A randomized, controlled study on the influence of acetaminophen, diclofenac, or naproxen on aspirin-induced inhibition of platelet aggregation

Not all (N)SAID and done: Effects of nonsteroidal anti-inflammatory drugs and paracetamol intake on platelets

Platelets are key mediators of hemostasis and thrombosis and can be inhibited by nonsteroidal anti-inflammatory drugs (NSAIDs). As a result, platelet donors are temporarily deferred from donating if they have recently taken NSAIDs such as aspirin or ibuprofen. Despite these measures, a proportion of platelet donations show exposure to these drugs; however, little is known about the effect of NSAIDs and their metabolites on platelet quality in vivo and during storage. In this review, the effect of NSAIDs on platelet function is summarized, with a focus on the widely consumed over-the-counter (OTC) medications aspirin, ibuprofen, and the non-NSAID paracetamol. Aspirin and ibuprofen have well-defined antiplatelet effects. In comparison, studies regarding the effect of paracetamol on platelets report variable findings. The timing and order of NSAID intake is important, as concurrent NSAID use can inhibit or potentiate platelet activation depending on the drug taken. NSAID deferral periods and maximum platelet shelf-life is set by each country and are revised regularly. Reduced donor deferral periods and longer platelet storage times may affect the quality of platelet products, and it is therefore important to identify the possible impact of NSAID intake on platelet quality before and after storage.

Biomarkers of subclinical atherosclerosis in patients with psoriatic arthritis

Background: Psoriatic arthritis (PsA) is a chronic immune-mediated disease. It is associated with an increase in cardiovascular risk factors (obesity, hypertension, diabetes, and dyslipidemia), giving a higher risk of major adverse cardiovascular events. Patients with PsA have an increased incidence of subclinical atherosclerosis and endothelial dysfunction. The aim of this study is to perform a review of the biomarkers of subclinical atherosclerosis in patients with PsA.

Methods: A search was performed in the electronic databases (PubMed, Web of Science, Scopus, and Embase) up until July 2017. Studies were considered if they included data on biomarkers of subclinical atherosclerosis in PsA, and each article was then reviewed for quality and clinical relevance. After completing the literature search, all screened literature was summarized and discussed in our study group (CaRRDs study group).

Results: The initial search produced 532 abstracts, which were limited to 258 potentially relevant articles by preliminary review of the titles and by excluding review articles and case reports (n=274). A further 102 articles were deemed ineligible after examining the abstracts. Full texts of the remaining 156 articles were retrieved. Most articles were excluded because they were not relevant to the biomarkers of subclinical atherosclerosis in psoriasis and/or PsA. In the end, 54 articles were deemed eligible for this review.

Conclusion: Patients with PsA showed more severe atherosclerotic disease compared with patients with only psoriasis. This may have been due to the higher systemic inflammatory burden from the combination of both diseases. In patients with PsA some molecules may be considered as markers of atherosclerotic disease, and their detection may be a prognostic marker, in addition to imaging procedures, for the development of atherosclerotic disease, and could be suitable for the management of patients with PsA.

Cardiovascular Risk Markers and Major Adverse Cardiovascular Events in Psoriatic Arthritis Patients

BACKGROUND

Psoriatic arthritis is a chronic inflammatory arthropathy that affects 14%- 30% of patients with skin and/or nail psoriasis, leading to severe physical limitations and disability. It has been included in the group of spondyloarthropathy with which it shares clinical, radiologic, and serologic features in addition to familial and genetic relationship. Beyond skin and joint involvement, psoriatic arthritis is characterized by a high prevalence of extra-articular manifestation and comorbidities, such as autoimmune, infectious and neoplastic diseases. In particular, an increased risk of cardiovascular comorbidity has been observed in psoriatic arthritis patients.

METHODS

A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE) up until January 2017. Studies were included if they contained data on CV disease and/or risk factors in PsA and each article was then reviewed for quality and clinical relevance. After completing the literature search all screened literature was summarized and discussed in our study group (CaRDDs study group). All literature and comments were included in the systematic review.

RESULTS

The initial search produced 278 abstracts, which were narrowed to 83 potentially relevant articles by preliminary review of the titles and by excluding review articles and case report (n = 195). Thirty articles were deemed ineligible after examining the abstracts. Full texts of the remaining 53 articles were retrieved. The majority of articles excluded were due to only providing data on patients with psoriasis or due to being not relevant to the CV risk in PsA. In the end, 32 articles were deemed eligible for this review.

CONCLUSION

Psoriatic arthritis appeared significantly associated with subclinical atherosclerosis and endothelial dysfunction and, in turn, with an increased cardiovascular risk. Thus, patients with psoriatic arthritis may benefit from a periodic assessment of surrogate markers of cardiovascular risk. This could help to establish more specific cardiovascular prevention strategies for these patients.

The Cardiovascular Pharmacology of Nonsteroidal Anti-Inflammatory Drugs

The principal molecular mechanisms underlying the cardiovascular (CV) and renal adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs), such as myocardial infarction and hypertension, are understood in more detail than most side effects of drugs. Less is known, however, about differences in the CV safety profile between chemically distinct NSAIDs and their relative predisposition to complications. In review article, we discuss how heterogeneity in the pharmacokinetics and pharmacodynamics of distinct NSAIDs may be expected to affect their CV risk profile. We consider evidence afforded by studies in model systems, mechanistic clinical trials, a meta-analysis of randomized controlled trials, and two recent large clinical trials, Standard Care vs. Celecoxib Outcome Trial (SCOT) and Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen (PRECISION), designed specifically to compare the CV safety of the cyclooxygenase-2-selective NSAID, celecoxib, with traditional NSAIDs. We conclude that SCOT and PRECISION have apparently not compared equipotent doses and have other limitations that bias them toward underestimation of the relative risk of celecoxib.

[DGRh recommendations for the implementation of current security aspects in the NSAID treatment of musculoskeletal pain]

NSAIDs exert their anti-inflammatory and analgesic effects by inhibition of COX‑2, a key enzyme for proinflammatory prostanoid synthesis. Therapy with NSAIDs is limited by their typical gastrointestinal, cardiovascular and renal side effects, which are caused by inhibition of COX‑1 (gastrointestinal toxicity), COX‑2 (cardiovascular side effects) or both COX-isoenzymes (renal side effects). Appropriate prevention strategies should be employed in patients at risk. If gastrointestinal risk factors are present, co-administration of a proton pump inhibitor or misoprostol is recommended; in patients with cardiovascular risk, coxibs, diclofenac and high-dose ibuprofen should be avoided. Furthermore, drug interactions and contraindications should be considered. In patients with renal impairment (GFR < 30 ml/min) all NSAIDs must be avoided. Ulcer anamnesis is a contraindication for traditional NSAIDs. Preexisting cardio- or cerebrovascular diseases are contraindications for coxibs. Treatment decisions should be individually based with a continuous monitoring of the risk - benefit ratio and exploitation of non-pharmacological treatment options.

Topical diclofenac does not affect the antiplatelet properties of aspirin as compared to the intermediate effects of oral diclofenac: A prospective, randomized, complete crossover study

Nonsteroidal anti-inflammatory drugs (NSAIDs) adversely interact with aspirin, diminishing its antiplatelet effect and potentially placing patients at an increased risk for recurrent thrombotic events. This crossover study aimed to determine whether the topical NSAID diclofenac epolamine 1.3% patch or oral diclofenac 50 mg interfered with the antiplatelet effects of aspirin 325 mg. Twelve healthy men and women aged 18-50 were included. Participants were randomized into 5 treatment arms: aspirin, diclofenac potassium 50 mg, diclofenac patch, diclofenac potassium plus ASA 325 mg, and diclofenac patch plus aspirin. Platelet responsiveness was determined using whole-blood impedance aggregation (WBA) to collagen 1 μg/mL and arachidonic acid (AA) 0.5 mM and was sampled every 2 hours. No significant difference in platelet function was observed following the diclofenac patch and aspirin vs aspirin alone. Oral diclofenac produced a mixed effect with significant reduction in platelet inhibition at hour 2 and hour 8 following aspirin administration. Topical diclofenac does not significantly interfere with the antiplatelet effects of aspirin and may be a safer alternative to the oral formulation.

Differential impairment of aspirin-dependent platelet cyclooxygenase acetylation by nonsteroidal antiinflammatory drugs

The cardiovascular safety of nonsteroidal antiinflammatory drugs (NSAIDs) may be influenced by interactions with antiplatelet doses of aspirin. We sought to quantitate precisely the propensity of commonly consumed NSAIDs—ibuprofen, naproxen, and celecoxib—to cause a drug-drug interaction with aspirin in vivo by measuring the target engagement of aspirin directly by MS. We developed a novel assay of cyclooxygenase-1 (COX-1) acetylation in platelets isolated from volunteers who were administered aspirin and used conventional and microfluidic assays to evaluate platelet function. Although ibuprofen, naproxen, and celecoxib all had the potential to compete with the access of aspirin to the substrate binding channel of COX-1 in vitro, exposure of volunteers to a single therapeutic dose of each NSAID followed by 325 mg aspirin revealed a potent drug-drug interaction between ibuprofen and aspirin and between naproxen and aspirin but not between celecoxib and aspirin. The imprecision of estimates of aspirin consumption and the differential impact on the ability of aspirin to inactivate platelet COX-1 will confound head-to-head comparisons of distinct NSAIDs in ongoing clinical studies designed to measure their cardiovascular risk.

Platelet reactivity and disease activity in subjects with psoriatic arthritis

OBJECTIVE

Platelet aggregation plays a major role in vascular mortality. Individuals with psoriatic arthritis (PsA) are highly predisposed to vascular mortality. We evaluated the correlation between disease activity and platelet aggregation in individuals with PsA.

METHODS

Individuals with PsA receiving tumor necrosis factor-α (TNF-α) blockers (n = 114) and healthy controls (n = 114) matched for age, sex, and cardiovascular risk factors were tested for light transmission aggregometry. None was receiving antiinflammatory drugs. Platelet aggregation (max-A%) was defined as maximal light transmittance achieved within 5 min after the addition of 0.1 or 0.2 mM arachidonic acid or 0.4 μM adenosine diphosphate. A value of ≥ 50% irreversible light transmittance (LT-50%) following platelet stimulation was used to define platelet hyperreactivity. Minimal disease activity (MDA) was evaluated in subjects with PsA.

RESULTS

Regardless of the agent used, individuals with PsA showed a higher max-A% and achieved LT-50% more often than controls. Among individuals with PsA, those achieving MDA exhibited a max-A% similar to that of controls, both being significantly lower (p < 0.001) than max-A% of subjects with active disease. Subjects with active disease showed platelet hyperreactivity (LT-50%) more often than those achieving MDA (p < 0.001). For increasing quartiles of max-A%, C-reactive protein levels increased and prevalence of MDA decreased.

CONCLUSION

Compared with those achieving MDA, subjects with active PsA disease had abnormally high platelet reactivity. Whether this is relevant for the cardiovascular risk profile of subjects with PsA receiving TNF-α blockers requires further evaluation.

Prediction of time-dependent interaction of aspirin with ibuprofen using a pharmacokinetic/pharmacodynamic model

WHAT IS KNOWN AND OBJECTIVE

Low-dose aspirin is widely used for prevention of thrombosis, but combined use of aspirin with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, reduces the antiplatelet effect of aspirin. However, there has been no report describing the effects of the timing of the ibuprofen dose on the degree of interaction between low-dose aspirin and ibuprofen. The purpose of this study was to predict the time-course of the antiplatelet effect of low-dose aspirin when ibuprofen is administered as a single dose or repeatedly in combination with aspirin at various time intervals.

METHODS

We simulated ex vivo platelet aggregation using a previously developed pharmacokinetic (PK)/pharmacodynamic (PD) model.

RESULTS AND DISCUSSION

The antiplatelet effect of low-dose aspirin (81 mg) was predicted to be markedly reduced when ibuprofen (200 mg; the usual prescribed dose in Japan) was administered 1 h or less after aspirin, but not when it was administered more than 2 h after the administration of aspirin. Moreover, the administration of ibuprofen up to 12 h before aspirin completely abrogated the antiplatelet effect of aspirin. When ibuprofen (200 mg) was administered three times daily for 3 days (day 1 to day 3) on a background of continuous low-dose aspirin (81 mg) once daily, 2 h after aspirin, no reduction in the antiplatelet effect of aspirin was predicted on day 1, but a reduction is predicted from day 2, with no return to the initial level until more than 3 days after discontinuation of ibuprofen. A marked reduction in the antiplatelet effect of aspirin was also seen on the same schedule when the dosage of ibuprofen was 150 mg, which is the dose used in over-the-counter (OTC) preparations.

WHAT IS NEW AND CONCLUSION

This study indicates that the antiplatelet effect of low-dose aspirin can be markedly reduced with combined use of ibuprofen, depending on the timing of co-administration. As even the lower OTC dose of ibuprofen (150 mg) was enough to affect the antiplatelet effect of aspirin, health professionals should take into account patients' use of OTC ibuprofen when prescribing low-dose aspirin.

Impact of a fixed-dose combination of naproxen and esomeprazole magnesium on serum thromboxane B2 inhibition by low-dose aspirin over 5 days in healthy adults: a phase I, randomized, double-blind, placebo-controlled, noninferiority trial

BACKGROUND

Low-dose aspirin (LDA) and nonsteroidal anti-inflammatory drugs (NSAIDs) are often used concomitantly; however, some NSAIDs may interfere with LDA antiplatelet activity.

OBJECTIVE

We evaluated the impact of coadministered enteric-coated naproxen 500 mg and immediate-release esomeprazole magnesium 20 mg (fixed-dose combination) on LDA-mediated platelet cyclooxygenase (COX)-1 inhibition.

METHODS

In this Phase I, single-center, double-blind, placebo-controlled study, healthy volunteers (50-75 years) received enteric-coated LDA 81 mg once daily (QD) on days 1 to 5 (open-label), then enteric-coated LDA 81 mg QD plus either naproxen/esomeprazole magnesium or placebo twice daily (BID) on days 6 to 10 (randomized). Serum thromboxane B(2) (TXB(2)) inhibition from baseline to day 11 was the primary end point. The primary analysis excluded volunteers with ≤95% inhibition at day 6. Assay sensitivity and noninferiority of naproxen/esomeprazole magnesium versus placebo were concluded if the 90% CI lower limit for percent inhibition of TXB(2) was >90.0% in both treatment groups (prespecified criterion). Tolerability was a secondary end point.

RESULTS

Overall, 42 volunteers were enrolled, 40 randomized, and 32 included in the primary pharmacodynamic analysis (day 6 TXB(2) inhibition ≥95%). Most volunteers (86%) were white, and 57% were female. Mean age was 60 (7) years, and mean body mass index was 26.4 (2.6) kg/m(2). Day 11 mean serum TXB(2) inhibition was 99.1% (90% CI, 98.7-99.6) in the LDA plus placebo group (n = 18) versus 99.6% (90% CI, 99.4-99.8) in the LDA plus naproxen/esomeprazole magnesium group (n = 14). Noninferiority of naproxen/esomeprazole magnesium versus placebo was established (CI lower limit >90.0%). Adverse event (AE) incidence was 40% (n = 8/20) in the LDA plus placebo group and 15% (n = 3/20) in the LDA plus naproxen/esomeprazole magnesium group. No serious AEs or discontinuations due to AEs were observed.

CONCLUSIONS

This pilot investigation suggests that LDA coadministered with naproxen/esomeprazole magnesium is noninferior to LDA alone for platelet COX-1 inhibition, as measured by serum TXB(2) concentration, in healthy volunteers. ClinicalTrials.gov identifier: NCT01094483.

Coagulation status in coronary artery disease patients with type II diabetes mellitus compared with non-diabetic coronary artery disease patients using the PFA-100® and ROTEM®

Previous investigations in patients with coronary artery disease (CAD) revealed differences in thromboelastographic parameters indicating different states of coagulability. The aim of the present study was to investigate the coagulation status of patients with documented CAD and type II diabetes mellitus (DM) and non-diabetic patients with coronary artery disease with the PFA-100® and the ROTEM®. No differences were found in platelet function as measured with collagen/epinephrine (263.6 ± 70.6 s vs. 254.6 ± 65.3 s) and collagen/ADP cartridges (105.3 ± 63.2 s vs. 90.6 ± 47.3 s) in CAD patients with DM and CAD patients without DM. Measured with the EXTEM reagent of the ROTEM®, mean maximum clot elasticity (MCE) in patients with CAD and DM (233.6 ± 86.9) was significantly longer than in CAD patients without DM (186.7 ± 54.5), (p = 0.03). A similar result was seen using the INTEM reagent; patients with CAD and DM (234.4 ± 83.9) showed a higher value for MCE than CAD patients without DM (190.8 ± 57.8) which was of borderline significance (p = 0.053). Moreover, a weak trend for higher maximum clot firmness (MCF) was seen in CAD patients with DM compared with CAD patients without DM with the EXTEM reagent (68.1 ± 7.5 vs. 63.6 ± 8.6, p = 0.08) and the INTEM reagent (68.4 ± 7.2 vs. 64.1 ± 8.2, p = 0.09). The ROTEM® analysis indicates increased coagulability in patients with coronary artery disease and diabetes mellitus compared to non-diabetic CAD patients. Moreover, the ROTEM® device seems to be an appropriate and easy-to-use tool to describe the coagulation status in these patients groups.

Effect of maximum OTC doses of naproxen sodium or acetaminophen on low-dose aspirin inhibition of serum thromboxane B2

OBJECTIVES

This study evaluated the platelet inhibitory effects of low-dose enteric-coated aspirin (EC-ASA) when used concomitantly with maximum over-the-counter (OTC) doses of naproxen sodium (NAPSO) or acetaminophen to determine whether NAPSO and acetaminophen interfere with the anti-platelet effect of aspirin.

RESEARCH DESIGN AND METHODS

Phase I, randomized, open-label, multi-dose, three-period, parallel group, pharmacodynamic trial conducted in healthy male and female volunteers (n = 47 randomized subjects and n = 37 evaluable subjects), mean age 40.2 years. All subjects received 5 days of EC-ASA 81 mg once daily followed by 5 days of EC-ASA 81 mg once daily alone or co-administered with either NAPSO 220 mg three times daily or acetaminophen 1 g four times daily.

PRIMARY OUTCOME MEASURE

Inhibition of serum thromboxane B(2) (TXB(2)), as a marker of platelet cyclooxygenase-1 (COX-1) inhibition, measured on Day 11.

RESULTS

Mean inhibition of TXB(2) on Day 11 was >99% for subjects taking EC-ASA alone as well as for those who received EC-ASA co-administered with NAPSO or acetaminophen. For subjects taking EC-ASA monotherapy, mean serum TXB(2) inhibition was 99.7% (range 99.0-100%), for those taking EC-ASA with acetaminophen it was 99.6% (range 98.3-99.9%), and for those taking EC-ASA with NAPSO, mean serum TXB(2) inhibition was 99.7% (range 99.2-100%).

STUDY LIMITATION

Small sample size and open-label trial design.

CONCLUSIONS

The anti-platelet effect of EC-ASA 81 mg once daily was maintained following its co-administration with maximum OTC doses of NAPSO or acetaminophen.