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Kranendonk J, Willems LH, Vijver-Coppen RVD, Coenen M, Adang E, Donders R, Zeebregts CJ, Deneer V, Reijnen M, Kramers C, Warlé MC. CYP2C19 genotype-guided antithrombotic treatment versus conventional clopidogrel therapy in peripheral arterial disease: study design of a randomized controlled trial (GENPAD). Am Heart J 2022; 254:141-148. [PMID: 35988587 DOI: 10.1016/j.ahj.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/04/2022] [Accepted: 08/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clopidogrel is recommended in international guidelines to prevent arterial thrombotic events in patients with peripheral arterial disease (PAD). Clopidogrel itself is inactive and metabolism is dependent on the CYP2C19 enzyme. About 30% of Caucasian PAD patients receiving clopidogrel carry 1 or 2 CYP2C19 loss-of-function allele(s) and do not or to a limited extent convert the prodrug into its active metabolite. As a result, platelet inhibition may be inadequate which could lead to an increased risk of adverse clinical events related to arterial thrombosis. A CYP2C19 genotype-guided antithrombotic treatment might be beneficial for PAD patients. METHODS GENPAD is a multicenter randomized controlled trial involving 2,276 PAD patients with an indication for clopidogrel monotherapy. Patients with a separate indication for dual antiplatelet therapy or stronger antithrombotic therapy are not eligible for study participation. Patients randomized to the control group will receive clopidogrel 75 mg once daily without pharmacogenetic guidance. Patients randomized to the intervention group will be tested for carriage of CYP2C19 *2 and *3 loss-of-function alleles, followed by a genotype-guided antithrombotic treatment with either clopidogrel 75 mg once daily for normal metabolizers, clopidogrel 150 mg once daily for intermediate metabolizers, or acetylsalicylic acid 80 mg once daily plus rivaroxaban 2.5 mg twice daily for poor metabolizers. The primary outcome is a composite of myocardial infarction, ischemic stroke, cardiovascular death, acute or chronic limb ischemia, peripheral vascular interventions, or death. The secondary outcomes are the individual elements of the primary composite outcome and clinically relevant bleeding complications. CONCLUSION The aim of the GENPAD study is to evaluate the efficacy, safety, and cost-effectiveness of a genotype-guided antithrombotic treatment strategy compared to conventional clopidogrel treatment in PAD patients.
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Affiliation(s)
- J Kranendonk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L H Willems
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - M Coenen
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E Adang
- Department of Epidemiology and Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University Of Groningen, Groningen, The Netherlands
| | - Vhm Deneer
- Department of Clinical Pharmacy, Division of Laboratories, Pharmacy and Biomedical Genetics University Medical Center Utrecht, Utrecht, The Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht university, Utrecht, The Netherlands
| | - Mmpj Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands; Multimodality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - C Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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de Lara DV, de Melo DO, Araújo Silva LC, Gonçalves TS, Júnior Lima Santos PC. Pharmacogenetics of clopidogrel and warfarin in the treatment of cardiovascular diseases: an overview of reviews. Pharmacogenomics 2022; 23:443-452. [PMID: 35380455 DOI: 10.2217/pgs-2021-0158] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pharmacogenetics (PGx) is the relationship between an individual's genetic variations and the response to pharmacological treatment. We chose to perform an overview of reviews on PGx testing-guided treatment for cardiovascular diseases, based on clinically relevant gene-drug pairs. We conducted a search on Medline, Embase and Cochrane Library, from their inception to 18 June 2020. The most studied gene-drug pairs were clopidogrel and warfarin associated with cytochrome p450 and vitamin K epoxide reductase complex subunit 1 genes (CYP2C19, CYP2C9 and VKORC1), classified as critically low quality. There is a need for more quality primary studies and systematic reviews that assess the risk of bias, with consistent definitions of clinical outcomes to consider the benefits of PGx testing for cardiovascular diseases.
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Affiliation(s)
- Danilo Vieira de Lara
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, EPM - Unifesp, São Paulo, 04044-020, Brazil
| | - Daniela Oliveira de Melo
- Department of Pharmaceutical Sciences, Institute of Environmental Sciences, Chemistry & Pharmaceuticals, Universidade Federal de São Paulo, Diadema, São Paulo, 09913-030, Brazil
| | - Lucas Caetano Araújo Silva
- Department of Pharmaceutical Sciences, Institute of Environmental Sciences, Chemistry & Pharmaceuticals, Universidade Federal de São Paulo, Diadema, São Paulo, 09913-030, Brazil
| | - Thuane Sales Gonçalves
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, EPM - Unifesp, São Paulo, 04044-020, Brazil
| | - Paulo Caleb Júnior Lima Santos
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, EPM - Unifesp, São Paulo, 04044-020, Brazil
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Liu J, Chen HB, Sun WZ, Jin XX, Zhang W, Yang YB, Li YR, Chen XL, Hou JB. Comparison of protective effects of alprostadil with Salvia miltiorrhiza against myocardial ischemia-reperfusion injury in rats. Rev Port Cardiol 2022; 41:197-205. [DOI: 10.1016/j.repc.2021.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/15/2020] [Accepted: 02/12/2021] [Indexed: 10/19/2022] Open
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Baturina O, Andreev D, Fedina L, Mirzaev K, Ivashchenko D, Ryzhikova K, Grishina E, Bochkov P, Shevchenko R, Sychev D. Influence of Clinically Significant Genes on Antiplatelet Effect of Clopidogrel and Clinical Outcomes in Patients with Acute Coronary Syndrome and Atrial Fibrillation. Pharmacology 2022; 107:216-226. [PMID: 35073541 DOI: 10.1159/000521531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The interindividual variability of the antiplatelet effect of clopidogrel is determined by multiple clinical and genetic factors. A lot of genotype-oriented studies have concentrated on the impact of CYP2C19 gene polymorphisms on platelet aggregation in patients receiving clopidogrel. However, the influence of this polymorphism may be only 12-20%, so other genetic markers should also be investigated. The aim of this work was to study the impact of carriage of CES1, PON1, ABCG2, CYP4F2, CYP3A4, IGTB3, P2Y12, PEAR1, and B4GALT2 polymorphisms on antiplatelet effect of clopidogrel and clinical outcomes in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF). METHODS 103 patients who underwent ACS with or without percutaneous coronary intervention and concomitant nonvalvular AF were included in an open multicenter prospective study to assess efficacy and safety of combined antithrombotic therapy. The study assessed the frequency of different primary clinical outcomes (incidence of major bleeding, hospital mortality, cardiovascular mortality, stroke and transient ischemic attacks (TIAs), renal mortality) and secondary outcomes (resistance to therapy - high residual platelet reactivity, excessive platelet suppression). Residual platelet reactivity was examined using the VerifyNow system (Accumetrics, Latham, NY, USA). RESULTS None of the studied genetic markers had no statistically significant effect on the antiaggregant response to clopidogrel in patients with ACS and AF. However, CYP4F2 C(Val433Met) T, PEAR1 rs41273215 C>T were statistically significantly associated with an increased frequency of bleeding on antithrombotic therapy. B4GALT2 rs1061781 was statistically significantly associated with increased frequency of strokes and TIA. CONCLUSION In our study, we determined that carriers of CYP4F2 gene polymorphisms C(Val433Met)T, PEAR1 rs41273215 C>T (CT+TT) were associated with lower safety of antithrombotic therapy in patients with ACS and AF. And, the B4GALT2 rs1061781 gene polymorphism was associated with a greater risk of insufficient efficacy of the therapy. The data obtained in our study may improve the understanding of the effect of less studied genetic markers on the efficacy and safety of antithrombotic therapy in patients with ACS and AF.
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Affiliation(s)
- Olga Baturina
- Department of Preventive and Emergency Cardiology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Denis Andreev
- Department of Preventive and Emergency Cardiology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Ludmila Fedina
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Karin Mirzaev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Dmitriy Ivashchenko
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Kristina Ryzhikova
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Elena Grishina
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Pavel Bochkov
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Roman Shevchenko
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Dmitriy Sychev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
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Hirata TDC, Dagli-Hernandez C, Genvigir FDV, Lauschke VM, Zhou Y, Hirata MH, Hirata RDC. Cardiovascular Pharmacogenomics: An Update on Clinical Studies of Antithrombotic Drugs in Brazilian Patients. Mol Diagn Ther 2021; 25:735-755. [PMID: 34357562 DOI: 10.1007/s40291-021-00549-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Anticoagulant and antiplatelet drugs effectively prevent thrombotic events in patients with cardiovascular diseases, ischemic stroke, peripheral vascular diseases, and other thromboembolic diseases. However, genetic and non-genetic factors affect the response to antithrombotic therapy and can increase the risk of adverse events. This narrative review discusses pharmacogenomic studies on antithrombotic drugs commonly prescribed in Brazil. Multiple Brazilian studies assessed the impact of pharmacokinetic (PK) and pharmacodynamic (PD) gene variants on warfarin response. The reduced function alleles CYP2C9*2 and CYP2C9*3, and VKORC1 rs9923231 (c.-1639G>A) are associated with increased sensitivity to warfarin and a low dose requirement to prevent bleeding episodes, whereas CYP4F2 rs2108622 (p.Val433Met) carriers have higher dose requirements (warfarin resistance). These deleterious variants and non-genetic factors (age, gender, body weight, co-administered drugs, food interactions, and others) account for up to 63% of the warfarin dose variability. Few pharmacogenomics studies have explored antiplatelet drugs in Brazilian cohorts, finding associations between CYP2C19*2, PON1 rs662 and ABCC3 rs757421 genotypes and platelet responsiveness or clopidogrel PK in subjects with coronary artery disease (CAD) or acute coronary syndrome (ACS), whereas ITGB3 contributes to aspirin PK but not platelet responsiveness in diabetic patients. Brazilian guidelines on anticoagulants and antiplatelets recommend the use of a platelet aggregation test or genotyping only in selected cases of ACS subjects without ST-segment elevation taking clopidogrel, and also suggest CYP2C9 and VKORC1 genotyping before starting warfarin therapy to assess the risk of bleeding episodes or warfarin resistance.
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Affiliation(s)
- Thiago Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Carolina Dagli-Hernandez
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Fabiana Dalla Vecchia Genvigir
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Volker Martin Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Solna, Sweden.,Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Solna, Sweden
| | - Mario Hiroyuki Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Rosario Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil.
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Global distribution of CYP2C19 risk phenotypes affecting safety and effectiveness of medications. THE PHARMACOGENOMICS JOURNAL 2021; 21:190-199. [PMID: 33082528 DOI: 10.1038/s41397-020-00196-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 12/27/2022]
Abstract
Genetic variability of CYP2C19 may affect safety or efficacy of many clinically important medications as outlined in the clinical pharmacogenetics implementation consortium (CPIC) dosing guidelines. To determine the predictive prevalence of high-risk phenotypes due to CYP2C19 genetic variants collectively in the world population and to establish a correlation how the identified high-risk phenotypes may affect safety or effectiveness of drugs, this study was conducted. Frequency of CYP2C19*2, *3 and *17 alleles were obtained from 1000 Genomes project Phase III in line with Fort Lauderdale principles. Phenotypes were assigned using international standardized consensus terms based on the carrier of characteristics alleles. Association of predicted high-risk phenotypes with the safety or effectiveness of medications was gained from CPIC dosing guidelines. Ultrarapid and poor metabolizers were considered as being as high-risk phenotypes for at least ten clinically important medications. Meta-analysis of the prevalence of high-risk phenotypes showed that it was statistically significant (p<0.0001) in different ethnic groups with pooled prevalence of 27.4% (95% CI 18-37%). The present study suggests that African (37.2; 95% CI 34-41%) and European (35.4; 95% CI 31-40%) population are being at particularly higher risk of either sub therapeutic drug responses or toxicities due to combined effects of CYP2C19*2, *3 and *17 variants. Large scale clinical studies are warranted to assess clinical outcomes of these medications considering CYP2C19 pharmacogenomics effects.
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Tan JW, Chew DP, Abdul Kader MAS, Ako J, Bahl VK, Chan M, Park KW, Chandra P, Hsieh IC, Huan DQ, Johar S, Juzar DA, Kim BK, Lee CW, Lee MKY, Li YH, Almahmeed W, Sison EO, Tan D, Wang YC, Yeh SJ, Montalescot G. 2020 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y 12 Receptor Antagonists in the Asia-Pacific Region. Eur Cardiol 2021; 16:e02. [PMID: 33708263 PMCID: PMC7941380 DOI: 10.15420/ecr.2020.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
The unique characteristics of patients with acute coronary syndrome in the Asia-Pacific region mean that international guidelines on the use of dual antiplatelet therapy (DAPT) cannot be routinely applied to these populations. Newer generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) have demonstrated improved clinical outcomes compared with clopidogrel. However, low numbers of Asian patients participated in pivotal studies and few regional studies comparing DAPTs have been conducted. This article aims to summarise current evidence on the use of newer generation P2Y12 inhibitors in Asian patients with acute coronary syndrome and provide recommendations to assist clinicians, especially cardiologists, in selecting a DAPT regimen. Guidance is provided on the management of ischaemic and bleeding risks, including duration of therapy, switching strategies and the management of patients with ST-elevation and non-ST-elevation MI or those requiring surgery. In particular, the need for an individualised DAPT regimen and considerations relating to switching, de-escalating, stopping or continuing DAPT beyond 12 months are discussed.
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Affiliation(s)
- Jack Wc Tan
- National Heart Centre Singapore.,Sengkang General Hospital Singapore
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | | | - Junya Ako
- Kitasato University and Hospital Tokyo, Japan
| | - Vinay K Bahl
- All India Institute of Medical Sciences New Delhi, India
| | - Mark Chan
- National University Hospital Singapore
| | - Kyung Woo Park
- Seoul National University Hospital Internal Medicine Seoul, South Korea
| | | | | | - Do Quang Huan
- Heart Institute of Ho Chi Minh City Ho Chi Minh, Vietnam
| | | | | | | | - Cheol Whan Lee
- Asan Medical Center, University of Ulsan Seoul, South Korea
| | | | - Yi-Heng Li
- National Cheng King University Hospital Tainan, Taiwan
| | | | - Eric Oliver Sison
- University of the Philippines-Philippine General Hospital Manila, Philippines
| | | | - Yu-Chen Wang
- China Medical University Hospital Taichung City, Taiwan
| | | | - Gilles Montalescot
- Sorbonne University Paris, France.,ACTION Study Group France.,Pitié-Salpêtrière Hospital (AP-HP) Paris, France
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9
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Zhang H, Xiang Q, Liu Z, Mu G, Xie Q, Zhou S, Ma L, Wang Z, Hu K, Wang Z, Cui Y. Genotype-guided antiplatelet treatment versus conventional therapy: A systematic review and meta-analysis. Br J Clin Pharmacol 2020; 87:2199-2215. [PMID: 33140858 DOI: 10.1111/bcp.14637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/29/2022] Open
Abstract
AIM This meta-analysis was carried out to explore if a personalized antiplatelet strategy based on genotyping is superior to conventional therapy. METHODS PubMed, Web of Science, EMBASE and the Cochrane Library were searched from the inception of each database to 5 May 2020. Studies reporting endpoints in genotype-guided treatment group and conventional treatment group were included. The endpoint results were presented as the risk ratio (RR), with 95% confidence interval (CI). RESULTS A total of 10 561 patients from 16 studies (eight randomized controlled trials [RCT] and eight cohort studies) were included in the meta-analysis. The rates of major adverse cardiovascular events (MACE), stent thrombosis and myocardial infarction (MI) were significantly lower in the genotype-guided group than in the conventional treatment group (RR 0.56, 95% CI 0.44-0.73, P < .0001; RR 0.40, 95% CI 0.24-0.67, P = .0005; RR 0.45, 95% CI 0.35-0.58, P < .00001, respectively). A significant difference was found between the two groups in major bleeding (RR 0.73, 95% CI 0.55-0.98, P = .04), which was not robust after sensitivity analysis. CONCLUSION Genotype-guided antiplatelet treatment could decrease the risk of MACE, stent thrombosis and MI in patients with coronary artery disease or undergoing percutaneous coronary intervention, without increasing the risk of bleeding over a long follow-up period. The decreased risk of efficacy outcomes was more obvious in cohort studies. Well-organized RCTs and clinical trials are required to verify the benefit of genotype-guided therapy.
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Affiliation(s)
- Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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Optimising Seniors' Metabolism of Medications and Avoiding Adverse Drug Events Using Data on How Metabolism by Their P450 Enzymes Varies with Ancestry and Drug-Drug and Drug-Drug-Gene Interactions. J Pers Med 2020; 10:jpm10030084. [PMID: 32796505 PMCID: PMC7563167 DOI: 10.3390/jpm10030084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 12/16/2022] Open
Abstract
Many individuals ≥65 have multiple illnesses and polypharmacy. Primary care physicians prescribe >70% of their medications and renew specialists’ prescriptions. Seventy-five percent of all medications are metabolised by P450 cytochrome enzymes. This article provides unique detailed tables how to avoid adverse drug events and optimise prescribing based on two key databases. DrugBank is a detailed database of 13,000 medications and both the P450 and other complex pathways that metabolise them. The Flockhart Tables are detailed lists of the P450 enzymes and also include all the medications which inhibit or induce metabolism by P450 cytochrome enzymes, which can result in undertreatment, overtreatment, or potentially toxic levels. Humans have used medications for a few decades and these enzymes have not been subject to evolutionary pressure. Thus, there is enormous variation in enzymatic functioning and by ancestry. Differences for ancestry groups in genetic metabolism based on a worldwide meta-analysis are discussed and this article provides advice how to prescribe for individuals of different ancestry. Prescribing advice from two key organisations, the Dutch Pharmacogenetics Working Group and the Clinical Pharmacogenetics Implementation Consortium is summarised. Currently, detailed pharmacogenomic advice is only available in some specialist clinics in major hospitals. However, this article provides detailed pharmacogenomic advice for primary care and other physicians and also physicians working in rural and remote areas worldwide. Physicians could quickly search the tables for the medications they intend to prescribe.
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Lyu SQ, Yang YM, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Ren JM. The efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy compared with conventional antiplatelet therapy in patients with acute coronary syndrome or undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Platelets 2020; 31:971-980. [PMID: 32546030 DOI: 10.1080/09537104.2020.1780205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cytochrome P450 (CYP) 2C19 genotype is closely associated with the metabolism and efficacy of clopidogrel, thereby having an important impact on clinical outcomes of patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). This study aimed to evaluate the efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy in patients with ACS or undergoing PCI. PubMed, EMBASE, the Cochrane Library and clinicaltrials.gov were searched to identify randomized controlled trials (RCTs) comparing CYP2C19 genotype-guided antiplatelet therapy with conventional therapy in patients with ACS or undergoing PCI. Eight RCTs involving 6708 patients were included in this meta-analysis. CYP2C19 genotype-guided antiplatelet therapy was slightly superior to the conventional antiplatelet therapy in reducing the risk of MACE [RR(95%CI): 0.71(0.51-0.98), p = .04]. Meanwhile, the genotype-guided therapy group had significantly lower incidence of myocardial infarction [RR(95%CI): 0.56(0.40-0.78), p < .01], but similar risk of all-cause mortality, cardiovascular mortality, stent thrombosis, urgent revascularization and stroke compared to the conventional therapy group. Incidences of major/minor bleeding and major bleeding were comparable between the two groups. In patients with ACS or undergoing PCI, CYP2C19 genotype-guided antiplatelet therapy displayed benefit over conventional antiplatelet therapy in reducing the risk of MACE and myocardial infarction, without increasing bleeding risk. Further RCTs are needed to provide more evidences for CYP2C19 genotype-guided antiplatelet therapy.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jia-Meng Ren
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
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12
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Genotype-guided antiplatelet therapy compared with standard therapy for patients with acute coronary syndromes or undergoing percutaneous coronary intervention: A systematic review and meta-analysis. Thromb Res 2020; 193:130-138. [PMID: 32559569 DOI: 10.1016/j.thromres.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine, in patients with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI), the effectiveness and safety between personalized P2Y12 inhibitors treatment based on genotypes and standard treatment. METHODS We systematically searched for articles from PubMed, Cochrane Library, Embase and Web of science from their inception to March 4, 2020, with no language restrictions. The search was performed to identify all randomized clinical trials (RCTs) in which genotype-guided versus standard treatment with P2Y12 inhibitors among patients with ACS or those undergoing PCI. The primary clinical outcomes were major adverse cardiovascular events (MACEs) including death, myocardial infarction (MI), stroke, stent thrombosis (ST), and targeted vessel revascularization (TVR). The secondary outcomes were high on-treatment platelet reactivity (HTPR) and safety outcomes including major bleeding events. RESULTS A total of 4859 patients from 7 RCTs were included in the meta-analysis. There were 2430 patients (50.01%) allocated to the genotype-guided group and 2429 (49.99%) allocated to the standard group. Pooled result showed that compared with the standard treatment group, the genotype-guided group had a significantly lower risk of HTPR (Risk Ratio [RR]: 0.35, 95% confidence interval [CI]: 0.14-0.83, P = 0.02, I2 = 58%), MI (RR: 0.52, 95% CI: 0.36-0.74, P = 0.0004, I2 = 0%) and ST (RR: 0.41, 95% CI: 0.17-0.98, P = 0.05, I2 = 0%). No significant difference was found between two groups for the risk of death (RR: 0.78, 95% CI: 0.54-1.12, P = 0.18, I2 = 34%), stroke (RR = 0.67, 95% CI: 0.35-1.30, P = 0.24, I2 = 0%), TVR (RR: 0.83, 95% CI: 0.46-1.50, P = 0.54, I2 = 0%) and major bleeding events (RR: 0.83, 95% CI: 0.60-1.15, P = 0.25, I2 = 0%). CONCLUSIONS Genotype-guided antiplatelet treatment could reduce the risk of HTPR, MI and ST compared with standard therapy in patients with ACS or undergoing PCI, and no significant difference was found between two groups in the major bleeding events.
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郑 小, 吴 黎. [The value of cytochrome P4502C19 gene assay for anti-platelet therapy after PCI in stable angina patients with left main coronary artery lesions]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:274-278. [PMID: 32376540 PMCID: PMC7086122 DOI: 10.12122/j.issn.1673-4254.2020.02.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of different antiplatelet therapies for stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer Cytochrome P450 2C19 gene (CYP2C19) undergoing PCI. METHODS A total of 247 patients diagnosed with stable angina in cardiology department of Fujian union hospital from February 2015 to February 2017 were retrospectively analyzed, among them, the elective PCI were performed on the left main coronary artery and the CYP2C19 gene poly-morphism were intermediate metabolize, they were divided into ticagrelor treatment group(aspirin combined with ticagrelor, n=95)and clopidogrel treatment group(aspirin combined with clopidogrel, n=152) according to the different antiplatelet treatment programs. Both groups were given aspirin 300 mg and clopidogrel 300 mg orally before PCI; the ticagrelor group were given the maintenance dose of ticagrelor (90 mg orally, twice a day) after PCI, while those in clopidogrel group were clopidogrel 75 mg orally (once a day) after PCI; both groups were given the maintenance dose of aspirin (100 mg orally, once a day)after PCI. The major adverse cardiovascular events (MACE) were observed within 12 months after PCI. RESULTS At 12 months after PCI, the incidence of MACE in the ticagrelor treatment group was significantly lower than that in the clopidogrel treatment group, the difference was statistically significant (2.1% vs 15.1%, P=0.001).There were no significant differences between the two groups in the restenosis rates of non- revascularized target vessel, recurrent rates of angina pectoris(but not myocardial infarction), recurrent rates of myocardial infarction, and revascularization rates of target vessel (P > 0.05). There were also no significant differences between the two groups in bleeding. CONCLUSIONS For stable angina patients with complicated left main coronary artery lesions and intermediate metabolizer CYP2C19 gene, aspirin combined with ticagrelor antiplatelet therapy after PCI is effective, the effect of ticagrelor is better than clopidogrel on MACE, and ticagrelor does not seem to increase the risk of bleeding.
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Affiliation(s)
- 小芳 郑
- 福建医科大学附属第三医院心内科,福建 福州 350108Department of Cardiology, The Third Affiliated Hospital of Fujian Medical University, Fuzhou 350108, China
| | - 黎明 吴
- 福建医科大学附属协和医院心内科,福建 福州 350001Department of Cardiology, Union Hospital affiliated to Fujian Medical University, Fuzhou 350001, China
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