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Charles-Schoeman C, Fleischmann R, Mysler E, Greenwald M, Ytterberg SR, Koch GG, Bhatt DL, Wang C, Mikuls TR, Chen AS, Connell CA, Woolcott JC, Menon S, Chen Y, Lee K, Szekanecz Z. Risk of Venous Thromboembolism With Tofacitinib Versus Tumor Necrosis Factor Inhibitors in Cardiovascular Risk-Enriched Rheumatoid Arthritis Patients. Arthritis Rheumatol 2024; 76:1218-1229. [PMID: 38481002 DOI: 10.1002/art.42846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/19/2024] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The ORAL Surveillance trial found a dose-dependent increase in venous thromboembolism (VTE) and pulmonary embolism (PE) events with tofacitinib versus tumor necrosis factor inhibitors (TNFi). We aimed to assess VTE incidence over time and explore risk factors of VTE, including disease activity, in ORAL Surveillance. METHODS Patients with rheumatoid arthritis (RA) aged 50 years or older with at least one additional cardiovascular risk factor received tofacitinib 5 or 10 mg twice daily (BID) or TNFi. Post hoc, cumulative probabilities and incidence rates (patients with first events/100 patient-years) by 6-month intervals were estimated for adjudicated VTE, deep vein thrombosis, and PE. Cox regression models identified risk factors. Clinical Disease Activity Index leading up to the event was explored in patients with VTE. RESULTS Cumulative probabilities for VTE and PE were higher with tofacitinib 10 mg BID, but not 5 mg BID, versus TNFi. Incidence rates were consistent across 6-month intervals within treatments. Across treatments, risk factors for VTE included prior VTE, body mass index greater than or equal to 35 kg/m2, older age, and history of chronic lung disease. At the time of the event, most patients with VTE had active disease as defined by Clinical Disease Activity Index. CONCLUSION Incidences of VTE and PE were higher with tofacitinib (10 > 5 mg BID) versus TNFi and were generally consistent over time. Across treatments, VTE risk factors were aligned with previous studies in the general RA population. These data highlight the importance of assessing VTE risk factors, including age, body mass index, and VTE history, when considering initiation of tofacitinib or TNFi in patients with active RA.
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Affiliation(s)
| | - Roy Fleischmann
- Metroplex Clinical Research Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | | | | | - Gary G Koch
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Ted R Mikuls
- University of Nebraska Medical Center and Veterans Affairs Nebraska Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Yan Chen
- Pfizer Inc, Collegeville, Pennsylvania
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Noumegni SR, Tromeur C, Hoffmann C, Mao RL, Moigne EL, Moreuil CD, Mansourati V, Nasr B, Gentric JC, Guegan M, Poulhazan E, Bressollette L, Lacut K, Didier R, Couturaud F. Predictors of Recurrent Venous Thromboembolism or Arterial Thrombotic Events during and after Anticoagulation for a First Venous Thromboembolism. Semin Thromb Hemost 2023; 49:688-701. [PMID: 36252603 DOI: 10.1055/s-0042-1757899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
After first episodes of venous thromboembolism (VTE), patients are at increased risk of recurrent VTE and arterial thrombotic events (ATE) compared with the general population, two disorders that are influenced by anticoagulation. However, risk factors of these conditions occurring during and after anticoagulation are little described. Using cause-specific hazard regression models, we aimed to determine risk factors of the composite outcome recurrent VTE/ATE, and separately recurrent VTE or ATE, during and after anticoagulation in patients with first episodes of VTE from a prospective cohort. Hazard ratios (HRs) are given with 95% confidence intervals (CIs). A total of 2,011 patients treated for at least 3 months were included. A total of 647 patients had recurrent VTE/ATE (incidence: 4.69% per patient-years) during overall follow-up (median: 92 months). Of these events, 173 occurred during anticoagulation (incidence: 3.67% per patient-years). Among patients free of events at the end of anticoagulation, 801 had a post-anticoagulation follow-up ≥3 months; and 95 had recurrent VTE/ATE (incidence: 1.27% per patient-years). After adjustment for confounders, cancer-associated VTE (HR: 2.64, 95% CI: 1.70-4.11) and unprovoked VTE (HR: 1.95, 95% CI: 1.35-2.81) were the identified risk factors of recurrent VTE/ATE during anticoagulation (vs. transient risk factor-related VTE). Risk factors of recurrent VTE/ATE after anticoagulation included 50 to 65 years of age (vs. < 50, HR: 1.99, 95% CI: 1.04-3.81), older than 65 years (vs. < 50, HR: 5.28, 95% CI: 3.03-9.21), and unprovoked VTE (vs. transient risk factor-related VTE, HR: 2.06, 95% CI: 1.27-3.34). Cancer-associated VTE and unprovoked VTE are the main risk factors of recurrent VTE/ATE during anticoagulation, while older age and unprovoked VTE mainly predict the risk of these events after anticoagulation.
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Affiliation(s)
- Steve Raoul Noumegni
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Cécile Tromeur
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Clément Hoffmann
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Raphael Le Mao
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Emmanuelle Le Moigne
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Claire de Moreuil
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Vincent Mansourati
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
- Department of Cardiology, Brest Teaching Hospital, Brest, France
| | - Bahaa Nasr
- Department of Vascular Surgery, Brest Teaching Hospital, Brest, France
| | - Jean-Christophe Gentric
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
- Department of Neuroradiology, Brest Teaching Hospital, Brest, France
| | - Marie Guegan
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Elise Poulhazan
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Luc Bressollette
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Karine Lacut
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
| | - Romain Didier
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
- Department of Cardiology, Brest Teaching Hospital, Brest, France
| | - Francis Couturaud
- Department of Internal Medicine, Vascular Medicine and Pneumology, Brest Teaching Hospital, Brest, France
- Inserm, UMR 1304 (GETBO), Western Brittany Thrombosis Study Group, Western Brittany University, Brest, France
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Exploring phenotypes of deep vein thrombosis in relation to clinical outcomes beyond recurrence. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:1238-1247. [PMID: 36736833 DOI: 10.1016/j.jtha.2023.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a multifactorial disease with several outcomes, but current classifications solely stratify it based on recurrence risk. OBJECTIVES We aimed to identify DVT phenotypes and assess their relation to recurrent venous thromboembolism (VTE), postthrombotic syndrome, arterial events, and cancer. PATIENTS/METHODS Hierarchical clustering was performed on a DVT cohort with a follow-up of up to 5 years using 23 baseline characteristics. Phenotypes were summarized by discriminative characteristics. Hazard ratios (HRs) were calculated using Cox regression; the recurrence risk was adjusted for the anticoagulant therapy duration. The study was carried out in accordance with the Declaration of Helsinki and approved by the medical ethics committee. RESULTS In total, 825 patients were clustered into 4 phenotypes: 1. women using estrogen therapy (n = 112); 2. patients with a cardiovascular risk profile (n = 268); 3. patients with previous VTE (n = 128); and 4. patients without discriminant characteristics (n = 317). Overall, the risks of recurrence, postthrombotic syndrome, arterial events, and cancer were low in phenotype 1 (reference), intermediate in phenotype 4 (HR: 4.6, 1.2, 2.2, 1.8), and high in phenotypes 2 (HR: 6.1, 1.6, 4.5, 2.9) and 3 (HR: 5.7, 2.5, 2.3, 3.7). CONCLUSIONS This study identified 4 distinct phenotypes among patients with DVT that are not only associated with the increasing recurrence risk but also with outcomes beyond recurrence. Our results thereby highlight the limitations of current risk stratifications that stratify based on the predictors of the recurrence risk only. Overall, risks were lowest in women using estrogen therapy and highest in patients with a cardiovascular risk profile. These findings might inform a more personalized approach to clinical management.
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Berthe P, Scailteux LM, Lescoat A, Staumont D, Coiffier G, Guéret P, Dupuy A, Oger E, Droitcourt C. Oral Janus kinase inhibitors and venous thromboembolic events in atopic dermatitis: protocols for a case-time control study and a nested case-control study based on the French national health insurance (SNDS) cohort. BMJ Open 2022; 12:e059979. [PMID: 36130766 PMCID: PMC9494565 DOI: 10.1136/bmjopen-2021-059979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 07/23/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Atopic dermatitis (AD) is a highly prevalent, chronic, inflammatory skin disease. Several orally administered Janus kinase inhibitors (JAKis, including baricitinib, upadacitinib and abrocitinib) have received a marketing authorisation for AD.Clinical trials in rheumatoid arthritis (RA) have flagged up a potential risk of JAKi-induced venous thromboembolic events (VTEs). Accordingly, the summary of product characteristics for a JAKi must mention VTEs as potential adverse drug reactions. In contrast to RA, AD per se is not associated with an elevated risk of VTEs. Assessing this potential risk among patients with AD would shed further light on the putative underlying relationship between JAKis and VTEs.Our research question is to investigate whether JAKi administration increases the risk of VTEs in adults with AD. Our primary objective is to assess the risk of VTEs in adults with AD exposed to JAKis compared to AD adults not exposed to JAKis, and our secondary objective is to evaluate whether JAKi initiation acts as a trigger of VTEs in adults with AD within 3 months. METHODS AND ANALYSIS Hence, we have designed (1) a nested case-control study and (2) a case-time control study in a cohort of adults with AD with data from the French national health insurance system (2017-2025).Here, we describe the study protocol, our methodological choices and certain novel aspects, including the combined value of the two assumptions and the use of an exhaustive national health insurance database with potentially greater statistical power for studying rare events in the population of patients with AD at a low risk of VTEs (thus limiting the influence of confounding factors). ETHICS AND DISSEMINATION The protocol has been approved by an independent ethics committee and registered with the French National Data Protection Commission. The study's findings will be published in peer-reviewed scientific journals and presented at international conferences.
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Affiliation(s)
| | - Lucie-Marie Scailteux
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Alain Lescoat
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
- Internal Medicine and Clinical Immunology, CHU Rennes, Rennes, France
| | - Delphine Staumont
- Department of Dermatology, Lille University Hospital Center, Lille, France
| | - Guillaume Coiffier
- Department of Rheumatology, CH Dinan, Dinan, France
- INSERM, INRA, Institut NUMECAN (Nutrition Metabolism and Cancer), Rennes, France
| | | | - Alain Dupuy
- Department of Dermatology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Catherine Droitcourt
- Department of Dermatology, CHU Rennes, Rennes, France
- Univ Rennes, INSERM, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
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Cordeanu EM, Jambert L, Tousch J, Mirea C, Delatte A, Younes W, Woehl B, Harter C, Frantz AS, Hamade A, Schini-Kerth V, Ohlmann P, Andres E, Stephan D. The Conundrum of Occult Cancer Screening in Venous Thromboembolism: Lessons from the REMOTEV Registry. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58070913. [PMID: 35888632 PMCID: PMC9317660 DOI: 10.3390/medicina58070913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
(1) Background and Objectives: Venous thromboembolism (VTE) is strongly associated with cancer, and may be the first event revealing occult neoplasia. Nonetheless, the reasonable extent of the etiological assessment after an unprovoked VTE event remains debated. The main objective of this study was to evaluate the incidence of occult neoplasia one year after an episode of VTE, in consecutively hospitalized patients for VTE from the REMOTEV registry. The secondary objectives were to assess the performance of the various tests used for occult cancer screening in a real-life setting and analyze the risk factors associated with the discovery of cancer and the 1-year prognosis. (2) Methods: REMOTEV is a prospective, non-interventional cohort study of patients with acute VTE. Patients included in the registry from 23 October 2013 to 28 July 2018 were analyzed after a follow-up of 12 months. Cancer detection was performed according to local practices and consisted of a limited strategy to which an abdominal ultrasound was added. In the presence of suggestive clinical manifestations, further examinations were performed on an individual basis. (3) Results: A total of 993 patients were included in the study. At 1 year, the incidence of newly diagnosed cancer was low (5.3%). Half of the detected cancers were metastatic at discovery (51%) and had a poor global prognosis (32% of mortality at 1 year). Admission pulmonary CT scans as well as (thoracic)-abdomino-pelvic CT scans (when performed) were responsible for the majority of detected cancers. Age over 65 years and the concomitant presence of an unusual site and lower-limb deep vein thrombosis were the only factors associated with occult neoplasia in this cohort. After 1-year FU, mortality was higher in cancer patients (HR 6.0 (CI 95% 3.5−10.3, p < 0.0001)), and cancer evolution was the leading cause of death in the cancer group. (4) Conclusions: In REMOTEV, VTE-revealed occult cancer prevalence was low, but similar to recent reports and associated with higher age, multiple thrombotic sites and worse prognosis.
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Affiliation(s)
- Elena-Mihaela Cordeanu
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
- Correspondence: ; Tel.: +33-0369-551-520
| | - Lucas Jambert
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Jonathan Tousch
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Corina Mirea
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Alexandre Delatte
- Department of Cardiology, Haguenau Regional Hospital, 67500 Haguenau, France;
| | - Waël Younes
- Department of Vascular Medicine, Colmar Regional Hospital, 68000 Colmar, France;
| | - Bastien Woehl
- Department of Vascular Medicine, Mulhouse Regional Hospital, 68100 Mulhouse, France; (B.W.); (A.H.)
| | - Claire Harter
- Department of Radiology, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Anne-Sophie Frantz
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Amer Hamade
- Department of Vascular Medicine, Mulhouse Regional Hospital, 68100 Mulhouse, France; (B.W.); (A.H.)
| | - Valérie Schini-Kerth
- UMR 1260 INSERM Regenerative Nanomedecine, Faculty of Pharmacy, Strasbourg University, 67400 Illkirch, France;
| | - Patrick Ohlmann
- Cardiology Department, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Emmanuel Andres
- Internal Medicine Department, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Dominique Stephan
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 298] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Margaglione M, Antonucci E, D’Andrea G, Migliaccio L, Ageno W, Bucherini E, Cosmi B, Falanga A, Martini G, Mastroiacovo D, Paparo C, Poli D, Testa S, Palareti G. Anticoagulation in Italian patients with venous thromboembolism and thrombophilic alterations: findings from START2 register study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:486-495. [PMID: 32955425 PMCID: PMC7605886 DOI: 10.2450/2020.0091-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Randomised control trials have assessed the efficacy and safety of direct oral anticoagulants in the prophylaxis and treatment of venous thromboembolism (VTE). Positive but limited results have been reported in patients with inherited thrombophilia. Using an Italian, multicentre, prospective registry of consecutive patients presenting with symptomatic, acute VTE, we aimed to assess which factors are involved in making the choice of the drug that best fits the patient's risk profile in a large real-world setting of VTE patients. MATERIALS AND METHODS We investigated 4,866 VTE patients who took oral anticoagulants in the period between 2012 and April 2018 to prevent a new thromboembolic episode. RESULTS The large majority of patients who underwent thrombophilic screening, regardless of the results obtained, were prescribed direct oral anticoagulants rather than conventional anticoagulant therapy (p<0.001). During anticoagulation, bleeding events occurred more frequently in patients on conventional anticoagulant therapy (4.2%) than in those receiving direct oral anticoagulants (1.8%) and an increase in bleeding events was observed in patients who tested positive at the thrombophilic screening. Overall, a higher number of recurrent VTE was observed in patients not screened for thrombophilia (n=36; 1.7%) than in those screened (n=20; 0.7%; adjusted odds ratio: 2.2; 95% confidence interval: 1.2-4.1). DISCUSSION The present data confirm previous findings from other post-marketing registries and suggest that the choice of oral anticoagulation is strongly driven by patients' characteristics and VTE manifestations. Factors leading to the prescription of thrombophilic screening may identify a patient with a lower risk of VTE recurrence during anticoagulation.
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Affiliation(s)
- Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Giovanna D’Andrea
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Benilde Cosmi
- Angiology Unit, “Sant’Orsola Malpighi” University Hospital, Bologna, Italy
| | - Anna Falanga
- Thrombosis and Haemostasis Centre, Department of Immunohaematology and Transfusion Medicine, Bergamo, Italy
| | | | | | | | - Daniela Poli
- Centre for Atherothrombotic Diseases, “Careggi” University Hospital, Florence, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Centre, Hospital of Cremona, Cremona, Italy
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Rodríguez-Núñez N, Ruano-Raviña A, Lama A, Ferreiro L, Ricoy J, Álvarez-Dobaño JM, Suárez-Antelo J, Toubes ME, Rábade C, Golpe A, Lourido T, González-Barcala FJ, Valdés L. Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor. J Thorac Dis 2020; 12:5411-5419. [PMID: 33209374 PMCID: PMC7656446 DOI: 10.21037/jtd-20-1634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/28/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis. METHODS A case-control study was performed of patients with PE admitted to our hospital [2010-2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus. RESULTS A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95-3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27-2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24-2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02-7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82-34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25-51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06-49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance. CONCLUSIONS A relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.
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Affiliation(s)
- Nuria Rodríguez-Núñez
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Alberto Ruano-Raviña
- Department of Preventive Medicine and Public Health, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
| | - Adriana Lama
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Lucía Ferreiro
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
- Interdisciplinary Research Group on Pulmonology, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Jorge Ricoy
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - José M. Álvarez-Dobaño
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
- Interdisciplinary Research Group on Pulmonology, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - M. Elena Toubes
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Carlos Rábade
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Antonio Golpe
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
- Interdisciplinary Research Group on Pulmonology, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Tamara Lourido
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Francisco Javier González-Barcala
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
- Interdisciplinary Research Group on Pulmonology, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Luis Valdés
- Department of Pulmonology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
- Interdisciplinary Research Group on Pulmonology, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
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Mease P, Charles-Schoeman C, Cohen S, Fallon L, Woolcott J, Yun H, Kremer J, Greenberg J, Malley W, Onofrei A, Kanik KS, Graham D, Wang C, Connell C, Valdez H, Hauben M, Hung E, Madsen A, Jones TV, Curtis JR. Incidence of venous and arterial thromboembolic events reported in the tofacitinib rheumatoid arthritis, psoriasis and psoriatic arthritis development programmes and from real-world data. Ann Rheum Dis 2020; 79:1400-1413. [PMID: 32759265 PMCID: PMC7569391 DOI: 10.1136/annrheumdis-2019-216761] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023]
Abstract
Objectives Tofacitinib is a Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ulcerative colitis, and has been investigated in psoriasis (PsO). Routine pharmacovigilance of an ongoing, open-label, blinded-endpoint, tofacitinib RA trial (Study A3921133; NCT02092467) in patients aged ≥50 years and with ≥1 cardiovascular risk factor identified a higher frequency of pulmonary embolism (PE) and all-cause mortality for patients receiving tofacitinib 10 mg twice daily versus those receiving tumour necrosis factor inhibitors and resulted in identification of a safety signal for tofacitinib. Here, we report the incidence of deep vein thrombosis (DVT), PE, venous thromboembolism (VTE; DVT or PE) and arterial thromboembolism (ATE) from the tofacitinib RA (excluding Study A3921133), PsA and PsO development programmes and observational studies. Data from an ad hoc safety analysis of Study A3921133 are reported separately within. Methods This post-hoc analysis used data from separate tofacitinib RA, PsO and PsA programmes. Incidence rates (IRs; patients with events per 100 patient-years’ exposure) were calculated for DVT, PE, VTE and ATE, including for populations stratified by defined baseline cardiovascular or VTE risk factors. Observational data from the US Corrona registries (including cardiovascular risk factor stratification), IBM MarketScan research database and the US FDA Adverse Event Reporting System (FAERS) database were analysed. Results 12 410 tofacitinib-treated patients from the development programmes (RA: n=7964; PsO: n=3663; PsA: n=783) were included. IRs (95% CI) of thromboembolic events among the all tofacitinib cohorts’ average tofacitinib 5 mg and 10 mg twice daily treated patients for RA, respectively, were: DVT (0.17 (0.09–0.27) and 0.15 (0.09–0.22)); PE (0.12 (0.06–0.22) and 0.13 (0.08–0.21)); ATE (0.32 (0.22–0.46) and 0.38 (0.28–0.49)). Among PsO patients, IRs were: DVT (0.06 (0.00–0.36) and 0.06 (0.02–0.15)); PE (0.13 (0.02–0.47) and 0.09 (0.04–0.19)); ATE (0.52 (0.22–1.02) and 0.22 (0.13–0.35)). Among PsA patients, IRs were: DVT (0.00 (0.00–0.28) and 0.13 (0.00–0.70)); PE (0.08 (0.00–0.43) and 0.00 (0.00–0.46)); ATE (0.31 (0.08–0.79) and 0.38 (0.08–1.11)). IRs were similar between tofacitinib doses and generally higher in patients with baseline cardiovascular or VTE risk factors. IRs from the overall Corrona populations and in Corrona RA patients (including tofacitinib-naïve/biologic disease-modifying antirheumatic drug-treated and tofacitinib-treated) with baseline cardiovascular risk factors were similar to IRs observed among the corresponding patients in the tofacitinib development programme. No signals of disproportionate reporting of DVT, PE or ATE with tofacitinib were identified in the FAERS database. Conclusions DVT, PE and ATE IRs in the tofacitinib RA, PsO and PsA programmes were similar across tofacitinib doses, and generally consistent with observational data and published IRs of other treatments. As expected, IRs of thromboembolic events were elevated in patients with versus without baseline cardiovascular or VTE risk factors, and were broadly consistent with those observed in the Study A3921133 ad hoc safety analysis data, although the IR (95% CI) for PE was greater in patients treated with tofacitinib 10 mg twice daily in Study A3921133 (0.54 (0.32–0.87)), versus patients with baseline cardiovascular risk factors treated with tofacitinib 10 mg twice daily in the RA programme (0.24 (0.13–0.41)).
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Affiliation(s)
- Philip Mease
- Rheumatology Clinical Research Division, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, Washington, USA
| | | | | | - Lara Fallon
- Inflammation and Immunology - Global Medical Affairs, Pfizer Inc, Kirkland, Quebec, Canada
| | - John Woolcott
- Inflammation and Immunology, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Huifeng Yun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joel Kremer
- Albany Medical College and The Center for Rheumatology, Albany, New York, USA
| | | | | | | | - Keith S Kanik
- Inflammation and Immunology TA, Pfizer Inc, Groton, Connecticut, USA
| | - Daniela Graham
- Inflammation and Immunology TA, Pfizer Inc, Groton, Connecticut, USA
| | - Cunshan Wang
- Statistics, Global Product Development, Pfizer Inc, Groton, Connecticut, USA
| | - Carol Connell
- Clinical Development & Operations, Pfizer Inc, Groton, Connecticut, USA
| | - Hernan Valdez
- Global Product Development, Inflammation and Immunology, Pfizer Inc, New York, New York, USA
| | - Manfred Hauben
- Worldwide Safety, Pfizer Inc, New York, New York, USA.,Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Eric Hung
- Worldwide Safety, Pfizer Inc, New York, New York, USA
| | - Ann Madsen
- Global Medical Epidemiology, Pfizer Inc, New York, New York, USA
| | - Thomas V Jones
- Worldwide Medical and Safety, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Oral Intake of EPA:DHA 6:1 by Middle-Aged Rats for One Week Improves Age-Related Endothelial Dysfunction in Both the Femoral Artery and Vein: Role of Cyclooxygenases. Int J Mol Sci 2020; 21:ijms21030920. [PMID: 32019237 PMCID: PMC7037507 DOI: 10.3390/ijms21030920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 12/20/2022] Open
Abstract
In humans, aging is associated with endothelial dysfunction and an increased risk of venous thromboembolism. Although intake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) at a ratio of 6:1 by old rats improved the endothelial dysfunction in arteries, the impact on veins remains unclear. Eight-month-old male Wistar rats were either untreated or orally administered corn oil, EPA:DHA 1:1, or EPA:DHA 6:1 (500 mg/kg/d) for seven days. Vascular reactivity was studied by myography. In middle-aged femoral artery rings, acetylcholine caused a partial relaxation at low concentrations and a contractile response at high concentrations, whereas in the old femoral vein only a partial relaxation was observed. The EPA:DHA 6:1 treatment blunted the contractile response to acetylcholine in the middle-aged femoral artery and both EPA:DHA 6:1 and 1:1 increased the relaxation to acetylcholine in the old femoral vein. No such effects were observed with corn oil. Both the non-selective cyclooxygenase inhibitor indomethacin and the COX-1 inhibitor SC-560 increased the relaxation to acetylcholine in the middle-aged femoral artery whereas the COX-2 inhibitor NS-398 increased that in the middle-aged femoral vein. In conclusion, our results indicate that aging is associated with an endothelial dysfunction in the femoral artery and vein, which can be improved by EPA:DHA 6:1 treatment-most likely via a cyclooxygenase-dependent mechanism.
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Olivieri O, Turcato G, Moruzzi S, Castagna A, Girelli D, Pizzolo F, Friso S, Sandri M, Bassi A, Martinelli N. Not Just Arterial Damage: Increased Incidence of Venous Thromboembolic Events in Cardiovascular Patients With Elevated Plasma Levels of Apolipoprotein CIII. J Am Heart Assoc 2020; 8:e010973. [PMID: 30646800 PMCID: PMC6497332 DOI: 10.1161/jaha.118.010973] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Apolipoprotein CIII (apo CIII) is a crucial player in triglyceride‐rich lipoprotein metabolism, but may also act pleiotropically, provoking inflammatory responses and stimulating coagulation. Elevated apoCIII plasma levels have been associated with increased activity of coagulation factors. Since these features of prothrombotic diathesis are linked with venous thromboembolism (VTE), we hypothesized that apo CIII plays a role in VTE. Methods and Results We recorded nonfatal VTE events in 1020 patients (age 63.3±11.4 years; 29.1% women) with or without coronary artery disease (79.1% with coronary artery disease and 20.9% without coronary artery disease) during a long follow‐up. Complete plasma lipid and apolipoproteins were available for all patients. Forty‐five patients (4.4%) experienced nonfatal VTE events during a median follow‐up period of 144 months. Apo CIII plasma concentration at enrollment was higher in patients with VTE compared with patients without VTE (12.2 [95% CI, 11.10–13.5] mg/dL vs 10.6 [95% CI, 10.4–10.9] mg/dL, respectively; P=0.011). Patients with apo CIII levels above the median value (10.6 mg/dL) exhibited an increased risk of VTE (incidence rate, 6.0 [95% CI, 4.0–8.0] vs 1.8 [95% CI, 0.7–2.9] VTE events/1000 person‐years; unadjusted hazard ratio [HR], 3.42 [95% CI, 1.73–6.75]; P<0.001). This association was confirmed after adjustment for sex, age, coronary artery disease diagnosis, body mass index, hypertension, and anticoagulant treatment at enrollment (HR, 2.66; 95% CI, 1.31–5.37 [P=0.007]), with inclusion of lipid parameters in the Cox model (HR, 3.74; 95% CI, 1.24–11.33 [P=0.019]), and even with exclusion of patients who died at follow‐up (HR, 3.92; 95% CI, 1.68–9.14 [P=0.002]) or patients taking anticoagulants (HR, 3.39; 95% CI, 1.72–6.69 [P<0.001]). Conclusions Our results suggest that high plasma apo CIII concentrations may predict an increased risk of VTE in patients with cardiovascular disease.
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Affiliation(s)
- Oliviero Olivieri
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | | | | | - Annalisa Castagna
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Domenico Girelli
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Francesca Pizzolo
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Simonetta Friso
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Marco Sandri
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Antonella Bassi
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy.,3 Laboratory of Clinical Chemistry and Hematology University Hospital of Verona Italy
| | - Nicola Martinelli
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
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Pulmonary Embolism and Coexisting Deep Vein Thrombosis: A Detrimental Association? J Clin Med 2019; 8:jcm8060899. [PMID: 31234594 PMCID: PMC6617259 DOI: 10.3390/jcm8060899] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/07/2023] Open
Abstract
Background: The prognostic significance of coexisting deep vein thrombosis (DVT) in acute pulmonary embolism (PE) is controversial. This study aimed to provide routine patient care data on the impact of this association on PE severity and 3-month outcomes in a population presenting with symptomatic venous thromboembolism (VTE) from the REMOTEV registry. Methods and Results: REMOTEV is a prospective, non-interventional study of patients with acute symptomatic VTE, treated with direct oral anticoagulants (DOACs) or standard anticoagulation (vitamin K antagonists (VKA) or parenteral heparin/fondaparinux alone) for at least 3 months. From 1 November 2013 to 28 February 2018, among 1241 consecutive patients included, 1192 had a follow-up of at least 3 months and, among them, 1037 had PE with (727) or without DVT (310). The median age was 69 (55–80, 25th–75th percentiles). Patients with PE-associated DVT had more severe forms of PE (p < 0.0001) and, when DVT was present, proximal location was significantly correlated to PE severity (p < 0.01). However, no difference in all-cause mortality rate (hazard ratio (HR) 1.36 (CI 95% 0.69–2.92)), nor in the composite criterion of all-cause mortality and recurrence rate (HR 1.56 (CI 95% 0.83–3.10)) was noted at 3 months of follow-up. Conclusion: In REMOTEV, coexisting DVT was associated with a higher severity of PE, with no impact on short-term prognosis.
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Quezada CA, Bikdeli B, Barrios D, Barbero E, Chiluiza D, Muriel A, Casazza F, Monreal M, Yusen RD, Jiménez D. Meta-Analysis of Prevalence and Short-Term Prognosis of Hemodynamically Unstable Patients With Symptomatic Acute Pulmonary Embolism. Am J Cardiol 2019; 123:684-689. [PMID: 30528278 DOI: 10.1016/j.amjcard.2018.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/09/2023]
Abstract
There remains limited information about the prevalence and outcomes of hemodynamic unstable patients with acute pulmonary embolism (PE). We performed a systematic review and meta-analysis of prospective registries that enrolled patients with acute PE to assess the prevalence and prognostic significance of hemodynamic instability for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We also assessed the association between use of thrombolytic therapy versus no use and short-term outcomes in the subgroup of unstable patients. We used a random-effects model to pool study results; and I2 testing to assess for heterogeneity. The authors' search retrieved 4 studies that enrolled 1,574 patients with unstable PE (1,574/40,363; 3.9%; 95% confidence interval [CI], 3.7% to 4.1%). Hemodynamic instability had a significant association with short-term all-cause mortality (odds ratio [OR], 5.9; 95% CI, 2.7 to 13.0; I2 = 94%), and with PE-related death (OR, 8.2; 95% CI, 3.4 to 19.7). In unstable patients, thrombolytic therapy was associated with reduced odds of short-term all-cause mortality (OR, 0.69; 95% CI, 0.49 to 0.95), and PE-related death (OR, 0.66; 95% CI, 0.45 to 0.97). In conclusion, hemodynamic instability significantly increased the risk of death shortly after PE diagnosis. Use of thrombolytic therapy was associated with significantly reduced short-term mortality.
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Ulas T, Dal MS. Should we screen hereditary thrombophilia testing in patients with provoked/unprovoked venous thromboembolism? Int J Cardiol 2018; 271:323. [PMID: 30017526 DOI: 10.1016/j.ijcard.2018.05.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Turgay Ulas
- Near East University, School of Medicine, Department of Internal Medicine, Division of Hematology, Nicosia, Cyprus.
| | - Mehmet Sinan Dal
- Dr. Abdurrahman Yurtaslan Training and Research Hospital, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
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