Meta-analysis of studies of patients in the United Arab Emirates with ST-elevation myocardial infarction treated with thrombolytic agents

Biosimilarity. Do not confuse biosimilar and biocopy. Example of tenecteplase

Non-innovator biological products (NIBPs) or 'biocopies' are available in several countries at lower prices than biosimilars. These drugs, sometimes so-called 'biosimilars', may not meet all of the quality criteria expected of clinically equivalent products. NIBPs can exhibit major differences in physicochemical and pharmacological properties compared with their reference biological but may be presented to prescribers based on clinical trial data and claimed clinical equivalence. Tenecteplase (TNK-tpA) is a recombinant derivative of tissue plasminogen activator, used as a third-generation thrombolytic agent for treatment of acute myocardial infarction. A TNK-tPA presented as biosimilar to the originator (Metalyse®, Boehringer Ingelheim; TNKase®, Roche/Genentech) is now available for use in India (Elaxim®, Gennova Pharmaceuticals). Elaxim® is not approved in Europe or the USA but has been proposed in several countries as a replacement for the originator. Based on available literature, we discuss why this biocopy cannot be considered biosimilar to the originator tenecteplase. We describe clear differences in physicochemical and pharmacological properties. For example, the biocopy demonstrates clot lysis activity that is substantially lower than the originator and contains high concentrations of foreign proteins that confer potential for immunological reactions. Clinical data on the biocopy are limited; randomized trials to demonstrate the absence of difference in efficacy and safety between the biocopy and originator have not been conducted. This example demonstrates that confirmation of similarity, by close examination of pharmaceutical quality attributes, and preclinical and clinical data, is mandatory before presenting to prescribers a biological product as clinically equivalent.

Characteristics of Patients With Diabetes Having Normal Coronary Arteries

We evaluated the association between risk variables in diabetic patients with normal and diseased coronary arteries in a retrospective cohort study conducted at Rashid Hospital, Dubai. A total of 4446 patients underwent coronary angiography due to various indications; 43% had type 2 diabetes mellitus (T2DM). Among the diabetic patients, 94% had diseased coronary arteries and the remaining 6% had absolutely normal arteries. The normal coronary group had significantly lower low-density lipoprotein cholesterol (LDL-C) and a higher high-density lipoprotein cholesterol (HDL-C) levels than the diseased group. Patients with normal coronaries were more likely to be females, have T2DM for a shorter duration, and were nonsmokers and non-South Asians. They also had lower levels of LDL, hemoglobin A1c, and fasting glucose and higher levels of HDL-C. Apart from these variables, genetic or environmental factors could protect these patients from atherosclerosis.

Clinical Profile and Mortality of ST-Segment Elevation Myocardial Infarction Patients Receiving Thrombolytic Therapy in the Middle East

Objective:

Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy.

Patients and Methods:

This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics.

Results:

Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use.

Conclusions:

Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.

Comparison of characteristics, management practices, and outcomes of patients between the global registry and the gulf registry of acute coronary events

The Arab Middle East is a unique region of the developing world where little is known about the outcomes of patients hospitalized with an acute coronary syndrome (ACS), despite playing an important role in the global burden of cardiovascular disease. The primary objectives of this observational study were to compare patients with ACS hospitalized in the Arab Middle East to patients enrolled in a multinational non-Arabian ACS registry. The study cohort consisted of patients hospitalized in 2007 with an ACS including 4,445 from the Global Registry of Acute Coronary Events (GRACE) and 6,706 from the Gulf Registry of Acute Coronary Events (Gulf RACE). Average age of patients in Gulf RACE was nearly a decade younger than that in GRACE (56 vs 66 years). Patients in Gulf RACE were more likely to be men, diabetic, and smoke and less likely to be hypertensive compared to patients in GRACE. Patients in Gulf RACE had higher odds of receiving aspirin and a lower likelihood of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β blockers, and clopidogrel during their index hospitalization. Although most eligible patients with ST-elevation myocardial infarction in Gulf RACE received thrombolytics, most of their counterparts in GRACE underwent a primary percutaneous coronary intervention. Multivariable adjusted in-hospital case-fatality rates were not significantly different between patients in Gulf RACE and those in GRACE. In conclusion, despite differences in patient characteristics and treatment practices, short-term mortality rates were comparable in patients with ACS enrolled in these 2 registries. Future studies should explore the effects of these differences on long-term prognosis and other pertinent patient outcomes.