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Alalawneh M, Awaisu A, Abdallah I, Elewa H, Danjuma M, Matar KM, ElKashlan AM, Elshayep Y, Ibrahim F, Rachid O. Pharmacokinetics of single-dose rivaroxaban under fed state in obese vs. non-obese subjects: An open-label controlled clinical trial (RIVOBESE-PK). Clin Transl Sci 2024; 17:e13853. [PMID: 38847347 PMCID: PMC11157419 DOI: 10.1111/cts.13853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/10/2024] Open
Abstract
The evidence of rivaroxaban's pharmacokinetics in obese compared with non-obese populations remains inconclusive. We aimed to compare the pharmacokinetic profile of rivaroxaban between obese and non-obese populations under fed state. Participants who met the study's eligibility criteria were assigned into one of two groups: obese (body mass index ≥35 kg/m2) or non-obese (body mass index 18.5-24.9 kg/m2). A single dose of rivaroxaban 20 mg was orally administered to each participant. Nine blood samples over 48 h, and multiple urine samples over 18 h were collected and analyzed for rivaroxaban concentration using ultra-performance liquid chromatography coupled with tandem mass detector. Pharmacokinetic parameters were determined using WinNonlin software. Thirty-six participants were recruited into the study. No significant changes were observed between obese and non-obese participants in peak plasma concentration, time to reach peak plasma concentration, area under the plasma concentration-time curve over 48 h or to infinity, elimination rate constant, half-life, apparent volume of distribution, apparent clearance, and fraction of drug excreted unchanged in urine over 18 h. Rivaroxaban's exposure was similar between the obese and non-obese subjects, and there were no significant differences in other pharmacokinetic parameters between the two groups. These results suggest that dose adjustment for rivaroxaban is probably unwarranted in the obese population.
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Affiliation(s)
| | - Ahmed Awaisu
- College of Pharmacy, Health SectorQatar UniversityDohaQatar
| | - Ibtihal Abdallah
- Internal Medicine, Hamad General HospitalHamad Medical CorporationDohaQatar
| | - Hazem Elewa
- College of Pharmacy, Health SectorQatar UniversityDohaQatar
| | - Mohammed Danjuma
- Internal Medicine, Hamad General HospitalHamad Medical CorporationDohaQatar
- College of Medicine, Health SectorQatar UniversityDohaQatar
| | - Kamal M. Matar
- Department of Pharmacology & Therapeutics, Faculty of PharmacyKuwait UniversityKuwait CityKuwait
| | - Akram M. ElKashlan
- Department of Biochemistry, Faculty of PharmacyUniversity of Sadat CitySadat CityEgypt
- International Center for Bioavailability, Pharmaceutical, and Clinical ResearchCairoEgypt
| | - Yasser Elshayep
- International Center for Bioavailability, Pharmaceutical, and Clinical ResearchCairoEgypt
| | - Fathy Ibrahim
- International Center for Bioavailability, Pharmaceutical, and Clinical ResearchCairoEgypt
- Faculty of PharmacyAl‐Azhar UniversityCairoEgypt
| | - Ousama Rachid
- College of Pharmacy, Health SectorQatar UniversityDohaQatar
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2
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Nwanosike EM, Merchant HA, Sunter W, Ansari MA, Conway BR, Hasan SS. Direct oral anticoagulants and the risk of adverse clinical outcomes among patients with different body weight categories: a large hospital-based study. Eur J Clin Pharmacol 2024; 80:163-173. [PMID: 37978999 PMCID: PMC10781787 DOI: 10.1007/s00228-023-03593-2] [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: 06/12/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Through predictable pharmacokinetics-including a convenient fixed-dose regimen, direct oral anticoagulants (DOACs) are preferred over previous treatments in anticoagulation for various indications. However, the association between higher body weight and the risk of adverse consequences is not well studied among DOAC users. We aim to explore the association of body weight and adverse clinical outcomes in DOAC users. METHODS A total of 97,413 anonymised DOAC users in a tertiary care setting were identified following structured queries on the electronic health records (EHRs) to extract the feature-rich anonymised dataset. The prepared dataset was analysed, and the features identified with machine learning (ML) informed the adjustments of covariates in the multivariate regression analysis to examine the association. Kaplan-Meier analysis was performed to evaluate the mortality benefits of DOACs. RESULTS Among DOAC users, the odds of adverse clinical outcomes, such as clinically relevant non-major bleeding (CRNMB), ischaemic stroke, all-cause mortality, and prolonged hospital stay, were lower in patients with overweight, obesity, or morbid obesity than in patients with normal body weight. The odds of ischaemic stroke (OR 0.42, 95% CI: 0.36-0.88, p = 0.001) and all-cause mortality (OR 0.87, 95% CI: 0.81-0.95, p = 0.001) were lower in patients with morbid obesity than in patients with normal body weight. In the Kaplan-Meier analysis, apixaban was associated with a significantly lower rate of mortality overall and in obesity and overweight subgroups than other DOACs (p < 0.001). However, rivaroxaban performed better than apixaban in the morbid obesity subgroup (p < 0.001). CONCLUSION This study shows the positive effects of DOAC therapy on clinical outcomes, particularly in patients with high body weight. However, this still needs validation by further studies particularly among patients with morbid obesity.
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Affiliation(s)
- Ezekwesiri Michael Nwanosike
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Hamid A Merchant
- Department for Bioscience, School of Health, Sport and Bioscience, the University of East London, London, E16 2RD, UK
| | - Wendy Sunter
- Calderdale and Huddersfield Pharmacy Services, Anticoagulation Services, Calderdale and Huddersfield NHS Foundation Trust Hospitals, Lindley, Huddersfield, HD3 3EA, UK
| | - Muhammad Ayub Ansari
- School of Computing and Engineering, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK.
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Rueda-Camino JA, Barba R, Otálora S, Bura-Riviere A, Visonà A, Mahé I, Alda-Lozano A, Alfonso Megido J, Pacheco-Gómez N, Rosovsky RP, Monreal M. Real life results of direct-acting oral anticoagulants recommended-dose in obese vs normal-weight patients with venous thromboembolism. Thromb Res 2024; 233:165-172. [PMID: 38070219 DOI: 10.1016/j.thromres.2023.12.001] [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: 08/30/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/01/2024]
Abstract
BACKGROUND There is scarce evidence on the effectiveness and safety of recommended-dose direct acting oral anticoagulants (DOACs) in obese patients with venous thromboembolism (VTE). MATERIAL AND METHODS We used the data in the RIETE registry to compare the rates of VTE recurrences and major bleeding during long-term therapy with DOACs at recommended doses in patients with body mass index ≥30 kg/m2 (obese) vs. those with BMI 18.5-24.9 kg/m2 (normal weight). We performed regression models with competing risks for death. RESULTS From January 2013 through October 2022, 2885 obese patients and 2676 with normal weight in RIETE received rivaroxaban (n = 3020), apixaban (n = 1754), edoxaban (n = 636) or dabigatran (n = 151). Median age was 63 years and 52 % were female. At baseline, obese patients were more likely to have diabetes (18.6 % vs. 8.4 %), hypertension (51.9 % vs. 31.4 %) or pulmonary embolism (67.7 % vs. 61 %), and less likely to have renal insufficiency (5.3 % vs. 16 %) or anaemia (21.8 % vs. 28 %%). During anticoagulation (median, 147 vs. 101 days), the obese had a similar rate of VTE recurrences (1.71 vs. 2.14 events per 100 patients-years; hazard ratio (HR): 0.81; 95 % CI: 0.49-1.34) or major bleeding (1.45 vs. 1.76 per 100 patients-years; HR: 0.91; 95 % CI: 0.52-1.59) than those with normal weight. These findings persisted after multivariable analysis (recurrent VTE, HR: 0.80; 95 % CI: 0.48-1.32; major bleeding, HR: 1.11; 95 % CI: 0.60-2.07). CONCLUSION The use of DOACs at recommended doses in obese patients with VTE was associated with similar rates of VTE recurrences or major bleeding than in patients with normal weight.
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Affiliation(s)
- José Antonio Rueda-Camino
- Department of Internal Medicine, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Health Research Institute Fundación Jiménez Díaz, Madrid, Spain.
| | - Raquel Barba
- Department of Internal Medicine, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Health Research Institute Fundación Jiménez Díaz, Madrid, Spain
| | - Sonia Otálora
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | | | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Isabelle Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris (AP-HP), Colombes, France; Université Paris Cité, France, INSERM UMR-S-1140, Paris, France
| | - Alicia Alda-Lozano
- Department of Internal Medicine, Hospital Reina Sofía, Tudela, Navarra, Spain
| | | | | | - Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Talerico R, Pola R, Klok FA, Huisman MV. Direct-Acting Oral Anticoagulants in patients at extremes of body weight: a review of pharmacological considerations and clinical implications. TH OPEN 2024; 8:e31-e41. [PMID: 38197017 PMCID: PMC10774013 DOI: 10.1055/s-0043-1776989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/16/2023] [Indexed: 01/11/2024] Open
Abstract
Patients at extremes of body weight are underrepresented in randomized controlled trials of direct-acting oral anticoagulants (DOACs). Therefore, their optimal anticoagulant treatment remains a topic of debate. The aim of this narrative review is to summarize the evidence on the pharmacokinetic and pharmacodynamic profile of DOACs for treating patients at extremes of body weight in venous thromboembolism (VTE) and in the prevention of cardioembolic stroke in nonvalvular atrial fibrillation (NVAF). A literature search was conducted in the main bibliographic databases, and the most relevant reviews and original articles on the topic were selected. Although data in these patient groups are limited, apixaban and rivaroxaban show a favorable pharmacokinetic and pharmacodynamic profile in obese VTE treatment and NVAF patients and, in the case of apixaban, also in underweight patients. In particular, these drugs demonstrated comparable efficacy and safety to standard therapy. Very few data were available for dabigatran and edoxaban; the latter drug was safer at a lower dose, mainly in underweight patients. Our findings are in line with the last International Society of Haemostasis and Thrombosis position paper and European Heart Rhythm Association 2021 practical guide, suggesting the use of apixaban and rivaroxaban in morbidly obese patients (>120 kg or body mass index ≥40 kg/m 2 ) and the reduced dosage of edoxaban in low-weight patients. Future studies should focus on large populations of patients at extremes of body weights to acquire more clinical and pharmacokinetic evidence on all available DOACs, especially those currently less investigated.
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Affiliation(s)
- Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- IRCCS San Raffaele, Rome, Italy
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frederikus Albertus Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Menno Volkert Huisman
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
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5
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [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: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Alalawneh M, Rachid O, Abdallah I, Mahfouz A, Elewa H, Danjuma MIM, Mohamed AE, Awaisu A. Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data. Eur J Clin Pharmacol 2023; 79:1675-1685. [PMID: 37816816 PMCID: PMC10663176 DOI: 10.1007/s00228-023-03572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/17/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To investigate real-world prescribing trends and clinical outcomes based on body mass index (BMI) categorization in patients who received rivaroxaban therapy. METHODS This was a retrospective cohort study involving all patients who received rivaroxaban therapy across all Hamad Medical Corporation (HMC) hospitals from 2015 to 2020. RESULTS The number of patients initiated on rivaroxaban therapy significantly increased from 152 (3.3%) in 2015 to 1342 (28.9%) in 2020 (p <0.001). Within BMI categories, a similar increasing trend was observed in underweight, normal, and overweight patients, while from 2018 to 2020, there was a decreasing trend in rivaroxaban prescribing in all obese classes. The prevalence rate of all-cause mortality differed significantly between the BMI groups, with the highest mortality being among morbidly obese patients (BMI ≥ 40 kg/m2) (p< 0.001). On the other hand, no significant differences were found between the BMI groups in terms of bleeding, pulmonary embolism, deep vein thrombosis and stroke incidences. Multivariate logistic regression analyses showed that the likelihood of all-cause mortality was significantly higher in overweight and all categories of obese patients compared to underweight patients: overweight (OR: 5.3, 95% CI: 2.3-11.9, p< 0.001); obese class 1 (OR: 5.4, 95% CI: 2.3 - 12.2, p< 0.001); obese class 2 (OR: 6.5, 95% CI: 2.7 - 15.6, p< 0.001); and obese class 3 (OR: 3.7, 95% CI: 1.6 - 8.7, p = 0.003). CONCLUSIONS Rivaroxaban prescribing has significantly increased over the years across general population, with a noticeable decline in obese population during the last few years (from 2018 onwards). Furthermore, an appreciable association was evident between all-cause mortality and BMI of these patients.
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Affiliation(s)
- Majdoleen Alalawneh
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ousama Rachid
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ibtihal Abdallah
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Mahfouz
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Mohammed Ibn-Mas'ud Danjuma
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
- College of Medicine, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Asmaa Ezzeldin Mohamed
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Awaisu
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
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7
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Sattler L, Wimmer J, Herb A, Gerout AC, Feugeas O, Desprez D. Apixaban for treatment of venous thromboembolism in an obese patient with Glanzmann thrombasthenia. Res Pract Thromb Haemost 2023; 7:100183. [PMID: 37538495 PMCID: PMC10394540 DOI: 10.1016/j.rpth.2023.100183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 08/05/2023] Open
Abstract
Background Glanzmann thrombasthenia (GT) is a rare congenital platelet function disorder associated with a severe bleeding diathesis. Thrombotic manifestations remain a rare condition. We report here the first case of recurrent venous thromboembolism (VTE) successfully treated with apixaban in a patient with GT. Our patient's morbid obesity was an additional challenge. Key Clinical Question The Key Clinical Question was to determine if direct oral anticoagulants are suitable for patients with both obesity and GT. Clinical Approach In our patient, the first episode of VTE occurred after the use of a low dose of activated recombinant factor VII for a minor procedure, whereas the second was unprovoked. Administration of rivaroxaban very quickly led to the appearance of bleeding symptoms and subsequently led to poor compliance and extension of deep vein thrombosis. The patient was switched to apixaban, with very good efficacy and safety over the cumulative 18 months of use. Conclusion The last updated guidelines now recommend the use of rivaroxaban and apixaban for management of VTE in patients with obesity. Regarding patients with GT, there is still insufficient data on the use of direct oral anticoagulants. Management of thrombotic manifestations in these patients remains a rare and complex condition and could be improved by the creation of a specific international registry.
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Affiliation(s)
- Laurent Sattler
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jordan Wimmer
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Agathe Herb
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Anne-Cécile Gerout
- Service de pharmacie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Olivier Feugeas
- Centre de Ressource et Compétence des Maladies Hémorragiques Constitutionnelles, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Dominique Desprez
- Centre de Ressource et Compétence des Maladies Hémorragiques Constitutionnelles, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Potere N, Di Nisio M, Porreca E, Wang TF, Tagalakis V, Shivakumar S, Delluc A, Mallick R, Wells PS, Carrier M. Apixaban thromboprophylaxis in ambulatory patients with cancer and obesity: Insights from the AVERT trial. Thromb Res 2023; 226:82-85. [PMID: 37121015 DOI: 10.1016/j.thromres.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND The use of direct oral anticoagulants (DOACs) in obese patients is uncertain. It is unclear if body mass index (BMI) affects the safety and efficacy of DOACs for the primary prevention of venous thromboembolism (VTE) in high-risk ambulatory patients with cancer. We sought to determine the outcomes associated with the use of apixaban for the primary prevention of cancer-associated VTE according to BMI. METHODS The randomized, double-blinded, placebo-controlled AVERT trial evaluated apixaban thromboprophylaxis in intermediate-to-high risk ambulatory cancer patients receiving chemotherapy. For this post-hoc analysis, the primary efficacy and safety outcomes were objectively confirmed VTE and clinically relevant bleeding (major and clinically relevant non-major bleeding), respectively. Obesity was defined as BMI ≥30 kg/m2. RESULTS Among 574 patients randomized, 217 (37.8 %) patients had BMI ≥30 kg/m2. Obese patients were overall younger, more likely to be female, had higher creatinine clearance and hemoglobin, lower platelet count, and better ECOG performance status. Compared to placebo, apixaban thromboprophylaxis was associated with reduced VTE in both obese (hazard ratio [HR] 0.26; 95 % confidence interval [CI], 0.14-0.46; p < 0.0001) and non-obese (HR 0.54; 95%CI, 0.29-1.00; p = 0.049) patients. The HR for clinically relevant bleeding (apixaban vs. placebo) was numerically higher in obese (2.09; 95%CI, 0.96-4.51; p = 0.062) than non-obese subjects (1.23; 95%CI, 0.71-2.13; p = 0.46), but overall in line with the risks observed in the general trial population. CONCLUSIONS In the AVERT trial enrolling ambulatory cancer patients receiving chemotherapy, we found no substantial differences in the efficacy or safety of apixaban thromboprophylaxis across obese and non-obese subjects.
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Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Tzu-Fei Wang
- Department of Medicine University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Vicky Tagalakis
- Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, Quebec, Canada
| | - Sudeep Shivakumar
- Department of Medicine, Dalhousie University, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Aurélien Delluc
- Department of Medicine University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Phil S Wells
- Department of Medicine University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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9
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Talerico R, Pola R, Huisman MV, Klok FA. DOACs plasma levels in relation to clinical outcome. How far have we come? Thromb Res 2023; 225:16-21. [PMID: 36906474 DOI: 10.1016/j.thromres.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases - Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; IRCCS San Raffaele, Rome, Italy.
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases - Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Menno Volkert Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - Frederikus Albertus Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
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10
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Rosovsky RP, Kline-Rogers E, Lake L, Minichiello T, Piazza G, Ragheb B, Waldron B, Witt DM, Moll S. Direct Oral Anticoagulants in Obese Patients with Venous Thromboembolism: Results of an Expert Consensus Panel. Am J Med 2023; 136:523-533. [PMID: 36803697 DOI: 10.1016/j.amjmed.2023.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/18/2023]
Abstract
In clinical practice, direct oral anticoagulants (DOACs) are increasingly used for venous thromboembolism treatment and prevention. A substantial proportion of patients with venous thromboembolism are also obese. International guidance published in 2016 stated that DOACs could be used in standard doses in patients with obesity up to a body mass index [BMI] of 40 kg/m2, but should not be used in those with severe obesity (BMI > 40 kg/m2) owing to limited supporting data at the time. Although updated guidance in 2021 removed this limitation, some healthcare providers still avoid DOACs even in patients with lower levels of obesity. Furthermore, there are still evidence gaps regarding treatment of severe obesity, the role of peak and trough DOAC levels in these patients, use of DOACs after bariatric surgery, and appropriateness of DOAC dose reduction in the setting of secondary venous thromboembolism prevention. This document describes proceedings and outcomes of a multidisciplinary panel convened to review these and other key issues regarding DOAC use for treatment or prevention of venous thromboembolism in individuals with obesity.
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Affiliation(s)
- Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Eva Kline-Rogers
- University of Michigan, Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Leslie Lake
- National Blood Clot Alliance, Philadelphia, Pennsylvania
| | - Tracy Minichiello
- University of California, Department of Veterans Affairs, San Francisco, California
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bishoy Ragheb
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, Salt Lake City, Utah
| | - Stephan Moll
- Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
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11
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Transferability of Published Population Pharmacokinetic Models for Apixaban and Rivaroxaban to Subjects with Obesity Treated for Venous Thromboembolism: A Systematic Review and External Evaluations. Pharmaceutics 2023; 15:pharmaceutics15020665. [PMID: 36839986 PMCID: PMC9967935 DOI: 10.3390/pharmaceutics15020665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/03/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Apixaban and rivaroxaban have first-line use for many patients needing anticoagulation for venous thromboembolism (VTE). The pharmacokinetics of these drugs in non-obese subjects have been extensively studied, and, while changes in pharmacokinetics have been documented in obese patients, data remain scarce for these anticoagulants. The aim of this study was to perform an external validation of published population pharmacokinetic (PPK) models of apixaban and rivaroxaban in a cohort of obese patients with VTE. A literature search was conducted in the PubMed/MEDLINE, Scopus, and Embase databases following the PRISMA statement. External validation was performed using MonolixSuite software, using prediction-based and simulation-based diagnostics. An external validation dataset from the university hospitals of Brest and Rennes, France, included 116 apixaban pharmacokinetic samples from 69 patients and 121 rivaroxaban samples from 81 patients. Five PPK models of apixaban and 16 models of rivaroxaban were included, according to the inclusion criteria of the study. Two of the apixaban PPK models presented acceptable performances, whereas no rivaroxaban PPK model did. This study identified two published models of apixaban applicable to apixaban in obese patients with VTE. However, none of the rivaroxaban models evaluated were applicable. Dedicated studies appear necessary to elucidate rivaroxaban pharmacokinetics in this population.
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12
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Challenges and Possible Solutions to Direct-Acting Oral Anticoagulants (DOACs) Dosing in Patients with Extreme Bodyweight and Renal Impairment. Am J Cardiovasc Drugs 2023; 23:9-17. [PMID: 36515822 DOI: 10.1007/s40256-022-00560-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
This article aims to highlight the dosing issues of direct oral anticoagulants (DOACs) in patients with renal impairment and/or obesity in an attempt to develop solutions employing advanced data-driven techniques. DOACs have become widely accepted by clinicians worldwide because of their superior clinical profiles, more predictable pharmacokinetics, and hence more convenient dosing relative to other anticoagulants. However, the optimal dosing of DOACs in extreme bodyweight patients and patients with renal impairment is difficult to achieve using the conventional dosing approach. The standard dosing approach (fixed-dose) is based on limited data from clinical studies. The existing formulae (models) for determining the appropriate doses for these patient groups leads to suboptimal dosing. This problem of mis-dosing is worsened by the lack of standardized laboratory parameters for monitoring the exposure to DOACs in renal failure and extreme bodyweight patients. Model-informed precision dosing (MIPD) encompasses a range of techniques like machine learning and pharmacometrics modelling, which could uncover key variables and relationships as well as shed more light on the pharmacokinetics and pharmacodynamics of DOACs in patients with extreme bodyweight or renal impairment. Ultimately, this individualized approach-if implemented in clinical practice-could optimise dosing for the DOACs for better safety and efficacy.
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13
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Samoš M, Bolek T, Stančiaková L, Péč MJ, Brisudová K, Škorňová I, Staško J, Mokáň M, Kubisz P. Tailored Direct Oral Anticoagulation in Patients with Atrial Fibrillation: The Future of Oral Anticoagulation? J Clin Med 2022; 11:jcm11216369. [PMID: 36362597 PMCID: PMC9655219 DOI: 10.3390/jcm11216369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022] Open
Abstract
Direct oral anticoagulants (DOAC) are currently the drug of choice for drug prevention of stroke or systemic embolism in patients with atrial fibrillation (AF). However, repeated ischemic stroke or systemic embolism and bleeding while on DOAC is still a challenging clinical phenomenon in the management of future long-term anticoagulation. It is not known whether tailoring the DOAC therapy to achieve optimal therapeutic drug levels could improve the clinical course of DOAC therapy. To be able to tailor the therapy, it is necessary to have a valid laboratory method for DOAC level assessment, to be aware of factors influencing DOAC levels and to have clinical options to tailor the treatment. Furthermore, the data regarding clinical efficacy/safety of tailored DOAC regimes are still lacking. This article reviews the current data on tailored direct oral anticoagulation in patients with AF.
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Affiliation(s)
- Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
- Correspondence: ; Tel.: +421-907-612-943 or +421-43-4203-820
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
| | - Lucia Stančiaková
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood, Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia
| | - Martin Jozef Péč
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
| | - Kristína Brisudová
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
| | - Ingrid Škorňová
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood, Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia
| | - Ján Staško
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood, Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
| | - Peter Kubisz
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood, Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia
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14
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Erstad BL, Barletta JF. Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity. Ann Pharmacother 2022; 57:727-737. [PMID: 36258660 DOI: 10.1177/10600280221130456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of the study was to discuss the controversies surrounding the use and dosing of direct-acting oral anticoagulants (DOACs) in obese patients recognizing the limitations of the existing evidence base that preclude strong recommendations. DATA SOURCES A literature search of MEDLINE was performed (2020 to end August 2022) subsequent to recent guidelines using the following search terms: direct acting anticoagulants, obesity, rivaroxaban, apixaban, edoxaban, dabigatran, dabigatran etexilate, and clinical practice guidelines. STUDY SELECTION AND DATA ABSTRACTION English-language studies and those conducted in adults were selected. DATA SYNTHESIS The available randomized studies evaluating DOACs had relatively small numbers of patients with more extreme forms of obesity (body mass index [BMI] > 40 kg/m2) and none of the larger studies had a specific focus on dosing DOACs in obese patients. Recent guidelines by the International Society on Thrombosis and Haemostasis (ISTH) have specific recommendations for dosing DOACs in obesity. There are pharmacokinetic/pharmacodynamic and observational studies published before and after the ISTH guidelines with a focus on DOAC dosing in obese patients that generally support the recommendations in the guidelines, but most involved small numbers of patients usually with BMIs <45 kg/m2. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review discusses DOAC dosing in obesity with important considerations for clinicians related to DOAC choice and dosing. CONCLUSIONS Dosing alterations of DOACs do not appear to be necessary when used for either prophylaxis or treatment in patients with BMIs up to approximately 45 to 50 kg/m2, but research is needed for BMIs >50 kg/m2.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale Campus, Midwestern University, Glendale, AZ, USA
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15
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Alalawneh M, Awaisu A, Rachid O. Rivaroxaban Pharmacokinetics in Obese Subjects: A Systematic Review. Clin Pharmacokinet 2022; 61:1677-1695. [PMID: 36201149 PMCID: PMC9734246 DOI: 10.1007/s40262-022-01160-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a leading cause of morbidity and mortality globally. The direct oral anticoagulants, including rivaroxaban, are relatively novel therapeutic options in the treatment and prevention of VTE. There is a conflicting and inconclusive evidence surrounding the pharmacokinetics (PK) of rivaroxaban in patients with VTE who are obese. OBJECTIVES We conducted a systematic review to provide an overview, and to synthesize the available evidence in the current literature pertaining to rivaroxaban PK in obese subjects who are healthy or diseased. METHODS The PubMed, Embase, ScienceDirect, Rayyan, and Cochrane Library databases were systematically searched from 1 May 2021 through 28 February 2022. Studies investigating rivaroxaban PK in adult obese subjects were included in the review. Pertinent data, including anthropometric parameters, rivaroxaban dosage regimen, PK parameters, PK model, and outcome measures were extracted. Reference values of rivaroxaban PK parameters in the general population were used for comparison purposes. The review protocol was registered in the PROSPERO database (CRD42020177770). RESULTS In the 11 studies included in this systematic review, over 7140 healthy or diseased subjects received rivaroxaban therapy, with varying clinical indications in the diseased population. The reported PK parameters of rivaroxaban in obese subjects compared with reference values in the general population were variable. The reported values of the volume of distribution (Vd) among obese subjects (73.4-82.8 L) fell within the range of values reported/calculated for the general population (59.4-104 L), assuming complete bioavailability. However, some of the reported values of clearance (CL) in obese subjects (7.86-16.8 L.h-1) do not fall within the range of values reported/calculated for the general population (5.57-11.3 L.h-1). The reported maximum plasma concentrations in obese subjects versus the general population following a 10 mg dose were 149 vs. 143-180 µg.L-1, and following a 20 mg dose were 214-305 vs. 299-360 µg.L-1, respectively. The area under the plasma concentration versus time curves (AUC) over different intervals in obese subjects versus the general population following a 10 mg dose were 1155 (AUC from time zero to infinity [AUC∞]) vs. 1029 (AUC∞) µg.h.L-1; and 1204-2800 (AUC from time zero to 24 h [AUC24]) vs. 3200 (AUC24) µg.h.L-1, respectively, following a 20 mg dose. The reported values of half-life and time to reach the maximum plasma concentration in obese subjects versus the general population were not consistent across studies. CONCLUSION Variable changes and inconsistencies in different rivaroxaban PK parameters were reported in obese subjects. Further well-designed studies are warranted to better characterize the PK and clinical outcomes of rivaroxaban in subjects with obesity.
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Affiliation(s)
| | - Ahmed Awaisu
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | - Ousama Rachid
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
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16
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Fender AC, Gawalko M, Dobrev D. Direct oral anticoagulation and severe obesity - One size fits all? IJC HEART & VASCULATURE 2021; 37:100923. [PMID: 34934804 PMCID: PMC8654775 DOI: 10.1016/j.ijcha.2021.100923] [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] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Indexed: 01/14/2023]
Abstract
Oral anticoagulation is obligatory in patients with atrial fibrillation (AF) to prevent thromboembolic stroke. Direct direct oral anticoagulants (DOAC) exhibit improved safety over Vitamin K antagonists, but any interference in haemostasis can impact on bleeding. Optimal anticoagulation remains challenging particularly in patients with co-morbidities. International Society of Thrombosis and Haemostasis (ISTH) guidelines recommend avoiding DOAC in patients with severe obesity, and systematic data on individual DOAC drug concentrations, clinical efficacy and safety in relation to body weight are lacking. A new study now provides reassurance that DOAC are safe and effective in a real-world cohort of morbidly obese patients, going some way to fill the knowledge gap pertaining to optimal management of concomitant obesity and AF.
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Affiliation(s)
- Anke C Fender
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany
| | - Monika Gawalko
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany.,Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dobromir Dobrev
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany
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