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Pereira NL, Cresci S, Angiolillo DJ, Batchelor W, Capers Q, Cavallari LH, Leifer D, Luzum JA, Roden DM, Stellos K, Turrise SL, Tuteja S. CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e129-e150. [PMID: 38899464 PMCID: PMC11300169 DOI: 10.1161/cir.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.
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Franchi F, Rollini F, Ortega-Paz L, Been L, Giordano S, Galli M, Ghanem G, Garabedian H, Al Saleh T, Uzunoglu E, Rivas A, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Mahowald M, Reiter B, Jilma B, Angiolillo DJ. Switching From Cangrelor to Prasugrel in Patients Undergoing Percutaneous Coronary Intervention: The Switching Antiplatelet-6 (SWAP-6) Study. JACC Cardiovasc Interv 2023; 16:2528-2539. [PMID: 37609698 DOI: 10.1016/j.jcin.2023.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND A drug-drug interaction (DDI) may occur when transitioning from intravenous P2Y12 inhibition with cangrelor to oral P2Y12 inhibition with prasugrel. However, this has never been tested in patients undergoing percutaneous coronary intervention (PCI). OBJECTIVES This study sought to rule out a DDI when cangrelor and prasugrel are concomitantly administered in PCI patients. METHODS SWAP-6 (Switching Antiplatelet-6) was a prospective, randomized, 3-arm, open-label pharmacokinetic (PK) and pharmacodynamic (PD) study. Patients (N = 77) were randomized to 1) prasugrel only at the start of PCI, 2) cangrelor plus prasugrel concomitantly at the start of PCI, or 3) cangrelor at the start of PCI plus prasugrel at the end of infusion. Cangrelor infusion was maintained for 2 hours. PK/PD assessments were performed at baseline and 6 time points postrandomization. The primary endpoint was noninferiority in VerifyNow (Werfen) P2Y12 reaction units measured at 4 hours after randomization between cangrelor plus prasugrel concomitantly administered vs prasugrel only. PK assessments included plasma levels of the active metabolite of prasugrel. RESULTS Compared with prasugrel, cangrelor further enhances P2Y12 inhibitory effects. At 4 hours postrandomization, P2Y12 reaction unit levels were significantly lower with prasugrel only compared to cangrelor and prasugrel concomitantly administered (least squares means difference = 130; 95% CI: 85-176), failing to meet the prespecified noninferiority margin. Findings were corroborated by multiple PD assays. The active metabolite of prasugrel levels were not affected by concomitant administration of cangrelor and were low at the end of cangrelor infusion. CONCLUSIONS In patients undergoing PCI, concomitant administration of prasugrel with cangrelor leads to a marked increase in platelet reactivity after stopping cangrelor infusion, supporting the presence of a DDI. (Switching Antiplatelet Therapy-6 [SWAP-6]; NCT04668144).
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Salvatore Giordano
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA; Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Cotignola, Italy
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Haroutioun Garabedian
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Tala Al Saleh
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ekin Uzunoglu
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Madeline Mahowald
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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Yamamoto K, Watanabe H, Morimoto T, Obayashi Y, Natsuaki M, Yamaji K, Domei T, Ogita M, Ohya M, Tatsushima S, Suzuki H, Tada T, Ishii M, Nikaido A, Watanabe N, Fujii S, Mori H, Nishikura T, Suematsu N, Hayashi F, Komiyama K, Shigematsu T, Isawa T, Suwa S, Ando K, Kimura T. Clopidogrel Monotherapy After 1-Month Dual Antiplatelet Therapy in Patients With Diabetes Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:19-31. [PMID: 36599584 DOI: 10.1016/j.jcin.2022.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes was reported to be associated with an impaired response to clopidogrel. OBJECTIVES The aim of this study was to evaluate the safety and efficacy of clopidogrel monotherapy after very short dual antiplatelet therapy (DAPT) in patients with diabetes undergoing percutaneous coronary intervention (PCI). METHODS A subgroup analysis was conducted on the basis of diabetes in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2) Total Cohort (N = 5,997) (STOPDAPT-2, n = 3,009; STOPDAPT-2 ACS [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS], n = 2,988), which randomly compared 1-month DAPT followed by clopidogrel monotherapy with 12-month DAPT with aspirin and clopidogrel after cobalt-chromium everolimus-eluting stent implantation. The primary endpoint was a composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (TIMI [Thrombolysis In Myocardial Infarction] major or minor) endpoints at 1 year. RESULTS There were 2,030 patients with diabetes (33.8%) and 3967 patients without diabetes (66.2%). Regardless of diabetes, the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (diabetes, 3.58% vs 4.12% [HR: 0.87; 95% CI: 0.56-1.37; P = 0.55]; nondiabetes, 2.46% vs 2.49% [HR: 0.99; 95% CI: 0.67-1.48; P = 0.97]; Pinteraction = 0.67) and for the cardiovascular endpoint (diabetes, 3.28% vs 3.05% [HR: 1.10; 95% CI: 0.67-1.81; P = 0.70]; nondiabetes, 1.95% vs 1.43% [HR: 1.38; 95% CI: 0.85-2.25; P = 0.20]; Pinteraction = 0.52), while it was lower for the bleeding endpoint (diabetes, 0.30% vs 1.50% [HR: 0.20; 95% CI: 0.06-0.68; P = 0.01]; nondiabetes, 0.61% vs 1.21% [HR: 0.51; 95% CI: 0.25-1.01; P = 0.054]; Pinteraction = 0.19). CONCLUSIONS Clopidogrel monotherapy after 1-month DAPT compared with 12-month DAPT reduced major bleeding events without an increase in cardiovascular events regardless of diabetes, although the findings should be considered as hypothesis generating, especially in patients with acute coronary syndrome, because of the inconclusive result in the STOPDAPT-2 ACS trial. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/KoYamamoto7
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/HirotWatanabeMD
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shojiro Tatsushima
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hirohiko Suzuki
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akira Nikaido
- Department of Cardiology, Minamino Cardiovascular Hospital, Hachioji, Japan
| | - Naoki Watanabe
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Shinya Fujii
- Department of Cardiology, Sendai Cardiovascular Center, Sendai, Japan
| | - Hiroyoshi Mori
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Tenjin Nishikura
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Nobuhiro Suematsu
- Division of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Fujio Hayashi
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tatsuya Shigematsu
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Franchi F, Ortega-Paz L, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Reiter B, Jilma B, Angiolillo DJ. Cangrelor in Patients With Coronary Artery Disease Pretreated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2023; 16:36-46. [PMID: 36317958 DOI: 10.1016/j.jcin.2022.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are no studies specifically designed to rule out a drug-drug interaction (DDI) when cangrelor is used among patients who have been pretreated with ticagrelor. OBJECTIVES This study sought to rule out a DDI among cangrelor-treated patients who have been pretreated with ticagrelor. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover, pharmacokinetic (PK) and pharmacodynamic (PD) study, patients with coronary artery disease (N = 20) were pretreated with a 180-mg ticagrelor loading dose and after 1 hour randomized to placebo or cangrelor (bolus and infusion for 2 hours). Patients crossed over after 1 to 4 weeks of washout. PK analysis included ticagrelor plasma levels and its active metabolite. PD assessments included VerifyNow P2Y12 reaction units (PRU), light transmittance aggregometry, vasodilator-stimulated phosphoprotein, and Total Thrombus-Formation Analysis System. PK/PD assessments were performed at 7 time points. RESULTS Compared with placebo, adding cangrelor to patients pretreated with ticagrelor resulted in a significant reduction in PRU at 30 minutes and 1 hour after starting infusion. At 2 hours after stopping cangrelor/placebo infusion, PRU were low and similar in both groups (16.9 vs 12.6; mean difference: 4.3; 95% CI: -28.6 to 37.3), meeting the noninferiority primary endpoint (predefined noninferiority margin 45 PRU). Consistent findings were shown with all PD assays. PK tracked PD findings with no differences between groups in plasma levels of ticagrelor and its metabolite. CONCLUSIONS Compared with placebo, the use of cangrelor in patients pretreated with ticagrelor results in enhanced platelet inhibition with no differences in PK/PD profiles after discontinuation of drug infusion indicating the absence of a DDI. (PD and PK Profiles of Switching Between Cangrelor and Ticagrelor Following Ticagrelor Pre-treatment [SWAP-5]; NCT04634162).
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
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5
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Choi Y, Kang DY, Lee J, Lee J, Kim M, Kim H, Park J, Cho S, Lee J, Cha SJ, Kim TO, Lee PH, Ahn JM, Park SJ, Park DW. Ticagrelor Versus Clopidogrel in East Asian Patients With Acute Coronary Syndrome and Diabetes Mellitus. JACC. ASIA 2022; 2:666-674. [PMID: 36444315 PMCID: PMC9700022 DOI: 10.1016/j.jacasi.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND It is still unknown whether diabetes mellitus (DM) affects the relative safety and efficacy of ticagrelor vs clopidogrel in East Asian patients with acute coronary syndrome (ACS). OBJECTIVES The authors sought to assess the safety and efficacy of ticagrelor vs clopidogrel according to the diabetic status of East Asian patients with ACS undergoing invasive management. METHODS This prespecified analysis of the TICA KOREA (Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management) trial included 800 Korean patients. The primary safety endpoint was clinically significant bleeding (PLATO [Platelet Inhibition and Clinical Outcomes] major or minor bleeding) at 12 months; the efficacy endpoint was major adverse cardiovascular events (cardiovascular death, myocardial infarction, and stroke). RESULTS Of 800 patients, 216 (27.0%) had DM. The incidence of clinically significant bleeding within 12 months was significantly higher with ticagrelor than clopidogrel in the nondiabetic group (10.2% vs 4.3%; HR: 2.45; 95% CI: 1.27-4.70; P = 0.007) and tended to be higher in the diabetic group (13.8% vs 8.0%; HR: 1.87; 95% CI: 0.54-4.36; P = 0.15); there was no significant interaction between treatment-arm and DM (P for interaction = 0.64). The incidences of major adverse cardiovascular events were not significantly different after ticagrelor or clopidogrel both in the diabetic group (10.8% vs 6.0%; HR: 1.90; 95% CI: 0.71-5.07; P = 0.20) and in the nondiabetic group (8.5% vs 5.7%; HR: 1.51; 95% CI: 0.81-2.81; P = 0.19) without significant interaction (P-for-interaction = 0.71). CONCLUSIONS In Korean ACS patients undergoing early invasive management, diabetes status did not affect the relative safety and efficacy of ticagrelor and clopidogrel. (Safety and Efficacy of Ticagrelor Versus Clopidogrel in Asian/Korean Patients With Acute Coronary Syndromes Intended for Invasive Management [TICA KOREA]; NCT02094963).
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - JungBok Lee
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mijin Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsun Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suji Cho
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Junghoon Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Joo Cha
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Oh Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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6
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Zhong H, Waresi M, Zhang W, Han L, Zhao Y, Chen Y, Zhou P, Chang L, Pan G, Wu B, Li J, Zhang S, Shi H, Luo X, Gao W, Qi Z, Ding Z. NOD2-mediated P2Y 12 upregulation increases platelet activation and thrombosis in sepsis. Biochem Pharmacol 2021; 194:114822. [PMID: 34748820 DOI: 10.1016/j.bcp.2021.114822] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/14/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Platelets from septic patients exhibit increased reactivity. However, the underlying mechanism of sepsis-induced platelet hyperactivity is still not completely understood. OBJECTIVE P2Y12 is a central receptor for platelet activation. In this study, we investigated the role of platelet P2Y12 in platelet hyperactivity during sepsis. METHODS We measured platelet P2Y12 expression and aggregation in response to ADP in septic patients and cecal ligation and puncture (CLP)-treated mice. We also detected the downstream signaling of P2Y12 in resting platelets from patients and mice with sepsis. The role of nucleotide-binding oligomerization domain 2 (NOD2)/RIP2/NF-κB/P65 pathway in sepsis-induced platelet P2Y12 high expression was also investigated. Finally, we compared the antiplatelet and antithrombotic effects of clopidogrel, prasugrel, and ticagrelor in experimental sepsis in mice and rats. RESULTS Compared to healthy subjects, platelets from septic patients exhibit P2Y12 hyperactivity and higher P2Y12 expression. pAkt is enhanced and pVASP is impaired in resting platelets from the patients, indicating the constitutive activation of platelet P2Y12 receptor. Mouse sepsis model recapitulates the findings in septic patients. NOD2 deficiency attenuates sepsis-induced platelet P2Y12 high expression, hyperactivity, and thrombosis. Prasugrel and ticagrelor are potent P2Y12 inverse agonists, and exhibit superior antiplatelet and antithrombotic efficacy over clopidogrel in mice and rats with sepsis. CONCLUSIONS NOD2 activation upregulates platelet P2Y12 expression, which is constitutively activated and contributes to platelet hyperactivity in septic status. Compared to clopidogrel, prasugrel and ticagrelor are potent P2Y12 inverse agonists with superior antiplatelet and antithrombotic efficacy in experimental sepsis.
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Affiliation(s)
- Haoxuan Zhong
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Maieryemu Waresi
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Wei Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Liping Han
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Yikai Zhao
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Yufei Chen
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Peng Zhou
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Lin Chang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Guanxing Pan
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Bangwei Wu
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Si Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China
| | - Haiming Shi
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China
| | - Wen Gao
- Department of Cardiology, Huashan Hospital, Fudan University. Shanghai, China.
| | - Zhiyong Qi
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China.
| | - Zhongren Ding
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Fudan University, Shanghai, China; School of Pharmacy, Tianjin Medical University, Tianjin, China.
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7
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Schilling U, Dingemanse J, Ufer M. Pharmacokinetics and Pharmacodynamics of Approved and Investigational P2Y12 Receptor Antagonists. Clin Pharmacokinet 2021; 59:545-566. [PMID: 32056160 DOI: 10.1007/s40262-020-00864-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronary artery disease remains the major cause of mortality worldwide. Antiplatelet drugs such as acetylsalicylic acid and P2Y12 receptor antagonists are cornerstone treatments for the prevention of thrombotic events in patients with coronary artery disease. Clopidogrel has long been the gold standard but has major pharmacological limitations such as a slow onset and long duration of effect, as well as weak platelet inhibition with high inter-individual pharmacokinetic and pharmacodynamic variability. There has been a strong need to develop potent P2Y12 receptor antagonists with more favorable pharmacological properties. Prasugrel and ticagrelor are more potent and have a faster onset of action; however, they have shown an increased bleeding risk compared with clopidogrel. Cangrelor is highly potent and has a very rapid onset and offset of effect; however, its indication is limited to P2Y12 antagonist-naïve patients undergoing percutaneous coronary intervention. Two novel P2Y12 receptor antagonists are currently in clinical development, namely vicagrel and selatogrel. Vicagrel is an analog of clopidogrel with enhanced and more efficient formation of its active metabolite. Selatogrel is characterized by a rapid onset of action following subcutaneous administration and developed for early treatment of a suspected acute myocardial infarction. This review article describes the clinical pharmacology profile of marketed P2Y12 receptor antagonists and those under development focusing on pharmacokinetic, pharmacodynamic, and drug-drug interaction liability.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
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8
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Bhat S, Yatsynovich Y, Sharma UC. Coronary revascularization in patients with stable coronary disease and diabetes mellitus. Diab Vasc Dis Res 2021; 18:14791641211002469. [PMID: 33926268 PMCID: PMC8482730 DOI: 10.1177/14791641211002469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE OF STUDY Diabetes mellitus accelerates the development of atherosclerosis. Patients with diabetes mellitus have higher incidence and mortality rates from cardiovascular disease and undergo a disproportionately higher number of coronary interventions compared to the general population. Proper selection of treatment modalities is thus paramount. Treatment strategies include medical management and interventional approaches including coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCI). The purpose of this review is to assimilate emerging evidence comparing CABG to PCI in patients with diabetes and present an outlook on the latest advances in percutaneous interventions, in addition to the optimal medical therapies in patients with diabetes. KEY METHODS A systematic search of PubMed, Web of Science and EMBASE was performed to identify prospective, randomized trials comparing outcomes of CABG and PCI, and also PCI with different generations of stents used in patients with diabetes. Additional review of bibliography of selected studies was also performed. MAIN CONCLUSIONS Most of the trials discussed above demonstrate a survival advantage of CABG over PCI in patients with diabetes. However, recent advances in PCI technology are starting to challenge this narrative. Superior stent designs, use of specific drug-eluting stents, image-guided stent deployment, and the use of contemporary antiplatelet and lipid-lowering therapies are continuing to improve the PCI outcomes. Prospective data for such emerging interventional technologies in diabetes is however lacking currently and is the need of the hour.
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Affiliation(s)
- Salman Bhat
- Department of Medicine, University at Buffalo, NY, USA
| | - Yan Yatsynovich
- Department of Medicine, University at Buffalo, NY, USA
- Division of Cardiovascular Diseases, University at Buffalo, NY, USA
| | - Umesh C Sharma
- Department of Medicine, University at Buffalo, NY, USA
- Division of Cardiovascular Diseases, University at Buffalo, NY, USA
- The Clinical and Translational Science Institute, University at Buffalo, NY, USA
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9
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Efficacy and Safety of Ticagrelor in Diabetes Patients Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2021; 77:536-543. [PMID: 33760801 DOI: 10.1097/fjc.0000000000000995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Dual antiplatelet treatment, consisting of aspirin and P2Y12 inhibitors, is essential for diabetes mellitus (DM) patients who have undergone percutaneous coronary intervention (PCI). This meta-analysis investigated whether ticagrelor, a novel P2Y12 inhibitor, was superior to clopidogrel and prasugrel in efficacy and safety for DM patients undergoing PCI. PubMed, the Cochrane Library and Google Scholar were searched for randomized controlled trials in which ticagrelor was administered. Eligible studies were independently scrutinized to extract data and assess the trials' quality. Statistical analysis was performed by calculating odds ratios (OR) and 95% confidence intervals (CI). A total of 8 studies consisting of 1056 patients were included. Results showed that ticagrelor reduced the major adverse cardiac events incidence compared with clopidogrel and prasugrel in the overall (OR = 0.40; 95% CI, 0.20-0.79; P = 0.008) and subgroup analyses compared with clopidogrel (OR = 0.39; 95% CI, 0.19-0.80; P = 0.01). No difference was observed in mortality rates (OR = 0.58; 95% CI, 0.23-1.45; P = 0.25), myocardial infarction (OR = 0.67; 95% CI, 0.28-1.60; P = 0.37), stroke (OR = 0.54; 95% CI, 0.10-3.01; P = 0.49), and total bleeding (OR = 1.70; 95% CI, 0.91-3.17; P = 0.10) between the ticagrelor and control groups. In DM patients undergoing PCI, ticagrelor significantly reduced major adverse cardiac events compared with clopidogrel and prasugrel in the overall and in the subgroup of clopidogrel. There was no difference regarding mortality, myocardial infarction, stroke, and bleeding. More randomized controlled trials are required to further validate these results.
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10
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Xu RJ, Kong WM, An XF, Zou JJ, Liu L, Liu XD. Physiologically-Based Pharmacokinetic-Pharmacodynamics Model Characterizing CYP2C19 Polymorphisms to Predict Clopidogrel Pharmacokinetics and Its Anti-Platelet Aggregation Effect Following Oral Administration to Coronary Artery Disease Patients With or Without Diabetes. Front Pharmacol 2021; 11:593982. [PMID: 33519456 PMCID: PMC7845657 DOI: 10.3389/fphar.2020.593982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022] Open
Abstract
Background and Objective: Clopidogrel (CLOP) is commonly used in coronary artery disease (CAD) patients with or without diabetes (DM), but these patients often suffer CLOP resistance, especially those with diabetes. This study was aimed to develop a physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) model to describe the pharmacokinetics and pharmacodynamics of clopidogrel active metabolite (CLOP-AM) in CAD patients with or without DM. Methods: The PBPK-PD model was first established and validated in healthy subjects and then in CAD patients with or without DM. The influences of CYP2C19, CYP2C9, CYP3A4, carboxylesterase 1 (CES1), gastrointestinal transit rates (Kt,i) and platelets response to CLOP-AM (kirre) on predicted pharmacokinetics and pharmacodynamics were investigated, followed with their individual and integrated effects on CLOP-AM pharmacokinetics due to changes in DM status. Results: Most predictions fell within 0.5–2.0 folds of observations, indicating successful predictions. Sensitivity analysis showed that contributions of interested factors to pharmacodynamics were CES1> kirre> Kt,i> CYP2C19 > CYP3A4> CYP2C9. Mimicked analysis showed that the decreased exposure of CLOP-AM by DM was mainly attributed to increased CES1 activity, followed by decreased CYP2C19 activity. Conclusion: The pharmacokinetics and pharmacodynamics of CLOP-AM were successfully predicted using the developed PBPK-PD model. Clopidogrel resistance by DM was the integrated effects of altered Kt,i, CYP2C19, CYP3A4, CES1 and kirre.
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Affiliation(s)
- Ru-Jun Xu
- Center of Pharmacokinetics and Metabolism, College of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Wei-Min Kong
- Center of Pharmacokinetics and Metabolism, College of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xiao-Fei An
- Department of Endocrinology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinse Medicine, Nanjing, China
| | - Jian-Jun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Li Liu
- Center of Pharmacokinetics and Metabolism, College of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xiao-Dong Liu
- Center of Pharmacokinetics and Metabolism, College of Pharmacy, China Pharmaceutical University, Nanjing, China
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11
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Pascoal MDANC, Dos Santos NBM, Completo AMG, Fernandes GVDO. Tensile strength assay comparing the resistance between two different autologous platelet concentrates (leucocyte-platelet rich fibrin versus advanced-platelet rich fibrin): a pilot study. Int J Implant Dent 2021; 7:1. [PMID: 33447875 PMCID: PMC7809075 DOI: 10.1186/s40729-020-00284-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/17/2020] [Indexed: 01/31/2023] Open
Abstract
Background Since the leucocyte-platelet rich fibrin (L-PRF) was published in 2001, many studies have been developed, analyzing its properties, and also verifying new possibilities to improve it. Thereby, it emerges the advanced-platelet rich fibrin (A-PRF) with a protocol that optimizes the properties obtained by the L-PRF. Nonetheless, there is a gap in the literature to landmark the evolutive process concerning the mechanical properties in specific the resistance to tensile strength which consequently may influence the time for membrane degradation. Thus, this study had the goal to compare the resistance to the traction of membranes produced with the original L-PRF and A-PRF protocols, being the first to this direct comparison. Findings The harvest of blood from a healthy single person, with no history of anticoagulant usage. We performed the protocols described in the literature, within a total of 13 membranes produced for each protocol (n = 26). Afterward, the membranes were prepared and submitted to a traction test assessing the maximal and the average traction achieved for each membrane. The data were analyzed statistically using the unpaired t test. Regarding average traction, A-PRF obtained a value of 0.0288 N mm−2 and L-PRF 0.0192 N mm−2 (p < 0.05 using unpaired t test). For maximal traction, A-PRF obtained 0.0752 N mm−2 and L-PRF 0.0425 N mm−2 (p < 0.05 using unpaired t test). Conclusion With this study, it was possible to conclude that indeed A-PRF has a significative higher maximal traction score and higher average traction compared to L-PRF, indicating that it had a higher resistance when two opposing forces are applied.
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Affiliation(s)
| | - Nuno Bernardo Malta Dos Santos
- Periodontics Department, Center for Interdisciplinary Research in Health (CIIS), Faculty of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal
| | | | - Gustavo Vicentis de Oliveira Fernandes
- Periodontics Department, Center for Interdisciplinary Research in Health (CIIS), Faculty of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal. .,Implantology and Biomaterials Department, Faculty of Dental Medicine, Universidade Católica Portuguesa, Quinta da Alagoa Ave., 225 - 1 DT, 3500-606, Viseu, Portugal.
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12
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Seecheran N, Boodhai B, Maharaj A, Ramdeen A, Debideen N, Ochalal V, Singh R, Seecheran R, Seecheran V, Persad S, Abdullah H, Peram L, Motilal S, Tello-Montoliu A, Schneider D. The Effect of Low-Dose Ticagrelor on Platelet Function Profiles in Patients With Stable Coronary Artery Disease in Trinidad: The TWIST Pilot Study. Cardiol Ther 2020; 9:493-503. [PMID: 32766961 PMCID: PMC7584691 DOI: 10.1007/s40119-020-00195-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION This prospective, pharmacodynamic study aimed to explore the potential applicability of a low-dose ticagrelor regimen in a heterogeneous Trinidadian subpopulation. METHODS Patients with stable coronary artery disease (n = 25) who were actively treated with dual antiplatelet therapy of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, CA, USA) and assessed before initiation of and after 14 days of treatment with a low-dose ticagrelor 45 mg twice daily maintenance dose regimen. Results were compared with a paired t test. RESULTS The mean P2Y12 reaction units (PRU) score on ticagrelor was significantly less compared to that of clopidogrel (50.4, 95% confidence interval (CI) 29-73.9; vs. 149.6, 95% CI 129.4-169.9; p value < 0.001). Of the patients, 4% experienced Medical Research Council class 1 dyspnea, and Bleeding Academic Research Consortium class 1 bleeding on the ticagrelor regimen (one patient each). CONCLUSIONS Significantly attenuated platelet reactivity was seen on the low ticagrelor maintenance dose as compared to clopidogrel. This dedicated pharmacodynamic study could be applicable and informative for Trinidadian stable coronary artery disease patients. Further studies are required to confirm these exploratory findings.(Funded by the University of the West Indies, St. Augustine). TRIAL REGISTRATION ClinicalTrials.gov number NCT04206176.
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Affiliation(s)
- Naveen Seecheran
- The University of the West Indies, St. Augustine, Port of Spain, Trinidad and Tobago.
| | - Brent Boodhai
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Aarti Maharaj
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Arvinash Ramdeen
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Niranjan Debideen
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Vishesh Ochalal
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Randall Singh
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Rajeev Seecheran
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Valmiki Seecheran
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Sangeeta Persad
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Harun Abdullah
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Lakshmipathi Peram
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | - Shastri Motilal
- North Central Regional Health Authority, Champs Fleurs, Mount Hope, Trinidad and Tobago
| | | | - David Schneider
- Cardiovascular Research Institute of Vermont, Colchester, Vermont, USA
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13
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Capodanno D, Angiolillo DJ. Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients With Coronary Artery Disease and Diabetes Mellitus. Circulation 2020; 142:2172-2188. [PMID: 33253005 DOI: 10.1161/circulationaha.120.045465] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with diabetes mellitus (DM) are characterized by enhanced thrombotic risk attributed to multiple mechanisms including hyperreactive platelets, hypercoagulable status, and endothelial dysfunction. As such, they are more prone to atherosclerotic cardiovascular events than patients without DM, both before and after coronary artery disease (CAD) is established. In patients with DM without established CAD, primary prevention with aspirin is not routinely advocated because of its increased risk of major bleeding that largely offsets its ischemic benefit. In patients with DM with established CAD, secondary prevention with antiplatelet drugs is an asset of pharmacological strategies aimed at reducing the risk of atherosclerotic cardiovascular events and their adverse prognostic consequences. Such antithrombotic strategies include single antiplatelet therapy (eg, with aspirin or a P2Y12 inhibitor), dual antiplatelet therapy (eg, aspirin combined with a P2Y12 inhibitor), and dual-pathway inhibition (eg, aspirin combined with the vascular dose of the direct oral anticoagulant rivaroxaban) for patients with chronic ischemic heart disease, acute coronary syndromes, and those undergoing percutaneous coronary intervention. Because of their increased risk of thrombotic complications, patients with DM commonly achieve enhanced absolute benefit from more potent antithrombotic approaches compared with those without DM, which most often occurs at the expense of increased bleeding. Nevertheless, studies have shown that when excluding individuals at high risk for bleeding, the net clinical benefit favors the use of intensified long-term antithrombotic therapy in patients with DM and CAD. Several studies are ongoing to establish the role of novel antithrombotic strategies and drug formulations in maximizing the net benefit of antithrombotic therapy for patients with DM. The scope of this review article is to provide an overview of current and evolving antithrombotic strategies for primary and secondary prevention of atherosclerotic cardiovascular events in patients with CAD and DM.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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14
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Valeria C, Carmine S, Valentina M, Teresa I, Maria C, Martina T, Giancarlo A, Giovanna N, Graziamaria C, Amelia F. The need of a multicomponent guiding approach to personalize clopidogrel treatment. THE PHARMACOGENOMICS JOURNAL 2020; 21:116-127. [PMID: 33033370 DOI: 10.1038/s41397-020-00189-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/13/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022]
Abstract
Patients bearing polymorphisms termed CYP2C19 loss of function (LoF) alleles and ABCB1-C3435T may do not properly respond to standard dosage of clopidogrel and have an increased risk of thrombosis. Moreover, co-administration of proton pump inhibitors (PPIs) and clopidogrel may attenuate the antiplatelet effect. The role of pharmacogenetics and PPIs/clopidogrel drug-drug interaction has been extensively investigated in patients with acute coronary syndrome after stent implantation (ACS/PCI), while data in patients undergoing vascular surgery are scarce. Here we have performed a systematic review to evaluate the available literature in such a clinical setting and have discussed the controversies about the use of CYP2C19 pharmacogenetics and platelet function testing to personalize clopidogrel treatment. In addition, we have made a comparison of the literature data with our findings concerning patients eligible for vascular surgery and treated with clopidogrel, in whom we used a combined management based on the CYP2C19 and ABCB1 pharmacogenetic testing with monitoring of therapeutic adherence and PPIs-clopidogrel interaction. Both our data and those produced during both observational studies and randomized clinical trials confirm the validity of pharmacogenetics to personalize clopidogrel treatment and stress the importance to make a drug monitoring considering all the known variables, potentially responsible for treatment failure. However, the American Heart Association and the European Cardiovascular Society recommend against the routine use of clopidogrel pharmacogenetic testing. An update of the international guidelines on antiplatelet therapy, incorporating the evidence related to CYP2C19 pharmacogenetics and PPIs-clopidogrel drug-drug interactions is warranted both in ACS/PCI patients and subjects undergoing vascular surgery.
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Affiliation(s)
- Conti Valeria
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy. .,Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo 1, Salerno, Italy.
| | - Sellitto Carmine
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Manzo Valentina
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Iannaccone Teresa
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Costantino Maria
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy.,Association non-profit F.I.R.S.Thermae (Interdisciplinary Training, Researches and spa Sciences) in Italian National Register of Research of MIUR, Via Marziale, 21, 80070, Bacoli, Naples, Italy
| | - Torsiello Martina
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Accarino Giancarlo
- Vascular surgery Unit, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno- via S. Leonardo 1, Salerno, Italy
| | - Nicolella Giovanna
- Vascular surgery Unit, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno- via S. Leonardo 1, Salerno, Italy
| | - Corbi Graziamaria
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis, 1, 86100, Campobasso, Italy
| | - Filippelli Amelia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy.,Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo 1, Salerno, Italy
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15
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Ndrepepa G, Kastrati A, Menichelli M, Neumann FJ, Wöhrle J, Bernlochner I, Richardt G, Witzenbichler B, Sibbing D, Gewalt S, Angiolillo DJ, Hamm CW, Hapfelmeier A, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Mayer K. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndromes and Diabetes Mellitus. JACC Cardiovasc Interv 2020; 13:2238-2247. [DOI: 10.1016/j.jcin.2020.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022]
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16
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Terrier J, Daali Y, Fontana P, Csajka C, Reny JL. Towards Personalized Antithrombotic Treatments: Focus on P2Y 12 Inhibitors and Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 58:1517-1532. [PMID: 31250210 DOI: 10.1007/s40262-019-00792-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral anticoagulants and antiplatelet drugs are commonly prescribed to lower the risk of cardiovascular diseases, such as venous and arterial thrombosis, which represent the leading causes of mortality worldwide. A significant percentage of patients taking antithrombotics will nevertheless experience bleeding or recurrent ischemic events, and this represents a major public health issue. Cardiovascular medicine is now questioning the one-size-fits-all policy, and more personalized approaches are increasingly being considered. However, the available tools are currently limited and they are only moderately able to predict clinical events or have a significant impact on clinical outcomes. Predicting concentrations of antithrombotics in blood could be an effective means of personalization as they have been associated with bleeding and recurrent ischemia. Target concentration interventions could take advantage of physiologically based pharmacokinetic (PBPK) and population-based pharmacokinetic (POPPK) models, which are increasingly used in clinical settings and have attracted the interest of governmental regulatory agencies, to propose dosages adapted to specific population characteristics. These models have the benefit of combining parameters from different sources, such as experimental in vitro data and patients' demographic, genetic, and physiological in vivo data, to characterize the dose-concentration relationships of compounds of interest. As such, they can be used to predict individual drug exposure. In the near future, these models could therefore be a valuable means of predicting personalized antithrombotic blood concentrations and, hopefully, of preventing clinical non-response or bleeding in a given patient. Existing approaches for personalization of antithrombotic prescriptions will be reviewed using practical examples for P2Y12 inhibitors and direct oral anticoagulants. The review will additionally focus on the existing PBPK and POPPK models for these two categories of drugs. Lastly, we address potential scenarios for their implementation in clinics, along with the main limitations and challenges.
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Affiliation(s)
- Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland.,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care Department, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Chantal Csajka
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland. .,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Division of Internal Medicine and Rehabilitation, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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17
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Rymer JA, Kaltenbach LA, Doll JA, Messenger JC, Peterson ED, Wang TY. Safety of Dual-Antiplatelet Therapy After Myocardial Infarction Among Patients With Chronic Kidney Disease. J Am Heart Assoc 2020; 8:e012236. [PMID: 31070112 PMCID: PMC6585341 DOI: 10.1161/jaha.119.012236] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Although recommended in the guidelines, the safety of chronic P2Y12 inhibitor therapy in patients with chronic kidney disease ( CKD ) after an acute myocardial infarction ( MI ) is not well studied. Methods and Results The TRANSLATE -ACS (Treatment with ADP Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study included 11 108 MI patients treated with percutaneous coronary intervention and discharged alive on a P2Y12 inhibitor from 233 US hospitals. We compared rates of GUSTO (Global Use of Strategies to Open Occluded Arteries) severe/moderate bleeding and premature discontinuation of P2Y12 inhibitor by 1 year after MI among patients with varying CKD severity. The majority of MI patients treated with percutaneous coronary intervention had CKD : 42% had stage 2 (mild), 27% had stage 3 (moderate), and 4% had stage ≥4 (severe/end stage). Higher potency P2Y12 inhibitors (prasugrel or ticagrelor) were prescribed at discharge in 39%, 35%, 23%, and 15% ( P<0.01) of patients with stages 1, 2, 3, and ≥4, respectively. One-year GUSTO severe/moderate bleeding rates were higher with each stage of CKD : 1% in patients with CKD stage 1 or no CKD , 2% with an adjusted hazard ratio of 1.61 (95% CI, 1.05-2.35) for CKD stage 2, 4% with an adjusted hazard ratio of 1.92 (95% CI, 1.21-3.02) for CKD stage 3, and 10% with an adjusted hazard ratio of 2.44 (95% CI, 1.40-4.23) for patients with CKD stage ≥4. By 1 year after MI , 16% of patients overall had prematurely discontinued P2Y12 inhibitor therapy; however, this rate was not largely affected by CKD stage. Premature P2Y12 inhibitor-discontinuation rates were higher for patients discharged on higher potency P2Y12 inhibitors in patients with CKD stage ≥2 ( P<0.01). Conclusions CKD severity was associated with a higher bleeding risk among those with acute MI treated with a P2Y12 inhibitor. Patients with more advanced CKD were not significantly more likely than those with less advance CKD to prematurely discontinue P2Y12 inhibitor therapy.
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Affiliation(s)
- Jennifer A Rymer
- 1 Department of Medicine Duke University Medical Center Durham NC
| | | | | | - John C Messenger
- 4 Division of Cardiology University of Colorado School of Medicine Aurora CO
| | - Eric D Peterson
- 1 Department of Medicine Duke University Medical Center Durham NC
| | - Tracy Y Wang
- 1 Department of Medicine Duke University Medical Center Durham NC
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18
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Abstract
BACKGROUND Aspirin (ASA) is the most used medication on the globe. ASA is a primary pillar of the secondary prevention of cardiovascular atherothromboembolic events. However, a fraction of the population does not respond to ASA as expected in a unique phenomenon called ASA resistance. Multiple mechanisms were described and studied in the literature to explain this phenomenon. AREA OF UNCERTAINTY ASA resistance is an interesting phenomenon that is worth studying and reviewing. Mechanisms behind this resistance are various and although the rarity of some, it is crucial for the modern health provider to be aware of such phenomenon and its possible explanations to provide more efficient preventive cardiology practice. Our study aimed to review and conclude the evidence behind ASA resistance and its implication on the cardiovascular health. DATA SOURCES We searched databases like PubMed, EMBASE, Ovid by midline, and Google Scholar for published articles and abstracts. RESULTS Our systemic search revealed more than 100 articles in relation to ASA resistance. We selected 40 articles, which were relevant for this review. Various mechanisms were described in the literature, with few of them very well documented and understood. Main mechanisms include medication nonadherence, interaction with proton pump inhibitors, esterase-mediated ASA inactivation, post-coronary artery bypass grafting (CABG) MRP-4-mediated ASA consumption, cyclooxygenase-1 (COX-1) polymorphisms, high platelet turnover-associated regeneration of platelet COX-1, and the documented platelet ability of de novo COX-1 synthesis in response to thrombin and fibrinogen. CONCLUSION Multiple mechanisms of ASA resistance were described in the literature. Awareness of such interaction is important for medical practitioners. Bottom line, further studies and reviews are needed to further study this phenomenon and its implication on the cardiovascular health and hence reaching a valid evidence-based conclusion that might change the practice and improve the patient preventive health care.
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Zhou AM, Xiang YJ, Liu EQ, Cai CH, Wu YH, Yang LB, Zeng CL. Salvianolic acid a inhibits platelet activation and aggregation in patients with type 2 diabetes mellitus. BMC Cardiovasc Disord 2020; 20:15. [PMID: 31931718 PMCID: PMC6956554 DOI: 10.1186/s12872-019-01316-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background Platelets in patients with type 2 diabetes mellitus (DM2) are characterized by increased activation and aggregation, which tends to be associated with a high morbidity and mortality due to cardiovascular disease (CVD). Moreover, a large proportion of DM2 patients show an inadequate response to standard antiplatelet treatments, contributing to recurrent cardiovascular events. In our previous study, we indicated that Salvianolic acid A (SAA) presents an antiplatelet effect in healthy volunteers. However, whether it can inhibit “activated platelets” with a pathologic status has not been explored. Therefore, this study was designed to investigate the antiplatelet effect of SAA and its diabetic complication-related difference in DM2. Methods Forty patients diagnosed with DM2 from January 2018 to April 2018 were recruited. Fibrinogen-binding (PAC-1) and P-selectin (CD62p) flow cytometry reagents were measured under resting and stimulated conditions by flow cytometry, while agonist-induced platelet aggregation was conducted by light transmission aggregometry. Before all these measurements were conducted, all platelet samples were preincubated with a vehicle or SAA for 10 min. Additionally, the diabetic complication-related difference in the antiplatelet effect of SAA was further studied in enrolled patients. Results The expressions of PAC-1 and CD62p were elevated in DM2, as well as the maximal platelet aggregation. In addition, SAA decreased the expressions of PAC-1 and CD62p, which were enhanced by ADP and thrombin (all P < 0.01). It also reduced the platelet aggregation induced by ADP (P < 0.001) and thrombin (P < 0.05). Comparing the antiplatelet effect of SAA on DM2, with and without diabetic complications, no statistically significant difference was found (all P > 0.05). Conclusions The present study demonstrated that SAA can inhibit platelet activation and aggregation in patients with DM2, and the inhibition did not abate for the existence of diabetic complications.
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Affiliation(s)
- Ai-Ming Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yi-Jia Xiang
- Department of Cardiology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, 323000, Zhejiang, China
| | - En-Qian Liu
- Zhejiang University School of Medicine, Hangzhou, 310029, Zhejiang, China
| | - Chang-Hong Cai
- The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Yong-Hui Wu
- The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Le-Bing Yang
- The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Chun-Lai Zeng
- Department of Cardiology, Lishui Hospital, Zhejiang University School of Medicine, Lishui, 323000, Zhejiang, China.
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Hein R, Gross L, Aradi D, Rieber J, Hadamitzky M, Merkely B, Huczek Z, Ince H, Hummel A, Baylacher M, Massberg S, Trenk D, Sibbing D. Diabetes and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: a pre-specified analysis from the randomised TROPICAL-ACS trial. EUROINTERVENTION 2019; 15:e513-e521. [PMID: 31012853 DOI: 10.4244/eij-d-18-01077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS A guided de-escalation of P2Y12 inhibitor treatment is considered an alternative treatment strategy in ACS patients undergoing PCI. However, the safety and efficacy of this strategy may differ in diabetic vs non-diabetic patients. The aim of this study was to compare the outcomes of platelet function testing (PFT)-guided de-escalation of dual antiplatelet therapy (DAPT) in ACS patients with and without diabetes mellitus. METHODS AND RESULTS The TROPICAL-ACS trial randomised 2,610 biomarker-positive ACS patients 1:1 to either standard treatment with prasugrel for 12 months (control group) or PFT-guided DAPT de-escalation. The association and interaction of diabetes on clinical endpoints across treatment groups and on platelet reactivity was investigated. In diabetic patients (n=527, 20.2%), the overall event rates were high and the one-year incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke or bleeding ≥grade 2) did not differ between guided de-escalation and control group patients (12.5% vs 10.8%; HR 1.17, 95% CI: 0.71-1.93, p=0.55). In non-diabetic patients (n=2,083, 79.8%), the one-year incidence of the primary endpoint was lower in the guided de-escalation vs control group (6.1% vs 8.5%; HR 0.71, 95% CI: 0.52-0.99, p=0.04, pint=0.10). Diabetic patients showed higher platelet reactivity levels in both control (=on prasugrel, p=0.01) and guided de-escalation group (=on clopidogrel, p=0.005) patients. CONCLUSIONS Although diabetic status did not significantly interfere with the treatment effects of guided DAPT de-escalation, our results suggest that this approach might be safe and effective in non-diabetic patients. Further investigation is definitely warranted in diabetic patients.
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Affiliation(s)
- Ralph Hein
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
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Seecheran N, Seebalack V, Seecheran R, Maharaj A, Boodhai B, Seecheran V, Persad S, Motilal S, Tello-Montoliu A, Schneider D. TRimetazidine as an Agent to affeCt clopidogrEl Response: The TRACER Study. Cardiol Ther 2019; 8:229-237. [PMID: 31292901 PMCID: PMC6828882 DOI: 10.1007/s40119-019-0139-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION This prospective study aimed to determine whether trimetazidine (TMZ) alters the pharmacodynamic (PD) effects of clopidogrel. METHODS Patients with stable coronary artery disease (SCAD) (n = 24) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, CA, USA) and assessed before the initiation of and after 14 days of treatment with TMZ. Results were compared using a paired t test. RESULTS Almost 80% of the study population were of South Asian descent and had diabetes mellitus (DM). P2Y12 reaction units (PRUs) were higher in patients on TMZ (204 ± 56 compared with 174 ± 71 before TMZ, p = 0.005). The average increase in PRU score was 29 (95% confidence interval 8.8-49.7). Before TMZ, the proportion of patients with high on-treatment platelet reactivity (PRU > 208 units) was 25%, which increased to 42% for patients on TMZ. CONCLUSION Higher platelet reactivity was seen in patients on TMZ, suggesting that TMZ attenuated the PD effects of clopidogrel in this study of a predominantly South Asian diabetic subpopulation. Alternative therapies should be considered and further research is warranted. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03603249.
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Affiliation(s)
- Naveen Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
| | - Victoria Seebalack
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Rajeev Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Aarti Maharaj
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Brent Boodhai
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Valmiki Seecheran
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Sangeeta Persad
- Department of Medicine, North Central Regional Health Authority, Port of Spain, Trinidad and Tobago
| | - Shastri Motilal
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | | | - David Schneider
- Cardiovascular Research Institute of Vermont, Colchester, VT, USA
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Sharma AN, Deyell JS, Sharma SN, Barseghian A. Role of and Recent Evidence for Antiplatelet Therapy in Prevention of Cardiovascular Disease in Diabetes. Curr Cardiol Rep 2019; 21:78. [PMID: 31254105 DOI: 10.1007/s11886-019-1168-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW When treating patients with diabetes mellitus (DM), the benefits of antiplatelet therapy in preventing cardiovascular disease must be weighed against an increased risk of bleeding. Recent trials have sought to determine both the optimal anti-platelet regimen for patients with DM, and who specifically requires medication among the DM population. This paper will review recent trials and evidence recommending the use of antiplatelet therapy in the prevention of cardiovascular disease in patients with diabetes. RECENT FINDINGS Seven notable trials assessed the effectiveness of antiplatelet therapy in the DM population. The ASCEND trial concluded 100 mg aspirin/day reduced rates of serious vascular events (OR 0.88, p < 0.01) but also increased rates of major bleeding events (OR 1.29, p < 0.01). The DAPT study revealed a longer dual antiplatelet regimen (30 months vs. 18 months) after coronary stent placement was more effective in reducing rates of stent thrombosis (0.5% vs. 1.1%, p = 0.06) and rates of myocardial infarction (3.5% vs. 4.8%, p = 0.06). DECLARE DIABETES showed that adding cilostazol to dual antiplatelet therapy after a coronary stent procedure reduced rates of in-stent and in-segment late loss and increased rates of revascularization (p < 0.04). In PEGASUS-TIMI, daily ticagrelor demonstrated reduced rates of major adverse cardiovascular and cerebrovascular events (OR 0.84, p < 0.04). The DAVID trial compared daily picotamide with daily aspirin therapy, finding reduced mortality rates in the picotamide group (OR 0.55, p < 0.05). Lastly, ACUITY found bivalirudin monotherapy resulted in lower rates of major bleeding events when compared to a glycoprotein IIb/IIa inhibitor and heparin or bivalirudin combination regimen (p < 0.01). Dual antiplatelet therapy guidelines still typically revolve around aspirin, but an increasing number of studies have demonstrated other drugs that may have a role in preventing atherosclerotic cardiovascular disease while decreasing the risk of major bleeding. Overall, it is wise to weigh the cardiovascular risk of a DM patient before prescribing antiplatelet medication. More research is necessary to determine a universal drug or combination of drugs that is safe and effective for DM patients.
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Affiliation(s)
- Ajay Nair Sharma
- School of Medicine, University of California Irvine, Irvine, CA, USA.,Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA
| | - Jacob S Deyell
- School of Medicine, University of California Irvine, Irvine, CA, USA.,Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA
| | | | - Ailin Barseghian
- Division of Cardiology, UC Irvine, 333 City Blvd West. Ste 400, Orange, CA, 92868, USA.
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Verdoia M, Pergolini P, Nardin M, Rolla R, Negro F, Kedhi E, Suryapranata H, Marcolongo M, Carriero A, De Luca G. Vitamin D levels and platelet reactivity in diabetic patients receiving dual antiplatelet therapy. Vascul Pharmacol 2019; 120:106564. [PMID: 31176855 DOI: 10.1016/j.vph.2019.106564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/08/2019] [Accepted: 05/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypovitaminosis D represents an emerging cardiovascular risk factor, and especially among higher-risk subsets of patients, such as in those with diabetes mellitus. The anti-inflammatory and anti-thrombotic properties of vitamin D, in fact, could be even more beneficial among diabetics, where platelet hyperreactivity and suboptimal response to antiplatelet drugs has been associated with poorer outcomes. However, no study has so far evaluated the impact of vitamin D levels on platelet reactivity and high-on treatment platelet reactivity (HRPR) among diabetic patients receiving dial antiplatelet therapy (DAPT). METHODS Our population is represented by a consecutive cohort ofdiabetic patients treated with DAPT (ASA + clopidogrel or ticagrelor or dose-adjusted prasugrel) for an acute coronary syndrome or elective PCI, undergoing platelet reactivity assessment at 30-90 days post-discharge. Aggregation was assessed by multiple-electrode aggregometry. HRPR was defined for values above the lower limit of normality (in non-treated patients). RESULTS We included 440 patients, that were divided according to quartiles values of vitamin D (< 9.4; 9.4-15.59; 15.6-21.64; ≥ 21.65 ng/ml). Among them, 31 were excluded as chronically treated with vitamin D supplementation. Lower vitamin D quartiles were associated with more advanced age (p = 0.01), female gender (p = 0.04), renal failure (p = 0.005), history of previous MI (p = 0.01), CABG and use of diuretics (p = 0.003), severe coronary disease (p = 0.002), but lower ejection fraction (p = 0.001), treatment with statins (p = 0.04) and new ADP-antagonists (p = 0.002). Vitamin D levels related with higher HbA1c (p = 0.001), cholesterol (p = 0.02) and creatinine (p = 0.004) and lower hemoglobin (p = 0.004). The prevalence of HRPR with ASA was low and not related to vitamin D quartiles (3.4% vs 2.7% vs 1.8% vs 2.1%, p = 0.44; adjusted OR[95%CI] = 1.16[0.60-2.26], p = 0.67). The prevalence of HRPR for ADP antagonists was associated to hypovitaminosis D (40.2% vs 29.1% vs 29.4% vs 25.5%, p = 0.03; (adjusted OR[95%CI] = 1.76[1.04-2.98], p = 0.036for I vs II-IV quartile). The impact of vitamin D quartiles, was significant only in patients on new ADP antagonists (n = 225, of whom 81 on prasugrel 5 mg; p = 0.03; adjusted OR[95%CI] = 3.12[1.34-7.49], p = 0.009) but not with clopidogrel (p = 0.85, adjusted OR[95%CI] = 1.05[0.49-2.24], p = 0.89). CONCLUSIONS Among diabetic patients receiving dual antiplatelet therapy for an acute coronary syndrome or elective percutaneous coronary intervention, severe vitamin D deficiency is associated with a higher ADP-mediated platelet reactivity and rate of HRPR, and especially for new ADP-antagonists over clopidogrel.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy; Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Patrizia Pergolini
- ClinicalChemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy
| | - Matteo Nardin
- Internal Medicine, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Roberta Rolla
- ClinicalChemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy
| | - Elvin Kedhi
- Department of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | | | - Marco Marcolongo
- Cardiology, Ospedale degli Infermi, ASL Biella, Italy; Internal Medicine, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Alessandro Carriero
- Radiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", EasternPiedmontUniversity, Novara, Italy.
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Verdoia M, Pergolini P, Nardin M, Rolla R, Barbieri L, Marino P, Carriero A, Suryapranata H, De Luca G. Prevalence and predictors of high-on treatment platelet reactivity during prasugrel treatment in patients with acute coronary syndrome undergoing stent implantation. J Cardiol 2019; 73:198-203. [DOI: 10.1016/j.jjcc.2018.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/06/2018] [Accepted: 10/04/2018] [Indexed: 02/03/2023]
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Seecheran NA, Maharaj A, Boodhai B, Seecheran R, Seecheran V, Persad S, Ramsaroop K, Sandy S, Giddings S, Sakhamuri S, Ali R, Motilal S, Teelucksingh S, Tello-Montoliu A. Prevalence of clOpidogrel 'resIstaNce' in a selected population of patients undergoing elective percutaneous coronary intervention at a tertiary cardiovascular centre in Trinidad: the POINT pilot study. Open Heart 2019; 6:e000841. [PMID: 30997117 PMCID: PMC6443217 DOI: 10.1136/openhrt-2018-000841] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 11/12/2018] [Accepted: 01/20/2019] [Indexed: 11/03/2022] Open
Abstract
Objectives This novel, pilot study aimed to assess the estimated prevalence of high on-treatment platelet reactivity (HPR) in Trinidad and Tobago. Methods Patients (n=40) who were awaiting elective percutaneous coronary intervention on maintenance dual antiplatelet therapy (DAPT) with aspirin 81 mg daily and clopidogrel 75 mg or loaded at least 48 hours prior were recruited. Platelet reactivity with the VerifyNow P2Y12 assay (Accriva Diagnostics, San Diego, California, USA) was assessed prior to cardiac catheterisation. Results 60.7% (17/28) of the South Asian (Indo-Trinidadians) patients had HPR, whereas 14.3% (1/7) of Africans and 40% (2/5) of mixed ethnicity had HPR. There was a significant association between HPR (P2Y12 reaction units >208) and ethnicity with South Asians (Indo-Trinidadians) (OR 5.4; 95% CI 1.18 to 24.66, p=0.029). Conclusions This pilot study serves to introduce the preliminary observation that the estimated prevalence of HPR is considerably higher within the heterogeneous population in Trinidad at 50% as compared with predominantly Caucasian studies. Furthermore, the HPR is significantly higher in South Asians (Indo-Trinidadians) (>60% of patients) which has severe clinical repercussions considering the cardiovascular disease pandemic. Clopidogrel may not be a satisfactory or optimal antiplatelet agent in this subgroup, and therefore, another more potent antiplatelet such as ticagrelor should be used instead. Further large-scale studies are imperative to confirm these findings. (Funded by the University of the West Indies, St. Augustine; POINT ClinicalTrials.gov number, NCT03667066.).
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Affiliation(s)
- Naveen Anand Seecheran
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Aarti Maharaj
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Brent Boodhai
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Rajeev Seecheran
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Valmiki Seecheran
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Sangeeta Persad
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Koomatie Ramsaroop
- Department of Medicine, North Central Regional Health Authority, Champ Fleurs, Trinidad and Tobago
| | - Sherry Sandy
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Stanley Giddings
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Sateesh Sakhamuri
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Ronan Ali
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Shastri Motilal
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
| | - Surujpal Teelucksingh
- Clinical Medical Sciences, University of the West Indies at Saint Augustine Faculty of Medical Sciences, Saint Augustine, Trinidad and Tobago
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Patti G, Cavallari I, Andreotti F, Calabrò P, Cirillo P, Denas G, Galli M, Golia E, Maddaloni E, Marcucci R, Parato VM, Pengo V, Prisco D, Ricottini E, Renda G, Santilli F, Simeone P, De Caterina R. Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs. Nat Rev Cardiol 2019; 16:113-130. [PMID: 30250166 PMCID: PMC7136162 DOI: 10.1038/s41569-018-0080-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diabetes mellitus is an important risk factor for a first cardiovascular event and for worse outcomes after a cardiovascular event has occurred. This situation might be caused, at least in part, by the prothrombotic status observed in patients with diabetes. Therefore, contemporary antithrombotic strategies, including more potent agents or drug combinations, might provide greater clinical benefit in patients with diabetes than in those without diabetes. In this Consensus Statement, our Working Group explores the mechanisms of platelet and coagulation activity, the current debate on antiplatelet therapy in primary cardiovascular disease prevention, and the benefit of various antithrombotic approaches in secondary prevention of cardiovascular disease in patients with diabetes. While acknowledging that current data are often derived from underpowered, observational studies or subgroup analyses of larger trials, we propose antithrombotic strategies for patients with diabetes in various cardiovascular settings (primary prevention, stable coronary artery disease, acute coronary syndromes, ischaemic stroke and transient ischaemic attack, peripheral artery disease, atrial fibrillation, and venous thromboembolism). Finally, we summarize the improvements in cardiovascular outcomes observed with the latest glucose-lowering drugs, and on the basis of the available evidence, we expand and integrate current guideline recommendations on antithrombotic strategies in patients with diabetes for both primary and secondary prevention of cardiovascular disease.
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Affiliation(s)
- Giuseppe Patti
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Ilaria Cavallari
- Unit of Cardiovascular Science, Campus Bio-Medico University, Rome, Italy
| | - Felicita Andreotti
- Cardiovascular and Thoracic Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Calabrò
- Department of Cardio-thoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Gentian Denas
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Mattia Galli
- Cardiovascular and Thoracic Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrica Golia
- Department of Cardio-thoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ernesto Maddaloni
- Department of Medicine, Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Vito Maurizio Parato
- Cardiology Unit, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
- Politecnica Delle Marche University, San Benedetto del Tronto, Italy
| | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Giulia Renda
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy
| | - Francesca Santilli
- Department of Medicine and Aging, G. d'Annunzio University, Chieti, Italy
| | - Paola Simeone
- Department of Medicine and Aging, G. d'Annunzio University, Chieti, Italy
| | - Raffaele De Caterina
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy.
- Fondazione G. Monasterio, Pisa, Italy.
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Candidate gene and pathway analyses identifying genetic variations associated with prasugrel pharmacokinetics and pharmacodynamics. Thromb Res 2018; 173:27-34. [PMID: 30458339 DOI: 10.1016/j.thromres.2018.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/16/2018] [Accepted: 11/14/2018] [Indexed: 01/29/2023]
Abstract
AIM We aimed to investigate the genetic polymorphisms and pharmacogenetic variability associated with the pharmacodynamics (PD) and pharmacokinetics (PK) of prasugrel, in healthy Han Chinese subjects. PATIENTS & METHODS Healthy, native, Han Chinese subjects (n = 36) aged 18 to 45 years with unknown genotypes were included. All subjects received a loading dose (LD) on day 1 and a maintenance dose (MD) from day 2 until day 11. Candidate gene association and gene-set analysis of biological pathways related to prasugrel and platelet activity were analyzed. RESULTS 28 SNPs of 17 candidate genes previously associated with prasugrel or platelet activity were selected after a literature search. In the 30 mg LD groups (n = 24), ITGA2-rs28095 was found to be significantly associated with the P2Y12 reaction unit (PRU) value at 24 h after the LD (p = 0.015). 165 study genes related to platelet activation-related processes and prasugrel activity were selected from the MSigDB database, including curated gene sets from KEGG, Bio Carta, and Gene Cards. 14 SNPs of 9 genes were found to be significantly correlated both at 24 h and 12 days after LD: ADAMTSL1, PRKCA, ITPR2, P2RY12, P2RY14, PLCB4, PRKG1, ADCY1, and LYN. Seven SNPs of 6 protein-coding genes associated with area under the concentration-time curve (AUC0-tlast) were significantly identified among the 47 selected genes, including ADAMTSL1, CD36, P2RY1, PCSK9, PON1, and SCD. CONCLUSION These results show that genetic variation affects the PK and PD of prasugrel in normal individuals. Further studies with larger sample sizes are required to explore whether the SNPs are associated only with prasugrel activity or also with cardiovascular events and all-cause mortality.
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Spoendlin J, Gagne JJ, Lewey JJ, Patorno E, Schneeweiss S, Desai RJ. Comparative effectiveness and safety of antiplatelet drugs in patients with diabetes mellitus and acute coronary syndrome. Pharmacoepidemiol Drug Saf 2018; 27:1361-1370. [DOI: 10.1002/pds.4668] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/24/2018] [Accepted: 08/10/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Julia Spoendlin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
| | - Jennifer J. Lewey
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
- Division of Cardiovascular Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
| | - Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
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Rivas Rios JR, Franchi F, Rollini F, Angiolillo DJ. Diabetes and antiplatelet therapy: from bench to bedside. Cardiovasc Diagn Ther 2018; 8:594-609. [PMID: 30498684 DOI: 10.21037/cdt.2018.05.09] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes mellitus (DM) is a metabolic disorder associated with accelerated atherogenesis and an increased risk of atherothrombotic complications. Multiple mechanisms contribute to the pro-thrombotic status which characterizes DM patients underscoring the importance of antiplatelet therapies used for secondary prevention in these patients. For many years, dual antiplatelet therapy (DAPT) with aspirin and the P2Y12 inhibitor clopidogrel has represented the mainstay of treatment following an acute coronary syndrome (ACS) or in patients undergoing percutaneous coronary interventions (PCI). Although DAPT reduces the incidence of atherothrombotic recurrences, these rates remain high in DM patients underscoring the need for more efficacious therapies. Oral platelet P2Y12 receptor inhibitors with enhanced potency, such as prasugrel and ticagrelor, as well as antiplatelet therapies such as vorapaxar inhibiting the thrombin-mediated platelet signaling pathway, constitute treatment opportunities for patients with DM and have shown to be associated with a greater reduction in ischemic recurrences, albeit at the cost of more bleeding. This article reviews currently available antiplatelet agents and delivers an update on the advances and drawbacks of these agents used for secondary prevention in DM patients experiencing an ACS or undergoing PCI.
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Affiliation(s)
- Jose R Rivas Rios
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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Zhuo X, Zhuo B, Ouyang S, Niu P, Xiao M. Adverse clinical outcomes associated with double dose clopidogrel compared to the other antiplatelet regimens in patients with coronary artery disease: a systematic review and meta-analysis. BMC Pharmacol Toxicol 2018; 19:54. [PMID: 30176938 PMCID: PMC6122215 DOI: 10.1186/s40360-018-0247-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recently, several newer antiplatelet treatment strategies have been used in patients with coronary artery disease (CAD). Apart from the dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, double dose clopidogrel (DDC), triple antiplatelet therapy (TAPT) consisting of aspirin, clopidogrel and cilostazol and other newer antiplatelet agents have shown to be effective in different ways. In this analysis, we aimed to systematically compare the adverse clinical outcomes and the bleeding events which were observed when DDC was compared to the other antiplatelet regimens in patients with CAD. METHODS English publications comparing DDC with other antiplatelet regimens were searched from MEDLARS/MEDLINE, EMBASE, www.ClinicalTrials.gov and Google Scholar. Adverse cardiovascular outcomes and bleeding events were the study endpoints. Statistical analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated. RESULTS A total number of 23,065 participants were included. Results of this analysis showed major adverse cardiac events (MACEs), all-cause mortality, cardiac death, stroke, stent thrombosis, revascularization and myocardial infarction (MI) to have been similarly manifested in patients who were treated with DDC versus the control group with OR: 0.98, 95% CI: 0.78-1.22; p = 0.83, OR: 0.95, 95% CI: 0.77-1.17; p = 0.62, OR: 0.97, 95% CI: 0.79-1.20; p = 0.81, OR: 0.98, 95% CI: 0.65-1.48; p = 0.94, OR: 0.84, 95% CI: 0.40-1.75; p = 0.64, OR: 0.88, 95% CI: 0.52-1.49; p = 0.63, and OR: 0.89, 95% CI: 0.65-1.21; p = 0.45 respectively. Any minor and major bleedings were also similarly manifested. When DDC was compared to DAPT, no significant difference was observed in any bleeding event with OR: 1.58, 95% CI: 0.86-2.91; p = 0.14. Even when DDC was compared with either ticagrelor or prasugrel or TAPT, still no significant difference was observed in terms of bleeding outcomes. CONCLUSIONS In patients with CAD, adverse clinical outcomes were not significantly different when DDC was compared to the other antiplatelet regimens. In addition, bleeding events were also similarly manifested when DDC was compared to DAPT, TAPT or ticagrelor/prasugrel.
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Affiliation(s)
- Xiaojun Zhuo
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, People's Republic of China
| | - Bi Zhuo
- Department of Pharmacology, People's Hospital of Laibin, Laibin, 546100, Guangxi, People's Republic of China
| | - Shenyu Ouyang
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, People's Republic of China
| | - Pei Niu
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, People's Republic of China
| | - Mou Xiao
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, People's Republic of China.
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Niijima S, Ohmori T, Kario K. Differential impact of diabetes mellitus on antiplatelet effects of prasugrel and clopidogrel. Thromb J 2018; 16:5. [PMID: 29568240 PMCID: PMC5853094 DOI: 10.1186/s12959-017-0159-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Although prasugrel exerts stronger antiplatelet effects compared with clopidogrel, the factors affecting platelet reactivity under prasugrel have not been fully determined. This study aimed to find the novel mechanistic differences between two thienopyridines and identify the factor that influence platelet reactivity to each drug. Methods Forty patients with stable angina who underwent elective percutaneous coronary intervention were randomly assigned to receive either prasugrel (20 mg) or clopidogrel (300 mg) as a loading dose. Platelet function (light transmission, laser light scattering, and vasodilator-stimulated phosphoprotein phosphorylation) and plasma active metabolite levels were measured after the loading dose. Results Prasugrel consistently inhibited adenosine diphosphate receptor P2Y12 signalling to abolish amplification of platelet aggregation. Prasugrel abolished even small platelet aggregates composed of less than 100 platelets. On the other hand, clopidogrel inhibited large aggregates but increased small and medium platelet aggregates. Diabetes was the only independent variable for determining antiplatelet effects and active metabolite concentration of prasugrel, but not clopidogrel. Sleep-disordered breathing was significantly correlated with platelet reactivity in patients who had clopidogrel. Conclusions Prasugrel efficiently abolishes residual P2Y12 signalling that causes small platelet aggregates, but these small aggregates are not inhibited by clopidogrel. Considering the differential effect of diabetes on antiplatelet effects between these two drugs, the pharmacokinetics of prasugrel, other than cytochrome P450 metabolism, might be affected by diabetes. Trial registration UMIN-CTR UMIN000017624, retrospectively registered 21 May 2015.
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Affiliation(s)
- Satoshi Niijima
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Tsukasa Ohmori
- 2Department of Biochemistry, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Kazuomi Kario
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
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Selhorst G, Schmidtler F, Ott A, Hitzke E, Tomelden J, Antoni D, Hoffmann E, Rieber J. Platelet reactivity in patients with acute coronary syndrome treated with prasugrel or ticagrelor in comparison to clopidogrel: a retrospective pharmacodynamic analysis. Platelets 2018. [PMID: 29521570 DOI: 10.1080/09537104.2018.1445836] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is a mainstay of the prevention of stent thrombosis following percutaneous coronary intervention (PCI). In the 2015 European guidelines for the management of acute coronary syndrome (ACS), prasugrel (PRA) and ticagrelor (TICA) combined with aspirin are recommended as first-line therapy. Clopidogrel (CLO) is recommended as an alternative medication for patients with contradictions to these new drugs. This single-center study analyzed the platelet function of 809 ACS patients undergoing PCI and treatment with DAPT. The platelet response to ADP was determined using Multiplate® analyzer at a median of 3 days after PCI in 254 patients treated with PRA (loading dose [LD] 60 mg, 10 mg qd), 162 patients receiving TICA (LD 180 mg, D 90 mg bid), and 393 CLO-treated patients (LD 600 mg, 75 mg qd). An aggregation >468 arbitrary units (AU)*min was defined as "high on-treatment platelet reactivity" (HPR), <188 AU*min as "low on-treatment platelet reactivity" (LPR). Platelet response in PRA-treated patients was lower compared to CLO or TICA (median; interquartile range: PRA 220 [163-275] AU*min vs. CLO 268 [186-387] AU*min, p < 0.001 vs. TICA 245 [190-320] AU*min, p = 0.001). Only 1.6% of PRA patients were stratified as HPR and 34.6% as LPR, while in the TICA group 1.9% fulfilled the criteria of HPR and 24.1% criteria of LPR. Sixteen percent of CLO patients were stratified as HPR and 26.2% as LPR. In a real-world cohort of ACS patients following PCI, PRA results in more potent inhibition of platelet function compared to CLO and TICA. TICA achieves a consistent antiplatelet effect with reduced rates of HPR and LPR in relation to CLO.
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Affiliation(s)
- Gerhard Selhorst
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - Fabian Schmidtler
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - Armin Ott
- b Institute of Medical Statistics und Epidemiology , Technical University of Munich , Munich , Germany
| | - Evelyn Hitzke
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - June Tomelden
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - Diethmar Antoni
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - Ellen Hoffmann
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany
| | - Johannes Rieber
- a Department of Cardiology, Bogenhausen Academic Teaching Hospital , Technical University of Munich , Munich , Germany.,c Department of Cardiology , Ludwig Maximilian University of Munich , Munich , Germany
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Pechlivani N, Ajjan RA. Thrombosis and Vascular Inflammation in Diabetes: Mechanisms and Potential Therapeutic Targets. Front Cardiovasc Med 2018; 5:1. [PMID: 29404341 PMCID: PMC5780411 DOI: 10.3389/fcvm.2018.00001] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/03/2018] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease remains the main cause of morbidity and mortality in patients with diabetes. The risk of vascular ischemia is increased in this population and outcome following an event is inferior compared to individuals with normal glucose metabolism. The reasons for the adverse vascular profile in diabetes are related to a combination of more extensive atherosclerotic disease coupled with an enhanced thrombotic environment. Long-term measures to halt the accelerated atherosclerotic process in diabetes have only partially addressed vascular pathology, while long-term antithrombotic management remains largely similar to individuals without diabetes. We address in this review the pathophysiological mechanisms responsible for atherosclerosis with special emphasis on diabetes-related pathways. We also cover the enhanced thrombotic milieu, characterized by increased platelet activation, raised activity of procoagulant proteins together with compromised function of the fibrinolytic system. Potential new therapeutic targets to reduce the risk of atherothrombosis in diabetes are explored, including alternative use of existing therapies. Special emphasis is placed on diabetes-specific therapeutic targets that have the potential to reduce vascular risk while keeping an acceptable clinical side effect profile. It is now generally acknowledged that diabetes is not a single clinical entity but a continuum of various stages of the condition with each having a different vascular risk. Therefore, we propose that future therapies aiming to reduce vascular risk in diabetes require a stratified approach with each group having a "stage-specific" vascular management strategy. This "individualized care" in diabetes may prove to be essential to improve vascular outcome in this high risk population.
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Affiliation(s)
- Nikoletta Pechlivani
- School of Medicine, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Ramzi A Ajjan
- School of Medicine, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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Antiplatelet treatment in diabetic patients with acute coronary syndrome undergoing percutaneous coronary intervention. Coron Artery Dis 2018; 29:53-59. [DOI: 10.1097/mca.0000000000000547] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Farhan S, Jarai R, Wojta J, Tentzeris I, Siller-Matula J, Huber K. Platelet function variability and non-genetic causes. Thromb Haemost 2017; 105 Suppl 1:S60-6. [DOI: 10.1160/ths11-01-0025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 03/25/2011] [Indexed: 12/16/2022]
Abstract
SummaryDual antiplatelet therapy (DAPT) has been established for the treatment of coronary artery disease, especially in and after acute coronary syndromes, and after coronary interventions. Data suggest that a significant percentage of individuals treated with clopidogrel do not receive the expected therapeutic benefit because of a decreased responsiveness of their platelets, which is caused by several extrinsic and intrinsic mechanisms. The clinical consequence of clopidogrel non-responsiveness is severe cardiovascular complications. Besides genetic variability in response to antiplatelet therapy, non-genetic causes such as drug interactions (proton-pump inhibitors, statins, calcium-channel blockers, coumarine derivates, antibiotics, antimycotics) and co-morbidities (diabetes mellitus, renal failure, obesity) are responsible for this phenomenon. Large clinical trials with standardised laboratory methods and hard clinical endpoints are needed to identify these interactions with clopidogrel and predictors for its non-responsiveness.
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Bernlochner I, Mayer K, Morath T, Orban M, Schulz S, Schömig A, Braun S, Kastrati A, Sibbing D. Antiplatelet efficacy of prasugrel in patients with high on-clopidogrel treatment platelet reactivity and a history of coronary stenting. Thromb Haemost 2017; 109:517-24. [DOI: 10.1160/th12-08-0552] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 12/14/2012] [Indexed: 12/26/2022]
Abstract
SummaryLittle is known about the antiplatelet action of the 3rd generation thienopyridine prasugrel in patients showing high platelet reactivity (PR) levels on clopidogrel. Thus, we aimed to determine the antiplatelet efficacy of prasugrel loading (LD) and maintenance dose (MD) treatment in a registry of patients with high PR levels on clopidogrel and a consecutive switch over to prasugrel in a setting of routine platelet function testing. In our registry of patients treated by percutaneous coronary intervention (n=73) with high levels of PR on clopidogrel, the ADP-induced platelet aggregation (PA, in AU x min) was assessed on a Multiplate analyser 1) after clopidogrel LD, 2) after prasugrel LD and 3) on prasugrel MD (5 vs. 10 mg/day). In patients with high PR levels on clopidogrel, prasugrel LD resulted in significantly lower PA values (574 [462–698] vs. 156 [89–234] AU x min; p<0.0001). Only 2.7% of patients showed high PR (HPR, 468 AU x min) following prasugrel LD. On prasugrel MD, PA was significantly higher as compared to prasugrel LD (248 [145–406] vs. 156 [89–234] AU x min; p<0.0001) with more patients showing HPR on MD vs. LD (16.4% vs. 2.7%; p=0.009). For prasugrel MD, HPR rates were higher in 5 vs. 10 mg/day treated patients (46.2% vs. 10.0%; p=0.006). In conclusion, for patients with high PR levels on clopidogrel, prasugrel LD abolished this status in the majority of patients. However, prasugrel response variability was detected, being more pronounced on prasugrel MD vs. LD treatment. The clinical impact of these findings warrants further investigation.
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Angiolillo D, DeRaad R, Frelinger A, Gurbel P, Costigan T, Jakubowski J, Ojeh C, Duvvuru S, Effron M, Saucedo J. Decrease in high on-treatment platelet reactivity (HPR) prevalence on switching from clopidogrel to prasugrel: Insights from the switching anti-platelet (SWAP) study. Thromb Haemost 2017; 109:347-55. [DOI: 10.1160/th12-06-0378] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 10/18/2012] [Indexed: 01/14/2023]
Abstract
SummaryThe prevalence of high platelet reactivity (HPR) in patients who have switched from clopidogrel to prasugrel during maintenance phase after an acute coronary syndrome (ACS) event is unknown. Therefore, the effect of switching from clopidogrel to prasugrel on the prevalence of HPR was evaluated. This analysis from the previously reported SWAP (SWitching Anti Platelet) study assessed HPR at baseline, 2 and 24 hours, and seven days after switching from clopidogrel to prasugrel maintenance dose (MD), with or without a prasugrel loading dose (LD) using four definitions: maximum platelet aggregation (MPA) >65% (primary endpoint), MPA >50%, P2Y12 reaction units (PRU) >235, and platelet reactivity index (PRI) ≥50%. A total of 95 patients were available for analysis; 56 patients provided DNA for genetic assessments of cytochrome P450 (CYP) 2C19. There were 26 (27.4%) patients with HPR at the end of the clopidogrel run-in (defined as MPA >65%). The HPR prevalence varied by each definition and ranged from 19% (PRU >235) to 68% (PRI ≥50%). A significantly higher HPR prevalence was observed during clopidogrel versus the combined prasugrel therapy groups at seven days as measured by MPA >65% (21.2% vs. 4.5%, p>0.05), PRU >235 (18.8% vs. 0%, p=0.001), and PRI ≥50% (66.7% vs. 7.9%, p<0.0001). There was a significantly higher percentage of subjects carrying at least one reduced function allele with HPR measured by MPA >65% (p=0.02) or PRU >235 (p=0.05) than non-carriers with HPR. Switching ACS patients during maintenance clopidogrel therapy to prasugrel with or without an LD is associated with a reduced HPR prevalence and may provide an alternative strategy to treat patients with HPR, independent of CYP2C19 genotype.
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Tamburino C, Capodanno D, Miccichè E, D’Urso L, Calvi V, Angiolillo D, Tamburino C, Capranzano P. Platelet function profiles in the elderly: Results of a pharmacodynamic study in patients on clopidogrel therapy and effects of switching to prasugrel 5 mg in patients with high platelet reactivity. Thromb Haemost 2017; 106:1149-57. [DOI: 10.1160/th11-05-0346] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 09/23/2011] [Indexed: 11/05/2022]
Abstract
SummaryStudies specifically designed to assess clopidogrel response in the elderly as well as treatment alternatives to improve platelet inhibition in this highrisk population are lacking. This study aimed to define phar-macodynamic (PD) profiles, including high platelet reactivity (HPR) rates, among elderly patients on maintenance clopidogrel therapy and to assess the PD effects of prasugrel 5 mg/day in elderly with HPR. This was a prospective observational PD study enrolling consecutive ≥75-year-old patients on maintenance clopidogrel therapy (75 mg/day) who were tested for clopidogrel response by the VerifyNow P2Y12 assay and light transmittance aggregometry (LTA). HPR rates were estimated using multiple definitions. HPR patients identified by the VerifyNow P2Y12 assay [P2Y12 reaction unit (PRU) ≥230] were switched to prasugrel 5 mg/day, and platelet function testing was performed after 15 days of treatment. PD testing was completed in 100 patients. The HPR prevalence varied between 25% and 32%, depending on the definition used. A PRU ≥230 was observed in 25 patients; of these, 20 switched to prasugrel 5 mg/day. This resulted in significant reduction in PRU mean values (279.8 ± 45.1 vs. 171.7 ± 65.2, p=0.0002) with an absolute between-treatment difference of 108.1 (95% confidence intervals 75.2–140.9). Accordingly, switching to prasugrel 5 mg/day overcame HPR in most (80%) patients. Consistently, all LTA measures were significantly lower after prasugrel compared with clopidogrel. In conclusion, a considerable proportion of elderly patients exhibit HPR while on standard clopidogrel therapy. Switching to 5 mg/day prasugrel in elderly patients with HPR is associated with enhanced platelet inhibition and overcomes HPR in the majority of these patients.
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Darlington A, Tello-Montoliu A, Rollini F, Ueno M, Ferreiro JL, Patel R, Desai B, Guzman L, Bass T, Angiolillo D. Pharmacodynamic effects of standard dose prasugrel versus high dose clopidogrel in non-diabetic obese patients with coronary artery disease. Thromb Haemost 2017; 111:258-65. [DOI: 10.1160/th13-07-0529] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/17/2013] [Indexed: 01/22/2023]
Abstract
SummaryIncreased body weight is independently associated with impaired clopidogrel pharmacodynamic (PD) response. Prasugrel has more potent PD effects compared with clopidogrel, although its PD effects in obese patients are unknown. The aim of this prospective, randomised, study was to compare the PD effects of standard-dose prasugrel [60 mg loading dose (LD)/10 mg daily maintenance dose (MD)] with highdose clopidogrel (900 mg LD/150 mg daily MD) in non-diabetic obese [body mass index (BMI) ≥30 kg/m2] patients, with coronary artery disease (CAD) on aspirin therapy. PD assessments (baseline, 2 hours post-LD and 6 ± 2 days after MD) were conducted using four platelet function assays, and the platelet reactivity index (PRI) assessed by VASP was used for sample size estimation. A total of 42 patients with a BMI of 36.42 ± 5.6 kg/m2 completed the study. There were no differences in baseline PD measures between groups. At 2 hours post-LD, prasugrel was associated with lower PRI compared with clopidogrel (24.3 ± 5.5 vs 58.7 ± 5.7, p≤0.001), with consistent findings for all assays. At one-week, PRI values on prasugrel MD were lower than clopidogrel MD without reaching statistical significance (34.7 ± 5.8 vs 42.9 ± 5.8, p=0.32), with consistent findings for all assays. Accordingly, rates of high on-treatment platelet reactivity were markedly reduced after prasugrel LD, but not after MD. In conclusion, in non-diabetic obese patients with CAD, standard prasugrel dosing achieved more potent PD effects than high-dose clopidogrel in the acute phase of treatment, but this was not sustained during maintenance phase treatment. Whether an intensified prasugrel regimen is required in obese patients warrants investigation.
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Labruyère C, Reny JL, Chapelle C, Piot M, Fontana P, Gris JC, Delavenne X, Mismetti P, Laporte S, Mallouk N. Prevalence of poor biological response to clopidogrel. Thromb Haemost 2017; 107:494-506. [DOI: 10.1160/th11-03-0202] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 12/14/2011] [Indexed: 12/28/2022]
Abstract
SummaryThe existence of poor biological response to clopidogrel has been shown in some patients. Despite the increasing number of studies, this phenomenon remains difficult to quantify. We performed a systematic review to estimate the prevalence of poor biological response to clopidogrel and investigate the factors known to modulate this. An exhaustive search was performed. Altogether 171 publications were identified, providing data for a total of 45,664 subjects. The estimated prevalence of poor biological response to clopidogrel ranged from 15.9% to 49.5% according to the platelet function assay employed. The assays most frequently used were light transmittance aggregometry (LTA), the vasodilator-stimulated phosphoprotein (VASP) assay and the Verify -now® assay. For all these assays, higher cut-off values were associated with a lower prevalence of poor biological response to clopidogrel. However, when choosing a fixed cut-off point for each assay, the prevalence of poor biological response to clopidogrel was highly variable suggesting that other factors could modulate poor biological response to clopidogrel. Finally, none of the studied factors could apparently explain the variability of poor biological response to clopidogrel. This meta-analysis shows that the prevalence of poor biological response depends on the assay employed, the cut-off value and on various unidentified additional factors.
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Shang LL, Guo DD, Zhao HY, Quan AJ, Cao PG. Comparison of pharmacodynamic effects of ticagrelor vs prasugrel in type 2 diabetes mellitus patients with coronary heart disease. J Clin Pharm Ther 2017; 43:342-347. [PMID: 29150850 DOI: 10.1111/jcpt.12651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/28/2017] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Patients with type 2 diabetes mellitus (T2DM) are at higher risk of thrombotic complications. Studies have indicated that patients with T2DM have impaired clopidogrel-induced antiplatelet effect. Ticagrelor and prasugrel are two latest generation P2Y12 inhibitors with advantageous platelet inhibitory profiles. However, the pharmacodynamic differences between the two drugs in patients with T2DM remain poorly explored. METHODS This study, involving 140 patients with T2DM following percutaneous coronary intervention (PCI), evaluated the efficacy of aspirin upon concomitant use of prasugrel (10 mg/d) or ticagrelor (90 mg/d). Platelet reactivity was assessed by value of ADP-induced light transmittance aggregometry (LTA) and vasodilator-stimulated phosphoprotein phosphorylation-platelet reactivity index (VASP-PRI) at baseline, 7 and 30 days after randomized P2Y12 inhibitor treatment. RESULTS The study showed a decreased platelet reactivity after use of P2Y12 inhibitors (both P < .001). On the basis of comparison between regimens, apart from the prasugrel group having a significantly higher LTA value at the 30-day time point (P = .043), there existed no significant differences in platelet reactivity at separate time points (all P > .05). As for intragroup measurements, when compared with 7-day and 30-day time points, similar platelet reactivity was documented in the ticagrelor group (both P > .05), but LTA tests showed a significant increase with time (days 7-30) in the prasugrel group (P = .050). WHAT IS NEW AND CONCLUSION Although ticagrelor and prasugrel have similar platelet inhibitory effects in patients with T2DM, if a P2Y12 inhibitor is necessitated in patients with T2DM, ticagrelor might exert a more stable antiplatelet effect with 30-day short-term treatment.
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Affiliation(s)
- L-L Shang
- Department of Intensive Medicine, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Ha'erbin, China
| | - D-D Guo
- Department of Cardiology, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Ha'erbin, China
| | - H-Y Zhao
- Department of Cardiology, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Ha'erbin, China
| | - A-J Quan
- Department of Intensive Medicine, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Ha'erbin, China
| | - P-G Cao
- Department of Cardiology, General Hospital of Heilongjiang Agricultural Reclamation Bureau, Ha'erbin, China
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Schoergenhofer C, Hobl EL, Schellongowski P, Heinz G, Speidl WS, Siller-Matula JM, Schmid M, Sunder-Plaßmann R, Stimpfl T, Hackl M, Jilma B. Clopidogrel in Critically Ill Patients. Clin Pharmacol Ther 2017; 103:217-223. [PMID: 28913918 PMCID: PMC5813104 DOI: 10.1002/cpt.878] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/21/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022]
Abstract
Only limited data are available regarding the treatment of critically ill patients with clopidogrel. This trial investigated the effects and the drug concentrations of the cytochrome P450 (CYP450) activated prodrug clopidogrel (n = 43) and the half‐life of the similarly metabolized pantoprazole (n = 16) in critically ill patients. ADP‐induced aggregometry in whole blood classified 74% (95% confidence intervals 59–87%) of critically ill patients as poor responders (n = 43), and 65% (49–79%) responded poorly according to the vasodilator‐stimulated phosphoprotein phosphorylation (VASP‐P) assay. Although the plasma levels of clopidogrel active metabolite normally exceed the inactive prodrug ∼30‐fold, the parent drug levels even exceeded those of the metabolite 2‐fold in critically ill patients. The half‐life of pantoprazole was several‐fold longer in these patients compared with reference populations. The inverse ratio of prodrug/active metabolite indicates insufficient metabolization of clopidogrel, which is independently confirmed by the ∼5‐fold increase in half‐life of pantoprazole. Thus, high‐risk patients may benefit from treatment with alternative platelet inhibitors.
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Affiliation(s)
| | - Eva-Luise Hobl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Department of Medicine I, Hematology, and Oncology, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Department of Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | - Walter S Speidl
- Department of Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Monika Schmid
- Department of Medicine III, Gastroenterology, and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Dehghani P, Lavoie A, Lavi S, Crawford JJ, Harenberg S, Zimmermann RH, Booker J, Kelly S, Cantor WJ, Mehta SR, Bagai A, Goodman SG, Cheema AN. Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI. Am Heart J 2017; 192:105-112. [PMID: 28938956 DOI: 10.1016/j.ahj.2017.07.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI. METHODS AND RESULTS Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, P<.001) and at 24 hours (34.5±35.0 and 153.5±75.5, respectively, P<.001). The primary end point was observed in 87.8% (n=65) in the ticagrelor-treated patients compared to 57.6% (n=38) of clopidogrel-treated patients, P<.001. CONCLUSION Fibrinolysis-treated STEMI patients who received clopidogrel and aspirin at the time of fibrinolysis and were undergoing early PCI frequently had PRU >208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591).
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada.
| | - Andrea Lavoie
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Shahar Lavi
- London Health Sciences, University of London, London, Ontario, Canada
| | - Jennifer J Crawford
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sebastian Harenberg
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Rodney H Zimmermann
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Jeff Booker
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Desai RJ, Spoendlin J, Mogun H, Gagne JJ. Contemporary Time Trends in Use of Antiplatelet Agents Among Patients with Acute Coronary Syndrome and Comorbid Diabetes Mellitus or Chronic Kidney Disease. Pharmacotherapy 2017; 37:1322-1327. [PMID: 28833345 DOI: 10.1002/phar.2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY OBJECTIVE To describe contemporary trends of P2Y12 inhibitor use in patients with acute coronary syndrome (ACS) and comorbid diabetes mellitus (DM) and/or chronic kidney disease (CKD) who have a higher risk of recurring ACS and may benefit from treatment with higher efficacy third-generation agents (prasugrel and ticagrelor). DESIGN Observational cohort study. SETTING A large U.S. commercial insurance program (2009-2015). PATIENTS P2Y12 inhibitor initiated within 2 weeks after an ACS event. MEASUREMENTS AND MAIN RESULTS We identified 98,649 P2Y12 inhibitor initiators, of whom 24.5% had comorbid DM (no CKD), 10.5% had CKD (no DM), and 12.6% had DM and CKD. Overall, 85.2% of patients initiated clopidogrel, followed by prasugrel (11.6%) and ticagrelor (3.2%). Prasugrel use decreased over time irrespective of preexisting DM and/or CKD; ticagrelor use increased. In logistic regression models accounting for patient demographics and clinical covariates, preexisting DM alone was not associated with prasugrel or ticagrelor versus clopidogrel treatment initiation; however, having CKD with or without DM significantly reduced the likelihood of receiving prasugrel versus clopidogrel (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.74-0.88 for CKD alone; OR 0.91, 95% CI 0.83-0.98 for DM and CKD). Comorbid DM and CKD reduced the odds of initiating ticagrelor versus clopidogrel (OR 0.80, 95% CI 0.70-0.92). PRINCIPAL CONCLUSIONS We observed lower or similar use of prasugrel and ticagrelor compared with clopidogrel in patients with ACS and comorbid DM and/or CKD. Given the potential for worse clinical outcomes with clopidogrel in these patients, our findings highlight the need to investigate the implications of these trends on recurrent ACS and bleeding events.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julia Spoendlin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Marian MJ, Alli O, Al Solaiman F, Brott BC, Sasse M, Leesar T, Prabhu SD, Leesar MA. Ticagrelor and Eptifibatide Bolus Versus Ticagrelor and Eptifibatide Bolus With 2-Hour Infusion in High-Risk Acute Coronary Syndromes Patients Undergoing Early Percutaneous Coronary Intervention. J Am Heart Assoc 2017; 6:e005562. [PMID: 28611098 PMCID: PMC5669172 DOI: 10.1161/jaha.117.005562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/12/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND In patients with non-ST-segment elevation acute coronary syndromes, inhibition of platelet aggregation (IPA) with a potent P2Y12 inhibitor, ticagrelor, was inferior to tirofiban infusion at 2 hours, indicating that glycoprotein IIb/IIIa inhibitors are still needed. Ticagrelor and eptifibatide bolus only may maximally inhibit platelet aggregation and decrease bleeding, but IPA with ticagrelor and eptifibatide bolus versus 2-hour infusion is unknown. METHODS AND RESULTS A total of 70 P2Y12-naïve patients, with high-risk non-ST-segment elevation acute coronary syndromes, were randomized to ticagrelor and eptifibatide bolus (group 1) versus ticagrelor and eptifibatide bolus with 2-hour infusion (group 2). Levels of IPA with ADP, thrombin receptor-activating peptide, collagen, and high on-treatment platelet reactivity were measured by light transmission aggregometry at baseline and at 2, 6, and 24 hours after percutaneous coronary intervention in both groups. The primary end point, IPA with ADP 20 μmol/L at 2 hours, was 99.59±0.43% in group 1 versus 99.88±1.0% in group 2 (P<0.001 for noninferiority). High on-treatment platelet reactivity with ADP was zero at 2, 6, and 24 hours in both groups. IPA levels with ADP, thrombin receptor-activating peptide, and collagen were significantly higher at 2 and 6 hours than at 24 hours in both groups. Periprocedural myocardial infarction was not significantly different between the groups. Hemoglobin level was significantly less at 24 hours versus baseline in group 2 (13.35±1.8 versus 12.38±1.8 g/dL, respectively; P<0.01). CONCLUSIONS Ticagrelor and eptifibatide bolus maximally inhibited platelet aggregation at 2 hours, which was associated with no significant hemoglobin drop after percutaneous coronary intervention. This obviates the need for eptifibatide 2-hour infusion and might decrease bleeding complications. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01919723.
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Affiliation(s)
- Moazez J Marian
- Division of Cardiology, University of Alabama at Birmingham, AL
| | - Oluseun Alli
- Division of Cardiology, University of Alabama at Birmingham, AL
| | | | | | - Mark Sasse
- Division of Cardiology, University of Alabama at Birmingham, AL
| | - Tara Leesar
- Division of Cardiology, University of Alabama at Birmingham, AL
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Dalby AJ, Gottlieb S, Cyr DD, Magnus Ohman E, McGuire DK, Ruzyllo W, Bhatt DL, Wiviott SD, Winters KJ, Fox KA, Armstrong PW, White HD, Prabhakaran D, Roe MT. Dual antiplatelet therapy in patients with diabetes and acute coronary syndromes managed without revascularization. Am Heart J 2017; 188:156-166. [PMID: 28577671 DOI: 10.1016/j.ahj.2017.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 03/23/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Patients with diabetes mellitus (DM) presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) derived enhanced benefit with dual antiplatelet therapy (DAPT) with prasugrel vs. clopidogrel. The risk profile and treatment response to DAPT for medically managed ACS patients with DM remains uncertain. METHODS The TRILOGY ACS trial compared aspirin + prasugrel vs. aspirin + clopidogrel for up to 30months in non-ST-segment elevation (NSTE) ACS patients managed medically without revascularization. We compared treatment-related outcomes among 3539 patients with DM vs. 5767 patients without DM. The primary endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. RESULTS Patients with vs. without DM were younger, more commonly female, heavier, and more often had revascularization prior to the index ACS event. The frequency of the primary endpoint through 30months was higher among patients with vs. without DM (24.8% vs. 16.3%), with a higher risk for those patients with DM treated with insulin vs. those treated without insulin (35.3% vs. 19.9%). There was no significant difference in the frequency of the primary endpoint by treatment with prasugrel vs. clopiodgrel in those with or without DM (Pint=0.82) and with or without insulin treatment among those with DM (Pint=0.304). CONCLUSIONS Among NSTE ACS patients managed medically without revascularization, patients with DM had a higher risk of ischemic events that was amplified among those treated with insulin. There was no differential treatment effect with a more potent DAPT regimen of aspirin + prasugrel vs. aspirin + clopidogrel.
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50
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Moore JM, Adeeb N, Shallwani H, Gupta R, Patel AS, Griessenauer CJ, Youn R, Siddiqui A, Ogilvy CS, Thomas AJ. A Multicenter Cohort Comparison Study of the Safety, Efficacy, and Cost of Ticagrelor Compared to Clopidogrel in Aneurysm Flow Diverter Procedures. Neurosurgery 2017; 81:665-671. [DOI: 10.1093/neuros/nyx079] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 04/20/2017] [Indexed: 11/12/2022] Open
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