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Silvain J, Montalescot G, Guedeney P. Antiplatelet Therapy, Pretreatment, and Primary PCI: Every Minute Counts. J Am Coll Cardiol 2024; 83:2640-2642. [PMID: 38897673 DOI: 10.1016/j.jacc.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Johanne Silvain
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France.
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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Gehin M, Storey RF, Bernaud C, Dingemanse J. Clinical pharmacology of selatogrel for self-administration by patients with suspected acute myocardial infarction. Expert Opin Drug Metab Toxicol 2023; 19:697-708. [PMID: 37795868 DOI: 10.1080/17425255.2023.2266384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION P2Y12 receptor antagonists (P2Y12 inhibitors) are well established for the treatment of coronary artery disease. The P2Y12 inhibitors currently commercially available present either pharmacokinetic limitations (due to delayed absorption, bioactivation requirement via CYP enzymes, or need of intravenous administration), pharmacodynamic (PD) limitations (limited % inhibition of platelet aggregation (IPA) or relevant PD interactions) or safety limitations (major bleeding in specific populations). AREAS COVERED Selatogrel, a 2-phenylpyrimidine-4-carboxamide analog, is a potent, reversible, and selective P2Y12 inhibitor administered subcutaneously that is under development for the treatment of acute myocardial infarction (AMI) in patients with a recent history of AMI. In this review, the authors summarize the results from preclinical, phase 1, and phase 2 trials which showed that selatogrel provides rapid, pronounced, and reversible P2Y12 receptor inhibition with a favorable safety profile. EXPERT OPINION These unique characteristics added to the limited potential to interact with co-medications and manageable PD interactions with other P2Y12 inhibitors provide a clear rationale for investigating the benefit of selatogrel as an emergency treatment to improve clinical outcomes in patients with AMI.
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Affiliation(s)
- Martine Gehin
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals, Allschwil, Switzerland
| | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Corine Bernaud
- Department of Clinical Science, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals, Allschwil, Switzerland
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Beavers CJ, Effoe SA, Dobesh PP. Selatogrel: A Novel Subcutaneous P2Y12 Inhibitor. J Cardiovasc Pharmacol 2022; 79:161-167. [PMID: 34132688 DOI: 10.1097/fjc.0000000000001079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/25/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The use of a P2Y12 inhibitor as a component of dual antiplatelet therapy in patients with an acute coronary syndrome (ACS) is well established. However, the P2Y12 inhibitors currently available have pharmacokinetic limitations due to delayed absorption, lack of enteral access for administration with oral formulations, need for intravenous access with cangrelor, or need for metabolization to be ideal in the critical 3-hour window during an ACS. Selatogrel is a novel, potent, reversible, and selective 2-phenylprimdine-4-carboxamide administered subcutaneously under development. Results from preclinical, phase 1, and phase 2 trials have confirmed that the agent provides sustained and reversible P2Y12 platelet inhibition with an acceptable safety profile. The most commonly reported adverse effects include minor bleeding and dyspnea. Phase 3 trials are being designed to understand the critical role this agent can play in upstream management of patients with ACS including a more defined understanding of the adverse effect profile, how to transition from this agent to an oral agent, who will be administering, and does this agent allow for a safe and quick transition to coronary artery bypass graft surgery if needed. Should it obtain approval, selatogrel has the potential to provide a unique and advantageous mechanism for P2Y12 inhibition.
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Affiliation(s)
- Craig J Beavers
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
- Department of Pharmacy Practice and Science, Cardiovascular Services, Baptist Health Paducah, Lexington, KY; and
| | - Samuel Aaron Effoe
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Paul P Dobesh
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE
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Jourdi G, Lordkipanidzé M, Philippe A, Bachelot-Loza C, Gaussem P. Current and Novel Antiplatelet Therapies for the Treatment of Cardiovascular Diseases. Int J Mol Sci 2021; 22:ijms222313079. [PMID: 34884884 PMCID: PMC8658271 DOI: 10.3390/ijms222313079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022] Open
Abstract
Over the last decades, antiplatelet agents, mainly aspirin and P2Y12 receptor antagonists, have significantly reduced morbidity and mortality associated with arterial thrombosis. Their pharmacological characteristics, including pharmacokinetic/pharmacodynamics profiles, have been extensively studied, and a significant number of clinical trials assessing their efficacy and safety in various clinical settings have established antithrombotic efficacy. Notwithstanding, antiplatelet agents carry an inherent risk of bleeding. Given that bleeding is associated with adverse cardiovascular outcomes and mortality, there is an unmet clinical need to develop novel antiplatelet therapies that inhibit thrombosis while maintaining hemostasis. In this review, we present the currently available antiplatelet agents, with a particular focus on their targets, pharmacological characteristics, and patterns of use. We will further discuss the novel antiplatelet therapies in the pipeline, with the goal of improved clinical outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Correspondence: (G.J.); (P.G.)
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Aurélien Philippe
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
- Service d’Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Christilla Bachelot-Loza
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
| | - Pascale Gaussem
- INSERM, Innovations Thérapeutiques en Hémostase, Université de Paris, F-75006 Paris, France; (A.P.); (C.B.-L.)
- Service d’Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
- Correspondence: (G.J.); (P.G.)
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Kunkel KJ, Lemor A, Mahmood S, Villablanca P, Ramakrishna H. 2021 Update for the Diagnosis and Management of Acute Coronary Syndromes for the Perioperative Clinician. J Cardiothorac Vasc Anesth 2021; 36:2767-2779. [PMID: 34400062 PMCID: PMC8297970 DOI: 10.1053/j.jvca.2021.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized.
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Affiliation(s)
| | - Alejandro Lemor
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Shazil Mahmood
- Division of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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Schilling U, Dingemanse J, Dobrow M, Baumann M, Riederer MA, Juif PE, Ufer M. Insights from In Vitro and Clinical Data to Guide Transition from the Novel P2Y12 Antagonist Selatogrel to Clopidogrel, Prasugrel, and Ticagrelor. Thromb Haemost 2021; 121:755-766. [PMID: 33412611 DOI: 10.1055/s-0040-1721773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Reduced pharmacodynamic (PD) effects of irreversible oral P2Y12 receptor antagonists have been reported when administered during cangrelor infusion. Therefore, the PD interaction liability of the novel P2Y12 receptor antagonist selatogrel with irreversible (i.e., clopidogrel, prasugrel) and reversible (i.e., ticagrelor) oral P2Y12 receptor antagonists was investigated in vitro and in healthy subjects. In vitro, selatogrel reduced the effects of clopidogrel and prasugrel in a concentration-dependent manner, while additive effects were observed for the combination of selatogrel and ticagrelor. Accordingly, a single-center, randomized, double-blind, two-way crossover study was conducted consisting of six groups. In each group (N = 12), an open-label loading dose of 300 or 600 mg clopidogrel, 60 mg prasugrel, or 180 mg ticagrelor was administered 30 minutes (i.e., at t max of selatogrel) or 12 hours after a single subcutaneous dose of 16 mg selatogrel or placebo. Inhibition of platelet aggregation (IPA) was assessed at various time points up to 48 hours. Reduced IPA was determined when clopidogrel or prasugrel was administered 30 minutes after selatogrel (∼40 and 70% lower IPA, respectively, at 24 hours postdosing). However, when administering prasugrel 12 hours after selatogrel, IPA was not impacted (>90% IPA) and in the case of clopidogrel reduced effects were partially mitigated. Similar IPA was determined for ticagrelor when administered 30 minutes after selatogrel or placebo. In conclusion, reduced IPA was observed for clopidogrel and prasugrel when administered after selatogrel, which can be mitigated by applying an appropriate time interval. No PD interaction with ticagrelor was observed.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Martine Baumann
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Markus A Riederer
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Pierre-Eric Juif
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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