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Konecki C, Holm M, Djerada Z. Negative Impact of ST-Segment Elevation Myocardial Infarction and Morphine Dose on Ticagrelor Uptake and Pharmacodynamics: A Population PK/PD Analysis of Pooled Individual Participant Data. Clin Pharmacokinet 2023; 62:905-920. [PMID: 37097605 DOI: 10.1007/s40262-023-01243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Ticagrelor is widely used in patients with stable and acute coronary artery disease. Understanding the factors that influence its pharmacokinetics (PK) and pharmacodynamics (PD) could improve therapeutic outcomes. We therefore performed a pooled population PK/PD analysis using individual patient data from two studies. We focused on the impact of morphine administration and ST-segment elevation myocardial infarction (STEMI) on the risk of high platelet reactivity (HPR) and dyspnea. METHODS A parent-metabolite population PK/PD model was developed based on data from 63 STEMI, 50 non-STEMI, and 25 chronic coronary syndrome (CCS) patients. Simulations were then run to evaluate the risk of non-response and adverse events associated with the identified variability factors. RESULTS The final PK model consisted of first-order absorption with transit compartments, distribution with two compartments for ticagrelor and one compartment for AR-C124910XX (active metabolite of ticagrelor), and linear elimination for both drugs. The final PK/PD model was an indirect turnover model with production inhibition. Morphine dose and STEMI, independently, had a significant negative effect on the absorption rate (reduction of log([Formula: see text]) by 0.21×morphine dose (mg) and by 2.37 in STEMI patients, both p < 0.001), and the presence of STEMI significantly impacted both efficacy and potency (both p < 0.001). The simulations run with the validated model showed a high rate of non-response in patients with those covariates (RR 1.19 for morphine, 4.11 for STEMI and 5.73 for morphine and STEMI, all three p < 0.001). By increasing ticagrelor dosage, the negative morphine effect was reversible in patients without STEMI and just limited in patients with STEMI. CONCLUSION The developed population PK/PD model confirmed the negative impact of morphine administration and presence of STEMI on ticagrelor PK and antiplatelet effect. Increasing ticagrelor doses seems effective in morphine users without STEMI, whereas the STEMI effect is not entirely reversible.
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Affiliation(s)
- Celine Konecki
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA 3801, Reims University Hospital, 51100, Reims, France
- Department of Pharmacology and Toxicology, Reims University Hospital, 51100, Reims, France
| | - Manne Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Perioperative Medicine and Intensive Care, B31, Huddinge, Sweden
| | - Zoubir Djerada
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA 3801, Reims University Hospital, 51100, Reims, France.
- Department of Pharmacology and Toxicology, Reims University Hospital, 51100, Reims, France.
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Ticagrelor Pharmacokinetics and Pharmacodynamics in Chinese Patients with STEMI and NSTEMI Without Opioid Administration. Adv Ther 2020; 37:4220-4232. [PMID: 32770531 DOI: 10.1007/s12325-020-01423-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The pharmacodynamics (PD) and pharmacokinetics (PK) study of ticagrelor loading dose (LD) in Chinese patients with acute coronary syndrome (ACS) without opioid administration has never been investigated. Therefore, the aim of this study was to evaluate the antiplatelet effects and the PK parameters of ticagrelor in Chinese patients with ACS without opioid administration. METHODS A sample size of 30 eligible patients with ACS were enrolled in this study. Blood samples were obtained predose and 1, 2, 4, 8, and 12 h after 180 mg LD of ticagrelor. P2Y12 reactivity units (PRU) and plasma concentrations of ticagrelor and its two metabolites were measured. RESULTS In total, 15 patients were admitted to ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) groups, respectively. For patients with NSTEMI, PRU declined significantly during the first 4 h and maintained a relatively stable antiplatelet effect from 4 to 12 h after LD. A similar trend was found in the STEMI group without significant differences of PRU in each designed time compared with patients with NSTEMI (P > 0.05). Tmax of metabolite AR-C124910XX was 4 h after LD for both groups. There were no significant differences for drug concentration, Cmax, or AUC of ticagrelor and AR-C124910XX between patients with STEMI and NSTEMI (P > 0.05). CONCLUSIONS For Chinese patients with ACS, at least 4 h was needed to achieve an adequate antiplatelet effect for ticagrelor LD. There were no differences in PK or PD between Chinese patients with STEMI and NSTEMI. CLINICAL TRIAL REGISTRATION ChiCTR1800014764.
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Holm M, Tornvall P, Henareh L, Jensen U, Golster N, Alström P, Santos-Pardo I, Witt N, Fedchenko N, Venetsanos D, Beck O, van der Linden J. The MOVEMENT Trial. J Am Heart Assoc 2020; 8:e010152. [PMID: 30636504 PMCID: PMC6497337 DOI: 10.1161/jaha.118.010152] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine‐Treated Patients With ST‐Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST‐segment–elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on‐treatment platelet reactivity and plasma concentrations of ticagrelor and AR‐C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31–50) versus 45.5 (37–60) minutes (P=0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on‐treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P=0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self‐estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02942550.
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Affiliation(s)
- Manne Holm
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,2 Perioperative Medicine and Intensive Care, B31 Karolinska University Hospital Huddinge, Stockholm Sweden
| | - Per Tornvall
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Loghman Henareh
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Ulf Jensen
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nanna Golster
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Patrik Alström
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Irene Santos-Pardo
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nils Witt
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nikolai Fedchenko
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Dimitrios Venetsanos
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Olof Beck
- 5 Department of Laboratory Medicine Karolinska Institutet Stockholm Sweden
| | - Jan van der Linden
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Danielak D, Karaźniewicz-Łada M, Główka F. Ticagrelor in modern cardiology - an up-to-date review of most important aspects of ticagrelor pharmacotherapy. Expert Opin Pharmacother 2017; 19:103-112. [DOI: 10.1080/14656566.2017.1421634] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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Adamski P, Sikora J, Laskowska E, Buszko K, Ostrowska M, Umińska JM, Sikora A, Skibińska N, Sobczak P, Adamska U, Rość D, Kubica A, Paciorek P, Marszałł MP, Navarese EP, Gorog DA, Kubica J. Comparison of bioavailability and antiplatelet action of ticagrelor in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction: A prospective, observational, single-centre study. PLoS One 2017; 12:e0186013. [PMID: 29023473 PMCID: PMC5638327 DOI: 10.1371/journal.pone.0186013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/22/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Data from available studies suggest that the presence of ST-elevation myocardial infarction (STEMI) may be associated with delayed and attenuated ticagrelor bioavailability and effect compared with non-ST-elevation myocardial infarction (NSTEMI). METHODS In a single-center, prospective, observational trial 73 patients with myocardial infarction (STEMI n = 49, NSTEMI n = 24) underwent a pharmacokinetic and pharmacodynamic assessment after a 180 mg ticagrelor loading dose (LD). Ticagrelor and its active metabolite (AR-C124910XX) plasma concentrations were determined with liquid chromatography tandem mass spectrometry, and their antiplatelet effect was measured with the VASP assay and multiple electrode aggregometry. RESULTS During the first six hours after ticagrelor LD, STEMI patients had 38% and 34% lower plasma concentration of ticagrelor and AR-C124910XX, respectively, than NSTEMI (ticagrelor AUC(0-6): 2491 [344-5587] vs. 3991 [1406-9284] ng*h/mL; p = 0.038; AR-C124910XX AUC(0-6): 473 [0-924] vs. 712 [346-1616] ng*h/mL; p = 0.027). STEMI patients also required more time to achieve maximal concentration of ticagrelor (tmax: 4.0 [3.0-12.0] vs. 2.5 [2.0-6.0] h; p = 0.012). Impaired bioavailability of ticagrelor and AR-C124910XX seen in STEMI subjects was associated with diminished platelet inhibition in this group, which was most pronounced during the initial hours of treatment. CONCLUSIONS Plasma concentrations of ticagrelor and AR-C124910XX during the first hours after ticagrelor LD were one third lower in STEMI than in NSTEMI patients. This reduced and delayed ticagrelor bioavailability was associated with weaker antiplatelet effect in STEMI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02602444 (November 09, 2015).
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Affiliation(s)
- Piotr Adamski
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- * E-mail:
| | - Joanna Sikora
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Ewa Laskowska
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Principles of Clinical Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Julia M. Umińska
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Adam Sikora
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Natalia Skibińska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Sobczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Urszula Adamska
- Chair of Dermatology, Sexually Transmitted Diseases and Immunodermatology, Faculty of Medicine, Nicolaus Copernicus University in Toruń, Poland
| | - Danuta Rość
- Department of Pathophysiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Paciorek
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał P. Marszałł
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Diana A. Gorog
- National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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