availability of non-vitamin K antagonist oral anti-coagulants alongside vitamin K antagonists has offered a variety of options for anti-coagulation, but has also necessitated a good understanding of the pharmacological properties of each of these drugs prior to their use, to maximise the therapeutic benefit and minimise patient harm Areas covered: This review article outlines the pharmacokinetic and pharmacodynamic profiles of the currently licensed VKAs and NOACs that are most commonly used in clinical practice, with the aim of demonstrating how variations in these characteristics influence their use in clinical practice. A literature search was conducted on PubMed using keywords and relevant articles published by the 31st of December 2018 were included. Expert opinion: The effect of a drug is determined by a combination of elements which include patient characteristics and external factors, in addition to its pharmacokinetic and pharmacodynamic properties. A good understanding of these is essential. Despite the wealth of information available, particularly on VKAs, our knowledge on the pharmacology responsible for certain drug effects and inter-individual variations is still limited. Increasing efforts are being made to understand these and include focus on pharmacogenomics and drug transporter proteins.
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Affiliation(s)
| | - Gregory Y H Lip
- b Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Sychev DA, Abdullaev SP, Mirzaev KB, Ryzhikova KA, Shuyev GN, Sozaeva ZA, Grishina EA, Mammaev SN, Gafurov DM, Kitaeva EY, Shprakh VV, Suleymanov SS, Bolieva LZ, Sozaeva MSH, Zhuchkova SM, Gimaldinova NE, Sidukova EE, Asoskova AV, Mumladze RB. Genetic determinants of dabigatran safety (CES1 gene rs2244613 polymorphism) in the Russian population: multi-ethnic analysis. Mol Biol Rep 2019; 46:2761-2769. [PMID: 30850966 DOI: 10.1007/s11033-019-04722-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/27/2019] [Indexed: 12/14/2022]
Abstract
This study was aimed to investigate the prevalence of the CES1 gene (c.1168-33A > C, rs2244613) polymorphism among 12 different ethnic groups living in Russia to provide a basis for future clinical studies concerning genetic determinants of dabigatran safety. The study involved 1630 apparently healthy, unrelated, and chronic medication-free volunteers of both genders from 12 different ethnic groups in Russia: 136 Russians, 90 Avars, 50 Dargins, 46 Laks, 120 Kabardians, 112 Balkars, 244 Ossetians, 206 Mari, 204 Mordvinians, 238 Chuvashes, 114 Buryats and 70 Nanays. Genotyping was performed by using real-time polymerase chain reaction-based methods. The allelic prevalence of the ethnic groups was compared with Caucasus population participating in the RE-LY study. Statistically significant differences for the following gene polymorphism were found between all ethnic groups and RE-LY participants. Based on obtained results, it can be assumed that patients of all ethnic groups living in Russia taking dabigatran have a lower risk of bleeding.
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Affiliation(s)
- Dmitry Alekseevich Sychev
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Sherzod Pardaboevich Abdullaev
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation.
| | - Karin Badavievich Mirzaev
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Kristina Anatolevna Ryzhikova
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Grigoriy Nikolaevich Shuyev
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Zhannet Alimovna Sozaeva
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Elena Anatolevna Grishina
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Suleiman Nurattinovich Mammaev
- Federal State Budgetary Educational Institution of Higher Education "Dagestan State Medical University" of the Ministry of Healthcare of the Russian Federation, Lenin Square, 1, Makhachkala, Republic Of Dagestan, 367000, Russian Federation
| | - Daniyal Musaevich Gafurov
- State Budgetary Institution of the Republic of Dagestan "Laksky Central District Hospital", Kumuh Village, Makhachkala, Republic of Dagestan, 368360, Russian Federation
| | - Elena Yurievna Kitaeva
- Irkutsk State Medical Academy of Postgraduate Education - Branch Campus of the Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Yubileinyi District, 100, Irkutsk, 664049, Russian Federation
| | - Vladimir Viktorovich Shprakh
- Irkutsk State Medical Academy of Postgraduate Education - Branch Campus of the Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Yubileinyi District, 100, Irkutsk, 664049, Russian Federation
| | | | - Laura Zelimkhanovna Bolieva
- Federal State Budgetary Educational Institution of Higher Education "North Ossetia State Medical Academy" of the Ministry of Healthcare of the Russian Federation, Pushkinskaya St., 40, Vladikavkaz, Republic of North Ossetia-Alania, 362019, Russian Federation
| | - Maryam Sultan-Hamitovna Sozaeva
- State Budgetary Healthcare Institution "Republican Clinical Hospital" of the Ministry of Healthcare of the Russian Federation, Nogmova St., 91, Nalchik, Kabardino-Balkarian Republic, 360003, Russian Federation
| | - Svetlana Mikhailovna Zhuchkova
- Autonomous Institution "Republican Clinical Oncologic Dispensary" of the Ministry of Health of the Chuvash Republic, Gladkov St., 31, Cheboksary, Chuvash Republic, 428020, Russian Federation
| | - Natalia Evgenievna Gimaldinova
- Federal State Budgetary Educational Institution of Higher Education "I. N. Ulianov Chuvash State University", Moskovskiy pr., 15, Cheboksary, Chuvash Republic, 428015, Russian Federation
| | - Elena Eduardovna Sidukova
- State Budgetary Institution of the Republic of Mari El "Kozmodemyansk Interdistrict Hospital", 3rd Microdistrict, 25, Kozmodemyansk, Republic Of Mari El, 425350, Russian Federation
| | - Anastasiia Valerievna Asoskova
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
| | - Robert Borisovich Mumladze
- Federal State Budgetary Educational Institution of Further Professional Education "Russian Medical Academy of Continuous Professional Education" of the Ministry of Healthcare of the Russian Federation, Barrikadnaya St., 2/1, Build. 1, Moscow, 125993, Russian Federation
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108
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de Vries R, Jacobs F, Mannens G, Snoeys J, Cuyckens F, Chien C, Ward P. Apalutamide Absorption, Metabolism, and Excretion in Healthy Men, and Enzyme Reaction in Human Hepatocytes. Drug Metab Dispos 2019; 47:453-464. [PMID: 30787101 DOI: 10.1124/dmd.118.084517] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/04/2019] [Indexed: 12/18/2022] Open
Abstract
In this phase 1 study, the absolute bioavailability and absorption, metabolism, and excretion (AME) of apalutamide, a competitive inhibitor of the androgen receptor, were evaluated in 12 healthy men. Subjects received 240 mg of apalutamide orally plus a 15-minute intravenous infusion of 100 µg of apalutamide containing 9.25 kBq (250 nCi) of 14C-apalutamide (2 hours postdose) for absolute bioavailability assessment or plus one 400-µg capsule containing 37 kBq (1000 nCi) of 14C-apalutamide for AME assessment. Content of 14C and metabolite profiling for whole blood, plasma, urine, feces, and expired air samples were analyzed using accelerator mass spectrometry. Apalutamide absolute oral bioavailability was ≈100%. After oral administration, apalutamide, its N-desmethyl metabolite (M3), and an inactive carboxylic acid metabolite (M4) accounted for most 14C in plasma (45%, 44%, and 3%, respectively). Apalutamide elimination was slow, with a mean plasma half-life of 151-178 hours. The mean cumulative recovery of total 14C over 70 days postdose was 64.6% in urine and 24.3% in feces. The urinary excretion of apalutamide, M3, and M4 was 1.2%, 2.7%, and 31.1% of dose, respectively. Fecal excretion of apalutamide, M3, and M4 was 1.5%, 2.0%, and 2.4% of dose, respectively. Seventeen apalutamide metabolites and six main metabolic clearance pathways were identified. In vitro studies confirmed CYP2C8 and CYP3A4 roles in apalutamide metabolism.
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Affiliation(s)
- Ronald de Vries
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Frank Jacobs
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Geert Mannens
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Jan Snoeys
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Filip Cuyckens
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Caly Chien
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
| | - Peter Ward
- Janssen Research & Development, Beerse, Belgium (R.d.V., F.J., G.M., J.S., F.C.); Janssen Research & Development, Spring House, Pennsylvania (C.C.); and Janssen Research & Development, San Diego, California (P.W.)
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109
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Kanuri SH, Kreutz RP. Pharmacogenomics of Novel Direct Oral Anticoagulants: Newly Identified Genes and Genetic Variants. J Pers Med 2019; 9:jpm9010007. [PMID: 30658513 PMCID: PMC6463033 DOI: 10.3390/jpm9010007] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/01/2023] Open
Abstract
Direct oral anticoagulants (DOAC) have shown an upward prescribing trend in recent years due to favorable pharmacokinetics and pharmacodynamics without requirement for routine coagulation monitoring. However, recent studies have documented inter-individual variability in plasma drug levels of DOACs. Pharmacogenomics of DOACs is a relatively new area of research. There is a need to understand the role of pharmacogenomics in the interpatient variability of the four most commonly prescribed DOACs, namely dabigatran, rivaroxaban, apixaban, and edoxaban. We performed an extensive search of recently published research articles including clinical trials and in-vitro studies in PubMed, particularly those focusing on genetic loci, single nucleotide polymorphisms (SNPs), and DNA polymorphisms, and their effect on inter-individual variation of DOACs. Additionally, we also focused on commonly associated drug-drug interactions of DOACs. CES1 and ABCB1 SNPs are the most common documented genetic variants that contribute to alteration in peak and trough levels of dabigatran with demonstrated clinical impact. ABCB1 SNPs are implicated in alteration of plasma drug levels of rivaroxaban and apixaban. Studies conducted with factor Xa, ABCB1, SLCOB1, CYP2C9, and VKORC1 genetic variants did not reveal any significant association with plasma drug levels of edoxaban. Pharmacokinetic drug-drug interactions of dabigatran are mainly mediated by p-glycoprotein. Strong inhibitors and inducers of CYP3A4 and p-glycoprotein should be avoided in patients treated with rivaroxaban, apixaban, and edoxaban. We conclude that some of the inter-individual variability of DOACs can be attributed to alteration of genetic variants of gene loci and drug-drug interactions. Future research should be focused on exploring new genetic variants, their effect, and molecular mechanisms that contribute to alteration of plasma levels of DOACs.
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Affiliation(s)
- Sri H Kanuri
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Rolf P Kreutz
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA.
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Shimada K, Hasegawa S, Nakao S, Mukai R, Sasaoka S, Ueda N, Kato Y, Abe J, Mori T, Yoshimura T, Kinosada Y, Nakamura M. Adverse reaction profiles of hemorrhagic adverse reactions caused by direct oral anticoagulants analyzed using the Food and Drug Administration Adverse Event Reporting System (FAERS) database and the Japanese Adverse Drug Event Report (JADER) database. Int J Med Sci 2019; 16:1295-1303. [PMID: 31588196 PMCID: PMC6775265 DOI: 10.7150/ijms.34629] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/02/2019] [Indexed: 11/05/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are used in anticoagulant therapy. The purpose of this study was to evaluate the association of DOAC-induced gastrointestinal (GI) and nervous system hemorrhage using the FDA's Adverse Event Reporting System (FAERS) database and the Japanese Adverse Drug Event Report (JADER) database. We identified and analyzed the reports of hemorrhagic reactions between 2004 and 2016 from the FAERS and JADER databases, and calculated the adjusted reported odds ratio (ROR) using the multiple logistic regression method. Additionally, we used the time-to-onset analysis. In the FAERS database, the adjusted ROR of apixaban, rivaroxaban, and dabigatran for GI hemorrhage was 6.79 (5.84-7.91), 19.58 (18.85-20.34), and 14.51 (13.58-15.51), respectively. In the JADER database, the adjusted ROR of apixaban, rivaroxaban, edoxaban, and dabigatran for GI hemorrhage was 11.80 (9.50-14.64), 11.03 (9.18-13.26), 10.17 (6.95-14.88), and 9.85 (7.23-13.42), respectively. We found that the association of GI hemorrhage with DOACs was affected by sex (female). Additionally, 30% of GI hemorrhage was observed after 30 days. Hemorrhagic reactions of both GI and nervous systems were observed in both the spontaneous reporting system databases. We recommend that female patients who experience symptoms related to GI hemorrhage should be closely monitored and advised to adhere to an appropriate care plan. Additionally, our results show that patients should be closely monitored for hemorrhage even after a month.
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Affiliation(s)
- Kazuyo Shimada
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Shiori Hasegawa
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Satoshi Nakao
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Ririka Mukai
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Sayaka Sasaoka
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Natsumi Ueda
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Yamato Kato
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
| | - Junko Abe
- Medical Database Co., Ltd., 3-11-10 Higashi, Shibuya-ku, Tokyo, 150-0011, Japan
| | - Takayuki Mori
- Department of Pharmacy, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502
| | - Tomoaki Yoshimura
- Department of Pharmacy, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502
| | - Yasutomi Kinosada
- United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Mitsuhiro Nakamura
- Laboratory of Drug Informatics, Gifu Pharmaceutical University; 1-25-4 Daigaku-Nishi, Gifu 501-1196, Japan
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Kato ET, Goto S, Giugliano RP. Overview of oral antithrombotic treatment in elderly patients with atrial fibrillation. Ageing Res Rev 2019; 49:115-124. [PMID: 30359765 DOI: 10.1016/j.arr.2018.10.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/06/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation (AF) is an age-related arrhythmia, particularly affecting elderly patients. The ultimate goals in the treatment of AF are to improve prognosis and quality of life. Anticoagulants are effective for stroke prevention in AF patients, however, managing anticoagulation in elderly patients is especially challenging; requiring a comprehensive assessment of the patient and deep understanding of available therapies and doses to maximize the net benefit. This review summarizes available evidence on the efficacy and safety of anticoagulation therapy, and provides contemporary updates on the management of elderly patients with AF.
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Approaches to prevent bleeding associated with anticoagulants: current status and recent developments. Drug Deliv Transl Res 2018; 8:928-944. [PMID: 28741113 DOI: 10.1007/s13346-017-0413-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Anticoagulants are widely used for the prophylaxis and treatment of cardiovascular disorders and to prevent blood clotting during surgeries. However, the major limitation associated with anticoagulant therapy is bleeding; all the current anticoagulants do have a bleeding risk. The propensity to bleed is much higher among the elderly population and patients with renal insufficiency. Therefore, there is an utmost and urgent clinical need for a highly efficient, nontoxic antidote with excellent anticoagulant reversal activity. This will significantly improve the safety of anticoagulation therapy. This review summarizes the current options and approaches to reverse anticoagulation activity of clinically used anticoagulants. We start with an introduction to thrombosis and then summarize the details of current clinically available anticoagulants and their mechanisms of action and limitations. This is followed by current practices in anticoagulant neutralization including the details of the only clinically approved unfractionated heparin antidote, protamine; recent advances in the development of antidotes against heparin-based drugs; and direct oral anticoagulants (DOACs).
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Association between activated partial thromboplastin time, age and bleeding events in NVAF patients receiving dabigatran. Eur J Clin Pharmacol 2018; 75:321-328. [DOI: 10.1007/s00228-018-2583-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/22/2018] [Indexed: 01/19/2023]
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Xu D, Su C, Pan J. Advances and Application of a Novel Oral Anticoagulant in Specific Populations: Dabigatran Etexilate. Curr Drug Metab 2018; 21:106-111. [PMID: 30317993 DOI: 10.2174/1389200219666181011160133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 05/31/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dabigatran etexilate (DE) was approved by the FDA in 2010 to reduce the risk of stroke and systemic embolism in adults with Non-valvular Atrial Fibrillation (NVAF). Compared with warfarin, a traditional anticoagulant drug, DE exhibits a shorter half-life, improved dose-effect relationship, fewer food and drug interactions, and can be taken orally without monitoring the conventional coagulation index. DE can also prevent or reduce the severity of adverse events, such as attenuated drug efficacy or bleeding. It is convenient for patients to take DE due to low levels of individual variation. This review aims to application of Dabigatran etexilate in specific populations. METHODS Fifty-five papers were included in the review. RESULTS We review the pharmacological mechanisms, pharmacokinetics and drug interactions, as well as the application of DE for different clinical populations, and provide clinical guidelines. CONCLUSION When using DE, one should consider the risk of bleeding, age, renal function, drug interactions, and other factors.
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Affiliation(s)
- Delai Xu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
| | - Cujin Su
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
| | - Jie Pan
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
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Padrini R. Clinical Pharmacokinetics and Pharmacodynamics of Direct Oral Anticoagulants in Patients with Renal Failure. Eur J Drug Metab Pharmacokinet 2018; 44:1-12. [DOI: 10.1007/s13318-018-0501-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Hoolwerf EW, Kraaijpoel N, Büller HR, van Es N. Direct oral anticoagulants in patients with liver cirrhosis: A systematic review. Thromb Res 2018; 170:102-108. [PMID: 30153564 DOI: 10.1016/j.thromres.2018.08.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/20/2018] [Accepted: 08/16/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Anticoagulant treatment in patients with liver cirrhosis is challenging. The aim of this systematic review was to evaluate clinical outcomes of direct oral anticoagulant (DOAC) therapy in cirrhosis patients. MATERIALS AND METHODS A systematic search was performed in MEDLINE, Embase, and conference proceedings up to November 7th, 2017, for studies that evaluated the efficacy and safety of DOACs in cirrhosis patients with venous thromboembolism (VTE), splanchnic vein thrombosis (SVT), or atrial fibrillation (AF). Two authors independently screened titles, abstracts, and full-text articles, and assessed risk of bias. A meta-analysis could not be performed due to heterogeneity of the included studies. RESULTS Of the 2927 articles assessed, five retrospective cohort studies were included (n = 239, including 20 patients overlap). All studies had fair methodological quality. Two studies evaluated DOAC treatment only, and three also evaluated vitamin K antagonists (VKAs) or low-molecular-weight heparins (LMWHs). Recurrent VTE (DOAC n = 12, LMWH/VKA n = 8) or ischemic stroke (DOAC n = 37, LMWH/VKA n = 9) occurred in none of the patients. Progression of VTE was 8% with DOACs (n = 12) and 13% with VKAs and LWWH (n = 8). Recurrent SVT occurred in 0 to 4% with DOACs (n = 31). Progression of SVT was 0 to 5% with DOACs (n = 24) and 0 to 47% with VKAs and LMWH (n = 33). Major bleeding risk ranged from 4 to 15% with DOACs (n = 172) and from 7 to 28% with VKAs and LMWH (n = 67). All-cause mortality risk was 6% with DOACs (n = 36). CONCLUSIONS There is paucity of data on the efficacy and safety of DOACs in patients with cirrhosis. This analysis suggests that DOACs may be effective and safe for treatment of VTE, SVT, and AF in these patients.
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Affiliation(s)
- Evert Willian Hoolwerf
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Harry Roger Büller
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Sivaraja M, Pozzi N, Rienzo M, Lin K, Shiau TP, Clemens DM, Igoudin L, Zalicki P, Chang SS, Estiarte MA, Short KM, Williams DC, Datta A, Di Cera E, Kita DB. Reversible covalent direct thrombin inhibitors. PLoS One 2018; 13:e0201377. [PMID: 30071045 PMCID: PMC6072017 DOI: 10.1371/journal.pone.0201377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/13/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In recent years, the traditional treatments for thrombotic diseases, heparin and warfarin, are increasingly being replaced by novel oral anticoagulants offering convenient dosing regimens, more predictable anticoagulant responses, and less frequent monitoring. However, these drugs can be contraindicated for some patients and, in particular, their bleeding liability remains high. METHODS We have developed a new class of direct thrombin inhibitors (VE-DTIs) and have utilized kinetics, biochemical, and X-ray structural studies to characterize the mechanism of action and in vitro pharmacology of an exemplary compound from this class, Compound 1. RESULTS We demonstrate that Compound 1, an exemplary VE-DTI, acts through reversible covalent inhibition. Compound 1 inhibits thrombin by transiently acylating the active site S195 with high potency and significant selectivity over other trypsin-like serine proteases. The compound inhibits the binding of a peptide substrate with both clot-bound and free thrombin with nanomolar potency. Compound 1 is a low micromolar inhibitor of thrombin activity against endogenous substrates such as fibrinogen and a nanomolar inhibitor of the activation of protein C and thrombin-activatable fibrinolysis inhibitor. In the thrombin generation assay, Compound 1 inhibits thrombin generation with low micromolar potency but does not increase the lag time for thrombin formation. In addition, Compound 1 showed weak inhibition of clotting in PT and aPTT assays consistent with its distinctive profile in the thrombin generation assay. CONCLUSION Compound 1, while maintaining strong potency comparable to the current DTIs, has a distinct mechanism of action which produces a differentiating pharmacological profile. Acting through reversible covalent inhibition, these direct thrombin inhibitors could lead to new anticoagulants with better combined efficacy and bleeding profiles.
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Affiliation(s)
- Mohanram Sivaraja
- Verseon Corporation, Fremont, California, United States of America
- * E-mail:
| | - Nicola Pozzi
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Matthew Rienzo
- Verseon Corporation, Fremont, California, United States of America
| | - Kenneth Lin
- Verseon Corporation, Fremont, California, United States of America
| | - Timothy P. Shiau
- Verseon Corporation, Fremont, California, United States of America
| | | | - Lev Igoudin
- Verseon Corporation, Fremont, California, United States of America
| | - Piotr Zalicki
- Verseon Corporation, Fremont, California, United States of America
| | | | | | - Kevin M. Short
- Verseon Corporation, Fremont, California, United States of America
| | | | - Anirban Datta
- Verseon Corporation, Fremont, California, United States of America
| | - Enrico Di Cera
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - David B. Kita
- Verseon Corporation, Fremont, California, United States of America
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Schumacher-Klinger A, Fanous J, Merzbach S, Weinmüller M, Reichart F, Räder AFB, Gitlin-Domagalska A, Gilon C, Kessler H, Hoffman A. Enhancing Oral Bioavailability of Cyclic RGD Hexa-peptides by the Lipophilic Prodrug Charge Masking Approach: Redirection of Peptide Intestinal Permeability from a Paracellular to Transcellular Pathway. Mol Pharm 2018; 15:3468-3477. [PMID: 29976060 DOI: 10.1021/acs.molpharmaceut.8b00466] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hydrophilic peptides constitute most of the active peptides. They mostly permeate via tight junctions (paracellular pathway) in the intestine. This permeability mechanism restricts the magnitude of their oral absorption and bioavailability. We hypothesized that concealing the hydrophilic residues of the peptide using the lipophilic prodrug charge masking approach (LPCM) can improve the bioavailability of hydrophilic peptides. To test this hypothesis, a cyclic N-methylated hexapeptide containing Arg-Gly-Asp (RGD) and its prodrug derivatives, masking the Arg and Asp charged side chains, were synthesized. The library was evaluated for intestinal permeability in vitro using the Caco-2 model. Further investigation of metabolic stability ex vivo models in rat plasma, brush border membrane vesicles (BBMVs), and isolated CYP3A4 microsomes and pharmacokinetic studies was performed on a selected peptide and its prodrug (peptide 12). The parent drug analogues were found to have a low permeability rate in vitro, corresponding to atenolol, a marker for paracellular permeability. Moreover, palmitoyl carnitine increased the Papp of peptide 12 by 4-fold, indicating paracellular permeability. The Papp of the prodrug derivatives was much higher than that of their parent peptides. For instance, the Papp of the prodrug 12P was 20-fold higher than the Papp of peptide 12 in the apical to basolateral (AB) direction. Whereas the permeability in the opposite direction (BA of the Caco-2 model) was significantly faster than the Papp AB, indicating the involvement of an efflux system. These results were corroborated when verapamil, a P-gp inhibitor, was added to the Caco-2 model and increased the Papp AB of prodrug 12P by 3-fold. The prodrug 12P was stable in the BBMVs environment, yet degraded quickly (less than 5 min) in the plasma into the parent peptide 12. Pharmacokinetic studies in rats showed an increase in the bioavailability of peptide 12 > 70-fold (from 0.58 ± 0.11% to 43.8 ± 14.9%) after applying the LPCM method to peptide 12 and converting it to the prodrug 12P. To conclude, the LPCM approach converted the absorption mechanism of the polar peptides from a paracellular to transcellular pathway that tremendously affects their oral bioavailability. The LPCM method provides a solution for the poor bioavailability of RGD cyclohexapeptides and paves the way for other active hydrophilic and charged peptides with poor oral bioavailability.
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Affiliation(s)
- Adi Schumacher-Klinger
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine , The Hebrew University of Jerusalem , P.O. Box 12065, Jerusalem 91120 , Israel
| | - Joseph Fanous
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine , The Hebrew University of Jerusalem , P.O. Box 12065, Jerusalem 91120 , Israel
| | - Shira Merzbach
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine , The Hebrew University of Jerusalem , P.O. Box 12065, Jerusalem 91120 , Israel
| | - Michael Weinmüller
- Institute for Advanced Study and Center of Integrated Protein Science, Department Chemie , Technische Universität München , Lichtenbergstrasse 4 , 85748 Garching , Germany
| | - Florian Reichart
- Institute for Advanced Study and Center of Integrated Protein Science, Department Chemie , Technische Universität München , Lichtenbergstrasse 4 , 85748 Garching , Germany
| | - Andreas F B Räder
- Institute for Advanced Study and Center of Integrated Protein Science, Department Chemie , Technische Universität München , Lichtenbergstrasse 4 , 85748 Garching , Germany
| | - Agata Gitlin-Domagalska
- Institute of Chemistry , The Hebrew University of Jerusalem, Edmond Safra Campus, Givat Ram Campus, The Hebrew University , Jerusalem 91904 , Israel
| | - Chaim Gilon
- Institute of Chemistry , The Hebrew University of Jerusalem, Edmond Safra Campus, Givat Ram Campus, The Hebrew University , Jerusalem 91904 , Israel
| | - Horst Kessler
- Institute for Advanced Study and Center of Integrated Protein Science, Department Chemie , Technische Universität München , Lichtenbergstrasse 4 , 85748 Garching , Germany
| | - Amnon Hoffman
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine , The Hebrew University of Jerusalem , P.O. Box 12065, Jerusalem 91120 , Israel
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Gelosa P, Castiglioni L, Tenconi M, Baldessin L, Racagni G, Corsini A, Bellosta S. Pharmacokinetic drug interactions of the non-vitamin K antagonist oral anticoagulants (NOACs). Pharmacol Res 2018; 135:60-79. [PMID: 30040996 DOI: 10.1016/j.phrs.2018.07.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/10/2018] [Accepted: 07/16/2018] [Indexed: 12/20/2022]
Abstract
The use of warfarin, the most commonly prescribed oral anticoagulant, is being questioned by clinicians worldwide due to warfarin several limitations (a limited therapeutic window and significant variability in dose-response among individuals, in addition to a potential for drug-drug interactions). Therefore, the need for non-vitamin K antagonist oral anticoagulants (NOACs) with a rapid onset of antithrombotic effects and a predictable pharmacokinetic (PK) and pharmacodynamic (PD) profile led to the approval of five new drugs: the direct factor Xa (F-Xa) inhibitors rivaroxaban, apixaban, edoxaban and betrixaban (newly approved by FDA) and the direct thrombin (factor-IIa) inhibitor dabigatran etexilate. The advantages of NOACs over warfarin are a fixed-dosage, the absence of the need for drug monitoring for changes in anti-coagulation and fewer clinically significant PK and PD drug-drug interactions. NOACs exposure will likely be increased by the administration of strong P-glycoprotein (P-gp) and cytochrome P450 (CYP) 3A4-inhibitors and may increase the risk of bleeds. On the contrary, P-gp inducers could significantly decrease the NOACs plasma concentration with an associated reduction in their anticoagulant effects. This manuscript gives an overview of NOACs PK profiles and their drug-drug interactions potential. This is meant to be of help to physicians in choosing the best therapeutic approach for their patients.
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Affiliation(s)
- Paolo Gelosa
- Centro Cardiologico Monzino IRCCS, Via C. Parea, 4, 20138 Milan, Italy.
| | - Laura Castiglioni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Marco Tenconi
- EDRA S.p.A., Via G. Spadolini, 7, 20141 Milan, Italy.
| | | | - Giorgio Racagni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
| | - Stefano Bellosta
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
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Kolb JM, Flack KF, Chatterjee-Murphy P, Desai J, Wallentin LC, Ezekowitz M, Connolly S, Reilly P, Brueckmann M, Ilgenfritz J, Aisenberg J. Locations and Mucosal Lesions Responsible for Major Gastrointestinal Bleeding in Patients on Warfarin or Dabigatran. Dig Dis Sci 2018; 63:1878-1889. [PMID: 29582237 DOI: 10.1007/s10620-018-5007-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Different oral anticoagulants may be associated with gastrointestinal bleeding (GIB) from different locations or mucosal lesions. We aimed to test this hypothesis. METHODS Two blinded gastroenterologists independently analyzed source documents from the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial of dabigatran 150 mg BID (D150), dabigatran 110 mg BID (D110) versus warfarin in non-valvular atrial fibrillation (NVAF). RESULTS Major GIB events (total n = 546) and life-threatening GIB events (n = 258) were more common with D150 versus warfarin (RR 1.57 [1.28-1.92] and RR 1.62 [1.20-2.18], respectively) and similar for D110 compared to warfarin (RR 1.11 [0.89-1.38] and RR 1.16 [0.84-1.61], respectively). Fatal bleeding was similarly rare across treatment groups. Lower GI major bleeding and life-threatening bleeding were more common with D150 compared to warfarin (RR 2.23 [1.47, 3.38] and RR 2.64 [1.36, 5.13], respectively) and with D110 compared to warfarin (RR 1.78 [1.16, 2.75] and RR 2.00 [1.00, 4.00], respectively). MGIB from colonic angiodysplasia was increased with dabigatran versus warfarin (P < 0.01 for both dose comparisons). Subacute and chronic MGIB events were more common with D150 than with warfarin (RR 1.72 [1.06, 2.78] and RR 1.66 [1.12, 2.45], respectively), as were hematochezia or melena (RR 1.67 [1.18, 2.36] and RR 1.72 [1.20, 2.47], respectively). CONCLUSIONS In a chronic NVAF population, D150 but not D110 is associated with increased major and life-threatening GI bleeding in comparison with warfarin. At both dabigatran doses, increased bleeding from the colorectum, in particular from angiodysplasia, is seen.
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Affiliation(s)
- Jennifer M Kolb
- Department of Gastroenterology and Hepatology, University of Colorado Hospital, Denver, CO, USA
| | - Kathryn Friedman Flack
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jay Desai
- Department of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lars C Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Michael Ezekowitz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Paul Reilly
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - James Aisenberg
- Department of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Gu ZC, Ma XW, Zheng XY, Shen L, Shi FH, Li H. Left Atrial Appendage Thrombus Formation in a Patient on Dabigatran Therapy Associated With ABCB1 and CES-1 Genetic Defect. Front Pharmacol 2018; 9:491. [PMID: 29867495 PMCID: PMC5962821 DOI: 10.3389/fphar.2018.00491] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023] Open
Abstract
Dabigatran, directly targeting thrombin, is widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF). We reported a rare case of left atrial appendage thrombus formation in a persistent NVAF patient despite the 31 months uninterrupted treatment with dabigatran 110 mg twice daily. The patient is a carrier of ABCB1 variant alleles with 7 heterozygote single nucleotide polymorphisms (SNPs: rs4148738, rs2235046, rs1128503, rs10276036, rs1202169, rs1202168, rs1202167) as well as CES-1 variant alleles with 2 homozygote SNPs (rs2244613 and rs4122238) and 2 heterozygote SNPs (rs8192935 and rs4580160), which may contribute to the changes of dabigatran plasma concentration. In addition, Drug-drug interaction with atorvastatin may also play a role to decrease dabigatran plasma concentration. There are only four such cases till date, of which had thrombus in the left atrium, reported in the literature. We firstly reported the documented case in a Chinese patient carrying multiple alleles of ABCB1 and CES-1, who suffered from thrombus in the left atrial appendage despite long-term anticoagulation with dabigatran. More clinical data are required to elucidate the impact of CES-1 and ABCB1 polymorphism on dabigatran pharmacokinetics, especially for Asian.
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Affiliation(s)
- Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Wei Ma
- Department of Clinical Laboratory, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Yuan Zheng
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Fang-Hong Shi
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hao Li
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Yadav J, Korzekwa K, Nagar S. Improved Predictions of Drug-Drug Interactions Mediated by Time-Dependent Inhibition of CYP3A. Mol Pharm 2018; 15:1979-1995. [PMID: 29608318 PMCID: PMC5938745 DOI: 10.1021/acs.molpharmaceut.8b00129] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Time-dependent inactivation (TDI) of cytochrome P450s (CYPs) is a leading cause of clinical drug-drug interactions (DDIs). Current methods tend to overpredict DDIs. In this study, a numerical approach was used to model complex CYP3A TDI in human-liver microsomes. The inhibitors evaluated included troleandomycin (TAO), erythromycin (ERY), verapamil (VER), and diltiazem (DTZ) along with the primary metabolites N-demethyl erythromycin (NDE), norverapamil (NV), and N-desmethyl diltiazem (NDD). The complexities incorporated into the models included multiple-binding kinetics, quasi-irreversible inactivation, sequential metabolism, inhibitor depletion, and membrane partitioning. The resulting inactivation parameters were incorporated into static in vitro-in vivo correlation (IVIVC) models to predict clinical DDIs. For 77 clinically observed DDIs, with a hepatic-CYP3A-synthesis-rate constant of 0.000 146 min-1, the average fold difference between the observed and predicted DDIs was 3.17 for the standard replot method and 1.45 for the numerical method. Similar results were obtained using a synthesis-rate constant of 0.000 32 min-1. These results suggest that numerical methods can successfully model complex in vitro TDI kinetics and that the resulting DDI predictions are more accurate than those obtained with the standard replot approach.
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Affiliation(s)
- Jaydeep Yadav
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, Pennsylvania 19140, United States
| | - Ken Korzekwa
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, Pennsylvania 19140, United States
| | - Swati Nagar
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, Pennsylvania 19140, United States
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Fujita M, Murao T, Osawa M, Hirai S, Fukushima S, Yo S, Nakato R, Ishii M, Matsumoto H, Tamaki T, Sakakibara T, Shiotani A. Colonic endoscopic mucosal resection in patients taking anticoagulants: Is heparin bridging therapy necessary? J Dig Dis 2018; 19:288-294. [PMID: 29687957 DOI: 10.1111/1751-2980.12598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Heparin bridging therapy (HBT) reportedly increases the risk of post-procedural bleeding, and its safety during endoscopic interventions remains unclear. We aimed to evaluate the effects of peri-procedural HBT in patients taking anticoagulants who underwent colonic endoscopic mucosal resection (EMR) for polyps. METHODS Patients who underwent colonic EMR while taking a single anticoagulant agent were enrolled in this study. Anticoagulants were temporarily ceased in all patients either without (the non-HBT group, prospectively enrolled) or with HBT (the HBT group, retrospectively enrolled). The incidences of post-procedural bleeding and anemia exacerbation and their length of hospitalization were evaluated and compared. RESULTS There were altogether 43 consecutive adult patients (30 men; mean age 72.2 ± 7.4 years) in the non-HBT group and 41 sex- and age-matched adults (32 men; mean age 72.9 ± 8.3 years) in the HBT group. There were no significant differences in the location, number or size of resected polyps between the two groups. The percentage of patients with post-procedural bleeding within 2 weeks after colonic EMR in the non-HBT group was lower than that in the HBT group (2.3% vs 9.8%, P = 0.15), although the frequency of anemia exacerbation was not significantly different between the two groups. The total hospitalization length was shorter in the non-HBT compared with the HBT group (4.5 days vs 6.0 days, P < 0.001). CONCLUSIONS No patient in either group developed embolism during hospitalization. Colonic EMR with the temporary cessation of anticoagulants without HBT may be acceptable and beneficial for patients taking anticoagulants.
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Affiliation(s)
- Minoru Fujita
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takahisa Murao
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Motoyasu Osawa
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shinsuke Hirai
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shinya Fukushima
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Syogen Yo
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Rui Nakato
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Manabu Ishii
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroshi Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takahiko Tamaki
- Department of Gastrointestinal Surgery, Sakakibara Heart Institute of Okayama, Kita-ku, Okayama, Japan
| | - Takashi Sakakibara
- Department of Gastrointestinal Surgery, Sakakibara Heart Institute of Okayama, Kita-ku, Okayama, Japan
| | - Akiko Shiotani
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Mullins B, Akehurst H, Slattery D, Chesser T. Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre. BMJ Open 2018; 8:e020625. [PMID: 29705761 PMCID: PMC5931299 DOI: 10.1136/bmjopen-2017-020625] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To determine whether not waiting for the elimination of direct oral anticoagulants (DOACs) has an effect on the amount of perioperative bleeding in patients who undergo operative treatment of a hip fracture. DESIGN Observation, retrospective case-control study. SETTING A single UK major trauma centre. PARTICIPANTS Patients who sustained a hip fracture were identified using the National Hip Fracture Database (NHFD). All those found to be taking a DOAC at the time of fracture were identified (n=63). A matched group not taking a DOAC was also identified from the NHFD (n=62). MAIN OUTCOME Perioperative drop in haemoglobin concentration. RESULTS There was no relationship between admission to operation interval and perioperative change in haemoglobin concentration in patients taking DOACs (regression coefficient=-0.06 g/L/hour; 95% CI -0.32-0.20; p=0.64). No relationship was found between the time from admission to operation interval and the probability of transfusion (OR=0.94; 95% CI 0.85 to 1.90; p=0.16) or reoperation (OR=1.04; 95% CI 0.93 to 1.16; p=0.49). One mortality was recorded in the DOAC group within 30 days of admission, and this compared with five in the matched group of patients (p=0.2). CONCLUSIONS Delaying surgery in patients who sustain a hip fracture who are taking a DOAC drug has not been shown to reduce perioperative bleeding or affect their mortality in this study.
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Affiliation(s)
- Barry Mullins
- Trauma and Orthopaedics, Southmead Hospital, Bristol, UK
| | | | - David Slattery
- Trauma and Orthopaedics, Melbourne Orthopaedic Group, Windsor, Victoria, Australia
| | - Tim Chesser
- Trauma and Orthopaedics, Southmead Hospital, Bristol, UK
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Havig SM, Lea D, Krpo M, Skari RM, Gustavsen I, Høiseth G. Fatal Adverse Event with Dabigatran in Elderly Patient with Reduced Kidney Function. Basic Clin Pharmacol Toxicol 2018; 123:221-226. [DOI: 10.1111/bcpt.12985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/04/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Stine Marie Havig
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Dordi Lea
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - Maja Krpo
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ragnhild Margrete Skari
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ingebjørg Gustavsen
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Gudrun Høiseth
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Department of Psychopharmacology; Diakonhjemmet Hospital; Oslo Norway
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Glund S, Gan G, Moschetti V, Reilly P, Honickel M, Grottke O, Van Ryn J. The Renal Elimination Pathways of the Dabigatran Reversal Agent Idarucizumab and its Impact on Dabigatran Elimination. Clin Appl Thromb Hemost 2018. [PMID: 29534609 PMCID: PMC6714879 DOI: 10.1177/1076029618755947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Idarucizumab, a humanized monoclonal antibody fragment (Fab), provides rapid and sustained reversal of dabigatran-mediated anticoagulation. Idarucizumab and dabigatran are mainly eliminated via the kidneys. This analysis aimed to characterize the renal elimination of idarucizumab and investigate the influence of idarucizumab on the pharmacokinetics (PK) of dabigatran and vice versa. Studies were conducted in 5/6 nephrectomized rats, in human volunteers with and without renal impairment, and in a porcine liver trauma model. In both rats and humans, renal impairment increased idarucizumab exposure and initial half-life but did not affect its terminal half-life. Urinary excretion of unchanged idarucizumab increased with increasing idarucizumab dose, suggesting saturation of renal tubular reuptake processes at higher doses. The PK of idarucizumab was unaffected by dabigatran. In contrast, idarucizumab administration resulted in redistribution of dabigatran to the plasma, where it was bound and inactivated by idarucizumab. Urinary excretion of dabigatran after administration of idarucizumab was delayed, but total dabigatran excreted in urine was unaffected. Idarucizumab and dabigatran were eliminated together via renal pathways.
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Affiliation(s)
- Stephan Glund
- 1 Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Guanfa Gan
- 2 Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | | | - Paul Reilly
- 2 Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Markus Honickel
- 4 Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Oliver Grottke
- 4 Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Joanne Van Ryn
- 1 Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
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Maegele M, Grottke O, Schöchl H, Sakowitz OA, Spannagl M, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:575-82. [PMID: 27658470 DOI: 10.3238/arztebl.2016.0575] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (nonvalvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are aking DOAC. METHODS This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. RESULTS Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. CONCLUSION DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Sugery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne and Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Experimental Hemostaseology, Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Department of Anesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg (Austria), Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Department of Anesthesiology, Ludwig Maximilian University of Munich, Munich, Institute for Transfusion Medicine, Charité University Medicine Berlin, Berlin
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Fasullo S, Davì S, Cosenza G, Di Franco F, La Manna N, Giubilato A, Vetrano G, Maringhini G. Acute agranulocytosis after oral administration of dabigatran: a rare case report and a short review of literature. J Thromb Thrombolysis 2018; 45:588-592. [DOI: 10.1007/s11239-018-1624-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Mumoli N, Mastroiacovo D, Tamborini-Permunian E, Vitale J, Giorgi-Pierfranceschi M, Cei M, Dentali F. Dabigatran in nonvalvular atrial fibrillation: from clinical trials to real-life experience. J Cardiovasc Med (Hagerstown) 2018; 18:467-477. [PMID: 28509761 DOI: 10.2459/jcm.0000000000000524] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
: Atrial fibrillation is the most common arrhythmia in over-midlife patients. In addition to systolic heart failure, cerebral thromboembolism represents the most dramatic complication of this rhythm disorder, contributing to morbidity and mortality. Traditionally, anticoagulation has been considered the main strategy in preventing stroke and systemic embolism in atrial fibrillation patients and vitamin K-dependent antagonists have been widely used in clinical practice. Recently, the development of direct oral anticoagulants has certainly improved the management of this disease, providing, for the first time, the opportunity to go beyond vitamin K-dependent antagonists limits. In the RE-LY trial, dabigatran 150 mg twice daily was superior to warfarin in the prevention of stroke or systemic embolism and dabigatran 110 mg twice daily was noninferior. Both doses greatly reduced hemorrhagic stroke, and dabigatran 110 mg twice daily significantly reduced major bleeding compared with warfarin. Based on these results, dabigatran, a direct thrombin inhibitor, was the first direct oral anticoagulant to receive the regulatory approval for nonvalvular atrial fibrillation patients. To date, a specific reversal agent has just been approved as an antidote for this molecule. This review provides a summary of randomized trials, postmarket registries and specific clinical-settings summary on dabigatran in nonvalvular atrial fibrillation.
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Affiliation(s)
- Nicola Mumoli
- aDepartment of Internal Medicine, Ospedale Civile di Livorno, Livorno bAngiology Unit, Ospedale SS, Filippo e Nicola, Avezzano cDepartment of Internal Medicine, Ospedale di Circolo, Varese dEmergency Department, Ospedale della Val d'Arda, Piacenza, Italy
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5-Fluororacil-Induced Gastrointestinal Damage Impairs the Absorption and Anticoagulant Effects of Dabigatran Etexilate. J Pharm Sci 2018; 107:1430-1433. [PMID: 29291414 DOI: 10.1016/j.xphs.2017.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 12/23/2022]
Abstract
Fluoropyrimidines, including 5-fluororacil (5-FU), cause gastrointestinal damage in the clinical setting and might affect the gastrointestinal absorption of concomitantly administered drugs. We aimed to evaluate the effects of fluoropyrimidine-induced gastrointestinal damage on the pharmacokinetics and pharmacodynamics of dabigatran etexilate (DABE), an anticoagulant, in rats with gastrointestinal damage induced by the repeated oral administration of 5-FU. Rats were administered DABE orally or dabigatran (DAB), an active moiety of DABE, intravenously. The plasma DAB concentration was determined using liquid chromatography-tandem mass spectrometry. The activated partial thromboplastin time (APTT) was measured before and 30 min after the administration of each drug, and the APTT ratio was calculated. In 5-FU-treated rats, the maximum plasma concentration, the area under the concentration-time curve of DAB after the oral administration of DABE, and the oral bioavailability of DABE were significantly decreased to 18.3%, 22.9%, and 16.3% of the respective control values. The 5-FU-treated rats' APTT ratio was also significantly lower than the control value. Fluoropyrimidine-induced gastrointestinal damage might reduce the plasma concentration of DAB by impairing DABE absorption and might attenuate the anticoagulant effects of DABE in the clinical setting.
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Vranckx P, Valgimigli M, Heidbuchel H. The Significance of Drug-Drug and Drug-Food Interactions of Oral Anticoagulation. Arrhythm Electrophysiol Rev 2018; 7:55-61. [PMID: 29636974 DOI: 10.15420/aer.2017.50.1] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Vitamin K antagonists (VKAs) such as warfarin are the most commonly prescribed oral anticoagulants worldwide. However, factors affecting the pharmacokinetics of VKAs, such as food and drugs, can cause deviations from their narrow therapeutic window, increasing the bleeding or thrombosis risk and complicating their long-term use. The use of direct oral anticoagulants (DOACs) offers a safer and more convenient alternative to VKAs. However, it is important to be aware that plasma levels of DOACs are affected by drugs that alter the cell efflux transporter P-glycoprotein and/or cytochrome P450. In addition to these pharmacokinetic-based interactions, DOACs have the potential for pharmacodynamic interaction with antiplatelet agents and non-steroidal anti-inflammatory drugs. This is an important consideration in patient groups already at high risk of bleeding, such as patients with renal impairment.
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Affiliation(s)
- Pascal Vranckx
- Hartcentrum Hasselt, Faculty of Medicine and Life Sciences, Hasselt UniversityHasselt, Belgium
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University HospitalBern, Switzerland
| | - Hein Heidbuchel
- Antwerp University and Antwerp University HospitalAntwerp, Belgium
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Ikeda T, Yasaka M, Kida M, Imura M. A survey of reasons for continuing warfarin therapy in the era of direct oral anticoagulants in Japanese patients with atrial fibrillation: the SELECT study. Patient Prefer Adherence 2018; 12:135-143. [PMID: 29398909 PMCID: PMC5775732 DOI: 10.2147/ppa.s152584] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Although warfarin has historically been the standard of care for preventing ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF), the use of direct oral anticoagulants (DOACs) is rapidly increasing. In this study, we examined the demographic and clinical characteristics of patients continuing warfarin therapy and investigated reasons for warfarin continuation. PATIENTS AND METHODS Each study site consecutively registered 10 patients with NVAF who had been taking warfarin for at least 12 months. Demographic and clinical characteristics and international normalized ratio (INR) values were collected from medical records. Physicians responded to questionnaires exploring reasons for continuing warfarin therapy. RESULTS Overall, 313 patients treated with warfarin were registered at 33 sites. Mean ± SD age was 76.4±9.6 years; 62.9% of patients were male. The proportion of patients with INR values in the therapeutic range was 74.6% and 48.8% among patients aged ≥70 years and <70 years, respectively. Over half of the patients (51.4%) had been advised to switch from warfarin to DOACs; the primary physician-reported reason for this recommendation was superior safety and effectiveness. However, patients reported continuing warfarin because of the high price of DOACs (47.2%) and long-term positive experiences with warfarin (31.7%). The remaining 48.6% of patients with NVAF had never been counseled by their physicians about DOACs as an alternative to warfarin. For 76% of these patients, physicians favored warfarin for medical reasons, such as impaired renal function and controlled INR, but in the remaining patients, medical reasons for continuing warfarin were lacking. CONCLUSION Approximately half of the patients in this study were informed of warfarin alternatives primarily for improved efficacy and safety, but elected not to change regimens because of the high price of DOACs and long-term positive experiences with warfarin. In the remaining half, physician preference or specific patient characteristics prevented a change in therapy.
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Affiliation(s)
- Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization, Kyushu Medical Center, Fukuoka
| | - Makoto Kida
- Medical & Development, Bristol-Myers Squibb KK, Tokyo
| | - Miki Imura
- PIH Medical Affairs, Pfizer Japan Inc, Tokyo, Japan
- Correspondence: Miki Imura, PIH Medical Affairs, Pfizer Japan Inc, Shinjuku Bunka Quint Building, 3-22-7, Yoyogi, Shibuya-ku, Tokyo 151-8589, Japan, Tel +81 805 001 3070, Fax +81 35 309 9198, Email
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Novak JE, Alamiri K, Yee J. Dabigatran Reversal in a Patient With End-Stage Liver Disease and Acute Kidney Injury. Am J Kidney Dis 2018; 71:137-141. [DOI: 10.1053/j.ajkd.2017.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/27/2017] [Indexed: 11/11/2022]
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Butler J, Malan E, Chunilal S, Tran H, Hapgood G. The effect of dabigatran on the activated partial thromboplastin time and thrombin time as determined by the Hemoclot thrombin inhibitor assay in patient plasma samples. Thromb Haemost 2017; 110:308-15. [DOI: 10.1160/th13-04-0301] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/31/2013] [Indexed: 11/05/2022]
Abstract
SummaryDabigatran is an oral direct thrombin inhibitor that does not require routine laboratory monitoring. However, an assessment of its anticoagulant effect in certain clinical settings is desirable. We examined the relationship between dabigatran levels, as determined by the Hemoclot thrombin inhibitor assay (HTI), the thrombin time (TT) and the activated partial thromboplastin time (aPTT) using different reagents. We describe these parameters with the clinical outcomes of patients receiving dabigatran. Seventy-five plasma samples from 47 patients were analysed. The HTI assay was established to measure dabigatran level. aPTTs were performed using TriniCLOT aPTT S reagent (TC) and three additional aPTT reagents. From linear regression lines, we established the aPTT ranges corresponding to the therapeutic drug levels for dabigatran (90–180 ng/ml). The aPTT demonstrated a modest correlation with the dabigatran level (r= 0.80) but the correlation became less reliable at higher dabigatran levels. The therapeutic aPTT ranges for reagents were clinically and statistically different compared with our reference reagent (46–54 s (TC) vs 51–60 s (SP), 54–64 s (SS) and 61–71 s (Actin FS) (p<0.05)). The TT was sensitive to the presence of dabigatran with a level of 60 ng/ml resulting in a TT > 300 s. In conclusion, the aPTT demonstrated a modest correlation with the dabigatran level and was less responsive with supra-therapeutic levels. aPTT reagents differed in their responsiveness, suggesting individual laboratories must determine their own therapeutic range for their aPTT reagent. The TT is too sensitive to quantify dabigatran levels, but a normal TT suggests minimal or no plasma dabigatran.
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Paikin JS, Hirsh J, Lauw MN, Eikelboom JW, Ginsberg JS, Chan NC. New oral anticoagulants for stroke prevention in atrial fibrillation: impact of study design, double counting and unexpected findings on interpretation of study results and conclusions. Thromb Haemost 2017; 111:798-807. [DOI: 10.1160/th13-11-0918] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/29/2014] [Indexed: 01/21/2023]
Abstract
SummaryFour recently introduced new oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban) have been shown to be at least as efficacious and safe as warfarin for stroke prevention in patients with atrial fibrillation in their respective trials. The first three have been approved, while edoxaban is awaiting regulatory approval. Several guidelines have endorsed the approved new oral anticoagulants over warfarin because of their favourable risk-benefit ratio, low propensity for food and drug interactions, and lack of requirement for routine coagulation monitoring. In this invited review, we summarise the results of the four studies and discuss widely held conclusions. We take a step further and discuss how differences in study design, analysis plan, and unexpected events affect the interpretation of the study results. Finally, we take our re-interpretation of study results and discuss how they might impact clinical practice and anticoagulant choice for patients.
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Yamamura N, Stangier J, Reilly P, Clemens A, Härtter S. Pharmacokinetics and pharmacodynamics in Japanese and Caucasian subjects after oral administration of dabigatran etexilate. Thromb Haemost 2017; 107:260-9. [DOI: 10.1160/th11-08-0551] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/10/2011] [Indexed: 11/05/2022]
Abstract
SummaryEthnic differences in drug disposition may potentially influence therapeutic response to dabigatran, a reversible direct thrombin inhibitor used for the prevention and/or treatment of various thromboembolic disorders. This analysis of data from 18 clinical studies in healthy volunteers and patients with non-valvular atrial fibrillation (AF) or undergoing knee or hip arthroplasty investigated whether there were any clinically relevant differences in the pharmacokinetics and pharmacodynamics of dabigatran, the active form of dabigatran etexilate, between Japanese and Caucasian subjects. In pooled data from 14 phase I trials, total exposure (i.e. area under the plasma concentration-time curve [AUC]) after administration of dabigatran 150 mg once or twice-daily was on average 20% higher in Japanese than Caucasian subjects (median [10th to 90th percentile] 1,110 [644–1,824] vs. 924 [420–1,654] ng·h/ml) although the difference between the groups was not significant. Within-trial comparisons in subjects treated with dabigatran 150 mg twice-daily showed that AUC and maximum plasma concentration differed by less than 10% between the two groups. In patients with AF, trough concentrations after administration of 150 mg twice-daily were similar in Japanese and Caucasian subjects (80.1 [34.5–193.8] vs. 71.0 [34.0–190] ng/ml). Various factors, including body weight and renal clearance, may explain these observed pharmacokinetic differences. The relationship between plasma concentration and coagulation markers was similar and indicative of no difference in the exposure-pharmacodynamic response between these two groups. In conclusion, the results of this analysis show that the pharmacokinetics and pharmacodynamics of dabigatran are similar in Japanese and Caucasian subjects and suggest that there is no need for dose adjustment of dabigatran in Japanese subjects.
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Schulman S. New oral anticoagulant agents – general features and outcomes in subsets of patients. Thromb Haemost 2017; 111:575-82. [DOI: 10.1160/th13-09-0803] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 12/19/2013] [Indexed: 11/05/2022]
Abstract
SummaryDuring the past four years the phase III trials on stroke prophylaxis in atrial fibrillation and on treatment of venous thromboembolism have been completed for four new oral anticoagulants – dabigatran, apixaban, edoxaban and rivaroxaban. The studies have revealed advantages in terms of a reduced risk of bleeding, most importantly of intracranial bleeding. These anticoagulants also have favourable pharmacokinetics, eliminating the need for routine laboratory monitoring and dose adjustments. There are, however, some differences between the drugs in certain subsets of patients, according to patient characteristics or to indication for treatment. These features are reviewed here. The management of patients in association with invasive procedures or major bleeding is also discussed. Finally, a strategy of how to select patients for warfarin or the new anticoagulants and thereafter possibly also among the latter is outlined.
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Lehr T, Liesenfeld KH, Haertter S, Staab A, Dansirikul C. A combined pharmacometric analysis of dabigatran etexilate in healthy volunteers and patients with atrial fibrillation or undergoing orthopaedic surgery. Thromb Haemost 2017; 107:775-85. [DOI: 10.1160/th11-09-0656] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 01/14/2012] [Indexed: 01/25/2023]
Abstract
SummaryDabigatran etexilate is the orally bioavailable pro-drug of dabigatran, a direct thrombin inhibitor. Using data from eight clinical studies in healthy volunteers and patients with non-valvular atrial fibrillation (AF) or undergoing orthopaedic surgery (OS), population pharmacokinetic (PK) and pharmacodynamic (PD) models were developed to investigate whether the PK and PD of dabigatran differ across different populations. In both healthy volunteers (n=80) and patients (n=1,965), the PK of dabigatran was best described by a two-compartment disposition model with first-order absorption and elimination. Renal function was the only covariate shown to have a clinically relevant impact on dabig-atran exposure. The patient PK model was successfully applied in predicting exposure observed in the RE-LY trial evaluating dabigatran treatment in patients with non-valvular AF. The relationship between dabigatran plasma concentrations and activated partial thromboplastin time in healthy volunteers and patients (n=762) was best described with a combination of a linear model and a maximum effect (Emax) model, consistent with previous reports. PK/PD relationships were robust across the various populations tested and were not affected by any of the covariates examined. In summary, the PK of dabigatran is sufficiently consistent to allow extrapolation of data generated in healthy volunteers to patients with AF or undergoing OS.
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Davis PK, Musunuru H, Mitra R, Ploplis V, Castellino FJ, Walsh M. The ex vivo reversibility of dabigatran-induced whole-blood coagulopathy as monitored by thromboelastography: Mechanistic implications for clinical medicine. Thromb Haemost 2017; 108:586-8. [DOI: 10.1160/th12-04-0222] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 05/19/2012] [Indexed: 12/12/2022]
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Eikelboom J, Weitz JI. Incorporating edoxaban into the choice of anticoagulants for atrial fibrillation. Thromb Haemost 2017; 115:257-70. [DOI: 10.1160/th15-02-0181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 09/10/2015] [Indexed: 12/24/2022]
Abstract
SummaryThe non-vitamin K antagonist oral anticoagulants (NOACs) are replacing warfarin for stroke prevention in many patients with nonvalvular atrial fibrillation. Edoxaban, an oral factor Xa inhibitor, is the newest entrant in this class. Results of the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation (ENGAGE AF) study demonstrate that edoxaban is noninferior to warfarin for prevention of stroke and systemic embolic events, and is associated with significantly less major bleeding, including intracranial bleeding, and reduced cardiovascular mortality. With a net clinical benefit over warfarin, edoxaban is well positioned as a choice among the NOACs, which include dabigatran, rivaroxaban, and apixaban. But how will clinicians choose amongst them? The purpose of this paper is to (a) place the ENGAGE AF trial results into context with results of the studies with the other NOACs, and (b) aid clinicians in selection of the right anticoagulant for the right atrial fibrillation patient.
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BCRP/ABCG2 and high-alert medications: Biochemical, pharmacokinetic, pharmacogenetic, and clinical implications. Biochem Pharmacol 2017; 147:201-210. [PMID: 29031817 DOI: 10.1016/j.bcp.2017.10.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/11/2017] [Indexed: 01/14/2023]
Abstract
The human breast cancer resistance protein (BCRP/ABCG2) is an ATP-binding cassette efflux transporter that uses ATP hydrolysis to expel xenobiotics from cells, including anti-cancer medications. It is expressed in the gastrointestinal tract, liver, kidney, and brain endothelium. Thus, ABCG2 functions as a tissue barrier to drug transport that strongly influences the pharmacokinetics of substrate medications. Genetic polymorphisms of ABCG2 are closely related to inter-individual variations in therapeutic performance. The common single nucleotide polymorphism c.421C>A, p.Q141K reduces cell surface expression of ABCG2 protein, resulting in lower efflux of substrates. Consequently, a higher plasma concentration of substrate is observed in patients carrying an ABCG2 c.421C>A allele. Detailed pharmacokinetic analyses have revealed that altered intestinal absorption is responsible for the distinct pharmacokinetics of ABCG2 substrates in genetic carriers of the ABCG2 c.421C>A polymorphism. Recent studies have focused on the high-alert medications among ABCG2 substrates (defined as those with high risk of adverse events), such as tyrosine kinase inhibitors (TKIs) and direct oral anti-coagulants (DOACs). For these high-alert medications, inter-individual variation may be closely related to the severity of side effects. In addition, ethnic differences in the frequency of ABCG2 c.421C>A have been reported, with markedly higher frequency in East Asian (∼30-60%) than Caucasian and African-American populations (∼5-10%). Therefore, ABCG2 polymorphisms must be considered not only in the drug development phase, but also in clinical practice. In the present review, we provide an update of basic and clinical knowledge on genetic polymorphisms of ABCG2.
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Kuwayama T, Osanai H, Ajioka M, Tokuda K, Ohashi H, Tobe A, Yoshida T, Masutomi T, Kambara T, Inoue Y, Nakashima Y, Asano H, Sakai K. Influence of proton pump inhibitors on blood dabigatran concentrations in Japanese patients with non-valvular atrial fibrillation. J Arrhythm 2017; 33:619-623. [PMID: 29255511 PMCID: PMC5729000 DOI: 10.1016/j.joa.2017.07.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 07/27/2017] [Indexed: 11/30/2022] Open
Abstract
Background Dabigatran is a direct thrombin inhibitor used to decrease the risk of ischemic stroke in patients with non-valvular atrial fibrillation (NVAF). Its prodrug, dabigatran etexilate (DE) is often co-administrated with a proton pump inhibitor (PPI) because of its adverse effects on the gastrointestinal tract. Drug-drug interactions between DE and PPIs in daily clinical practice have not been fully elucidated. Methods Changes in blood dabigatran concentration (DC) were investigated using the dilute thrombin time test in a randomized, open-label, two-period crossover study including 34 Japanese patients with NVAF receiving dabigatran therapy with or without PPI. Results The average trough DC was significantly higher without PPI than with PPI (83 ± 42.3 vs. 55.5 ± 24.6 ng/mL, respectively; P < 0.001). Similarly, the average peak DC was significantly higher without PPI than with PPI (184.1 ± 107.7 vs. 124 ± 59.2 ng/mL, respectively; P = 0.0029). The average ratio of DC change at the trough and peak levels did not differ significantly among the three PPI types. Conclusions PPI administration significantly decreased the trough and peak DCs in patients with NVAF. Therefore, when prescribing PPIs for patients with NVAF in a clinical setting, the possibility that the bioavailability of dabigatran may decrease should be considered.
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Affiliation(s)
- Tasuku Kuwayama
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Hiroyuki Osanai
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Masayoshi Ajioka
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Kotaro Tokuda
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Hirofumi Ohashi
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Akihiro Tobe
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Tatsuya Yoshida
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Tomohiro Masutomi
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Takahiro Kambara
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | | | - Hiroshi Asano
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
| | - Kazuyoshi Sakai
- Department of Cardiovascular Medicine, Tosei General Hospital, Japan
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146
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Cucchi EW. Anticoagulation: The Successes and Pitfalls of Long-Term Management. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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147
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Abstract
Spontaneous hemothorax due to anticoagulant use is extremely rare in clinical practice. Dabigatran is a novel anticoagulant to prevent stroke or thromboembolic episodes in patients with nonvalvular atrial fibrillation. We report on an 83-year-old man who received dabigatran therapy (110 mg twice daily) for 7 months and developed massive spontaneous hemothorax and acute renal failure. The patient was admitted to the hospital with complaint of a dull ache in the chest and dyspnea. Chest computed tomography scan revealed massive pleural effusion in the left hemithorax with atelectasis. Acute renal failure was observed 4 days later after admission. Almost 2500 mL of blood was repeatedly drained by ultrasound-guided thoracocentesis, followed by a dramatic decrease in serum red blood cell count, hemoglobin and hematocrit. After excluding other possible causes, diagnostic withdrawal was performed for dabigatran, and plasma transfusion was conducted to supply the lost blood volume. A causal relationship was established, because the patient's renal function gradually improved and no further pleural effusion developed after dabigatran was discontinued. This is a rare case report of massive spontaneous hemothorax caused by dabigatran. Therefore, practitioners should be aware of hemothorax as a potential complication of dabigatran therapy.
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148
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Oertel LB, Fogerty AE. Use of direct oral anticoagulants for stroke prevention in elderly patients with nonvalvular atrial fibrillation. J Am Assoc Nurse Pract 2017; 29:551-561. [PMID: 28805310 DOI: 10.1002/2327-6924.12494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Lynn B Oertel
- Anticoagulant Management Service, Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts
| | - Annemarie E Fogerty
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts
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Yoshio T, Tomida H, Iwasaki R, Horiuchi Y, Omae M, Ishiyama A, Hirasawa T, Yamamoto Y, Tsuchida T, Fujisaki J, Yamada T, Mita E, Ninomiya T, Michitaka K, Igarashi M. Effect of direct oral anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection. Dig Endosc 2017; 29:686-694. [PMID: 28295638 DOI: 10.1111/den.12859] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Anticoagulants are used to prevent thromboembolic events. Direct oral anticoagulants (DOAC) are our new choice; however, their effect on bleeding risk for endoscopic treatment has not been reported. We aimed to assess the clinical effect of DOAC compared to warfarin for gastric endoscopic submucosal dissection (ESD). METHODS We retrospectively studied 97 patients on anticoagulants and treated 108 gastric neoplasms with ESD in three referral institutes. Twenty-four patients were taking DOAC, including dabigatran (12), rivaroxaban (11), and apixaban (one) and 73 were taking warfarin. RESULTS In the DOAC group, delayed bleeding rate was significantly higher in patients on rivaroxaban than in patients on dabigatran (45% vs 0%, P < 0.05) without relation to heparin bridge therapy (HBT). In the warfarin group, 78% of patients underwent HBT, and delayed bleeding rate was significantly higher in patients with HBT than in those without (36% vs 0%, P < 0.05). Delayed bleeding rate increased as intake of antithrombotic agents increased (P < 0.05). HBT period was shorter (P < 0.05) in DOAC because DOAC achieve the maximum effect quicker, and hospitalization period was shorter (P < 0.05), compared with warfarin. Multivariate analysis showed that HBT (OR, 10.7), rivaroxaban (OR, 6.00) and multiple antithrombotic agents (OR, 4.35) were independent delayed bleeding risk factors. CONCLUSIONS The DOAC effect differs in each agent. Dabigatran is a feasible alternative to warfarin for shortening the hospitalization period and decreasing delayed bleeding rate, although rivaroxaban has a significantly higher delayed bleeding risk.
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Affiliation(s)
- Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hideomi Tomida
- Gastroenterology Center, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Ryuichiro Iwasaki
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Yusuke Horiuchi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masami Omae
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Ishiyama
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yorimasa Yamamoto
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Tsuchida
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuya Yamada
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Eiji Mita
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Tomoyuki Ninomiya
- Gastroenterology Center, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Kojiro Michitaka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Masahiro Igarashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Leentjens J, Peters M, Esselink AC, Smulders Y, Kramers C. Initial anticoagulation in patients with pulmonary embolism: thrombolysis, unfractionated heparin, LMWH, fondaparinux, or DOACs? Br J Clin Pharmacol 2017; 83:2356-2366. [PMID: 28593681 DOI: 10.1111/bcp.13340] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/13/2017] [Accepted: 05/30/2017] [Indexed: 12/27/2022] Open
Abstract
The initial treatment of haemodynamically stable patients with pulmonary embolism (PE) has dramatically changed since the introduction of low molecular weight heparins (LMWHs). With the recent discovery of the direct oral anticoagulant drugs (DOACs), initial treatment of PE will be simplified even further. In several large clinical trials it has been demonstrated that DOACs are not inferior to standard therapy for the initial treatment of PE, and because of their practicability they are becoming the agents of first choice. However, many relative contraindications to DOACs were exclusion criteria in the clinical trials. Therefore, LMWHs will continue to play an important role in initial PE treatment and in some cases there still is a role for unfractionated heparin (UFH). In this review we will give an overview of the biophysical, pharmacokinetic and pharmacodynamic properties of anticoagulants currently available for the initial management of PE. In addition, we will provide a comprehensive overview of the indications for the use of UFH, LMWHs and DOACs in the initial management of PE from a pharmacokinetic/-dynamic point of view.
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Affiliation(s)
- Jenneke Leentjens
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Mike Peters
- VU University Medical Center, Amsterdam, The Netherlands
| | - Anne C Esselink
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Yvo Smulders
- VU University Medical Center, Amsterdam, The Netherlands
| | - Cornelis Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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