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Tsoupras A, Gkika DA, Siadimas I, Christodoulopoulos I, Efthymiopoulos P, Kyzas GZ. The Multifaceted Effects of Non-Steroidal and Non-Opioid Anti-Inflammatory and Analgesic Drugs on Platelets: Current Knowledge, Limitations, and Future Perspectives. Pharmaceuticals (Basel) 2024; 17:627. [PMID: 38794197 PMCID: PMC11124379 DOI: 10.3390/ph17050627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely utilized pharmaceuticals worldwide. Besides their recognized anti-inflammatory effects, these drugs exhibit various other pleiotropic effects in several cells, including platelets. Within this article, the multifaceted properties of NSAIDs on platelet functions, activation and viability, as well as their interaction(s) with established antiplatelet medications, by hindering several platelet agonists' pathways and receptors, are thoroughly reviewed. The efficacy and safety of NSAIDs as adjunctive therapies for conditions involving inflammation and platelet activation are also discussed. Emphasis is given to the antiplatelet potential of commonly administered NSAIDs medications, such as ibuprofen, diclofenac, naproxen and ketoprofen, alongside non-opioid analgesic and antipyretic medications like paracetamol. This article delves into their mechanisms of action against different pathways of platelet activation, aggregation and overall platelet functions, highlighting additional health-promoting properties of these anti-inflammatory and analgesic agents, without neglecting the induced by these drugs' side-effects on platelets' functionality and thrombocytopenia. Environmental issues emerging from the ever-increased subscription of these drugs are also discussed, along with the need for novel water treatment methodologies for their appropriate elimination from water and wastewater samples. Despite being efficiently eliminated during wastewater treatment processes on occasion, NSAIDs remain prevalent and are found at significant concentrations in water bodies that receive effluents from wastewater treatment plants (WWTPs), since there is no one-size-fits-all solution for removing all contaminants from wastewater, depending on the specific characteristics of the wastewater. Several novel methods have been studied, with adsorption being proposed as a cost-effective and environmentally friendly method for wastewater purification from such drugs. This article also presents limitations and future prospects regarding the observed antiplatelet effects of NSAIDs, as well as the potential of novel derivatives of these compounds, with benefits in other important platelet functions.
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Affiliation(s)
- Alexandros Tsoupras
- Hephaestus Laboratory, Department of Chemistry, School of Science, Democritus University of Thrace, GR 65404 Kavala, Greece; (D.A.G.); (P.E.); (G.Z.K.)
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2
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Carciotto G, Costa F, Garcia-Ruiz V, Galli M, Soraci E, Magliarditi A, Teresi L, Nasso E, Carerj S, Di Bella G, Micari A, De Luca G. Individualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based Review. J Clin Med 2023; 12:7144. [PMID: 38002756 PMCID: PMC10672070 DOI: 10.3390/jcm12227144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is the cornerstone of post-percutaneous coronary intervention treatment to prevent stent thrombosis and reduce the risk of adverse cardiovascular events. The selection of an optimal DAPT regimen, considering the interplay of various antiplatelet agents, patient profiles, and procedural characteristics, remains an evolving challenge. Traditionally, a standard duration of 12 months has been recommended for DAPT in most patients. While contemporary guidelines provide general frameworks, DAPT modulation with longer or shorter treatment courses followed by aspirin or P2Y12 inhibitor monotherapy are evolving towards an individualized strategy to optimize the balance between efficacy and safety. This review comprehensively examines the current landscape of DAPT strategies after coronary stenting, with a focus on emerging evidence for treatment individualization.
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Affiliation(s)
- Gabriele Carciotto
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Francesco Costa
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | | | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy;
| | - Emmanuele Soraci
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Alberto Magliarditi
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Lucio Teresi
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Enrica Nasso
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Antonio Micari
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | - Giuseppe De Luca
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
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Naseem MA, Maqbool U. Comment on: Managing the Acute Coronary Syndrome Patient: Evidence Based Recommendations for Anti-Platelet Therapy. Curr Probl Cardiol 2023; 48:101839. [PMID: 37244511 DOI: 10.1016/j.cpcardiol.2023.101839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Affiliation(s)
| | - Umar Maqbool
- King Edward Boys Hostel, King Edward University, Lahore, Pakistan
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Ning G, Sun Y, Ling J, Chen J, He J. BDN-DDI: A bilinear dual-view representation learning framework for drug-drug interaction prediction. Comput Biol Med 2023; 165:107340. [PMID: 37603959 DOI: 10.1016/j.compbiomed.2023.107340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/23/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
Drug-drug interactions (DDIs) refer to the potential effects of two or more drugs interacting with each other when used simultaneously, which may lead to adverse reactions or reduced drug efficacy. Accurate prediction of DDIs is a significant concern in recent years. Currently, the drug chemical substructure-based learning method has substantially improved DDIs prediction. However, we notice that most related works ignore the detailed interaction among atoms when extracting the substructure information of drugs. This problem results in incomplete information extraction and may limit the model's predictive ability. In this work, we proposed a novel framework named BDN-DDI (a bilinear dual-view representation learning framework for drug-drug interaction prediction) to infer potential DDIs. In the proposed framework, the encoder consists of six stacked BDN blocks, each of which extracts the feature representation of drug molecules through a bilinear representation extraction layer. The extracted feature is then used to learn embeddings of drug substructures from the single drug learning layer (intra-layer) and the drug-pair learning layer (inter-layer). Finally, the learned embeddings are fed into a decoder to predict DDI events. Based on our experiments, BDN-DDI has an AUROC value of over 99% for the warm-start task. Additionally, it outperformed the state-of-the-art methods by an average of 3.4% for the cold-start tasks. Finally, our method's effectiveness is further validated by visualizing several case studies.
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Affiliation(s)
- Guoquan Ning
- School of Computer Science and Technology, Guangdong University of Technology, Guangzhou 510006, China
| | - Yuping Sun
- School of Computer Science and Technology, Guangdong University of Technology, Guangzhou 510006, China.
| | - Jie Ling
- School of Computer Science and Technology, Guangdong University of Technology, Guangzhou 510006, China
| | - Jijia Chen
- School of Computer Science and Technology, Guangdong University of Technology, Guangzhou 510006, China
| | - Jiaxi He
- School of Computer Science and Technology, Guangdong University of Technology, Guangzhou 510006, China
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Ferreira PMP, Almeida AACD, Conceição MLP, Pessoa ODL, Marques LGA, Capasso R, Pessoa C. Cordia oncocalyx and oncocalyxones: From the phytochemistry to the anticancer action and therapeutic benefits against chronic diseases. Fitoterapia 2023; 169:105624. [PMID: 37500017 DOI: 10.1016/j.fitote.2023.105624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
Cordia oncocalyx Allemão is an endemic economically underexploited plant from Brazilian semi-arid region. Herein, we carried out a well-defined bibliographic review about the pharmacological activities of oncocalyxones from C. oncocalyx and mechanisms responsible for the biomedical properties. MeSH terms were used in the scientific databases for a narrative exploration. Technological development and bioproducts were also examined. Cordia oncocalyx is a deciduous tree of sexual reproduction rich in terpenoid quinones. Among them, oncocalyxone A, a 1,4-benzoquinone, the main compound from heartwood ethanol extracts, revealed anti-inflammatory and anti-edematogenic actions induced by carrageenan and dextran and antinociceptive potential in mice provoked by acetic acid and formalin. Oncocalyxone A inhibits platelet aggregation via activation of the soluble guanylate cyclase enzyme and blocks glycation processes. In addition to the antimicrobial effects against protozoa, fungi and bacteria and relaxation of smooth muscles, oncocalyxone A reduces mean blood pressure and glycemia in diabetic rats, decreases glomerular filtration parameters and tubular transport of electrolytes, and presents in vitro antimitotic and cytotoxic action upon different types of cancers, including resistant lung carcinoma lines. It has low oral acute toxicity (LD50 > 2000 mg/kg) and activates cellular apoptosis through the production of free radicals and interactions with DNA. However, no patents were found, which also emphasizes that Brazil, as the cradle of the main articles on C. oncocalyx, is wasting time and money. Moreover, slight systemic deleterious effects in mammals stimulate the use of oncocalyxone A and related compounds as lead constituents of safer drugs against chronic diseases.
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Affiliation(s)
- Paulo Michel Pinheiro Ferreira
- Laboratory of Experimental Cancerology (LabCancer), Department of Biophysics and Physiology, Federal University of Piauí, Teresina, Brazil.
| | - Antonia Amanda Cardoso de Almeida
- Laboratory of Experimental Cancerology (LabCancer), Department of Biophysics and Physiology, Federal University of Piauí, Teresina, Brazil
| | - Micaely Lorrana Pereira Conceição
- Laboratory of Experimental Cancerology (LabCancer), Department of Biophysics and Physiology, Federal University of Piauí, Teresina, Brazil
| | | | - Lana Grasiela Alves Marques
- Postgraduate Program in Biotechnology of Natural Resources, Federal University of Ceará, Fortaleza, Brazil; Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Brazil
| | - Raffaele Capasso
- Department of Agricultural Sciences, University of Naples Federico II, Naples, Italy
| | - Cláudia Pessoa
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, Brazil
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Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Yeh BY, Liu GH, Lee TY, Wong AMK, Chang HH, Chen YS. Efficacy of Electronic Acupuncture Shoes for Chronic Low Back Pain: Double-Blinded Randomized Controlled Trial. J Med Internet Res 2020; 22:e22324. [PMID: 33104004 PMCID: PMC7652696 DOI: 10.2196/22324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Chronic low back pain is a common problem and is associated with high costs, including those related to health care and indirect costs due to absence at work or reduced productivity. Previous studies have demonstrated that acupuncture or electroacupuncture can relieve low back pain. Electronic acupuncture shoes (EAS) are a novel device designed in this study. This device combines the properties of acupuncture and transcutaneous electrical nerve stimulation for clinical use. OBJECTIVE The aim of this study was to evaluate the efficacy of EAS in patients with chronic low back pain. METHODS In this prospective double-blinded randomized controlled study, the data of 83 patients who experienced chronic low back pain were analyzed. Patients came to our clinic for 20 visits and underwent assessment and treatment. Patients were randomly allocated to receive either EAS plus placebo nonsteroidal anti-inflammatory drugs (NSAIDs) (EAS group, n=42) or sham EAS plus NSAIDs (NSAID group, n=41). The visual analog scale (VAS) score and range of motion were assessed at baseline, before and after each EAS treatment, and 2 weeks after the last treatment. The time for achieving pain remission was recorded. Quality of life was assessed at the 2nd, 14th, and 20th visits. RESULTS After 6 weeks of treatment, the treatment success rate in each visit in the EAS group was higher than that in the NSAID group, as revealed by the intention-to-treat (ITT) and per-protocol (PP) analyses, but significant differences were observed only during the 16th visit in the ITT analysis (EAS group: 31/37, 84% and NSAID group: 21/34, 62%; P=.04). The change in the VAS score from baseline in each visit in the EAS group was greater than that in the NSAID group, as revealed by the ITT and PP analyses, and significant differences were observed in the 5th visit and 9th visit in the ITT analysis (P=.048 and P=.048, respectively). Significant differences were observed in the left rotation in the 2nd visit and 4th visit (P=.049 and P=.03, respectively). No significant differences were observed in the VAS score before and after treatment in each visit and in the quality of life in both groups. CONCLUSIONS EAS might serve as a reliable alternative therapeutic tool for patients with chronic low back pain who are contraindicated for oral NSAIDs. TRIAL REGISTRATION ClinicalTrials.gov NCT02468297 https://clinicaltrials.gov/ct2/show/NCT02468297.
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Affiliation(s)
- Bo-Yan Yeh
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Geng-Hao Liu
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.,Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tzung-Yan Lee
- Graduate Institute of Traditional Chinese Medicine, School of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Alice May-Kuen Wong
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hen-Hong Chang
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, and Chinese Medicine Research Center, China Medical University, Taichung, Taiwan.,Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Sheng Chen
- Division of Acupuncture and Moxibustion, Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
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Bain KT, McGain D, Cicali EJ, Knowlton CH, Michaud V, Turgeon J. Precision medication: An illustrative case series guiding the clinical application of multi-drug interactions and pharmacogenomics. Clin Case Rep 2020; 8:305-312. [PMID: 32128178 PMCID: PMC7044418 DOI: 10.1002/ccr3.2604] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/06/2019] [Accepted: 11/21/2019] [Indexed: 12/22/2022] Open
Abstract
Precision medication entails selecting the precise medication, dose, and timing of administration. Multi-drug interactions and genetics significantly affect precision medication. In this article, we present two simulated cases for real-world applications of precision medication. Clinicians may need to acquire additional skills to apply the principles illustrated by these cases.
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Affiliation(s)
- Kevin T. Bain
- Tabula Rasa HealthCareMoorestownNJUSA
- Department of PharmacyUniversity of the SciencesPhiladelphiaPAUSA
| | | | - Emily J. Cicali
- Department of Pharmacotherapy and Translational ResearchUniversity of FloridaGainesvilleFLUSA
| | | | - Veronique Michaud
- Tabula Rasa HealthCareMoorestownNJUSA
- Faculty of PharmacyUniversité de MontréalMontrealQCCanada
| | - Jacques Turgeon
- Tabula Rasa HealthCareMoorestownNJUSA
- Faculty of PharmacyUniversité de MontréalMontrealQCCanada
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Prami T, Khanfir H, Hasvold P, Reissell E, Airaksinen J, Kytö V. Concomitant use of drugs known to cause interactions with oral antiplatelets-polypharmacy in acute coronary syndrome outpatients in Finland. Eur J Clin Pharmacol 2019; 76:257-265. [PMID: 31773191 DOI: 10.1007/s00228-019-02777-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Use of oral antiplatelets (OAPs) is essential for preventing thrombotic events in patients with acute coronary syndrome (ACS). Effects of clopidogrel, prasugrel, and ticagrelor may be enhanced due to pharmacodynamic interactions, but as CYP substrates, they are prone to pharmacokinetic interactions too. The aim was to study polypharmacy in ACS patients following hospital discharge. METHODS This observational drug utilization study linked patient-level data from nationwide registers. The study population consisted of adult ACS patients discharged from Finnish hospitals in 2009-2013. Logistic regression was used to model the probability of drug-drug interactions with odd ratios for predefined predictors such as age, gender, and ACS type. RESULTS In the cohort of 54,416 ACS patients, 91% of those treated with OAP received clopidogrel. Of clopidogrel-treated patients, 12% purchased warfarin at least once while on clopidogrel treatment. Old age, male sex, ST-elevation myocardial infarction as index event, and a history of previous ACS events were associated with an increased risk of warfarin-OAP interaction (p < 0.001 for all). Ibuprofen, and serotonergic drugs tramadol, citalopram, and escitalopram were the next most common drugs causing pharmacodynamic interactions. In general, concomitant use of drugs known to cause pharmacokinetic interactions was rare, but both esomeprazole and omeprazole were prescribed in more than 6% of clopidogrel-treated patients. CONCLUSIONS Warfarin and ibuprofen were the most commonly used concomitant medications causing pharmacodynamic interactions and potentially increasing the risk of bleeding in OAP-treated patients. Esomeprazole and omeprazole were used in clopidogrel-treated patients although there are alternatives available for gastric protection.
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Affiliation(s)
| | | | - Pål Hasvold
- AstraZeneca Nordic Baltic, Södertälje, Sweden
| | - Eeva Reissell
- National Institute for Health and Welfare, Helsinki, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, PO Box 52, FI-20521, Turku, Finland.,Department of Medicine, University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, PO Box 52, FI-20521, Turku, Finland. .,Department of Medicine, University of Turku, Turku, Finland. .,Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland. .,Centre for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland. .,Administrative Centre, Hospital District of Southwest Finland, Turku, Finland.
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Farhat N, Fortin Y, Haddad N, Birkett N, Mattison DR, Momoli F, Wu Wen S, Krewski D. Systematic review and meta-analysis of adverse cardiovascular events associated with proton pump inhibitors used alone or in combination with antiplatelet agents. Crit Rev Toxicol 2019; 49:215-261. [DOI: 10.1080/10408444.2019.1583167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Nawal Farhat
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Yannick Fortin
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nisrine Haddad
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nicholas Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Donald R. Mattison
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
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12
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Trends in concomitant clopidogrel and proton pump inhibitor treatment among ACS inpatients, 2000-2016. Eur J Clin Pharmacol 2018; 75:227-235. [PMID: 30324301 DOI: 10.1007/s00228-018-2564-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The US Food and Drug Administration (FDA) issued three safety announcements between January 2009 and October 2010 warning against concomitant use of clopidogrel and proton pump inhibitors (PPIs) due to a potential drug-drug interaction that may attenuate clopidogrel's antiplatelet activity. This primary objective of this study was to examine trends in concomitant clopidogrel/PPI use among acute coronary syndrome (ACS) inpatients in the US between 2000 and 2016, in relation to the FDA safety communications. METHODS Adult inpatients with a primary diagnosis of ACS were identified from the Cerner Health Facts® database. The standardized (age, sex, race, and census region) prevalence of clopidogrel use with PPIs was calculated yearly and quarterly. Findings were stratified by PPIs' potential to inhibit clopidogrel's activity and by age. RESULTS A total of 204,533 inpatients were identified. In 2008, the prevalence of concomitant clopidogrel and PPI treatment was 34.9%, decreasing to 24.4 and 16.4% in 2009 and 2010, respectively, with the decline being similar across age groups. Treatment with inhibiting PPIs (omeprazole and esomeprazole) and clopidogrel has continued to decrease since 2010, with a prevalence of 0.8% in 2016. A similar reduction was not observed with clopidogrel and non-inhibiting PPIs (pantoprazole, lansoprazole, rabeprazole, and dexlansoprazole). During the FDA warning period, the combined treatment with clopidogrel and H2 receptor antagonists, an alternative to PPIs suggested by the FDA, temporarily increased from 7.8% in 2008 to 12.8 and 14.5% in 2009 and 2010, respectively. CONCLUSIONS Findings suggest that clinical practice recommendations made by the FDA were followed. Further research is needed to determine how changes in drug labels and the availability of new drugs may have influenced the observed trends.
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Uncertain Associations of Major Bleeding and Concurrent Use of Antiplatelet Agents and Chinese Medications: A Nested Case-Crossover Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:9417186. [PMID: 28831288 PMCID: PMC5558644 DOI: 10.1155/2017/9417186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/23/2017] [Accepted: 06/22/2017] [Indexed: 11/17/2022]
Abstract
Despite the evidence that some commonly used Chinese medications (CMs) have antiplatelet/anticoagulant effects, many patients still used antiplatelets combined with CMs. We conducted a nested case-crossover study to examine the associations between the concomitant use of antiplatelets and CMs and major bleeding using population-based health database in Taiwan. Among the cohort of 79,463 outpatients prescribed antiplatelets (e.g., aspirin and clopidogrel) continuously, 1,209 patients hospitalized with new occurring bleeding in 2012 and 2013 were included. Those recruited patients served as their own controls to compare different times of exposure to prespecified CMs (e.g., Asian ginseng and dong quai) and antiplatelet agents. The periods of case, control 1, and control 2 were defined as 1–4 weeks, 6–9 weeks, and 13–16 weeks before hospitalization, respectively. Conditional logistic regression analyses found that concurrent use of antiplatelet drugs with any of the prespecified CMs in the case period might not significantly increase the risks of bleeding over that in the control periods (OR = 1.00, 95% CI 0.51 to 1.95 and OR = 1.13, 95% CI 0.65 to 1.97). The study showed no strong relationships between hospitalization for major bleeding events and concurrent use of antiplatelet drugs with the prespecified CMs.
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Additive antithrombotic effect of ASP6537, a selective cyclooxygenase (COX)-1 inhibitor, in combination with clopidogrel in guinea pigs. Eur J Pharmacol 2017; 798:72-76. [PMID: 28095326 DOI: 10.1016/j.ejphar.2017.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/13/2017] [Accepted: 01/13/2017] [Indexed: 11/21/2022]
Abstract
Clopidogrel (Plavix®, Sanofi-Aventis), the adenosine diphosphate P2Y12 receptor antagonist, is reported to be effective in the prevention of cardiovascular events and is often used in combination with aspirin, particularly in high-risk patients. ASP6537 is a reversible cyclooxygenase (COX)-1 inhibitor that is under investigation as an anti-platelet agent. First, we investigated the reversibility of the antiplatelet effect of ASP6537 and its interaction with ibuprofen to compare the usability of ASP6537 with that of aspirin. We then evaluated the antithrombotic effect of ASP6537 in combination with clopidogrel using a FeCl3-induced thrombosis model in guinea pigs. ASP6537 exerted reversible antiplatelet activity, and no pharmacodynamic interaction with ibuprofen was noted. When administered as monotherapy, ASP6537 exerted a significant antithrombotic effect at ≥3mg/kg, while aspirin inhibited thrombosis at 100mg/kg. ASP6537 exerted significant additive effects in combination with clopidogrel, and the minimum antithrombotic dose was reduced by concomitant administration of clopidogrel. Our study showed that ASP6537 did not interact with ibuprofen and has clear additive effects in combination with clopidogrel. ASP6537 may therefore represent a promising antiplatelet agent for use in clinical settings in combination with clopidogrel.
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Wang CY, Lin ZF, Lee CM, Tsai YW, Huang TY, Shen LJ, Hsiao FY. Concomitant use of calcium channel blockers with dual antiplatelet therapy and re-hospitalization for acute coronary syndrome. Pharmacoepidemiol Drug Saf 2017; 26:229-238. [DOI: 10.1002/pds.4147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/17/2016] [Accepted: 11/14/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Chen-Yu Wang
- Graduate Institute of Clinical Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- School of Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
| | - Zhen-Fang Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- School of Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Pharmacy; National Taiwan University Hospital; Taipei Taiwan
| | - Chii-Ming Lee
- Department of Internal Medicine, College of Medicine; National Taiwan University; Taipei Taiwan
| | - Yi-Wen Tsai
- Institute of Health and Welfare; National Yang-Ming University; Taipei Taiwan
| | - Ting-Ying Huang
- Department of Pharmaceutical Health Services Research, School of Pharmacy; University of Maryland; Baltimore MD USA
| | - Li-Jiuan Shen
- Graduate Institute of Clinical Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- School of Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Pharmacy; National Taiwan University Hospital; Taipei Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- School of Pharmacy, College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Pharmacy; National Taiwan University Hospital; Taipei Taiwan
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Schneider JL, Kolitsopoulos F, Corley DA. Risk of gastric cancer, gastrointestinal cancers and other cancers: a comparison of treatment with pantoprazole and other proton pump inhibitors. Aliment Pharmacol Ther 2016; 43:73-82. [PMID: 26541643 DOI: 10.1111/apt.13450] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 06/24/2015] [Accepted: 10/07/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) have been shown to be carcinogenic in rodent studies. AIM As part of a long-term post-marketing surveillance study requested by the US Food and Drug Administration, to compare incidence rates of gastric and other cancers after sustained exposures to pantoprazole, a long-acting PPI, compared with other shorter acting PPIs. METHODS We conducted a cohort study within the membership of the Kaiser Permanente Northern California healthcare system and compared rates of gastric and other cancers among pantoprazole users and users of other PPI medications. The Cox proportional hazards model was used to adjust for potential confounders such as sex, age, receipt of treatment for Helicobacter pylori, cumulative PPI dose, total years PPI treatment and year of index date. The study was developed in consultation with, and approved by, the FDA. RESULTS A total of 61 684 persons with at least a 240-day supply of medication (34 178 pantoprazole and 27 686 other PPIs) were followed up for a total of 547 020 person-years (274 700 vs. 272 321 person-years, respectively). The primary analyses demonstrated comparable risks between the pantoprazole and other PPI groups for gastric cancer [hazard ratio (HR) = 0.68, 95% CI 0.24-1.93); colorectal, liver, pancreatic, or small bowel cancers (HR = 0.95, 95% CI 0.65-1.40) or any cancer (HR = 1.06, 95% CI 0.93-1.21). CONCLUSIONS We found no evidence that pantoprazole, a longer acting PPI, compared with shorter-acting agents, conferred an excess risk of gastric cancer, other gastrointestinal cancers or all cancers for pantoprazole compared with other shorter-acting PPIs.
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Affiliation(s)
- J L Schneider
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - D A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Moore N, Pollack C, Butkerait P. Adverse drug reactions and drug-drug interactions with over-the-counter NSAIDs. Ther Clin Risk Manag 2015. [PMID: 26203254 PMCID: PMC4508078 DOI: 10.2147/tcrm.s79135] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have a long history of safe and effective use as both prescription and over-the-counter (OTC) analgesics/antipyretics. The mechanism of action of all NSAIDs is through reversible inhibition of cyclooxygenase enzymes. Adverse drug reactions (ADRs) including gastrointestinal bleeding as well as cardiovascular and renal effects have been reported with NSAID use. In many cases, ADRs may occur because of drug-drug interactions (DDIs) between the NSAID and a concomitant medication. For example, DDIs have been reported when NSAIDs are coadministered with aspirin, alcohol, some antihypertensives, antidepressants, and other commonly used medications. Because of the pharmacologic nature of these interactions, there is a continuum of risk in that the potential for an ADR is dependent on total drug exposure. Therefore, consideration of dose and duration of NSAID use, as well as the type or class of comedication administered, is important when assessing potential risk for ADRs. Safety findings from clinical studies evaluating prescription-strength NSAIDs may not be directly applicable to OTC dosing. Health care providers can be instrumental in educating patients that using OTC NSAIDs at the lowest effective dose for the shortest required duration is vital to balancing efficacy and safety. This review discusses some of the most clinically relevant DDIs reported with NSAIDs based on major sites of ADRs and classes of medication, with a focus on OTC ibuprofen, for which the most data are available.
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Affiliation(s)
- Nicholas Moore
- Department of Pharmacology, Université de Bordeaux, Bordeaux, France
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Zangbar B, Pandit V, Rhee P, Khalil M, Kulvatunyou N, O'Keeffe T, Tang A, Gries L, Green DJ, Friese RS, Joseph B. Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury. Am J Surg 2015; 209:921-6. [DOI: 10.1016/j.amjsurg.2014.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 05/11/2014] [Accepted: 05/28/2014] [Indexed: 11/15/2022]
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Abstract
Patients with rheumatic diseases, including rheumatoid arthritis and osteoarthritis, almost universally describe pain and stiffness as important contributors to reduced health-related quality of life. Of the treatment options available, NSAIDs are the most widely used agents for symptomatic treatment. NSAIDs are effective anti-inflammatory and analgesic drugs by virtue of their ability to inhibit biosynthesis of prostaglandins at the level of the cyclooxygenase enzyme. However, many of the adverse effects of NSAIDs are also related to inhibition of prostaglandin production, making their use problematic in some patient populations. For the clinician, understanding the biology of prostaglandin as it relates to gastrointestinal, renal, and cardiovascular physiology and the pharmacologic properties of specific NSAIDs is key to using these drugs safely. Of particular importance is the recognition of co-morbid conditions and concomitant drugs that may increase the risk of NSAIDs in particular patients. In patients with risk factors for NSAID toxicity, using the lowest dose of a drug with a short half-life only when it is needed is likely to be the safest treatment option. For those patients whose symptoms cannot be managed with intermittent treatment, using protective strategies is essential.
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20
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Morlion B. Chronic low back pain: pharmacological, interventional and surgical strategies. Nat Rev Neurol 2013; 9:462-73. [DOI: 10.1038/nrneurol.2013.130] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Zantek ND, Luepker RV, Duval S, Miller K, Oldenburg N, Hirsch AT. Confirmation of reported aspirin use in community studies: utility of serum thromboxane B2 measurement. Clin Appl Thromb Hemost 2013; 20:385-92. [PMID: 23653145 DOI: 10.1177/1076029613486537] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aspirin (ASA) is recommended for the prevention of cardiovascular disease; however, the compliance is low. Reported use may not reflect actual use. Serum thromboxane B2 (STxB2) measurement was evaluated to validate reported ASA use. Males aged 45 to 79 years and females aged 55 to 79 years completed a survey and STxB2 measurement (Thromboxane B2 EIA Kit; Cayman Chemical, Ann Arbor, Michigan). The 107 patients were grouped by use of ASA (56 ASA+ and 51 ASA-) and possible interfering medications (INT) such as nonsteroidal anti-inflammatory drugs. The STxB2 levels (ng/mL) were significantly lower in ASA users: ASA+ INT- 3.0 (0.7, 8.4), ASA+ INT+ 2.0 (0.8, 4.9), ASA- INT+ 176 (75, 390), and ASA- INT- 271 (199, 366). The INT use did not cause a significant difference in STxB2 levels. A STxB2 cut point of 25 ng/mL had high sensitivity (94.1%) and specificity (91.1%) for ASA use. The STxB2 was a reliable marker of ASA use and could be used to confirm ASA exposure in population-based health studies.
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Affiliation(s)
- Nicole Dodge Zantek
- 1Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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Stathopoulou MG, Monteiro P, Shahabi P, Peñas-Lledó E, El Shamieh S, Silva Santos L, Thilly N, Siest G, Llerena A, Visvikis-Siest S. Newly identified synergy between clopidogrel and calcium-channel blockers for blood pressure regulation possibly involves CYP2C19 rs4244285. Int J Cardiol 2013; 168:3057-8. [PMID: 23643422 DOI: 10.1016/j.ijcard.2013.04.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/06/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Maria G Stathopoulou
- UMR INSERM U 1122, IGE-PCV "Interactions Gène-Environnement en Physiopathologie Cardio-Vasculaire", Université de Lorraine, 30 Rue Lionnois, Nancy 54000, France
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Hohlfeld T, Saxena A, Schrör K. High on treatment platelet reactivity against aspirin by non-steroidal anti-inflammatory drugs--pharmacological mechanisms and clinical relevance. Thromb Haemost 2012; 109:825-33. [PMID: 23238666 DOI: 10.1160/th12-07-0532] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 11/13/2012] [Indexed: 12/22/2022]
Abstract
Inhibition of platelet function by aspirin results from irreversible inhibition of platelet cyclooxygenase (COX)-1. While sufficient inhibition is obtained at antiplatelet doses (75-325 mg/day) in most (≥95%) treated patients, the antiplatelet effect of aspirin and subsequent cardiovascular risk reduction is much less in clinical settings and disease-dependent. Several reasons for this "high on treatment platelet reactivity" are known. This paper reviews the evidence for an interaction between aspirin and other COX inhibitors, namely non-steroidal anti-inflammatory drugs (NSAIDs). Numerous experimental studies demonstrated a pharmacodynamic interaction between aspirin and NSAIDs. This likely occurs within the hydrophobic substrate channel of platelet COX-1 and might be explained by molecular competition between inhibitor drugs and substrate (arachidonic acid) at overlapping binding sites. This interaction is found with some compounds, notably ibuprofen and dipyrone (metamizole), but not with others, such as diclofenac and acetaminophen (paracetamol). Hence, this interaction is not a class effect of NSAIDs and/or non-steroidal analgesics but rather due to specific structural requirements which still remain to be defined. In vivo studies on healthy subjects and patients tend to confirm this type of interaction as well as large differences between NSAIDs and non-steroidal analgesics, respectively. These interactions may be clinically relevant and may increase the cardiovascular risk in long-term treatment for primary and secondary cardiovascular prevention in patients with chronic inflammation, such as rheumatoid arthritis. These patients have an elevated risk for myocardial infarctions and may require chronic antiplatelet treatment by aspirin in addition to treatment of inflammatory pain.
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Affiliation(s)
- T Hohlfeld
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, Düsseldorf, Germany.
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25
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Abstract
Clinically relevant drug-drug interactions contribute considerably to potentially dangerous drug side-effects and are frequently the reason for hospitalization. Nevertheless they are often overlooked in daily practice. For most antirheumatic drugs a vast number of interactions have been described but only a minority with clinical relevance. Several potentially important drug interactions exist for non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate, azathioprine, mycophenolate-mofetil and especially for cyclosporin A. Most importantly co-medication with methotrexate and sulfmethoxazole trimethoprim as well as azathioprine and allopurinol carries the risk of severe, sometimes life-threatening consequences. Nevertheless, besides these well-known high-risk combinations in each case of polypharmacy with antirheumatic drugs it is necessary to bear in mind the possibility of drug interactions. As polypharmacy is a common therapeutic practice in older patients with rheumatic diseases, they are at special risk.
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[Removal of epidural catheter under dual antiplatelet therapy following acute coronary syndrome : scenario without special consideration to the current guidelines on epidural regional anesthesia]. Anaesthesist 2012; 61:686-90. [PMID: 22847559 DOI: 10.1007/s00101-012-2067-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 07/07/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022]
Abstract
This article reports the case of a patient who developed acute coronary syndrome while receiving postoperative pain treatment via an epidural catheter (EC). Platelet function testing was performed before removal of the EC to assess the bleeding risk under ongoing dual antiplatelet therapy. Platelet function testing showed low responsiveness to clopidogrel and acetylsalicylic acid (ASS). The EC was removed uneventfully and clopidogrel was subsequently replaced by prasugrel and platelet function showed improved depression of thrombocyte aggregation. Possible reasons for low responsiveness to clopidogrel and ASS, such as drug-drug interactions with proton pump inhibitors and genetic factors are discussed.
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Lange U, Müller-Ladner U. [Potential interactions of rheumatologic medications in the elderly]. DER ORTHOPADE 2012; 41:539-545. [PMID: 22732770 DOI: 10.1007/s00132-012-1930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Improving the safety of prescriptions for elderly patients is of substantial interest for physicians of all specialities as well as for general health policy and health services. Owing to the increase in drug prescriptions with age and various drug-drug interactions, the number of adverse drug event-related hospital admissions needs to be minimized as far as possible. Therefore, the present overview focuses on the most important potential drug-drug interactions with a specific focus on antirheumatic medications prescribed for elderly patients.
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Affiliation(s)
- U Lange
- Internistische Rheumatologie, Osteologie, Physikalische Medizin, Justus-Liebig-Universität Gießen, Gießen, Deutschland.
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Pulley JM, Denny JC, Peterson JF, Bernard GR, Vnencak-Jones CL, Ramirez AH, Delaney JT, Bowton E, Brothers K, Johnson K, Crawford DC, Schildcrout J, Masys DR, Dilks HH, Wilke RA, Clayton EW, Shultz E, Laposata M, McPherson J, Jirjis JN, Roden DM. Operational implementation of prospective genotyping for personalized medicine: the design of the Vanderbilt PREDICT project. Clin Pharmacol Ther 2012; 92:87-95. [PMID: 22588608 DOI: 10.1038/clpt.2011.371] [Citation(s) in RCA: 304] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The promise of "personalized medicine" guided by an understanding of each individual's genome has been fostered by increasingly powerful and economical methods to acquire clinically relevant information. We describe the operational implementation of prospective genotyping linked to an advanced clinical decision-support system to guide individualized health care in a large academic health center. This approach to personalized medicine entails engagement between patient and health-care provider, identification of relevant genetic variations for implementation, assay reliability, point-of-care decision support, and necessary institutional investments. In one year, approximately 3,000 patients, most of whom were scheduled for cardiac catheterization, were genotyped on a multiplexed platform that included genotyping for CYP2C19 variants that modulate response to the widely used antiplatelet drug clopidogrel. These data are deposited into the electronic medical record (EMR), and point-of-care decision support is deployed when clopidogrel is prescribed for those with variant genotypes. The establishment of programs such as this is a first step toward implementing and evaluating strategies for personalized medicine.
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Affiliation(s)
- J M Pulley
- Department of Medical Administration, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Wangorsch G, Butt E, Mark R, Hubertus K, Geiger J, Dandekar T, Dittrich M. Time-resolved in silico modeling of fine-tuned cAMP signaling in platelets: feedback loops, titrated phosphorylations and pharmacological modulation. BMC SYSTEMS BIOLOGY 2011; 5:178. [PMID: 22034949 PMCID: PMC3247139 DOI: 10.1186/1752-0509-5-178] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 10/28/2011] [Indexed: 02/13/2023]
Abstract
Background Hemostasis is a critical and active function of the blood mediated by platelets. Therefore, the prevention of pathological platelet aggregation is of great importance as well as of pharmaceutical and medical interest. Endogenous platelet inhibition is predominantly based on cyclic nucleotides (cAMP, cGMP) elevation and subsequent cyclic nucleotide-dependent protein kinase (PKA, PKG) activation. In turn, platelet phosphodiesterases (PDEs) and protein phosphatases counterbalance their activity. This main inhibitory pathway in human platelets is crucial for countervailing unwanted platelet activation. Consequently, the regulators of cyclic nucleotide signaling are of particular interest to pharmacology and therapeutics of atherothrombosis. Modeling of pharmacodynamics allows understanding this intricate signaling and supports the precise description of these pivotal targets for pharmacological modulation. Results We modeled dynamically concentration-dependent responses of pathway effectors (inhibitors, activators, drug combinations) to cyclic nucleotide signaling as well as to downstream signaling events and verified resulting model predictions by experimental data. Experiments with various cAMP affecting compounds including anti-platelet drugs and their combinations revealed a high fidelity, fine-tuned cAMP signaling in platelets without cross-talk to the cGMP pathway. The model and the data provide evidence for two independent feedback loops: PKA, which is activated by elevated cAMP levels in the platelet, subsequently inhibits adenylyl cyclase (AC) but as well activates PDE3. By multi-experiment fitting, we established a comprehensive dynamic model with one predictive, optimized and validated set of parameters. Different pharmacological conditions (inhibition, activation, drug combinations, permanent and transient perturbations) are successfully tested and simulated, including statistical validation and sensitivity analysis. Downstream cyclic nucleotide signaling events target different phosphorylation sites for cAMP- and cGMP-dependent protein kinases (PKA, PKG) in the vasodilator-stimulated phosphoprotein (VASP). VASP phosphorylation as well as cAMP levels resulting from different drug strengths and combined stimulants were quantitatively modeled. These predictions were again experimentally validated. High sensitivity of the signaling pathway at low concentrations is involved in a fine-tuned balance as well as stable activation of this inhibitory cyclic nucleotide pathway. Conclusions On the basis of experimental data, literature mining and database screening we established a dynamic in silico model of cyclic nucleotide signaling and probed its signaling sensitivity. Thoroughly validated, it successfully predicts drug combination effects on platelet function, including synergism, antagonism and regulatory loops.
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Affiliation(s)
- Gaby Wangorsch
- Department of Bioinformatics, Biocenter, University of Würzburg, Germany
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Leontiadis GI, Yuan Y, Howden CW. The interaction between proton pump inhibitors and clopidogrel and upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2011; 21:637-56. [PMID: 21944415 DOI: 10.1016/j.giec.2011.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There is increasing concern regarding a possible adverse interaction between proton pump inhibitors (PPIs) and clopidogrel that could lead to reduced cardiovascular protection by clopidogrel. We performed a literature search for relevant original studies and systematic reviews. PPIs likely affect the antiplatelet activity of clopidogrel as measured in vitro, and this may be a class effect. We conclude that the pharmacodynamic effect has not been translated into any clinically meaningful adverse effect. PPI cotherapy reduces the incidence of recurrent peptic ulcer and of upper gastrointestinal bleeding among patients on clopidogrel.
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Affiliation(s)
- Grigorios I Leontiadis
- Division of Gastroenterology, Health Sciences Centre, McMaster University, Hamilton, ON, Canada.
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Abstract
INTRODUCTION There are numerous drug-drug interactions (DDIs) related to cardiovascular medications and many of these are mediated via the cytochrome P450 (CYP) system. Some of these may lead to serious adverse events and it is, therefore, essential that clinicians are aware of the important interactions that occur. AREAS COVERED An extensive literature search was performed to analyze the CYP-mediated cardiovascular DDIs that lead to a loss of efficacy or potential toxicity. Cardiovascular drugs may be victims or act as perpetrators of DDIs. The paper analyzes CYP-mediated drug interactions concerning anticoagulants, antiplatelet agents, antiarrhythmics, β-blockers, calcium antagonists, antihypertensive medications, lipid-lowering drugs and oral antidiabetic agents. EXPERT OPINION Cardiovascular DDIs involving the CYP system are numerous. Additionally, the spectrum of drugs prescribed is constantly changing, particularly with cardiovascular diseases and it is not necessarily the case that drugs that had shown safety earlier will always show safety. Clinicians are encouraged to develop their knowledge of CYP-mediated DDIs so that they can choose safe drug combination regimens, adjust drug dosages appropriately and conduct therapeutic drug monitoring for drugs with narrow therapeutic indices.
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Affiliation(s)
- André J Scheen
- University of Liège, Division of Diabetes, Nutrition and Metabolic Disorders, Division of Clinical Pharmacology, Department of Medicine, CHU Liege, Belgium.
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