Impact of the proton pump inhibitors and CYP2C19*2 polymorphism on platelet response to clopidogrel as assessed by four platelet function assays

Factors associated with clopidogrel resistance and clinical outcomes in ischemic cerebrovascular disease: A retrospective study

OBJECTIVE

Clopidogrel resistance may lead to the recurrence of cerebrovascular diseases. We aimed to identify potential factors associated with clopidogrel resistance and evaluate the clinical outcomes of the patients.

MATERIALS AND METHODS

In this retrospective study, patients with ischemic cerebrovascular disease treated with clopidogrel were included and classified into 2 groups according to the adenosine diphosphate (ADP)-induced platelet aggregation. Patients with the ADP inhibition rate of <30 % were included in clopidogrel resistance group, otherwise were included in clopidogrel sensitive group. CYP2C19 genotype and other clinical data were analyzed to identify factors and clinical features in the multivariate analysis. The outcomes were vascular events in 6 months.

RESULTS

In total, 139 patients were enrolled with 81 (58.27 %) in clopidogrel sensitive group and 58 (41.73 %) in clopidogrel resistance group. Female and CYP2C19 *2*3 carrying were risk factors for clopidogrel resistance, and female was an independent risk factor (OR 2.481, 95 % CI 1.066-5.771, P=0.035). The clopidogrel resistance group showed a higher use rate of argatroban (P=0.030) and a lower arachidonic acid-induced inhibition of platelet aggregation (P=0.036). Clopidogrel resistance was related to the progressing stroke (HR 3.521, 95 % CI 1.352-9.170, P=0.010), but had no influence on the bleeding events (P>0.05).

CONCLUSIONS

The risk of clopidogrel resistance increased significantly in female patients. Patients with clopidogrel resistance may have an increased incidence of stroke progression in the acute phase.

Purinergic signaling: a potential therapeutic target for ischemic stroke

Pathogenesis of ischemic stroke is mainly characterized by thrombosis and neuroinflammation. Purinergic signaling pathway constitutes adenosine triphosphate (ATP), adenosine diphosphate (ADP), adenosine monophosphate (AMP), and adenosine (ADO). ATP is hydrolyzed to ADP and then to AMP by extracellular nucleotidase CD39; AMP is subsequently converted to adenosine by CD73. All these nucleotides and nucleosides act on purinergic receptors protecting against thrombosis and inhibit inflammation. In addition, many physical methods have been found to play a neuroprotective role through purinergic signaling. This review mainly introduces the role and potential mechanism of purinergic signalings in the treatment of ischemic stroke, so as to provide reference for seeking new treatment methods for stroke.

Systematic Review and Meta-analysis: The Effects of Prophylactic Proton Pump Inhibitor Treatment in Patients With Coronary Heart Disease Receiving Dual Antiplatelet Therapy

Dual antiplatelet therapy (DAPT) and proton pump inhibitors (PPIs) are widely used in clinical treatment. However, the pharmacokinetic interaction between PPIs and DAPT is still unclear in patients with cardiovascular disease. This systematic review and meta-analysis aimed to evaluate the risks and benefits of the combination of PPI and DAPT in patients with coronary heart disease. The PubMed, EMBASE, Cochrane, and Web of Science databases were systematically searched from inception to April 1, 2020, for eligible studies. The outcomes investigated in this study included major adverse cardiovascular events, myocardial infarction, all-cause death, gastrointestinal complications, and platelet function testing. Studies were excluded from the review if other gastrointestinal medication or aspirin or P2Y12 receptor inhibitor monotherapy was administered. The review included 52 studies, and data from 40 studies were extracted for meta-analysis. No association was found between the risk of adverse clinical outcomes and the combination of PPI and DAPT based on the randomized controlled trial data (risk ratio: 0.98; 95% confidence interval: 0.87-1.09; P = 0.877; I2 = 0%). However, an increased risk of adverse clinical outcomes due to the use of PPIs was observed in patients treated with DAPT based on the data from observational studies (risk ratio: 1.259; 95% confidence interval: 1.079-1.468; P = 0.003; I2 = 67.8%), although the heterogeneity of these studies was high. In conclusion, this systematic review and meta-analysis demonstrated that pharmacokinetic interactions between PPI and DAPT do not lead to adverse clinical outcomes.

Risk of major adverse cardiovascular events for concomitant use of clopidogrel and proton pump inhibitors in patients inheriting CYP2C19 loss-of-function alleles: meta-analysis

Background Efficacy of clopidogrel may be diminished due to either co-administration of proton pump inhibitors or carrying CYP2C19 loss-of-function alleles. However, patients may be at greater risk of major adverse cardiovascular events if taking clopidogrel together with proton pump inhibitors and also inherited the CYP2C19 loss-of-function alleles which may cause further reduction of clopidogrel efficacy. This is due to the cumulative effects of drug-drug interactions and drug-gene interactions collectively referred to as multifactorial drug-gene interactions. Aim of the review The aim of this analysis was to estimate aggregated risk of major adverse cardiovascular events for either coronary heart disease or stroke patients with multifactorial drug-gene interactions versus clopidogrel alone with or without drug-gene interactions. Methods Literatures were searched using different resources based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analysis was performed using RevMan software following either fixed/random effects model based on the levels of heterogeneity. A p value < 0.05 (2-sided) was considered statistically significant. Results In total, five studies consisting 8,802 patients of coronary artery diseases or stroke were included in this meta-analysis in which 3,767 were prescribed clopidogrel alone, 1,931 were concomitantly taking clopidogrel and PPIs, 2,146 were carrying CYP2C19 loss-of-function alleles and 958 were taking both clopidogrel and proton pump inhibitors while also carrying CYP2C19 loss-of-function alleles. It was found that patients with multifactorial drug-gene interactions were associated with significantly increased risk of major adverse cardiovascular events compared to those taking clopidogrel alone without CYP2C19 loss-of-function alleles (12% vs. 5.8%; RR 1.73; 95% CI 1.12-2.67; p = 0.01). Patients with multifactorial drug-gene interactions were also associated with significantly increased risk of major adverse cardiovascular events compared to drug-gene interactions (RR 1.63; 95% CI 1.31-2.03; p < 0.0001). Patients taking clopidogrel with proton pump inhibitors were also associated with 35% significantly increased risk of major adverse cardiovascular events compared to those taking only clopidogrel (RR 1.35; 95% CI 1.11-1.65; p = 0.003). Conclusion Patients inheriting CYP2C19 loss-of-function alleles have significantly increased risk of major adverse cardiovascular events when taking clopidogrel and proton pump inhibitors concurrently.

A SNP involved in alternative splicing of ABCB1 is associated with clopidogrel resistance in coronary heart disease in Chinese population

Although many scientists are studying the association between genetic polymorphism of ABCB1 and CR in patients, the molecular mechanism has not been further studied in patients with CHD. This study investigated the relationship between SNP of the ABCB1 gene in patients with CHD and CR, and whether the polymorphism of the ABCB1 gene affects the AS of the gene. 741 patients were enrolled in the study, 316 CR cases and 425 NCR cases. The correlation between CR risk and clinical-pathological characteristics were studied. Additionally, the five SNPs were analysed by PCR and Mass Array genotyping methods. Furthermore, silicon analysis was used to predict whether the polymorphism affects the process of AS. Results showed that there was a significant correlation between rs1045642 polymorphism and CR in genotyping and allele analysis. The rs1045642 polymorphism of the ABCB1 gene of CHD patients carrying the A allele are more likely to develop CR. Silicon analysis showed that rs1045642 generated a new ESE sequence which might affect AS of ABCB1 gene. We hypothesize that the mechanism of CR might be caused by a change in the AS caused by the polymorphism of the gene. Thus, this work provides guidance for the clinical use of clopidogrel.

Association of FMO3 rs1736557 polymorphism with clopidogrel response in Chinese patients with coronary artery disease

PURPOSE

Dual antiplatelet therapy with aspirin and clopidogrel is commonly used for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention to prevent stent thrombosis and ischemic events. However, some patients show high on-treatment platelet reactivity (HTPR) during clopidogrel therapy. Genetic factors such as loss-of-function variants of CYP2C19 are validated to increase the risk of HTPR. Flavin-containing monooxygenase 3 (FMO3) is reported to be associated with potency of platelet responsiveness and thrombosis. This study aimed to explore the association between FMO3 rs1736557 polymorphism and clopidogrel response.

METHODS

Five hundred twenty-two Chinese CAD patients treated with dual antiplatelet therapy were recruited from Xiangya Hospital. After oral administration of 300 mg loading dose (LD) clopidogrel for 12-24 h or 75 mg daily maintenance dose (MD) clopidogrel for at least 5 days, the platelet reaction index (PRI) was determined by vasodilator-stimulated phosphoprotein-phosphorylation assay. FMO3 rs1736557, CYP2C19*2, and CYP2C19*3 polymorphisms were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Mean PRI value was significantly higher in CYP2C19 poor metabolizers (PMs) and intermediate metabolizers (IMs) than the extensive metabolizers (EMs) (p < 0.001). In addition, FMO3 rs1736557 AA homozygotes showed significantly lower PRI as compared with carriers of the major rs1736557 G allele in the entire cohort and in the MD cohort (p = 0.011, p = 0.008, respectively). The risk of HTPR was decreased significantly in carriers of the rs1736557 A allele (AA vs GG: OR = 0.316, 95% CI: 0.137-0.726, p = 0.005; AA vs GA: OR = 0.249, 95% CI: 0.104-0.597, p = 0.001; AA vs GG+GA: OR = 0.294, 95% CI: 0.129-0.669, p = 0.002), and the association was observed mainly in patients carrying the CYP2C19 LOF allele and in those administered with MD.

CONCLUSION

The FMO3 rs1736557 AA genotype was related to an increased the antiplatelet potency of clopidogrel in Chinese CAD patients. Additional studies are required to verify this finding.

Body weight, CYP2C19, and P2Y12 receptor polymorphisms relate to clopidogrel resistance in a cohort of Chinese ischemic stroke patients with aspirin intolerance

PURPOSE

Dual antiplatelet therapy (DAT) with clopidogrel and aspirin is not suitable for clopidogrel resistance (CR) patients with aspirin intolerance. To investigate the prevalence of CR in patients with aspirin intolerance after ischemic stroke (IS) and to assess the relationship between CR and CYP2C19, P2Y12 receptor genotypes in patients with aspirin intolerance after IS.

METHODS

We enrolled 126 IS patients with aspirin intolerance from Han Chinese in Shangqiu from January 2016 to November 2018. All IS patients with aspirin intolerance were treated with clopidogrel for 7 days. Adenosine diphosphate-induced platelet inhibition rate was measured by thrombelastography (TEG) mapping assay. The SNPs CYP2C19*2, CYP2C19*3, and P2Y12 receptor (52 G >T) were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Binary logistic regression analyses were performed using SPSS version 20.0.

RESULTS

The prevalence of CR in patients with aspirin intolerance after IS was approximately 31.0%. Multivariate regression analysis showed that body weight (OR 1.091 (95% CI 1.031-1.155), p = 0.003), CYP2C19 phenotype intermediate metabolizer (IM) (OR 3.820 (95% CI 1.021-14.288), p = 0.046), and CYP2C19 phenotype poor metabolizer (PM) (OR 14.481 (95% CI 2.791-75.129), p = 0.001) significantly increased the risk of CR and P2Y12 receptors (52 G >T) (OR 3.498 [95% CI 1.251-9.784], p = 0.017) increased the risk of CR.

CONCLUSIONS

The patients with high body weight, the CYP2C19 phenotypes, and P2Y12 receptor (52 G >T) variant alleles are at risk of CR during clopidogrel treatment in Chinese IS patients with aspirin intolerance. The higher body weight and relevant polymorphisms may help to predict CR in Chinese IS patients with aspirin intolerance.

Interaction of CYP2C19 G681A polymorphism and omeprazole on clopidogrel responsiveness and impact in patients with acute coronary syndrome

OBJECTIVE

The aim of this study was to explore the individual effects of the CYP2C19 G681A polymorphism and omeprazole use and their interaction on clopidogrel responsiveness in acute coronary syndrome (ACS). The CYP2C19 G681A polymorphism and omeprazole use were both known for retarding the effects of clopidogrel under broad cardiovascular conditions; however, data from ACS patients were limited.

METHODS

We conducted a cross-sectional study of 102 ACS patients who received clopidogrel before percutaneous coronary intervention. The platelet function was assessed by a Platelet Function Analyzer-200, in which clopidogrel hyporesponsiveness was defined as a closure time (CT) of ≤ 106 s. The CYP2C19 G681A polymorphism was investigated using the PCR-RFLP technique. Statistical analysis was performed by using χ test, Student's t-test, binary logistic regression, and receiver-operating characteristic (ROC) curve.

RESULTS

Carriages of the CYP2C19 681A allele and omeprazole use were present in 47.1 and 37.3% patients, respectively. The mean CT ± SD was 103.1 ± 1.7 s and the prevalence of clopidogrel hyporesponsiveness was 66.7%. The CT was significantly shorter in carriages of the 681A allele compared with the 681G allele (P = 0.002), but had no significant difference in patients with vs. without omeprazole use (P = 0.467). The ROC analysis of an effect on clopidogrel hyporesponsiveness of CYP2C19 G681A alone and combination with omeprazole use had area under the curve values of 0.654 and 0.672, respectively.

CONCLUSION

In ACS patients, the effect of the CYP2C19 G681A polymorphism on clopidogrel responsiveness, but not omeprazole use, is strong. However, a combination of both factors enhances clopidogrel hyporesponsiveness.

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

Background

Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms.

Summary

We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period.

Key Message

Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.

Two common mutations within CYP2C19 affected platelet aggregation in Chinese patients undergoing PCI: a one-year follow-up study

The effect of dual antiplatelet therapy, clopidogrel combined with aspirin, was influenced by CYP2C19 gene mutation and heterogeneity of population. Related studies remained controversial and limited, especially in Chinese. Total 3295 unrelated ACS Chinese patients undergoing percutaneous coronary intervention (PCI) were recruited and followed up to 1 year. Meanwhile, baseline and clinical data were retrieved. CYP2C19*2 and *3 were genotyped by sequencing. Associations of variants and metabolic types with platelet reactivity (PR) were analyzed by a logistic regression model. And, a Cox proportional hazards model was utilized to analyze survival data. Confounders included gender, age, smoking status, dosage of aspirin and clopidogrel, and BMI. It was found that patients with allele A in CYP2C19*2 and *3 were susceptibility to high PR (OR, 95%CI and P values were 1.34, 1.20-1.50, <0.0001 and 1.42, 1.13-1.79, 0.0029, respectively) after taking clopidogrel. The PR increased along with the number of loss of function (LOF) allele increased and did in order of haplotype*1, *2, and *3. This research suggested that LOF alleles and risk haplotypes in CYP2C19 could significantly attenuate the response to clopidogrel, which resulted in platelet aggregation.

Concomitant Use of Proton-Pump Inhibitors and Clopidogrel Increases the Risk of Adverse Outcomes in Patients With Ischemic Stroke Carrying Reduced-Function CYP2C19*2

OBJECTIVE

Conflicting data exist as to whether proton-pump inhibitors (PPIs) diminish the efficacy of clopidogrel. The aim of this study was to investigate the association between cytochrome P450 ( CYP) genetic variants and clinical adverse outcomes of concomitant use of PPIs and clopidogrel by patients.

METHODS

We consecutively enrolled 523 patients with ischemic stroke receiving clopidogrel. Platelet aggregation was measured before and after 7 to 10 days of clopidogrel treatment. Single-nucleotide polymorphisms of CYP3A4, CYP3A5, CYP2C19*2, and CYP2C19*3 were examined using mass spectrometry. The primary outcome was a composite of recurrent ischemic stroke (RIS), myocardial infarction (MI), and vascular death that occurred during the 1-year follow-up period. The safety outcome was hemorrhagic episodes that occurred during the 1-year follow-up period.

RESULTS

This study comprised a total of 523 patients with IS, 96.3% (155/161) patients treated with PPIs and 95.9% (347/362) in patients treated without PPIs completed 1-year follow-up. The primary outcome was observed in 69 (13.7%) patients (56 RIS, 7 MI, and 6 died). There was no significant difference in the frequencies of primary outcome and safety outcome between patients treated with or without PPIs. The frequency of primary outcome was significantly higher in patients carrying CYP2C19*2 AG/AA genotype receiving PPIs compared with the same genotype in those not receiving PPIs. The PPIs used in patients carrying CYP2C19*2 AG/AA was independently associated with the primary outcome after adjusting for other risk factors.

CONCLUSIONS

The concomitant use of PPIs and clopidogrel may be associated with an increased risk of RIS, MI, or vascular death in patients with IS carrying reduced-function CYP2C19*2.

Impact of Cardiogenic Vomiting in Patients with STEMI: A Study From China

BACKGROUND Different patients with ST-elevation myocardial infarction (STEMI) have different symptoms. A third of them may have medical emergencies caused by symptoms such as vomiting and syncope. These concomitant symptoms may influence subsequent therapy and final outcomes. The aim of this study was to determine whether cardiogenic vomiting is a predictor of clinical outcomes in patients with STEMI. MATERIAL AND METHODS We classified 152 STEMI patients from different areas into 2 groups on the basis of vomiting: group A and group B. Their demographics and conditions of hospitalization were recorded. After follow-up, major adverse cardiac events (MACE) were regarded as study endpoints for the effect of cardiogenic vomiting in STEMI patients. RESULTS We found no significant difference in demographic and clinical characteristics of the 2 groups (P>0.05). The hospitalized conditions of group A were more serious than in group B. During a follow-up of 6 months, MACE rate was higher in vomiting patients (42; 67.7%) compared with group B (25; 27.8%). Multivariate Cox regression analysis revealed that cardiogenic vomiting was an independent predictor of clinical outcomes. CONCLUSIONS Cardiogenic vomiting is a useful predictor of major adverse cardiac events in STEMI patients for the hospitalization and after discharge.

Rationale and design of the RT-AF study: Combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention

OBJECTIVE

Optimal antithrombotic strategy for patients with concomitant coronary artery disease and atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is still controversial, and the role of novel antithrombotic agents has nerve been tested. Therefore, the aim of this study is to evaluate and overall safety and efficacy profile of the combination of rivaroxaban and ticagrelor in this particular population.

DESIGN

The RT-AF study is an open-label, randomized, active-controlled, multicenter clinical trial with up to 420 subjects enrolled in 5 centers. Eligible patients, who have a history or new onset paroxysmal, persistent, or permanent non-valvular AF, referred to the study centers with indications for PCI will be randomly assigned to receive triple therapy (including warfarin, clopidogrel and aspirin) or dual therapy (rivaroxaban and ticagrelor). All subjects will have clinical follow-up at discharge, at 30 days, 6 months and 12 months. The primary end point is major or clinically relevant non-major bleeding events at 12 months. The major secondary end point is the composite efficacy outcome of death, myocardial infarction, stent thrombosis and ischemic stroke.

CONCLUSION

The study will be sufficiently powered to provide data primarily regarding the safety of dual therapy with rivaroxaban and ticagrelor over the traditional triple therapy in patients with AF undergoing PCI at 12 months. It will also provide important information regarding the efficacy of the two different antithrombotic regimens. (ClinicalTrials.gov identifier: NCT02334254).

Comparison of Intravenous plus Oral Pantoprazole Therapy and Oral Pantoprazole Alone for Preventing Gastrointestinal Bleeding in Acute Coronary Syndrome Patients with High Bleeding Risk

BACKGROUND

It is unclear whether intravenous proton pump inhibition is more effective than oral administration in preventing gastrointestinal (GI) bleeding in high bleeding risk patients with acute coronary syndromes (ACS).

METHODS AND RESULTS

A total of 504 patients with ACS and high bleeding risk were randomly assigned into two groups. Study group (n=252) received intravenous pantoprazole for five days and subsequent oral pantoprazole for 12 months. Control group (n=252) received oral pantoprazole for 12 months. Major adverse cardiac events (death, re-infarction, re-revascularisation and stroke) and GI bleeding were registered after a follow-up of 12 months. No statistically significant differences were found in the major adverse cardiac events between the two groups after the follow-up (p >0.05). The incidence of major GI bleeding in the study group was lower than in the control group (1.2% vs. 3.9%, p=0.049). The bleeding rates in the first 30 days in the study group were also lower than in the control group (0.3% vs. 2.7%, p=0.032).

CONCLUSIONS

The main outcome of cardiac events did not differ between the treatment groups. Intravenous plus oral pantoprazole therapy seemed more effective than oral therapy alone in the prevention of GI bleeding in high bleeding risk patients with ACS.

Rationale and design of MANJUSRI trial: a randomized, open-label, active-controlled multicenter study to evaluate the safety of combined therapy with ticagrelor and warfarin in AF subjects after PCI-eS

BACKGROUND

Long-term oral anticoagulant treatment is obligatory in patients with atrial fibrillation (AF, score of CHA₂DS₂VASc≥2). When these patients undergo percutaneous coronary intervention with a drug-eluting stent (PCI-eS), there is also an indication for aspirin and clopidogrel treatment, according to the ESC Guidelines. However, triple therapy has been known to increase the risk of bleeding complications. Unfortunately, there is little prospective data available to resolve this issue. Therefore, it is imperative that an optimal therapy for AF patients with indications of both anticoagulation and antiplatelet intervention to prevent thrombotic complications without increasing the risk of bleeding is found.

OBJECTIVES

This prospective, randomized, multicenter study is going to assess the hypothesis that in persistent or permanent AF patients (score of CHA₂DS₂VASc≥2) after PCI-eS, the combination therapy of oral anticoagulation (warfarin) and ticagrelor (90 mg/bid) could reduce the risk of bleeding events.

DESIGN

A multicenter, active-controlled, open-label, randomized trial is to be performed to evaluate dual antithrombotic therapy (ticagrelor+warfarin) in persistent or permanent AF patients (score of CHA₂DS₂VASc≥2) after PCI-eS versus the combination of triple antithrombosis (clopidogrel+aspirin+warfarin). The primary endpoint is the overall bleeding up to 6 months, according to TIMI criteria and classifications. The secondary endpoints are the major bleeding events up to 6 months, according to TIMI criteria. The sample size is estimated at 296.

CONCLUSION

This study is intended to provide information about the safety characteristics of warfarin and ticagrelor in persistent or permanent AF patients after PCI-eS. No prospective randomized study has been conducted on the issue of antithrombotic therapy using warfarin and ticagrelor in these patients. Therefore, the MANJUSRI trial will help to explore and determine a new potential therapeutic regimen for AF patients after PCI-eS.

TRIAL REGISTRATION

Clinical Trials.gov # NCT02206815, registered July 30, 2014.

PA32540 for the secondary prevention of cardiovascular disease in patients at risk for aspirin-associated gastric ulcers

Prescribed in patients with a history of myocardial infarction, stroke, transient ischemic attack, coronary intervention or bypass surgery, aspirin is one of the medications most commonly used in the secondary prevention of cardiovascular diseases. It has become a mainstay of therapy after years of solid evidence supporting its efficacy in clinical trials. However, a number of risks and side effects accompany its benefits, including the notable risk of bleeding and gastrointestinal side effects. Numerous mechanisms have been proposed to attenuate these effects to promote adherence and to expand the population for which aspirin is a reasonable treatment option. A polypill or combination formulation that includes a proton pump inhibitor, a drug commonly prescribed alongside aspirin, is one potential avenue of therapy. One such combination pill, PA32540, has undergone Phase I and Phase III trials and shows promising safety and efficacy results in these preliminary trials.