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Kranendonk J, Willems LH, Vijver-Coppen RVD, Coenen M, Adang E, Donders R, Zeebregts CJ, Deneer V, Reijnen M, Kramers C, Warlé MC. CYP2C19 genotype-guided antithrombotic treatment versus conventional clopidogrel therapy in peripheral arterial disease: study design of a randomized controlled trial (GENPAD). Am Heart J 2022; 254:141-148. [PMID: 35988587 DOI: 10.1016/j.ahj.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/04/2022] [Accepted: 08/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clopidogrel is recommended in international guidelines to prevent arterial thrombotic events in patients with peripheral arterial disease (PAD). Clopidogrel itself is inactive and metabolism is dependent on the CYP2C19 enzyme. About 30% of Caucasian PAD patients receiving clopidogrel carry 1 or 2 CYP2C19 loss-of-function allele(s) and do not or to a limited extent convert the prodrug into its active metabolite. As a result, platelet inhibition may be inadequate which could lead to an increased risk of adverse clinical events related to arterial thrombosis. A CYP2C19 genotype-guided antithrombotic treatment might be beneficial for PAD patients. METHODS GENPAD is a multicenter randomized controlled trial involving 2,276 PAD patients with an indication for clopidogrel monotherapy. Patients with a separate indication for dual antiplatelet therapy or stronger antithrombotic therapy are not eligible for study participation. Patients randomized to the control group will receive clopidogrel 75 mg once daily without pharmacogenetic guidance. Patients randomized to the intervention group will be tested for carriage of CYP2C19 *2 and *3 loss-of-function alleles, followed by a genotype-guided antithrombotic treatment with either clopidogrel 75 mg once daily for normal metabolizers, clopidogrel 150 mg once daily for intermediate metabolizers, or acetylsalicylic acid 80 mg once daily plus rivaroxaban 2.5 mg twice daily for poor metabolizers. The primary outcome is a composite of myocardial infarction, ischemic stroke, cardiovascular death, acute or chronic limb ischemia, peripheral vascular interventions, or death. The secondary outcomes are the individual elements of the primary composite outcome and clinically relevant bleeding complications. CONCLUSION The aim of the GENPAD study is to evaluate the efficacy, safety, and cost-effectiveness of a genotype-guided antithrombotic treatment strategy compared to conventional clopidogrel treatment in PAD patients.
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Affiliation(s)
- J Kranendonk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L H Willems
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - M Coenen
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E Adang
- Department of Epidemiology and Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University Of Groningen, Groningen, The Netherlands
| | - Vhm Deneer
- Department of Clinical Pharmacy, Division of Laboratories, Pharmacy and Biomedical Genetics University Medical Center Utrecht, Utrecht, The Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht university, Utrecht, The Netherlands
| | - Mmpj Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands; Multimodality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - C Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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Tamargo J, Kaski JC, Kimura T, Barton JC, Yamamoto K, Komiyama M, Drexel H, Lewis BS, Agewall S, Hasegawa K. Racial and ethnic differences in pharmacotherapy to prevent coronary artery disease and thrombotic events. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:738-751. [PMID: 35848895 PMCID: PMC9520447 DOI: 10.1093/ehjcvp/pvac040] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/05/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022]
Abstract
Awareness of racial/ethnic disparities represents a key challenge for healthcare systems that attempt to provide effective healthcare and to reduce existing inequalities in the use of and adherence to guideline-recommended cardiovascular drugs to improve clinical outcomes for cardiovascular disease (CVD). In this review, we describe important racial/ethnic differences between and within ethnic groups in the prevalence, risk factors, haemostatic factors, anti-inflammatory and endothelial markers, recurrence, and outcomes of CVD. We discuss important differences in the selection, doses, and response [efficacy and adverse drug reactions (ADRs)] in ethnically diverse patients treated with antithrombotics or lipid-lowering drugs. Differences in drug response are mainly related to racial/ethnic differences in the frequency of polymorphisms in genes encoding drug-metabolizing enzymes (DMEs) and drug transporters. These polymorphisms markedly influence the pharmacokinetics, dose requirements, and safety of warfarin, clopidogrel, and statins. This review aims to support a better understanding of the genetic differences between and among populations to identify patients who may experience an ADR or a lack of drug response, thus optimizing therapy and improving outcomes. The greater the understanding of the differences in the genetic variants of DMEs and transporters that determine the differences in the exposure, efficacy, and safety of cardiovascular drugs between races/ethnicities, the greater the probability that personalized medicine will become a reality.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Instituto De Investigación Sanitaria Gregorio Marañón, Universidad Complutense , 28040 Madrid , Spain
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London , London SW17 0RE, UK
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University , Kyoto 606-8303, Japan
| | - Jack Charles Barton
- Critical Care and Perioperative Medicine Research Group, Royal London Hospital , London E1 1FR, UK
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University , Kyoto 606-8303, Japan
| | - Maki Komiyama
- Division of Translational Research, National Hospital Organization Kyoto Medical Center , 1-1 Fukakusa Mukaihatacho, Kyoto 612-8555, Japan
| | - Heinz Drexel
- Department of Internal Medicine & Intensive Care, Academic Teaching Hospital Bregenz, 6900 Bregenz, Austria; Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, 6800 Feldkirch , Austria
| | - Basil S Lewis
- Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology , Haifa 3200003 , Israel
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital , 0424 Oslo, Norway
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center , 1-1 Fukakusa Mukaihatacho, Kyoto 612-8555, Japan
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3
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Utility of a pharmacogenetic-driven algorithm in guiding dual antiplatelet therapy for patients undergoing coronary drug-eluting stent implantation in China. Eur J Clin Pharmacol 2021; 78:215-225. [PMID: 34636928 DOI: 10.1007/s00228-021-03224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
PURPOSES The POPular Risk Score (PRiS), a pharmacogenetic-driven algorithm consisting of CYP2C19 genotype, platelet reactivity, and clinical risk factors, is developed to evaluate ischemic risk and guide dual antiplatelet therapy (DAPT). This study aimed to evaluate the efficacy and safety of DAPT in accordance with the PRiS in patients undergoing drug-eluting stent (DES) implantation. METHODS A total of 1757 patients recruited in this cohort study were divided into four groups according to the PRiS and type of P2Y12 receptor inhibitor treatment at discharge. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and target vessel revascularization) during 1-year follow-up. The safety endpoints were defined by Bleeding Academic Research Consortium (BARC) criteria as major bleeding (BARC 3a, 3b, 3c, and 5) and clinically relevant bleeding (BARC 2, 3a, 3b, 3c, and 5). RESULTS Among 1046 patients with PRiS < 2 and 711 patients with PRiS ≥ 2, 34.2% and 38.3% of them were treated with ticagrelor, respectively. The PRiS ≥ 2 was an independent predictor for the 1-year incidence of MACE (HR(95%CI): 2.09 (1.37-3.20), p = 0.001). Multivariable Cox regression indicated that in the PRiS ≥ 2 group, ticagrelor was superior to clopidogrel in reducing the risk of MACE (HR(95%CI): 0.53 (0.29-0.98), p = 0.042), without increasing the bleeding risk. On the other hand, in the PRiS < 2 group, clopidogrel treatment was related to a remarkably lower rate of BARC class ≥ 2 bleeding (HR(95%CI): 0.39 (0.20-0.72), p = 0.003), but comparable incidences of MACE and BARC class ≥ 3 bleeding during 1-year follow-up. Similar associations between P2Y12 receptor inhibitors and 1-year endpoints in the PRiS < 2 and PRiS ≥ 2 group could also be identified in propensity score-weighted analysis and propensity score-matched analysis. CONCLUSION Tailored DAPT based on the PRiS could assist in improving the prognosis of patients undergoing DES implantation. Further randomized controlled trials are required to provide more evidence for PRiS-guided DAPT.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China.
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5
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Jafrin S, Naznin NE, Reza MS, Aziz MA, Islam MS. Risk of stroke in CYP2C19 LoF polymorphism carrier coronary artery disease patients undergoing clopidogrel therapy: An ethnicity-based updated meta-analysis. Eur J Intern Med 2021; 90:49-65. [PMID: 34092486 DOI: 10.1016/j.ejim.2021.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antiplatelet agent clopidogrel has been widely used for stroke management for many years, although resistance to clopidogrel may increase the chance of stroke recurrence. CYP2C19 loss-of-function (LoF) polymorphism is assumed to be responsible for the poor metabolism of clopidogrel that ultimately turns to resistance. Previous publications could not provide firm evidence due to highly conflicting and heterogeneous outcomes. AIM To get clear evidence from an updated meta-analysis on CYP2C19 LoF polymorphism association with stroke risk in clopidogrel treated patients, this study has been performed. METHODS We conducted a meta-analysis with 72 selected studies from authentic databases, including 40,035 coronary artery disease patients treated with clopidogrel. RESULTS This analysis showed that the worldwide carrier of one or more CYP2C19 LoF alleles had a significantly higher risk of stroke and composite events than the non-LoF carriers (RR=1.78, 95% CI=1.52-2.07, p<0.00001 and RR=1.39, 95% CI=1.26-1.54, p<0.00001, respectively). Besides, subgroup analysis showed that Asian CYP2C19 LoF carriers had a significantly increased risk of stroke (RR=1.91, 95% CI=1.60-2.28, p<0.00001) while the risk of composite events was significantly higher in all ethnic populations (Asian: RR=1.58, 95% CI=1.32-1.89, p<0.00001; Caucasian: RR=1.27, 95% CI=1.08-1.50, p=0.003; Hispanic and others: RR=1.21, 95% CI=1.09-1.34, p=0.0003). CONCLUSION Our meta-analysis confirmed that the presence of CYP2C19 LoF alleles increases the risk of stroke and composite events recurrence in the worldwide population, especially in Asians undergoing clopidogrel treatment. Alternative antiplatelet therapy should be investigated thoroughly for the intermediate and poor metabolizers.
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Affiliation(s)
- Sarah Jafrin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Nura Ershad Naznin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Sharif Reza
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Abdul Aziz
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Mohammad Safiqul Islam
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh.
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6
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Rodriguez Cairoli F, Appiani F, Sambade JM, Comandé D, Camacho Arteaga L, Ciapponi A. Efficacy and safety of opioid therapy guided by pharmacogenetics: a systematic review. Pharmacogenomics 2021; 22:573-586. [PMID: 34013775 DOI: 10.2217/pgs-2021-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim: To perform a systematic review to determine the efficacy/safety of PGx-guided opioid therapy for chronic/postoperative pain. Materials & methods: We searched PubMed and other specialized databases. Articles were considered if they compared the efficacy/safety of PGx-guided opioid therapy versus usual care. The risk of bias assessment was performed using Cochrane tools. Results: A total of 3794 records were retrieved. Only five were included for data extraction. A lower requirement of analgesics during postoperative in the PGx-guided intervention arm was reported in two studies. Also, two studies reported significant pain improvement in favor of the PGx-guided therapy when analyzing the subgroup of patients with a high-risk CYP2D6 phenotype. Conclusion: Despite the findings described, information on the efficacy/safety of this intervention is scarce.
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Affiliation(s)
- Federico Rodriguez Cairoli
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina.,Neuropsychopharmacology Unit, Pharmacology Division, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Francisco Appiani
- Neuropsychopharmacology Unit, Pharmacology Division, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan Manuel Sambade
- Servicio de Clínica Médica, Hospital "Prof. Dr. Bernardo Houssay" Asociado a la Universidad de Buenos Aires, Municipalidad de Vicente Lopez, Buenos Aires, Argentina
| | - Daniel Comandé
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina
| | - Lina Camacho Arteaga
- Department of Clinical Pharmacology, University Hospital Hall d' Hebron, Barcelona, Spain
| | - Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina
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7
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Lunenburg CATC, Thirstrup JP, Bybjerg-Grauholm J, Bækvad-Hansen M, Hougaard DM, Nordentoft M, Werge T, Børglum AD, Mors O, Mortensen PB, Gasse C. Pharmacogenetic genotype and phenotype frequencies in a large Danish population-based case-cohort sample. Transl Psychiatry 2021; 11:294. [PMID: 34006849 PMCID: PMC8131614 DOI: 10.1038/s41398-021-01417-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
Pharmacogenetics aims to improve clinical care by studying the relationship between genetic variation and variable drug response. Large population-based datasets could improve our current understanding of pharmacogenetics from selected study populations. We provide real-world pharmacogenetic frequencies of genotypes and (combined) phenotypes of a large Danish population-based case-cohort sample (iPSYCH2012; data of the Integrative Psychiatric Research consortium). The genotyped sample consists of 77,684 individuals, of which 51,464 individuals had diagnoses of severe mental disorders (SMD case-cohort) and 26,220 were individuals randomly selected from the Danish population (population cohort). Array-based genotype data imputed to 8.4 million genetic variants was searched for a selected pharmacogenetic panel of 42 clinically relevant variants and a CYP2D6 gene deletion and duplication. We identified 19 of 42 variants. Minor allele frequencies (MAFs) were consistent with previously reported MAFs, and did not differ between SMD cases and population cohorts. Almost all individuals carried at least one genetic variant (> 99.9%) and 87% carried three or more genetic variants. When genotypes were translated into phenotypes, also > 99.9% of individuals had at least one divergent phenotype (i.e. divergent from the common phenotypes considered normal, e.g. extensive metabolizer). The high number of identified individuals with at least one pharmacogenetic variant or divergent phenotype indicates the importance of pharmacogenetic panel-based genotyping. Combined CYP2C19-CYP2D6 phenotypes revealed that 72.7% of individuals had divergent phenotypes for one or both enzymes. As CYP2D6 and CYP2C19 have an important role in the metabolism of psychotropic drugs, this indicates the relevance of pharmacogenetic testing specifically in individuals using psychotropic drugs.
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Affiliation(s)
- Carin A. T. C. Lunenburg
- grid.154185.c0000 0004 0512 597XDepartment of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Janne P. Thirstrup
- grid.7048.b0000 0001 1956 2722Department of Biomedicine, Faculty of Health, Aarhus University, Aarhus, Denmark ,grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.7048.b0000 0001 1956 2722Center for Genomics and Personalized Medicine, Aarhus University, Aarhus, Denmark
| | - Jonas Bybjerg-Grauholm
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.6203.70000 0004 0417 4147Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Marie Bækvad-Hansen
- grid.6203.70000 0004 0417 4147Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - David M. Hougaard
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.6203.70000 0004 0417 4147Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Merete Nordentoft
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.4973.90000 0004 0646 7373Mental Health Centre Copenhagen, Capital Region of Denmark, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Werge
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Biological Psychiatry, Mental Health Services, Copenhagen University, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XLundbeck Foundation Center for GeoGenetics, GLOBE Institute, University of Copenhagen, Copenhagen, Denmark
| | - Anders D. Børglum
- grid.7048.b0000 0001 1956 2722Department of Biomedicine, Faculty of Health, Aarhus University, Aarhus, Denmark ,grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.7048.b0000 0001 1956 2722Center for Genomics and Personalized Medicine, Aarhus University, Aarhus, Denmark
| | - Ole Mors
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.154185.c0000 0004 0512 597XPsychosis Research Unit, Aarhus University Hospital Psychiatry, Aarhus, Denmark
| | - Preben B. Mortensen
- grid.452548.a0000 0000 9817 5300The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus/Copenhagen, Denmark ,grid.7048.b0000 0001 1956 2722NCRR National Centre for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| | - Christiane Gasse
- Department of Affective Disorders, Aarhus University Hospital Psychiatry, Aarhus, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. .,Psychosis Research Unit, Aarhus University Hospital Psychiatry, Aarhus, Denmark.
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8
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Nazir S, Ahuja KR, Virk HUH, Elzanaty A, Waheed TA, Changal KH, Wohlfarth K, Lakhter V, Grande RD, Eltahawy EA. A meta-analysis of efficacy and safety of genotype-guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome. Catheter Cardiovasc Interv 2021; 97:788-794. [PMID: 32243053 DOI: 10.1002/ccd.28860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 03/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y12 inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies. METHODS Electronic databases were searched for studies of ACS patients that underwent genotype-guided treatment (GGT) with P2Y12 inhibitors versus standard of care treatment (SCT). Studies with a minimum follow-up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. RESULTS A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50-0.80, p < .001, I2 = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41-0.96; p = .03; I2 = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes. CONCLUSION In patients with ACS, genotype-guided initiation of P2Y12 inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.
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Affiliation(s)
- Salik Nazir
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Keerat R Ahuja
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hafeez U H Virk
- Department of Cardiology, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Ahmed Elzanaty
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tayyab A Waheed
- Department of Medicine, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - Khalid H Changal
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | | | - Vladimir Lakhter
- Department of Cardiology, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Ehab A Eltahawy
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
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9
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Liu M, Roden DM, Peterson JF. The Case for Expanding the FDA Box Warning on Clopidogrel to CYP2C19 Intermediate Metabolizers. Clin Pharmacol Ther 2021; 110:860-862. [PMID: 33690885 DOI: 10.1002/cpt.2215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Josh F Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Magavern EF, Kaski JC, Turner RM, Drexel H, Janmohamed A, Scourfield A, Burrage D, Floyd CN, Adeyeye E, Tamargo J, Lewis BS, Kjeldsen KP, Niessner A, Wassmann S, Sulzgruber P, Borry P, Agewall S, Semb AG, Savarese G, Pirmohamed M, Caulfield MJ. The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy: A position statement from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:85-99. [PMID: 33638977 DOI: 10.1093/ehjcvp/pvab018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/05/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite diverse availability, interpretation and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. Aside from the considerable barriers to implementing pharmacogenomic testing and the complexities of clinically actioning results, there are differences in the availability of resources and expertise internationally within Europe. Diverse legal and ethical approaches to genomic testing and clinical therapeutic application also require serious thought. As direct-to-consumer genomic testing becomes more common, it can be anticipated that data may be brought in by patients themselves, which will require critical assessment by the clinical cardiovascular prescriber. In a modern, pluralistic and multi-ethnic Europe, self-identified race/ethnicity may not be concordant with genetically detected ancestry and thus may not accurately convey polymorphism prevalence. Given the broad relevance of pharmacogenomics to areas such as thrombosis and coagulation, interventional cardiology, heart failure, arrhythmias, clinical trials, and policy/regulatory activity within cardiovascular medicine, as well as to genomic and pharmacology subspecialists, this position statement attempts to address these issues at a wide-ranging level.
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Affiliation(s)
- E F Magavern
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J C Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom
| | - R M Turner
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - H Drexel
- Vorarlberg Institute for Vascular Investigation & Treatment (VIVIT), Feldkirch, A Private University of the Principality of Liechtenstein, Triesen, FL.,Drexel University College of Medicine, Philadelphia, USA
| | - A Janmohamed
- Department of Clinical Pharmacology, St George's, University of London, United Kingdom
| | - A Scourfield
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK
| | - D Burrage
- Whittington Health NHS Trust, London, UK
| | - C N Floyd
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, UK.,Department of Clinical Pharmacology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Adeyeye
- Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - B S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - A Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna
| | - S Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany
| | - P Sulzgruber
- Medical University of Vienna, Department of Medicine II, Division of Cardiology
| | - P Borry
- Center for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Leuven Institute for Human Genetics and Society, Leuven, Belgium
| | - S Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - A G Semb
- Preventive Cardio-Rheuma clinic, department of rheumatology, innovation and research, Diakonhjemmet hospital, Oslo, Norway
| | - G Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - M J Caulfield
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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11
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Zhang H, Xiang Q, Liu Z, Mu G, Xie Q, Zhou S, Ma L, Wang Z, Hu K, Wang Z, Cui Y. Genotype-guided antiplatelet treatment versus conventional therapy: A systematic review and meta-analysis. Br J Clin Pharmacol 2020; 87:2199-2215. [PMID: 33140858 DOI: 10.1111/bcp.14637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/29/2022] Open
Abstract
AIM This meta-analysis was carried out to explore if a personalized antiplatelet strategy based on genotyping is superior to conventional therapy. METHODS PubMed, Web of Science, EMBASE and the Cochrane Library were searched from the inception of each database to 5 May 2020. Studies reporting endpoints in genotype-guided treatment group and conventional treatment group were included. The endpoint results were presented as the risk ratio (RR), with 95% confidence interval (CI). RESULTS A total of 10 561 patients from 16 studies (eight randomized controlled trials [RCT] and eight cohort studies) were included in the meta-analysis. The rates of major adverse cardiovascular events (MACE), stent thrombosis and myocardial infarction (MI) were significantly lower in the genotype-guided group than in the conventional treatment group (RR 0.56, 95% CI 0.44-0.73, P < .0001; RR 0.40, 95% CI 0.24-0.67, P = .0005; RR 0.45, 95% CI 0.35-0.58, P < .00001, respectively). A significant difference was found between the two groups in major bleeding (RR 0.73, 95% CI 0.55-0.98, P = .04), which was not robust after sensitivity analysis. CONCLUSION Genotype-guided antiplatelet treatment could decrease the risk of MACE, stent thrombosis and MI in patients with coronary artery disease or undergoing percutaneous coronary intervention, without increasing the risk of bleeding over a long follow-up period. The decreased risk of efficacy outcomes was more obvious in cohort studies. Well-organized RCTs and clinical trials are required to verify the benefit of genotype-guided therapy.
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Affiliation(s)
- Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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12
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Biswas M, Kali MSK, Biswas TK, Ibrahim B. Risk of major adverse cardiovascular events of CYP2C19 loss-of-function genotype guided prasugrel/ticagrelor vs clopidogrel therapy for acute coronary syndrome patients undergoing percutaneous coronary intervention: a meta-analysis. Platelets 2020; 32:591-600. [PMID: 32664772 DOI: 10.1080/09537104.2020.1792871] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The most effective antiplatelet treatments for acute coronary syndrome (ACS) patients carrying CYP2C19 loss-of-function (LoF) alleles undergoing percutaneous coronary intervention (PCI) is still debating and conflicting. It was aimed to compare the efficacy and safety endpoints for these patients treated with alternative P2Y12 receptor blockers (e.g. prasugrel or ticagrelor) against clopidogrel. Literature was searched in PubMed, Cochrane library, Synapse and 1000 Genomes databases following PRISMA guidelines for identifying relevant studies. Aggregated risk was estimated by RevMan software using either fixed/random-effects models where P values<0.05 (two-sided) were considered statistically significant. Nine studies comprising 16,132 ACS patients undergoing PCI were included in this analysis in which 2,746 and 2,640 patients were in the CYP2C19 LoF clopidogrel and alternatives treatment group, respectively. It was demonstrated that patients treated with prasugrel or ticagrelor significantly reduced the risk of MACEs (RR 0.58; 95% CI 0.45-0.76; P<0.0001) as compared to patients with clopidogrel where both groups carrying CYP2C19 LoF alleles. Subgroup analysis showed that prasugrel or ticagrelor significantly reduced the risk of cardiovascular death (RR 0.44; 95% CI: 0.25-0.74; P=0.002) and MI (RR 0.60; 95% CI: 0.44-0.81; P=0.0008) while other clinical outcomes were not found statistically significant between these two groups; stroke (RR 0.77; 95% CI: 0.43-1.38; P =0.39), stent thrombosis (RR 0.67; 95% CI: 0.38-1.18; P =0.17), unstable angina (RR 0.55; 95% CI: 0.13-2.33; P =0.42), revascularisation (RR 0.79; 95% CI: 0.28-2.24; P=0.66). Bleeding events were not found significantly different between these groups (RR 1.06; 95% CI: 0.88-1.28; P=0.55). Considering efficacy and safety, alternative antiplatelets (e.g. prasugrel or ticagrelor) may be regarded as better treatment option as compared to clopidogrel for ACS patients undergoing PCI.
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Affiliation(s)
- Mohitosh Biswas
- Department of Pharmacy, University of Rajshahi, Rajshahi, Bangladesh
| | | | - Tapash Kumar Biswas
- Department of Medicine, Faridpur Medical College Hospital, Faridpur, Bangladesh
| | - Baharudin Ibrahim
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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13
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Lyu SQ, Yang YM, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Ren JM. The efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy compared with conventional antiplatelet therapy in patients with acute coronary syndrome or undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Platelets 2020; 31:971-980. [PMID: 32546030 DOI: 10.1080/09537104.2020.1780205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cytochrome P450 (CYP) 2C19 genotype is closely associated with the metabolism and efficacy of clopidogrel, thereby having an important impact on clinical outcomes of patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). This study aimed to evaluate the efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy in patients with ACS or undergoing PCI. PubMed, EMBASE, the Cochrane Library and clinicaltrials.gov were searched to identify randomized controlled trials (RCTs) comparing CYP2C19 genotype-guided antiplatelet therapy with conventional therapy in patients with ACS or undergoing PCI. Eight RCTs involving 6708 patients were included in this meta-analysis. CYP2C19 genotype-guided antiplatelet therapy was slightly superior to the conventional antiplatelet therapy in reducing the risk of MACE [RR(95%CI): 0.71(0.51-0.98), p = .04]. Meanwhile, the genotype-guided therapy group had significantly lower incidence of myocardial infarction [RR(95%CI): 0.56(0.40-0.78), p < .01], but similar risk of all-cause mortality, cardiovascular mortality, stent thrombosis, urgent revascularization and stroke compared to the conventional therapy group. Incidences of major/minor bleeding and major bleeding were comparable between the two groups. In patients with ACS or undergoing PCI, CYP2C19 genotype-guided antiplatelet therapy displayed benefit over conventional antiplatelet therapy in reducing the risk of MACE and myocardial infarction, without increasing bleeding risk. Further RCTs are needed to provide more evidences for CYP2C19 genotype-guided antiplatelet therapy.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jia-Meng Ren
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
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14
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Genotype-guided antiplatelet therapy compared with standard therapy for patients with acute coronary syndromes or undergoing percutaneous coronary intervention: A systematic review and meta-analysis. Thromb Res 2020; 193:130-138. [PMID: 32559569 DOI: 10.1016/j.thromres.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine, in patients with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI), the effectiveness and safety between personalized P2Y12 inhibitors treatment based on genotypes and standard treatment. METHODS We systematically searched for articles from PubMed, Cochrane Library, Embase and Web of science from their inception to March 4, 2020, with no language restrictions. The search was performed to identify all randomized clinical trials (RCTs) in which genotype-guided versus standard treatment with P2Y12 inhibitors among patients with ACS or those undergoing PCI. The primary clinical outcomes were major adverse cardiovascular events (MACEs) including death, myocardial infarction (MI), stroke, stent thrombosis (ST), and targeted vessel revascularization (TVR). The secondary outcomes were high on-treatment platelet reactivity (HTPR) and safety outcomes including major bleeding events. RESULTS A total of 4859 patients from 7 RCTs were included in the meta-analysis. There were 2430 patients (50.01%) allocated to the genotype-guided group and 2429 (49.99%) allocated to the standard group. Pooled result showed that compared with the standard treatment group, the genotype-guided group had a significantly lower risk of HTPR (Risk Ratio [RR]: 0.35, 95% confidence interval [CI]: 0.14-0.83, P = 0.02, I2 = 58%), MI (RR: 0.52, 95% CI: 0.36-0.74, P = 0.0004, I2 = 0%) and ST (RR: 0.41, 95% CI: 0.17-0.98, P = 0.05, I2 = 0%). No significant difference was found between two groups for the risk of death (RR: 0.78, 95% CI: 0.54-1.12, P = 0.18, I2 = 34%), stroke (RR = 0.67, 95% CI: 0.35-1.30, P = 0.24, I2 = 0%), TVR (RR: 0.83, 95% CI: 0.46-1.50, P = 0.54, I2 = 0%) and major bleeding events (RR: 0.83, 95% CI: 0.60-1.15, P = 0.25, I2 = 0%). CONCLUSIONS Genotype-guided antiplatelet treatment could reduce the risk of HTPR, MI and ST compared with standard therapy in patients with ACS or undergoing PCI, and no significant difference was found between two groups in the major bleeding events.
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15
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Genotype-Guided Strategy for P2Y12 Inhibitors in Coronary Artery Disease. JACC Cardiovasc Interv 2020; 13:659-661. [DOI: 10.1016/j.jcin.2019.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/21/2019] [Accepted: 11/05/2019] [Indexed: 12/11/2022]
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16
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郑 小, 吴 黎. [The value of cytochrome P4502C19 gene assay for anti-platelet therapy after PCI in stable angina patients with left main coronary artery lesions]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:274-278. [PMID: 32376540 PMCID: PMC7086122 DOI: 10.12122/j.issn.1673-4254.2020.02.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of different antiplatelet therapies for stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer Cytochrome P450 2C19 gene (CYP2C19) undergoing PCI. METHODS A total of 247 patients diagnosed with stable angina in cardiology department of Fujian union hospital from February 2015 to February 2017 were retrospectively analyzed, among them, the elective PCI were performed on the left main coronary artery and the CYP2C19 gene poly-morphism were intermediate metabolize, they were divided into ticagrelor treatment group(aspirin combined with ticagrelor, n=95)and clopidogrel treatment group(aspirin combined with clopidogrel, n=152) according to the different antiplatelet treatment programs. Both groups were given aspirin 300 mg and clopidogrel 300 mg orally before PCI; the ticagrelor group were given the maintenance dose of ticagrelor (90 mg orally, twice a day) after PCI, while those in clopidogrel group were clopidogrel 75 mg orally (once a day) after PCI; both groups were given the maintenance dose of aspirin (100 mg orally, once a day)after PCI. The major adverse cardiovascular events (MACE) were observed within 12 months after PCI. RESULTS At 12 months after PCI, the incidence of MACE in the ticagrelor treatment group was significantly lower than that in the clopidogrel treatment group, the difference was statistically significant (2.1% vs 15.1%, P=0.001).There were no significant differences between the two groups in the restenosis rates of non- revascularized target vessel, recurrent rates of angina pectoris(but not myocardial infarction), recurrent rates of myocardial infarction, and revascularization rates of target vessel (P > 0.05). There were also no significant differences between the two groups in bleeding. CONCLUSIONS For stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer CYP2C19 gene, aspirin combined with ticagrelor antiplatelet therapy after PCI is effective, the effect of ticagrelor is better than clopidogrel on MACE, and ticagrelor does not seem to increase the risk of bleeding.
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Affiliation(s)
- 小芳 郑
- 福建医科大学附属第三医院心内科,福建 福州 350108Department of Cardiology, The Third Affiliated Hospital of Fujian Medical University, Fuzhou 350108, China
| | - 黎明 吴
- 福建医科大学附属协和医院心内科,福建 福州 350001Department of Cardiology, Union Hospital affiliated to Fujian Medical University, Fuzhou 350001, China
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17
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Sychev DA, Baturina OA, Mirzaev KB, Rytkin E, Ivashchenko DV, Andreev DA, Ryzhikova KA, Grishina EA, Bochkov PO, Shevchenko RV. CYP2C19*17 May Increase the Risk of Death Among Patients with an Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Who Receive Clopidogrel and Rivaroxaban. Pharmgenomics Pers Med 2020; 13:29-37. [PMID: 32158254 PMCID: PMC6986167 DOI: 10.2147/pgpm.s234910] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The aim of this study is to assess the influence of gene CYP2C19, CYP3A4, CYP3A5 and ABCB1 polymorphisms on clopidogrel antiplatelet activity, rivaroxaban concentration equilibrium, and clinical outcomes among patients with acute coronary syndrome and non-valvular atrial fibrillation. METHODS In the multicenter prospective registry study of the efficacy and safety of a combined antithrombotic therapy 103 patients with non-valvular atrial fibrillation both undergoing or not a percutaneous coronary intervention were enrolled. The trial assessed the primary outcomes (major bleeding, in-hospital death, cardiovascular death, stroke\transient ischaemic attack, death/renal insufficiency) and secondary outcomes (platelet reactivity units (PRU), rivaroxaban concentration). RESULTS For none of the clinical outcomes when combined with other covariates, the carriership of polymorphisms CYP3A5*3 rs776746, CYP2C19*2 rs4244285;*17 rs12248560, ABCB1 3435 C>T, ABCB1 rs4148738 was significant. None of the markers under study (CYP3A5*3 rs776746, CYP2C19*2 rs4244285, *17 rs12248560, ABCB1 3435 C>T, ABCB1 rs4148738) has proven to affect rivaroxaban equilibrium concentration in blood plasma among patients with atrial fibrillation and acute coronary syndrome. CONCLUSION In situations of double or triple antithrombotic rivaroxaban and clopidogrel therapy among patients with atrial fibrillation and acute coronary syndrome, the genetic factors associated with bleeding complications risk (CYP2C19*17) may prove to be clinically relevant.
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Affiliation(s)
- D A Sychev
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | | | - K B Mirzaev
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - E Rytkin
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - D V Ivashchenko
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - D A Andreev
- Sechenov University, Moscow, Russian Federation
| | - K A Ryzhikova
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - E A Grishina
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - P O Bochkov
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - R V Shevchenko
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow, Russian Federation
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18
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Claassens DM, Ten Berg JM. Genotype-guided treatment of oral P2Y 12 inhibitors: where do we stand? Pharmacogenomics 2020; 21:83-86. [PMID: 31957547 DOI: 10.2217/pgs-2019-0162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
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19
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Abstract
BACKGROUND Acute coronary syndrome (ACS) is a highly thrombotic state, and a sustained antiplatelet effect is vital to the prevention of thrombotic complications. Clopidogrel, the most widely used oral P2Y12 receptor antagonist in ACS, has attracted considerable attention because of significant variability in antiplatelet effect depending on the presence of CYP2C19 allele. Other P2Y12 receptor antagonists offer sustained and more predictable antiplatelet effects than clopidogrel albeit at an increased cost. Several studies have demonstrated the promising application of pharmacogenetics in choosing personalized antiplatelet therapy using the point-of-care genotype assays. AREAS OF UNCERTAINTY Guidelines regarding the genotype-guided approach to the selection of antiplatelet therapy have been conflicting, and studies evaluating the effect of pharmacogenetic-guided selection of antiplatelet therapy on the outcomes have demonstrated mixed results. DATA SOURCES A literature search was conducted using MEDLINE and EMBASE for studies reporting the association of pharmacogenetic-guided selection of antiplatelet therapy and the outcomes in patients with ACS until December 2018. RESULTS Presence of specific CYP2C19 allele significantly influences clopidogrel metabolism and associated outcomes in patients with ACS. Thrombotic and bleeding complications are more common in patients with loss-of-function (LOF) and gain-of-function (GOF) alleles, respectively. Although the pharmacogenetic-guided approach to the selection of antiplatelet therapy appears promising in ACS, studies have shown conflicting results, and direct randomized evidence linking this approach with the better outcomes is lacking. CONCLUSIONS Genotype-guided selection of antiplatelet therapy is expected to be useful in patients undergoing percutaneous coronary intervention (PCI) with a high risk of adverse outcomes. The patient-physician discussion should be an essential part of this decision-making process. Large-scale multicenter randomized controlled trials using the point-of-care genotype assay are needed to investigate this approach further before its use can be recommended in all comers.
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20
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Kheiri B, Abdalla A, Osman M, Barbarawi M, Zayed Y, Haykal T, Chahine A, Bachuwa G, Hassan M, Bhatt DL. Personalized antiplatelet therapy in patients with coronary artery disease undergoing percutaneous coronary intervention: A network meta-analysis of randomized clinical trials. Catheter Cardiovasc Interv 2019; 94:181-186. [PMID: 30628754 DOI: 10.1002/ccd.28075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/09/2018] [Accepted: 12/26/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to evaluate the efficacy and safety of genotype- and phenotype-guided intensified antiplatelet therapy compared with conventional therapy in patients undergoing stent implantation. BACKGROUND Although potent P2Y12 receptor inhibitors are recommended for percutaneous coronary intervention (PCI)-treated acute coronary syndrome, their usage is limited by a high bleeding risk. Therefore, personalized antiplatelet therapy could provide a valuable foundation for selection of antiplatelet therapy in this population. METHODS We conducted a Bayesian network meta-analysis for all randomized clinical trials (RCTs) that evaluated genotype- and/or phenotype-guided therapy in PCI-treated coronary artery disease. RESULTS Thirteen RCTs were included with a total of 6,845 patients. The results showed no significant differences in major adverse cardiovascular events (MACE) between the treatment options ((genotype guided vs. standard of care; OR 0.64; 95% CI: 0.38-1.05) and (phenotype vs. standard of care; OR 0.93; 95% CI: 0.54-1.37)). In addition, no significant differences were demonstrated in bleeding events ((genotype guided vs. standard of care; OR 0.73; 95% CI: 0.45-1.25) and (phenotype vs. standard of care; OR 0.90; 95% CI: 0.62-1.39)). CONCLUSIONS In this mixed treatment meta-analysis of RCTs, neither genotype- nor phenotype-guided antiplatelet therapy in patients with PCI-treated coronary artery disease was superior to conventional therapy.
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Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Ahmed Abdalla
- Division of Hematology & Oncology, St. John Hospital, Grosse Pointe Woods, Michigan
| | - Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Mahmoud Barbarawi
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Yazan Zayed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Tarek Haykal
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
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21
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Lin B, Chung WK. Cases in Precision Medicine: The Role of Pharmacogenetics in Precision Prescribing. Ann Intern Med 2019; 170:796-804. [PMID: 31108507 PMCID: PMC7458588 DOI: 10.7326/m18-2357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pharmacogenetics may help physicians deliver individualized treatments based on how a person's genes affect a drug's effects and metabolism. This information can help prevent adverse events or improve drug efficacy by enabling the physician to optimize dosage or to avoid a medication with adverse reactions and to prescribe an alternative therapy. This article discusses the current clinical utility of pharmacogenetic testing in the context of a patient who requires anticoagulation with warfarin.
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Affiliation(s)
- Bohan Lin
- Columbia University, New York, New York (B.L., W.K.C.)
| | - Wendy K Chung
- Columbia University, New York, New York (B.L., W.K.C.)
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22
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Dávila-Fajardo CL, Díaz-Villamarín X, Antúnez-Rodríguez A, Fernández-Gómez AE, García-Navas P, Martínez-González LJ, Dávila-Fajardo JA, Barrera JC. Pharmacogenetics in the Treatment of Cardiovascular Diseases and Its Current Progress Regarding Implementation in the Clinical Routine. Genes (Basel) 2019; 10:genes10040261. [PMID: 30939847 PMCID: PMC6523655 DOI: 10.3390/genes10040261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
There is a special interest in the implementation of pharmacogenetics in clinical practice, although there are some barriers that are preventing this integration. A large part of these pharmacogenetic tests are focused on drugs used in oncology and psychiatry fields and for antiviral drugs. However, the scientific evidence is also high for other drugs used in other medical areas, for example, in cardiology. In this article, we discuss the evidence and guidelines currently available on pharmacogenetics for clopidogrel, warfarin, acenocoumarol, and simvastatin and its implementation in daily clinical practice.
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Affiliation(s)
- Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Alba Antúnez-Rodríguez
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | - Ana Estefanía Fernández-Gómez
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Paloma García-Navas
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Luis Javier Martínez-González
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
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