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Douxfils J, Raskin L, Didembourg M, Donis N, Dogné JM, Morimont L, Beaudart C. Are natural estrogens used in contraception at lower risk of venous thromboembolism than synthetic ones? A systematic literature review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1428597. [PMID: 39220361 PMCID: PMC11362054 DOI: 10.3389/fendo.2024.1428597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024] Open
Abstract
Background Venous thromboembolism (VTE) poses a significant global health challenge, notably exacerbated by the use of combined oral contraceptives (COCs). Evidence mainly focuses on the type of progestogen used in COCs to establish the increased risk of VTE with less data assessed on the type of estrogen used. This meta-analysis aims to assess the risk of VTE associated with COCs containing synthetic estrogens like ethinylestradiol (EE) versus natural estrogens like estradiol (E2). Methods A systematic review and meta-analysis was conducted following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature searches were performed in December 2023 in MEDLINE and EMBASE to identify clinical studies comparing the VTE risk between COCs containing synthetic versus natural estrogens. Studies were selected through rigorous screening, and data extraction followed standardized protocols, with statistical analyses employing a random effects model. Results The search yielded five relevant studies, involving over 560,000 women/time, demonstrating a significant 33% reduction in VTE risk among users of natural estrogen-based COCs compared to synthetic estrogen-based COCs (OR 0.67, 95% CI 0.51-0.87). Stratification analyses using adjusted hazard ratios (HR) of the main observationnal studies showed a 49% reduced VTE risk of E2-based pills compared to EE in association with levonorgestrel. Discussion and conclusion Despite the longstanding use of EE-based COCs, emerging evidence supports a lower thrombotic risk associated with natural estrogens. This meta-analysis substantiates the lower VTE risk associated with natural estrogen-based COCs compared to synthetic alternatives, advocating for a re-evaluation of contraceptive guidelines to prioritize patient safety and reduce thrombotic risks.
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Affiliation(s)
- Jonathan Douxfils
- Qualiblood sa, QUALIresearch, Namur, Belgium
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- Department of Biological Hematology, Centre Hospitalier Universitaire Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Lucie Raskin
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Marie Didembourg
- Qualiblood sa, QUALIresearch, Namur, Belgium
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Jean-Michel Dogné
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Laure Morimont
- Qualiblood sa, QUALIresearch, Namur, Belgium
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Charlotte Beaudart
- Department of Pharmacy, Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Vrotniakaite-Bajerciene K, Carrier M. Venous thromboembolism and estrogen-dance with the devil in thrombosis medicine. J Thromb Haemost 2024; 22:2150-2152. [PMID: 39048267 DOI: 10.1016/j.jtha.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Kristina Vrotniakaite-Bajerciene
- Department of Internal Medicine, Division of Hematology, The Ottawa Hospital, Ottawa, Ontario, Canada; Department of Hematology and Central Hematology Laboratory, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Internal Medicine, Division of Hematology, The Ottawa Hospital, Ottawa, Ontario, Canada.
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3
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van Dievoet MA, Morimont L, Bouvy C, Gruson D, Stephenne X, Douxfils J. Biological variation of thrombin generation on ST Genesia. Int J Lab Hematol 2024; 46:564-567. [PMID: 38253351 DOI: 10.1111/ijlh.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024]
Affiliation(s)
- M A van Dievoet
- Hematology Department of Laboratory Medicine, Saint-Luc University Hospital, Brussels, Belgium
| | - L Morimont
- Department of Pharmacy, Faculty of Medicine, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | - C Bouvy
- Department of Pharmacy, Faculty of Medicine, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | - D Gruson
- Biochemistry Department of Laboratory Medicine, Saint-Luc University Hospital, Brussels, Belgium
| | - X Stephenne
- Pediatric Hepatology and Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - J Douxfils
- Department of Pharmacy, Faculty of Medicine, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
- Department of Biological Hematology, Centre Hospitalier Universitaire Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
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Light J, Abrams CM, Ilich A, Huang S, Zhu H, Baskin-Miller J, Sparkenbaugh EM. Disease severity drives risk of venous thrombotic events in women with sickle cell disease in a single-center retrospective study. Res Pract Thromb Haemost 2024; 8:102471. [PMID: 39099800 PMCID: PMC11295566 DOI: 10.1016/j.rpth.2024.102471] [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: 04/16/2024] [Revised: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 08/06/2024] Open
Abstract
Background Estrogen-containing hormonal contraception (HC) is a well-established risk factor for venous thromboembolism (VTE). Women with sickle cell disease (SCD) also have an increased risk of VTE. However, it is unknown if exposure to HC exacerbates the risk of VTE in women with SCD. Objectives Assess the impact of HC on VTE risk in women with SCD and explore additional risk factors contributing to VTE development. Methods We analyzed a retrospective cohort of women of reproductive age (15-49 years) with SCD at the University of North Carolina from 2010 to 2022. Results We identified 370 women with SCD, and 93 (25.1%) had a history of VTE. Among 219 women exposed to HC, 38 of 184 (20.6%) had a VTE while actively using HC, whereas 20 of 151 (13.2%) women never exposed to HC had a VTE. Of the patients exposed to HC, 64 of 184 (34.7%) were on estrogen-containing HC, with 120 of 184 (65.3%) using progestin-only formulations. Cox regression analysis found that progestin-only formulations increased VTE risk (hazard ratio: 2.03; 95% CI: 1.107-3.726, P < .05). However, when accounting for disease severity, the association between progestin-only treatment and VTE risk was not significant. Indeed, a nuanced analysis revealed that both severe (odds ratio: 11.79; 95% CI: 5.14-27.06; P < .001) and moderate (odds ratio: 4.37; 95% CI: 1.77-10.76; P = .001) disease increased risk compared with mild disease. Neither genotype nor hydroxyurea use influenced VTE risk. Conclusion Overall, we found that increased thrombotic risk is more likely influenced by disease status than HC exposure and should play a role in shared decision-making with patients.
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Affiliation(s)
- Jennifer Light
- Division of Hematology, Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pediatric Hematology and Oncology, University of Illinois Chicago at Peoria, Peoria, Illinois, USA
| | - Christina M. Abrams
- Division of Hematology/Oncology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anton Ilich
- Division of Hematology, Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shuai Huang
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hongtu Zhu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jacquelyn Baskin-Miller
- Division of Hematology, Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erica M. Sparkenbaugh
- Division of Hematology, Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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5
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Morimont L, Didembourg M, Bouvy C, Jost M, Taziaux M, Oligschlager Y, van Rooijen M, Gaspard U, Foidart JM, Douxfils J. Low thrombin generation in postmenopausal women using estetrol. Climacteric 2024; 27:193-201. [PMID: 38241059 DOI: 10.1080/13697137.2023.2292066] [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: 10/18/2023] [Accepted: 12/01/2023] [Indexed: 03/13/2024]
Abstract
OBJECTIVE Estetrol (E4) represents a novel estrogen of interest to relieve vasomotor symptoms. E4 activates the nuclear estrogen receptor α (ERα) but antagonizes the estradiol ERα-dependent membrane-initiated steroid signaling pathway. The distinct pharmacological properties of E4 could explain its low impact on hemostasis. This study aimed to assess the effect of E4 on coagulation in postmenopausal women, using the thrombin generation assay (TGA). METHODS Data were collected from a multicenter, randomized, placebo-controlled, dose-finding study in postmenopausal women (NCT02834312). Oral E4 (2.5 mg, n = 42; 5 mg, n = 29; 10 mg, n = 34; or 15 mg, n = 32) or placebo (n = 31) was administered daily for 12 weeks. Thrombograms and TGA parameters were extracted for each subject at baseline and after 12 weeks of treatment. RESULTS After 12 weeks of treatment, all treatment groups showed a mean thrombogram (±95% confidence interval [CI] of the mean) within the reference ranges, that is, the 2.5th-97.5th percentile of all baseline thrombograms (n = 168), as well as for TGA parameters. CONCLUSIONS The intake of E4 15 mg for 12 weeks led to significant but not clinically relevant changes compared to baseline as the mean values (±95% CI of the mean) remained within reference ranges, demonstrating a neutral profile of this estrogen on hemostasis.
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Affiliation(s)
- L Morimont
- QUALIresearch, Qualiblood s.a, Namur, Belgium
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - M Didembourg
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - C Bouvy
- QUALIresearch, Qualiblood s.a, Namur, Belgium
| | - M Jost
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Taziaux
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Y Oligschlager
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - M van Rooijen
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - J-M Foidart
- Estetra SRL, An affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
- Clinical Sciences Department, Faculty of Medicine, University of Liège, Liège, Belgium
| | - J Douxfils
- QUALIresearch, Qualiblood s.a, Namur, Belgium
- Clinical Pharmacology and Toxicology Research Unit (CPRU), Namur Research Institute for LIfe Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
- Department of Biological Hematology, Centre Hospitalier Universitaire Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
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6
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Özcan Ö, den Elzen WPJ, Hillebrand JJ, den Heijer M, van Loendersloot LL, Fischer J, Hamer H, de Jonge R, Heijboer AC. The effect of hormonal contraceptive therapy on clinical laboratory parameters: a literature review. Clin Chem Lab Med 2024; 62:18-40. [PMID: 37419659 DOI: 10.1515/cclm-2023-0384] [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: 04/15/2023] [Accepted: 06/14/2023] [Indexed: 07/09/2023]
Abstract
Hormonal contraceptives (HC) are widely used among women in reproductive ages. In this review, the effects of HCs on 91 routine chemistry tests, metabolic tests, and tests for liver function, hemostatic system, renal function, hormones, vitamins and minerals were evaluated. Test parameters were differently affected by the dosage, duration, composition of HCs and route of administration. Most studies concerned the effects of combined oral contraceptives (COC) on the metabolic, hemostatic and (sex) steroids test results. Although the majority of the effects were minor, a major increase was seen in angiotensinogen levels (90-375 %) and the concentrations of the binding proteins (SHBG [∼200 %], CBG [∼100 %], TBG [∼90 %], VDBP [∼30 %], and IGFBPs [∼40 %]). Also, there were significant changes in levels of their bound molecules (testosterone, T3, T4, cortisol, vitamin D, IGF1 and GH). Data about the effects of all kinds of HCs on all test results are limited and sometimes inconclusive due to the large variety in HC, administration routes and dosages. Still, it can be concluded that HC use in women mainly stimulates the liver production of binding proteins. All biochemical test results of women using HC should be assessed carefully and unexpected test results should be further evaluated for both methodological and pre-analytical reasons. As HCs change over time, future studies are needed to learn more about the effects of other types, routes and combinations of HCs on clinical chemistry tests.
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Affiliation(s)
- Ömer Özcan
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Wendy P J den Elzen
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jacquelien J Hillebrand
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Martin den Heijer
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Laura L van Loendersloot
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johan Fischer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henrike Hamer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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Kobayashi T, Hirayama M, Nogami M, Meguro K, Iiduka M, Foidart JM, Douxfils J, Harada T. Impact of Estetrol Combined with Drospirenone on Blood Coagulation and Fibrinolysis in Patients with Endometriosis: A Multicenter, Randomized, Open-Label, Active-Controlled, Parallel-Group Study. Clin Appl Thromb Hemost 2024; 30:10760296241286514. [PMID: 39327996 DOI: 10.1177/10760296241286514] [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] [Indexed: 09/28/2024] Open
Abstract
Venous thromboembolism is a serious safety concern in women using combined oral contraceptives; ethinyl estradiol (EE) is widely used as an estrogen. Estetrol (E4) is a native estrogen with selective tissue activity and exclusively produced by the fetal liver. This study used a multicenter, randomized, open-label, active-controlled, parallel-group design to evaluate the effects of E4 combined with drospirenone (DRSP) on coagulation and fibrinolysis in Japanese patients with endometriosis. Participants were randomized to receive either E4 15 mg/DRSP 3 mg or EE 20 µg/DRSP 3 mg for 12 weeks. E4/DRSP and EE/DRSP were administered orally once a day in a cyclic regimen, ie, 24-day active use followed by a 4-day hormone-free period, and a flexible extended regimen, respectively, and blood coagulation and fibrinolysis markers were measured. The effect on coagulation and fibrinolysis was considerably less in the E4/DRSP group than in the EE/DRSP group. Major anticoagulant proteins, protein S (free, total) and tissue factor pathway inhibitor (free), were reduced following EE/DRSP treatment. Consequently, thrombin generation determined by the activated protein C sensitivity ratio was increased by approximately 4-fold in the EE/DRSP group than in the E4/DRSP group. Eventually, the fibrinolysis cascade was triggered to compensate for disturbed coagulation, and D-dimer levels were 4.7-fold higher in the EE/DRSP group than in the E4/DRSP group. This study demonstrated that the effect of E4/DRSP on the blood coagulation and fibrinolysis cascades was significantly less than that of EE/DRSP in participants with endometriosis, a disease of women of advanced and reproductive age (jRCT2080225090, https://jrct.niph.go.jp/en-latest-detail/jRCT2080225090).
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Affiliation(s)
- Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Masashi Hirayama
- Department of Clinical Development, Fuji Pharma Co., Ltd, Tokyo, Japan
| | - Masayoshi Nogami
- Department of Clinical Development, Fuji Pharma Co., Ltd, Tokyo, Japan
| | - Kanna Meguro
- Department of Clinical Development, Fuji Pharma Co., Ltd, Tokyo, Japan
| | - Masato Iiduka
- Department of Clinical Development, Fuji Pharma Co., Ltd, Tokyo, Japan
| | - Jean-Michel Foidart
- Estetra SRL, Mithra Pharmaceuticals, Liège, Belgium
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, University of Namur, Namur, Belgium
- Research Department, Qualiblood sa, Namur, Belgium
| | - Tasuku Harada
- Department of Obstetrics and Gynecology, Tottori University Faculty of Medicine, Yonago, Japan
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8
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Douxfils J, Morimont L, Gaspard U, Utian WH, Foidart JM. Estetrol is not a SERM but a NEST and has a specific safety profile on coagulation. Thromb Res 2023; 232:148-150. [PMID: 36130859 DOI: 10.1016/j.thromres.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, Namur, Belgium; Qualiblood sa, Namur, Belgium.
| | - Laure Morimont
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, Namur, Belgium; Qualiblood sa, Namur, Belgium
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Belgium
| | - Wulf H Utian
- Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
| | - Jean-Michel Foidart
- Estetra SRL, An affiliate's Company of Mithra Pharmaceuticals, Liège, Belgium; University of Liège, Liège, Belgium
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9
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Douxfils J, Gaspard U, Taziaux M, Jost M, Bouvy C, Lobo RA, Utian WH, Foidart JM. Impact of estetrol (E4) on hemostasis, metabolism and bone turnover in postmenopausal women. Climacteric 2023; 26:55-63. [PMID: 36399023 DOI: 10.1080/13697137.2022.2139599] [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: 11/19/2022]
Abstract
OBJECTIVE This study aimed to determine the effects of estetrol (E4) on hemostasis, lipids, carbohydrate metabolism and bone turnover in postmenopausal women. METHODS This study was a multicenter, randomized, double-blind placebo-controlled phase 2 trial. Participants (n = 180, age 43-64 years) received E4 2.5 mg, 5 mg, 10 mg and 15 mg or placebo once daily for 12 weeks. Changes from baseline at week 12 were evaluated versus placebo for hemostasis parameters, sex hormone binding globulin (SHBG), lipids, carbohydrate metabolism and bone markers. RESULTS Changes for hemostasis parameters were minimal with a small increase only in the normalized activated protein C sensitivity ratio in the E4 15 mg group versus placebo. SHBG increased in the E4 5 mg, 10 mg and 15 mg groups versus placebo. High-density lipoprotein cholesterol increased in all E4 groups; changes were not consistent for other lipids. Significant decreases versus placebo were seen for insulin resistance (E4 10 mg group), hemoglobin A1c (E4 15 mg group) and type 1 collagen C-terminal telopeptide (E4 10 mg and 15 mg groups). Small decreases in osteocalcin in the E4 5 mg, 10 mg and 15 mg groups were significant versus the increase observed in placebo. CONCLUSION E4 had limited impact on hemostasis and potentially beneficial effects on lipids, carbohydrate metabolism and bone turnover.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,QUALIblood s.a, Namur, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - M Taziaux
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Jost
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - C Bouvy
- QUALIblood s.a, Namur, Belgium
| | - R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - W H Utian
- Case Western Reserve Medical School, Cleveland, OH, USA
| | - J-M Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium.,Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
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10
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Douxfils J, Bouvy C, Morimont L. Evaluation of Activated Protein C Resistance Using Thrombin Generation Test. Methods Mol Biol 2023; 2663:211-224. [PMID: 37204712 DOI: 10.1007/978-1-0716-3175-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Activated protein C (APC) resistance (APCR) has been identified as a risk factor of venous thromboembolism (VTE). A mutation at the level of factor (F) V has at first permitted the description of this phenotypic pattern and corresponded to a transition (guanine to adenine) at nucleotide 1691 in the gene coding for factor V, resulting in the replacement of arginine at position 506 by a glutamine. This confers to this mutated FV a resistance toward the proteolytic action of the complex formed by activated protein C with protein S. However, many other factors also lead to APCR, such as other F5 mutations (e.g., FV Hong Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy, and postpartum. All these conditions lead to the phenotypic expression of APCR and are associated with an increased risk of VTE. Considering the large population affected, the proper detection of this phenotype is a public health challenge. Currently, two types of tests are available: clotting time-based assays and their multiple variants and a thrombin generation-based assays and the endogenous thrombin potential (ETP)-based APCR assay. As APCR was thought to be uniquely related to the FV Leiden mutation, clotting time-based assays were specifically designed to detect this inherited condition. Nevertheless, other APCR conditions have been reported but were not captured by these clotting methods. Thus, the ETP-based APCR assay has been proposed as a global coagulation test able to these multiple APCR conditions, as it provides much more information, which makes it a potential candidate for screening coagulopathic conditions before therapeutic interventions. This chapter will describe the current method used for the realization of the ETP-based APC resistance assay.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, University of Namur, Faculty of Medicine, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, Namur, Belgium.
- Department of Research and Development, QUALIblood s.a., Namur, Belgium.
| | - Céline Bouvy
- Department of Research and Development, QUALIblood s.a., Namur, Belgium
| | - Laure Morimont
- Department of Pharmacy, University of Namur, Faculty of Medicine, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, Namur, Belgium
- Department of Research and Development, QUALIblood s.a., Namur, Belgium
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11
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Morimont L, Jost M, Gaspard U, Foidart JM, Dogné JM, Douxfils J. Low Thrombin Generation in Users of a Contraceptive Containing Estetrol and Drospirenone. J Clin Endocrinol Metab 2022; 108:135-143. [PMID: 36099501 PMCID: PMC9759169 DOI: 10.1210/clinem/dgac511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/11/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the impact on thrombin generation of the new combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone with ethinylestradiol (30 or 20 mcg) associated either with 150 mcg levonorgestrel or with 3 mg drospirenone. METHODS Data were collected from the "E4/DRSP Endocrine Function, Metabolic Control and Hemostasis Study" (NCT02957630). Overall, the per-protocol set population included 24 subjects in the ethinylestradiol/levonorgestrel arm, 28 subjects in the ethinylestradiol/drospirenone arm, and 34 subjects in the estetrol/drospirenone arm. Thrombograms and thrombin generation parameters (lag time, peak, time to peak, endogenous thrombin potential, and mean velocity rate index) were extracted for each subject at baseline and after 6 cycles of treatment. RESULTS After 6 cycles of treatment, ethinylestradiol-containing products arms show a mean thrombogram outside the upper limit of the reference range, that is the 97.5th percentile of all baseline thrombograms. On the other hand, the mean thrombogram of estetrol/drospirenone is within this reference interval. After 6 cycles of treatment, all thrombin generation parameters are statistically less affected by estetrol/drospirenone than ethinylestradiol-containing products. CONCLUSIONS In conclusion, an association of 15 mg estetrol with 3 mg drospirenone does not have an impact on thrombin generation compared with ethinylestradiol-containing products that, either associated with levonorgestrel or drospirenone, are able to increase the production of procoagulant factors and decrease the production of anticoagulant ones, shifting the patient to a prothrombotic state. Ethinylestradiol-containing products thus generate prothrombotic environments contrary to estetrol which demonstrates a neutral profile on hemostasis.
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Affiliation(s)
- Laure Morimont
- Correspondence: Laure Morimont, PharmD, Research Department, Qualiblood sa, Rue du Séminaire 20a, 5000 Namur, Belgium.
| | - Maud Jost
- Estetra SRL, An Affiliate’s Company of Mithra Pharmaceuticals, Liège, 4020 Liège, Belgium
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, 4000 Liège, Belgium
| | - Jean-Michel Foidart
- Estetra SRL, An Affiliate’s Company of Mithra Pharmaceuticals, Liège, 4020 Liège, Belgium
- University of Liège, 4000 Liège, Belgium
| | - Jean-Michel Dogné
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, University of Namur, 5000 Namur, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood sa, 5000 Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, University of Namur, 5000 Namur, Belgium
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022. [PMID: 36063850 DOI: 10.1055/s-0042-1757136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Gemzell-Danielsson K, Cagnacci A, Chabbert-Buffet N, Douxfils J, Foidart JM, Kubba A, Lasa LIL, Mansour D, Neulen J, Neves J, Palma F, Römer T, Ski RS, Tóth V. A novel estetrol-containing combined oral contraceptive: European expert panel review. CESKA GYNEKOLOGIE 2022; 87:440-452. [PMID: 36543594 DOI: 10.1080/13625187.2022.2093850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Despite considerable advances in recently developed combined oral contraceptives (COCs), resulting in lower rates of adverse events while maintaining contraceptive efficacy, there is interest in further innovation. MATERIALS AND METHODS Estetrol (E4), a native oestrogen, and progestin drospirenone (DRSP) were combined in a new COC. A European expert panel reviewed the pharmacology, efficacy, and safety and tolerability of this combination. Their findings are presented as a narrative review. RESULTS E4 15mg/DRSP 3 mg in a 24/4 regimen provided effective contraception with good cycle control, characterised by a predictable regular bleeding pattern and minimal unscheduled bleeding, together with a good safety profile. The combination was associated with high user satisfaction, wellbeing, and minimal changes in body weight. The effects on endocrine and metabolic parameters were limited, and the combination was found to have a limited impact on liver function and lipid and carbohydrate metabolism. Moreover, its effect on several haemostatic parameters was lower than that of comparators containing ethinyl oestradiol (EE) 20mg/DRSP 3 mg and EE 30mg/levonorgestrel 150mg. CONCLUSION E4 15 mg/DRSP 3 mg provides safe and effective contraception, with high user satisfaction and predictable bleeding. Further research will evaluate the long-term safety of the COC.
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [PMID: 36055270 DOI: 10.1055/s-0042-1753511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [DOI: 10.1055/s-0042-1758162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractActivated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Favaloro EJ. 2021 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards. Semin Thromb Hemost 2022. [PMID: 35413734 DOI: 10.1055/s-0042-1743175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, Australia
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Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
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Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
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Favaloro EJ. 2020 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards. Semin Thromb Hemost 2021; 47:229-237. [PMID: 33794547 DOI: 10.1055/s-0041-1724120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Sydney Centres for Thrombosis and Haemostasis, Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, Australia
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Affiliation(s)
- Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
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