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Zhao N, Liu Z, Xie Q, Wang Z, Sun Z, Xiang Q, Cui Y. A Combined Pharmacometrics Analysis of Biomarker Distribution Under Treatment With Standard- or Low-Dose Rivaroxaban in Real-World Chinese Patients With Nonvalvular Atrial Fibrillation. Front Pharmacol 2022; 13:814724. [PMID: 35370683 PMCID: PMC8971662 DOI: 10.3389/fphar.2022.814724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The rivaroxaban dose regimen for patients with nonvalvular atrial fibrillation (NVAF) is complex in Asia. Given the high interindividual variability and the risk of bleeding caused by rivaroxaban in Asians, the influencing factors and the relationship between outlier biomarkers and bleeding events need exploration. Methods: The integrated pharmacokinetics (PK)/pharmacodynamics (PD) models were characterized based on rich PK/PD data from 304 healthy volunteers and sparse PD [anti-factor Xa activity (anti-Xa) and prothrombin (PT)] data from 223 patients with NVAF. The correlations between PD biomarkers and clinically relevant bleedings in 1 year were explored. The final integrated PK/PD model was used to evaluate the influence of dosage and individual covariates on PD parameters. Results: A two-compartment, linear model with sequential zero-order and first-order absorption was adopted. The dose-specific relative bioavailability (F1), diet status, creatinine clearance, and body mass index (BMI) improved the model fit. The apparent systemic clearance was 7.39 L/h, and the central and peripheral volumes were 10.9 and 50.9 L, respectively. The linear direct-effects model with shape factor plus the additive (and/or proportional) error model described the correlation between anti-Xa/PT and plasma concentration. Bodyweight, total cholesterol (TCHO), and diet status were selected as the covariates of the anti-Xa/PT model. Anti-Xa was more sensitive to the increase in rivaroxaban exposure compared with PT. An elevated bleeding tendency was seen with higher peak anti-Xa and PT. For a typical Chinese patient, the peak anti-Xa value (median (5%–95% PI)) of 20 and 15 mg were 309 ng/ml (139–597 ng/ml) and 296 ng/ml (138–604 ng/ml), both median values were within the expected range. For patients with CrCL 30–49 ml/min, the median peak anti-Xa with recommended 10 mg other than 15 mg were within the expected range. Conclusion: Fixed doses of rivaroxaban could be prescribed for patients with NVAF without adjustment for bodyweight, BMI, and TCHO. Randomized studies should be performed to evaluate the efficacy and safety of low-dose rivaroxaban in Chinese patients with NVAF.
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Affiliation(s)
- Nan Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhongyi Sun
- Shanghai Qiangshi Information Technology Co., Ltd, Shanghai, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- Institute of Clinical Pharmacology, Peking University, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
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Nakagawa J, Kinjo T, Iizuka M, Ueno K, Tomita H, Niioka T. Impact of gene polymorphisms in drug-metabolizing enzymes and transporters on trough concentrations of rivaroxaban in patients with atrial fibrillation. Basic Clin Pharmacol Toxicol 2020; 128:297-304. [PMID: 32920985 DOI: 10.1111/bcpt.13488] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/30/2020] [Accepted: 09/04/2020] [Indexed: 11/28/2022]
Abstract
Rivaroxaban is excreted from the body via multiple pathways involving glomerular filtration, drug-metabolizing enzymes and transporters. In this study, we aimed to examine the impact of single nucleotide polymorphisms in P-glycoprotein, breast cancer resistance protein, cytochrome P450 (CYP) 3A5 and CYP2J2 on the pharmacokinetics of rivaroxaban. Eighty-six patients with non-valvular atrial fibrillation (NVAF) undergoing AF catheter ablation were enrolled in this study. In these analyses, the dose-adjusted plasma trough concentration ratio (C0h /D) of rivaroxaban was used as the pharmacokinetic index. The median (quartile range) rivaroxaban C0h /D was 3.39 (2.08-5.21) ng/mL/mg (coefficient of variation: 80.5%). The C0h /D did not differ significantly among ABCB1 c.3435C>T, c.2677G>A/T, c.1236C>T, ABCG2 c.421C>A, CYP3A5*3 and CYP2J2*7 genotypes. Stepwise selection multiple linear regression analysis showed that the estimated glomerular filtration rate was the only independent factor influencing the C0h /D of rivaroxaban (R2 = 0.152, P < 0.001). There was a significant correlation between the C0h of rivaroxaban and prothrombin time (PT) (rho = 0.357, P = 0.001). In patients with NVAF, pharmacokinetic genotype tests are unlikely to be useful for prediction of the C0h of rivaroxaban.
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Affiliation(s)
- Junichi Nakagawa
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Mei Iizuka
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Kayo Ueno
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takenori Niioka
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan.,Department of Pharmaceutical Science, Hirosaki University Graduate School of Medicine, Aomori, Japan
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Wongcharoen W, Pacharasupa P, Norasetthada L, Gunaparn S, Phrommintikul A. Anti-Factor Xa Activity of Standard and Japan-Specific Doses of Rivaroxaban in Thai Patients With Non-Valvular Atrial Fibrillation. Circ J 2020; 84:1075-1082. [PMID: 32461505 DOI: 10.1253/circj.cj-20-0056] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recommended rivaroxaban doses for stroke prevention in atrial fibrillation (SPAF) are 20 and 15 mg/day in patients with normal and reduced renal function, respectively, but lower doses (15 and 10 mg) have been tested and approved in Japan. It is not known whether 15 and 10 mg rivaroxaban are appropriate in other Asian populations. This study compared the anti-Factor Xa (FXa) activity of 20 and 15 mg rivaroxaban in Thai patients with normal renal function and 15 and 10 mg rivaroxaban in patients with reduced renal function.Methods and Results:Sixty non-valvular atrial fibrillation patients receiving rivaroxaban (mean [±SD] age 69.3±9.1 years, mean creatinine clearance 59.2±22.7 mL/min) were enrolled. The anti-FXa activity of standard rivaroxaban and Japan-specific doses was measured at peak and trough concentrations. Median anti-FXa activity at peak concentrations was significantly higher for the standard than Japan-specific dose. Median anti-FXa activity measured at the trough was significantly higher for the standard dose only in those with impaired renal function. A higher proportion of patients receiving the Japan-specific rather than standard dose had anti-FXa activity at peak concentrations within the expected range (87.7% vs. 64.4%; P=0.001). One-third of those receiving the standard dose had anti-FXa activity higher than the expected range. CONCLUSIONS A significantly higher proportion of Thai patients receiving the Japan-specific dose of rivaroxaban had anti-FXa activity at peak concentrations within the expected range.
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Affiliation(s)
- Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Phongsathon Pacharasupa
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Lalita Norasetthada
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
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Silva VM, Scanavacca M, Darrieux F, Cavalheiro C, Strunz CC. Routine Coagulation Tests in Patients With Nonvalvular Atrial Fibrillation Under Dabigatran and Rivaroxaban Therapy: An Affordable and Reliable Strategy? Clin Appl Thromb Hemost 2019; 25:1076029619835053. [PMID: 30907118 PMCID: PMC6714955 DOI: 10.1177/1076029619835053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Dabigatran and rivaroxaban, direct oral anticoagulants (DOACs), affect coagulation tests,
and knowledge of their effects is important for therapeutic monitoring. Our aim was to
examine the association between DOAC levels and routine coagulation tests in patients with
nonvalvular atrial fibrillation. Samples from patients receiving dabigatran (150 mg) and
patients receiving rivaroxaban (20 mg) were collected 2 hours after drug intake. Direct
oral anticoagulant concentrations were determined using direct Hemoclot thrombin inhibitor
(HTI) assay (HTI test) and a direct Xa inhibitor (Anti Xa-Riva). The routine coagulation
measured included activated partial thromboplastin time (aPTT) and prothrombin time (PT).
The median plasmatic dabigatran was 128.3 ng/mL (95% confidence interval [CI]: 93.7-222.6
ng/mL). The HTI exhibited a good correlation with aPTT (R2 =
0.74; P < .0001). The median plasmatic rivaroxaban was 223.9 ng/mL
(95% CI: 212.3-238.9 ng/mL). Anti-Xa-Riva correlated with PT (R2 = 0.69, P< .0001) and aPTT (R2 = 0.36, P < .001), but prolonged PT results were obtained,
even below the rivaroxaban therapeutic range (20%). The routine coagulation tests were
able to identify out of therapeutic range concentrations for dabigatran and rivaroxaban.
We suggest the use of these screening tests to better understand and monitor the
subtherapeutic concentrations of these DOACs.
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Affiliation(s)
- Vanessa M Silva
- 1 Clinical Laboratory Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Maurício Scanavacca
- 2 Arrhythmia Outpatient Unit-Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Francisco Darrieux
- 2 Arrhythmia Outpatient Unit-Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Cyrillo Cavalheiro
- 3 Hematology Outpatient Unit-Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Celia C Strunz
- 1 Clinical Laboratory Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Park SH, Seo YH, Park PW, Kim KH, Seo JY, Lee HT, Kwoun WJ, Ahn JY. Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution. J Clin Lab Anal 2019; 33:e22869. [PMID: 30860622 PMCID: PMC6595315 DOI: 10.1002/jcla.22869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Apixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on-therapy ranges using conventional tests. METHODS A total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti-factor Xa chromogenic assay. PT, APTT, antithrombin, D-dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On-therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs. RESULTS Anti-factor Xa chromogenic assay-based DOACs levels were 26.0-279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9-565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3-395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6-494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6-431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On-therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32-1.52 for apixaban 2.5 mg BID, 1.12-1.75 for apixaban 5 mg BID, 1.11-1.78 for rivaroxaban 15 mg OD, 1.09-1.64 for rivaroxaban 20 mg OD, and 1.22-1.81 for rivaroxaban 20 mg BID. CONCLUSIONS Apixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.
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Affiliation(s)
- Soon Ho Park
- Department of Laboratory Medicine, Hongcheon Asan Hospital, Gangwon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung-Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jae Kwoun
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Takatsuki S, Kimura T, Sugimoto K, Misaki S, Nakajima K, Kashimura S, Kunitomi A, Katsumata Y, Nishiyama T, Nishiyama N, Aizawa Y, Fukuda K. Real-world monitoring of direct oral anticoagulants in clinic and hospitalization settings. SAGE Open Med 2017; 5:2050312117734773. [PMID: 29085636 PMCID: PMC5648091 DOI: 10.1177/2050312117734773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 09/05/2017] [Indexed: 02/05/2023] Open
Abstract
Background: The monitoring of the effects of direct oral anticoagulants may be beneficial during emergencies and adverse events. We aimed to explore direct oral anticoagulant monitoring in “real-world” settings, in which monitoring methods are limited and loading time can be estimated based on only patient reports. Methods: In 164 patients, plasma anti-Xa activity was assessed using a STA®-Liquid Anti-Xa reagent (Diagnostica Stago, Asnieres, France), and prothrombin time was measured using HemosIL® RecombiPlasTin 2G (Instrumentation Laboratory, Bedford, MA, USA). The loading time was calculated according to the previous dosing time reported by the patient. In the clinic setting, rivaroxaban and apixaban were administered to 103 patients with atrial fibrillation and a blood sample was tested once during a clinic visit. In the hospitalization setting, edoxaban was administered to 61 patients undergoing arthroplasty for prophylaxis of a venous thrombosis and blood samples were tested 3 and 18 h after the last intake. Results: Plasma Xa activity in the clinical setting ranged widely (rivaroxaban: 1.1–424.4 ng/mL, apixaban: 15.4–469.2 ng/mL) during the 11.7 ± 7.0 h following the previous dose. The values varied over a wide range (up to a factor of 2) at the same loading time, especially around the peak period. The plasma anti-Xa activity of rivaroxaban and apixaban showed linear correlations with prothrombin time (R2 = 0.828 and 0.717, respectively). Edoxaban administration prolonged the prothrombin time by only 1.6 ± 1.1 s from the trough to the peak, to a degree that was negatively correlated with age, but not with plasma creatinine level, creatinine clearance, or body mass index. Conclusion: In real-world settings, plasma anti-Xa monitoring should be interpreted considering the wide variations in data, reflecting the variability in patient-reported loading time and interpatient variability.
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Affiliation(s)
- Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Sadaya Misaki
- Sonoda Joint Replacement and Sports Medical Center, Tokyo, Japan
| | - Kazuaki Nakajima
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shin Kashimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Akira Kunitomi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Takahiko Nishiyama
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Nishiyama
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyasu Aizawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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