1
|
McCarley SC, Murphy DA, Thompson J, Shovlin CL. Pharmacogenomic Considerations for Anticoagulant Prescription in Patients with Hereditary Haemorrhagic Telangiectasia. J Clin Med 2023; 12:7710. [PMID: 38137783 PMCID: PMC10744266 DOI: 10.3390/jcm12247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia that commonly results in bleeding but with frequent indications for therapeutic anticoagulation. Our aims were to advance the understanding of drug-specific intolerance and evaluate if there was an indication for pharmacogenomic testing. Genes encoding proteins involved in the absorption, distribution, metabolism, and excretion of warfarin, heparin, and direct oral anticoagulants (DOACs) apixaban, rivaroxaban, edoxaban, and dabigatran were identified and examined. Linkage disequilibrium with HHT genes was excluded, before variants within these genes were examined following whole genome sequencing of general and HHT populations. The 44 genes identified included 5/17 actionable pharmacogenes with guidelines. The 76,156 participants in the Genome Aggregation Database v3.1.2 had 28,446 variants, including 9668 missense substitutions and 1076 predicted loss-of-function (frameshift, nonsense, and consensus splice site) variants, i.e., approximately 1 in 7.9 individuals had a missense substitution, and 1 in 71 had a loss-of-function variant. Focusing on the 17 genes relevant to usually preferred DOACs, similar variant profiles were identified in HHT patients. With HHT patients at particular risk of haemorrhage when undergoing anticoagulant treatment, we explore how pre-emptive pharmacogenomic testing, alongside HHT gene testing, may prove beneficial in reducing the risk of bleeding and conclude that HHT patients are well placed to be at the vanguard of personalised prescribing.
Collapse
Affiliation(s)
- Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Daniel A. Murphy
- Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| | - Jack Thompson
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| |
Collapse
|
2
|
Grobost V, Hammi S, Pereira B, Guilhem A, Duffau P, Seguier J, Parrot A, Gautier G, Alric L, Kerjouan M, Le Guillou X, Simon D, Chaussavoine L, Rondeau-Lutz M, Leguy-Seguin V, Delagrange L, Lavigne C, Maillard H, Dupuis-Girod S. Antiplatelet and anticoagulant therapies in hereditary hemorrhagic telangiectasia: A large French cohort study (RETROPLACOTEL). Thromb Res 2023; 229:107-113. [PMID: 37437516 DOI: 10.1016/j.thromres.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND It is unclear whether hereditary hemorrhagic telangiectasia (HHT) patients can tolerate antithrombotic therapies (AT) including antiplatelet (AP) and/or anticoagulant (AC) agents. OBJECTIVES Primary endpoint was tolerance to AT in HHT. Secondary endpoints were to identify factors associated with major bleeding events (MBE) and premature discontinuation of AT. METHODS Retrospective multicenter study in French national HHT Registry patients exposed to AT. RESULTS We included 126 patients with 180 courses of AT. Median follow-up was 24 [11-52] months. Mean age was 65.6 ± 13.1 years. The first 3 months of AT exposure had an increased risk of hospitalization for hemorrhage (p < 0.001) and transfusions (p < 0.001). MBE (n = 63) occurred more frequently in the first 3 months of AT exposure (p < 0.001). Premature discontinuation of AT occurred in 61 cases. Rate of premature discontinuation was 29 % under both AP and AT therapy but significantly higher under dual AP therapy (n = 4/7, 57 % p = 0.008). Risk factors for MBE were: age ≥ 60 years (HR 2.34 [1.12;4.87], p = 0.023), prior hospitalization in the 3 months before starting AT for hemorrhage (HR 3.59 [1.93;6.66], p < 0.001) or transfusion (HR 3.15 [1.61;6.18], p = 0.001), previous history of gastro-intestinal bleeding (HR 2.71 [1.57;4.65], p < 0.001) or MBE (HR 4.62 [2.68;7.98], p < 0.001). Frequency of MBE did not differ between groups except for a higher risk in the dual AP group (HR 3.92 [1.37;11.22], p = 0.011). CONCLUSION Tolerance of AC or AP therapy was similar in HHT population but not dual AP therapy. We identified risk factors for MBE occurrence or premature discontinuation under AT.
Collapse
Affiliation(s)
- Vincent Grobost
- Service de Médecine Interne, Clermont-Ferrand University Hospital, CHU Estaing, 63000 Clermont-Ferrand, France.
| | - Sami Hammi
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Bruno Pereira
- Biostatistics Unit, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France
| | - Alexandre Guilhem
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Pierre Duffau
- Bordeaux University Hospital, Internal Medicine and Clinical Immunology Department, Université de Bordeaux, CNRS ImmunoConcEpT UMR 5164, 33000 Bordeaux, France
| | - Julie Seguier
- Département de Médecine Interne, Marseille University Hospital, 13000 Marseille, France
| | - Antoine Parrot
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie et Centre de Compétence de la Maladie de Rendu Osler, Hôpital Tenon, 75020 Paris, France
| | - Giovanni Gautier
- Nantes Université, Nantes University Hospital, Department of Internal and Vascular Medicine, 44000 Nantes, France
| | - Laurent Alric
- Internal Medicine-Digestive Medicine, CHU Rangueil Toulouse 3 University, 31000 Toulouse, France
| | - Mallorie Kerjouan
- Service de Pneumologie, Hôpital Pontchaillou, CHU Rennes, 35000 Rennes, France
| | - Xavier Le Guillou
- Medical Genetics Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Delphine Simon
- Service de Médecine Interne, CHU Charles Nicolle, 76000 Rouen, France
| | - Laurent Chaussavoine
- Centre Hospitalier Universitaire de Caen Normandie, Service de Médecine Vasculaire, 14000 Caen, France
| | - Murielle Rondeau-Lutz
- Service de Médecine Interne, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 67 091 Strasbourg cedex, France
| | | | - Laura Delagrange
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| | - Christian Lavigne
- Department of Internal Medicine, Angers University Hospital, 49100 Angers, France
| | - Hélène Maillard
- Department of Internal Medicine and Clinical Immunology, Referral Centre for rare systemic autoimmune diseases for North and North-West France (CeRAINO), CHU Lille, 59000, Lille, France
| | - Sophie Dupuis-Girod
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service de Génétique et centre de référence de la maladie de Rendu-Osler, 69677 Bron, France
| |
Collapse
|
3
|
Virk ZM, Zhang E, Rodriguez-Lopez J, Witkin A, Wong AK, Luther J, Lin AE, Ning M, Grabowski E, Holbrook EH, Al-Samkari H. Safety, tolerability, and effectiveness of anticoagulation and antiplatelet therapy in hereditary hemorrhagic telangiectasia. J Thromb Haemost 2023; 21:26-36. [PMID: 36695393 PMCID: PMC10082473 DOI: 10.1016/j.jtha.2022.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Antithrombotic therapy (anticoagulation and antiplatelet therapy) is frequently needed in patients with hereditary hemorrhagic telangiectasia (HHT); however, data describing and guiding its use are very limited. OBJECTIVES To investigate the safety, tolerability, and effectiveness of antithrombotic therapy in HHT in a cohort large enough to compare agents, evaluate for baseline predictors of premature discontinuation, and evaluate hematologic support requirements and healthcare utilization before and after antithrombitc therapy initiation. METHODS We performed a multicenter observational cohort study characterizing the outcomes of antithrombic therapy in adults with HHT. RESULTS A total of 119 patients with HHT with 187 discrete antithrombotic therapy episodes were included. Of these, 59 patients (50%) dose-reduced and/or prematurely discontinued therapy (including 52 patients [44%] who discontinued) due to worsened bleeding complications. Initiation at reduced dose intensity had a similar premature discontinuation rate (49%) as initiation at standard dose intensity (43%). In a multivariable logistic model, a history of gastrointestinal bleeding was associated with 3.25-fold odds of discontinuation (p = .001). Hemoglobin was significantly lower (10.8 g/dL vs 12.2 g/dL, p < .001), and the need for hematologic support (intravenous iron and/or red blood cell transfusion) was significantly higher (29 patients vs 12 patients, p = .004) in the 3 months after antithrombotic therapy initiation vs the 3 months before; emergency department visits and hospital admissions due to bleeding also increased. The rates of dose-reduction and/or premature discontinuation were similar regardless of the anticoagulant class (warfarin, 46%; heparin-based, 48%; direct oral anticoagulants, 44%) or with multiple simultaneous agents (44%) but were slightly lower with single-agent antiplatelet therapy (37%). Thromboembolism despite receiving antithrombotic therapy was common (18 patients, 15%) with varying outcomes. CONCLUSION Antithrombotic therapy is challenging in HHT, resulting in objectively higher morbidity and health care utilization from worsened bleeding. Discontinuation rates approached 50% regardless of the dose intensity at initiation or type of antithrombotic agent used and were higher in patients with a gastrointestinal bleeding history.
Collapse
Affiliation(s)
- Zain M Virk
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ellen Zhang
- Harvard Medical School, Boston, Massachusetts, USA
| | - Josanna Rodriguez-Lopez
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alison Witkin
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexandra K Wong
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jay Luther
- Harvard Medical School, Boston, Massachusetts, USA; Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Angela E Lin
- Harvard Medical School, Boston, Massachusetts, USA; Medical Genetics, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - MingMing Ning
- Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric Grabowski
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric H Holbrook
- Harvard Medical School, Boston, Massachusetts, USA; Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Institute, Boston, Massachusetts, USA
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|