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Chen JH, Lee MC, Yen TH, Huang PY, Lu DE, Lee CH, Chang HC, Wang JY, Lee JA. Effect of drug interactions with non-vitamin-K oral anticoagulants on thromboembolic events in patients with nonvalvular atrial fibrillation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:69-79. [PMID: 38920231 DOI: 10.47102/annals-acadmedsg.2023137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Few real-world studies have investigated drug-drug interactions (DDIs) involving non-vitamin-K antagonist oral anticoagulants (NOACs) in patients with nonvalvular atrial fibrillation (NVAF). The interactions encompass drugs inducing or inhibiting cytochrome P450 3A4 and permeability glycoprotein. These agents potentially modulate the breakdown and elimination of NOACs. This study investigated the impact of DDIs on thromboembolism in this clinical scenario. Method Patients who had NVAF and were treated with NOACs were selected as the study cohort from the National Health Insurance Research Database of Taiwan. Cases were defined as patients hospitalised for a thromboembolic event and who underwent a relevant imaging study within 7 days before hospitalisa-tion or during hospitalisation. Each case was matched with up to 4 controls by using the incidence density sampling method. The concurrent use of a cytochrome P450 3A4/permeability glycoprotein inducer or inhibitor or both with NOACs was identified. The effects of these interactions on the risk of thromboembolic events were examined with univariate and multivariate conditional logistic regressions. Results The study cohort comprised 60,726 eligible patients. Among them, 1288 patients with a thromboembolic event and 5144 matched control patients were selected for analysis. The concurrent use of a cytochrome P450 3A4/permeability glycoprotein inducer resulted in a higher risk of thromboembolic events (adjusted odds ratio [AOR] 1.23, 95% confidence interval [CI] 1.004-1.51). Conclusion For patients with NVAF receiving NOACs, the concurrent use of cytochrome P450 3A4/ permeability glycoprotein inducers increases the risk of thromboembolic events.
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Affiliation(s)
- Jin-Hua Chen
- Biostatistics Center, College of Management, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chia Lee
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Department of Pharmacy, New Taipei City Hospital, New Taipei City, Taiwan
- Department of Nursing, Cardinal Tien College of Healthcare and Management, Taipei, Taiwan
| | - Tzu-Hsin Yen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Pei-Yu Huang
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - De-En Lu
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hsin Lee
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Chen Chang
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Ai Lee
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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de Fautereau-Vassel A, Mokhtarian A, Mangenot M, Krekounian O, Kousignian I, Delavenne X, Curis E, Gouin-Thibault I, Siguret V. Comparisons between diluted thrombin time, ecarin chromogenic assays, and UPLC-MS for plasma level dabigatran quantification: Results from DRIVING study. Int J Lab Hematol 2024; 46:120-127. [PMID: 37710085 DOI: 10.1111/ijlh.14166] [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: 07/17/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION The knowledge of dabigatran levels is helpful for decision-making in specific situations such as urgent surgery or when the question of reversal arises (uncontrolled bleeding, eligibility for thrombolysis). However, a limited number of observational studies are available regarding comparisons between quantification methods. The objective of the study was to compare dabigatran plasma levels using three assays including the reference method (high-performance liquid chromatography coupled with mass spectrometry), focusing on the agreement around the 30-50 ng/mL clinically relevant thresholds. METHODS Sixty healthy volunteers from DRIVING trial (NCT01627665) were given a single 300-mg dabigatran etexilate dose. Serial blood samplings were performed at pre-defined time points (0 to 24 h). We analyzed plasma samples using ultra-performance-liquid chromatography coupled with tandem mass spectrometry (UPLC-MS) (dabigatran reference method); ii/diluted thrombin time (dTT) (Hemoclot-DTI-Hyphen-Biomed); iii/ecarin-based chromogenic assay (ECA-II-Stago). RESULTS Nine hundred sixty samples were analyzed using the three assays (2759 values). dTT and ECA-II values were highly correlated with those of UPLC-MS (Deming regression). Most values >50 ng/mL were higher using dTT and ECA-II compared to UPLC-MS: biases were constant, +14% and +16% with dTT and ECA-II, respectively (Bland-Altman plots), suggesting that active metabolites accounted for ~15% of thrombin inhibition. Regarding values <30 ng/mL, 30-50 ng/mL, or ≥50 ng/mL, the agreement probability between dTT and ECA-II was of 90.6% [88.4-92.5] (Cohen's kappa coefficient 0.84). CONCLUSION dTT and ECA-II assays rapidly provide accurate dabigatran-level results for clinical practice, both assays being suitable in emergency, taking into account the thrombin inhibitory effect of dabigatran metabolites.
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Affiliation(s)
| | - Antoine Mokhtarian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Manon Mangenot
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Ombeline Krekounian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Isabelle Kousignian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Xavier Delavenne
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Emmanuel Curis
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
- INSERM UMRS-1140, Université Paris Cité, Paris, France
- Service d'hématologie Biologique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Isabelle Gouin-Thibault
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire Pontchaillou, Univ Rennes, CHU Rennes, Inserm, IRSET UMR-S-1085, Rennes, France
| | - Virginie Siguret
- INSERM UMRS-1140, Université Paris Cité, Paris, France
- Service d'hématologie Biologique, Hôpital Lariboisière, APHP Nord, Paris, France
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [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: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Chung H, Kim JM, Park JW, Noh J, Kim KA, Park JY. Effects of Simvastatin on Pharmacokinetics and Anticoagulant Effects of Dabigatran in Healthy Subjects. Pharmaceuticals (Basel) 2023; 16:364. [PMID: 36986464 PMCID: PMC10056008 DOI: 10.3390/ph16030364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
Higher risk of major hemorrhage associated with concomitant use of dabigatran and simvastatin compared to other statins was previously reported with a suggestion of P-glycoprotein-mediated interaction. The aim of this study was to evaluate the effects of simvastatin on pharmacokinetics and anticoagulant effects of dabigatran, a direct oral anticoagulant. A total of 12 healthy subjects were enrolled in an open-label, two-period, single sequence study. Subjects were given 150 mg of dabigatran etexilate followed by 40 mg of once-daily simvastatin for seven days. Dabigatran etexilate was administered with simvastatin on the seventh day of simvastatin administration. Blood samples for pharmacokinetic and pharmacodynamic analyses were obtained until 24 h post-dose of dabigatran etexilate with or without co-administration of simvastatin. Pharmacokinetic parameters were derived from noncompartmental analysis for dabigatran etexilate, dabigatran, and dabigatran acylglucuronide. When simvastatin was co-administered, geometric mean ratios of area under time-concentration curves for dabigatran etexilate, dabigatran, and dabigatran acylglucuronide were 1.47, 1.21, and 1.57, respectively, compared to when dabigatran etexilate was administered alone. Thrombin generation assay and coagulation assay showed similar profiles between before and after co-administration of simvastatin. This study provides evidence that simvastatin treatment plays a minor role in modulating pharmacokinetics and anticoagulant effects of dabigatran etexilate.
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Affiliation(s)
- Hyewon Chung
- Department of Clinical Pharmacology and Toxicology, Guro Hospital, Korea University College of Medicine, Seoul 08308, Republic of Korea
| | - Jong-Min Kim
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Jin-Woo Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
- Department of Neurology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Jihyeon Noh
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Kyoung-Ah Kim
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ji-Young Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Li H, Zhang Z, Weng H, Qiu Y, Zubiaur P, Zhang Y, Fan G, Yang P, Vuorinen AL, Zuo X, Zhai Z, Wang C. Association between CES1 rs2244613 and the pharmacokinetics and safety of dabigatran: Meta-analysis and quantitative trait loci analysis. Front Cardiovasc Med 2022; 9:959916. [PMID: 35990949 PMCID: PMC9386138 DOI: 10.3389/fcvm.2022.959916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/29/2022] [Indexed: 12/02/2022] Open
Abstract
Objective To date, the influence of the carboxylesterase 1 (CES1) rs2244613 genotype on the pharmacokinetics (PKs) and safety of dabigatran remains controversial. Hence, a systematic review was performed to study the association between CES1 rs2244613 genotype and the PKs and safety of dabigatran and CES1 relative expression. Methods In addition to the three English databases (Web of Science, PubMed, and Embase), two Chinese databases (CNKI and Wanfang) were thoroughly revised. The mean differences (MD) and corresponding 95% confidence intervals (CI) were applied to evaluate the differences in PKs between the CES1 rs2244613 genotype. Odds ratio (OR) was used to study the risk for bleeding events between the CES1 rs2244613 genotypes. Subsequent expression quantitative trait loci (eQTL) analyses were performed to evaluate genotype-specific expressions in human tissues. Results Ten studies (n = 2,777) were included. CES1 rs2244613 G allele carriers exhibited significantly lower dabigatran trough concentrations compared to T allele carriers (MD: −8.00 ng/mL; 95% CI: −15.08 to −0.92; p = 0.03). The risk for bleeding events was significantly lower in carriers of the G allele compared to T allele carriers (OR: 0.65; 95% CI: 0.44–0.96; p = 0.03). Subsequent eQTL analysis showed significant genome-wide expressions in two human tissues, whole blood (p = 5.1 × 10–10) and liver (p = 6.2 × 10–43). Conclusion Our meta-analysis indicated a definite relation between the CES1 rs2244613 genotype and tolerability variations or pharmacokinetic fluctuations. The carriers of T allele showed higher dabigatran concentrations; therefore, they would benefit from a dose reduction. Systematic review registration [https://inplasy.com/inplasy-2022-6-0027/], identifier [NPLASY202260027].
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Affiliation(s)
- Haobo Li
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Haoyi Weng
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
- WeGene, Shenzhen Zaozhidao Technology Co., Ltd., Shenzhen, China
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
| | - Yuting Qiu
- Graduate School of Capital Medical University, Beijing, China
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria, Universidad Autónoma de Madrid, Madrid, Spain
| | - Yu Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Capital Medical University, Beijing, China
| | - Guohui Fan
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Peiran Yang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | | | - Xianbo Zuo
- Department of Dermatology, China-Japan Friendship Hospital, Beijing, China
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Xianbo Zuo,
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Zhenguo Zhai,
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Shaikh K, Mungantiwar A, Halde S, Pandita N. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for determination of free and total dabigatran in human plasma and its application to a pharmacokinetic study. Drug Dev Ind Pharm 2022; 47:1835-1846. [PMID: 35452338 DOI: 10.1080/03639045.2022.2069257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A high performance liquid chromatography tandem mass spectrometric method for the determination of free and total dabigatran in human plasma has been developed and validated using stable labeled internal standard (IS) as dabigatran D4. The extraction of analyte and IS was accomplished by solid phase extraction technique. Chromatographic separations were achieved using Peerless basic C8 (150 x 4.6) mm, 5µ column eluted at flow rate of 1 mL/min with mobile phase Acetonitrile: 5 mM ammonium formate: Methanol and 0.2% formic acid (30:20:50, v/v/v). The run time of method was about 2.5 min with elution times of dabigatran and dabigatran D4 at around 1.2 min. The multiple reaction monitoring transitions (Q1/Q3) were set at 472/289, 172 (m/z) for dabigatran and 476/293 (m/z) for dabigatran D4. The calibration curves were linear (r2 ≥0.99) over the range of 1.04 - 406.49 ng/mL.The presented method was successfully employed in analysis of pharmacokinetic studies with an added advantage of demonstrating the effect of co-administration of dabigatran with the proton pump inhibitor pantoprazole on bioavailability and pharmacokinetic characteristics. Re-analysis of incurred sample resulted with >98% compliance indicating good assay precision of target analytes.Re-analysis of incurred sample resulted with >98% compliance which indicated good assay precision of target analytes.
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Affiliation(s)
- Khurshid Shaikh
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India.,Department of Chemistry, Sunandan Divatia School of Science, NMIMS University, Mumbai, India
| | - Ashish Mungantiwar
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India
| | - Supriya Halde
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India
| | - Nancy Pandita
- Department of Chemistry, Sunandan Divatia School of Science, NMIMS University, Mumbai, India
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Abd Allah FI, Ali Almrasy A, Abdelhmaid A, Abd-Elmegid OA, Alkashlan A, El-Attar AAMM. Development and Validation of UPLC-MS/MS Method for Quantifying of Free and Total Dabigatran in Human Plasma: An Application for a Bioequivalence Study. Biomed Chromatogr 2022; 36:e5382. [PMID: 35389511 DOI: 10.1002/bmc.5382] [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: 11/27/2021] [Revised: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 11/11/2022]
Abstract
Dabigatran etexilate mesylate (DABE), a prodrug, quickly changes in our bodies after its oral administration into dabigatran (DAB). Accordingly, detecting DABE in plasma is practically unmanageable. A UPLC-MS/MS technique was developed and validated to compute free DAB in participants. For the first time, the central composite design- a type of response surface methodology- was utilized for optimizing variables affecting the cleavage of glucuronide bond. Additionally, the pharmacokinetic parameters of generic medication (okanadab) were determined, and the obtained outcomes were compared to those of branded drug (pradaxa®). The sample preparation was done using methanol as a protein precipitant and the separation was achieved via ACQUITY UPLC BEH C18 column (2.1x50mm, 1.7μm). The elution was isocratically conducted using 10mM ammonium formate: methanol (72:28, v/v) as a mobile phase (MP) and the flow rate was 0.25mL/min. Multiple reaction monitoring (MRM) and positive electrospray ionization (ESI) were used. The determination was performed within 1min, and the calibration growth curve was established over a range of (1.19 - 475) ng/mL using dabigatran-d3 as a tagged internal standard (IS). Bioequivalence research was validated following FDA guidelines for bio-analytical procedures and acceptable outcomes were achieved. The outcomes for okanadab and pradaxa® did not differ significantly.
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Affiliation(s)
- Fathy Ibrahim Abd Allah
- Department of Pharmaceutics, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt.,International Center for Bioavailability, Pharmaceutical, and Clinical Research
| | - Ahmed Ali Almrasy
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Cairo11751, Egypt
| | - Ahmed Abdelhmaid
- International Center for Bioavailability, Pharmaceutical, and Clinical Research
| | - Osama A Abd-Elmegid
- International Center for Bioavailability, Pharmaceutical, and Clinical Research
| | - Akram Alkashlan
- International Center for Bioavailability, Pharmaceutical, and Clinical Research
| | - Abdul-Aziz M M El-Attar
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Cairo11751, Egypt
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Dabigatran Acylglucuronide, the Major Metabolite of Dabigatran, Shows a Weaker Anticoagulant Effect than Dabigatran. Pharmaceutics 2022; 14:pharmaceutics14020257. [PMID: 35213990 PMCID: PMC8875894 DOI: 10.3390/pharmaceutics14020257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Dabigatran (DAB) is an orally administered thrombin inhibitor. Both DAB and its main metabolite dabigatran acylglucuronide (DABG) have established anticoagulant effects. Here, we aimed to compare the relative anticoagulant effects of DABG and DAB in humans. Anticoagulant effects of DAB and DABG were measured in vitro using a thrombin generation assay. Additionally, their effects on other coagulation assays including PT, aPTT, TT, and fibrinogen were compared. Both DAB and DABG showed inhibitory effects on thrombin generation in a dose-dependent manner, but DABG exhibited a weaker inhibitory effect than that of DAB. The IC50 values of DAB and DABG on thrombin generation AUC were 134.1 ng/mL and 281.9 ng/mL, respectively. DABG also exhibited weaker anticoagulant effects than DAB on PT, aPTT, and TT. The results of the present study indicate that the anticoagulant effect of DABG, a main active DAB metabolite, is weaker than that of DAB.
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Shnayder NA, Petrova MM, Shesternya PA, Savinova AV, Bochanova EN, Zimnitskaya OV, Pozhilenkova EA, Nasyrova RF. Using Pharmacogenetics of Direct Oral Anticoagulants to Predict Changes in Their Pharmacokinetics and the Risk of Adverse Drug Reactions. Biomedicines 2021; 9:biomedicines9050451. [PMID: 33922084 PMCID: PMC8143539 DOI: 10.3390/biomedicines9050451] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
Dabigatran, rivaroxaban, apixaban, and edoxaban are direct oral anticoagulants (DOACs) that are increasingly used worldwide. Taking into account their widespread use for the prevention of thromboembolism in cardiology, neurology, orthopedics, and coronavirus disease 2019 (COVID 19) as well as their different pharmacokinetics and pharmacogenetics dependence, it is critical to explore new opportunities for DOACs administration and predict their dosage when used as monotherapy or in combination with other drugs. In this review, we describe the details of the relative pharmacogenetics on the pharmacokinetics of DOACs as well as new data concerning the clinical characteristics that predetermine the needed dosage and the risk of adverse drug reactions (ADRs). The usefulness of genetic information before and shortly after the initiation of DOACs is also discussed. The reasons for particular attention to these issues are not only new genetic knowledge and genotyping possibilities, but also the risk of serious ADRs (primarily, gastrointestinal bleeding). Taking into account the effect of the carriership of single nucleotide variants (SNVs) of genes encoding biotransformation enzymes and DOACs metabolism, the use of these measures is important to predict changes in pharmacokinetics and the risk of ADRs in patients with a high risk of thromboembolism who receive anticoagulant therapy.
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Affiliation(s)
- Natalia A. Shnayder
- The Centre of Personalized Psychiatry and Neurology, V. M. Bekhterev National Medical Research Center for Psychiatry and Neurology (V.M. Bekhterev NMRC PN) 3, Bekhterev Str., 192019 Saint-Petersburg, Russia;
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-670-02-20 (N.A.S. & R.F.N.)
| | - Marina M. Petrova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Pavel A. Shesternya
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Alina V. Savinova
- The Centre of Personalized Psychiatry and Neurology, V. M. Bekhterev National Medical Research Center for Psychiatry and Neurology (V.M. Bekhterev NMRC PN) 3, Bekhterev Str., 192019 Saint-Petersburg, Russia;
| | - Elena N. Bochanova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Olga V. Zimnitskaya
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Elena A. Pozhilenkova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Regina F. Nasyrova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-670-02-20 (N.A.S. & R.F.N.)
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Savinova AV, Dobrodeeva VS, Petrova MM, Nasyrova RF, Shnayder NA. Pharmacokinetics and Pharmacogenetics of Dabigatran. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-01-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Dabigatran etexilate is a prodrug of dabigatran, a oral direct inhibitor of thrombin. Pharmacokinetics of dabigatran etexilate doesn’t have the disadvantages of vitamin K antagonists. However, pharmacokinetics and pharmacogenetics of dabigatran are variable. This can affect both effectiveness and safety of anticoagulant therapy. It is considered that CES1 enzyme and P-glycoprotein (CES1 and ABCB1 genes accordingly) play important role in pharmacokinetics of dabigatran etexilate. UDP-glucuronosyltransferase enzymes UGT2B15, UGT1A9, UGT2B7 (UGT2B15, UGT1A9, UGT2B7 genes accordingly) take part in the metabolism of active dabigatran. Presence of these gene’s single-nucleotide variants (SNV) can affect effectiveness and safety of dabigatran etexilate usage. The goal of this review is analysis of associated researches of SNV genes CES1 and ABCB1 and search for new candidate genes that reveal effectiveness and safety of dabigatran etexilate usage.Materials and methods. The search for full-text publications in Russian and English languages containing key words “dabigatran etexilate”, “dabigatran”, “pharmacokinetics”, “effectiveness”, “safety” was carried out amongst literature of the past twenty years with the use of eLibrary, PubMed, Web of Science, OMIM data bases. Pharmacokinetics and pharmacogenetics of dabigatran etexilate are considered in this review. The hypothesis about UDP-glucuronosyltransferase enzymes influence on dabigatran metabolism was examined. Nowadays more than 2000 SNV CES1 and ABCB1 genes are identified, but their potential influence on pharmacokinetics of dabigatran etexilate and its active metabolite (dabigatran) in clinical practice needs to be further researched. Role of SNV UDP-glucuronosyltransferase genes (UGT2B15, UGT1A9, UGT2B7) in dabigatran’s effectiveness and safety is not explored enough. However, UGT2B15 gene can be a potential candidate gene for research on safety of this drug.
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Affiliation(s)
- A. V. Savinova
- Bekhterev National Medical Research Center of Psychiatry and Neurology
| | - V. S. Dobrodeeva
- Bekhterev National Medical Research Center of Psychiatry and Neurology
| | - M. M. Petrova
- Voyno-Yasenetsky Krasnoyarsk State Medical University
| | - R. F. Nasyrova
- Bekhterev National Medical Research Center of Psychiatry and Neurology;
Kazan Federal University
| | - N. A. Shnayder
- Bekhterev National Medical Research Center of Psychiatry and Neurology;
Voyno-Yasenetsky Krasnoyarsk State Medical University
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11
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Farhan N, Cristofoletti R, Basu S, Kim S, Lingineni K, Jiang S, Brown JD, Fang LL, Lesko LJ, Schmidt S. Physiologically-based pharmacokinetics modeling to investigate formulation factors influencing the generic substitution of dabigatran etexilate. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:199-210. [PMID: 33449439 PMCID: PMC7965836 DOI: 10.1002/psp4.12589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/12/2020] [Accepted: 12/17/2020] [Indexed: 01/06/2023]
Abstract
The exposure‐response relationship of direct acting oral anti‐coagulants (DOACs) for bleeding risk is steep relative to ischemic stroke reduction. As a result, small changes in exposure may lead to bleeding events. The overall goal of this project was to determine the effect of critical formulation parameters on the pharmacokinetics (PKs) and thus safety and efficacy of generic DOACs. In this first installment of our overall finding, we developed and verified a physiologically‐based PK (PBPK) model for dabigatran etexilate (DABE) and its metabolites. The model was developed following a middle out approach leveraging available in vitro and in vivo data. External validity of the model was confirmed by overlapping predicted and observed PK profiles for DABE as well as free and total dabigatran for a dataset not used during model development. The verified model was applied to interrogate the impact of modulating the microenvironment pH on DABE systemic exposure. The PBPK exploratory analyses highlighted the high sensitivity of DABE exposure to supersaturation ratio and precipitation kinetics.
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Affiliation(s)
- Nashid Farhan
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Rodrigo Cristofoletti
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Sumit Basu
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Sarah Kim
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Karthik Lingineni
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Sibo Jiang
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Lanyan Lucy Fang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lawrence J Lesko
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
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12
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Lingineni K, Farhan N, Kim S, Cristofoletti R, Gordon LA, Kumar P, Penzak S, Hadigan C, George JM, Brown JD, Schmidt S. Quantitative Benefit-Risk Assessment of P-gp-Mediated Drug-Drug Interactions of Dabigatran Coadministered With Pharmacokinetic Enhancers in Patients With Renal Impairment. Clin Pharmacol Ther 2020; 109:193-200. [PMID: 33073366 DOI: 10.1002/cpt.2087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/10/2020] [Indexed: 11/12/2022]
Abstract
Drug-drug interactions (DDIs) between dabigatran and ritonavir/cobicistat are of major concern in people living with HIV, particularly in those with impaired renal function, because they can result in increased dabigatran exposure and thus an increased risk of major bleeding events. However, the extent of this interaction and subsequent need for dose adjustment in subjects with varying degrees of renal function is currently not yet fully understood. To close this knowledge gap, we conducted an integrated population physiologically-based pharmacokinetic/pharmacodynamic analysis linking changes in dabigatran exposure due to DDIs and varying degrees of renal function to the probability of experiencing an ischemic stroke or major bleeding event within 1 year. The results of our analysis suggest that coadministration of dabigatran etexilate (dabigatran prodrug) and ritonavir/cobicistat should be avoided in subjects with severe renal impairment. A 2-hour dose separation or dabigatran etexilate dose reduction to 110 mg b.i.d. (twice daily) should be considered in subjects with moderate renal impairment when coadministered with ritonavir, while the dabigatran etexilate dose should be further reduced to 75 mg b.i.d. when coadministered with cobicistat. No dabigatran etexilate dose adjustment is needed in subjects with normal renal function receiving ritonavir, but dabigatran etexilate dose reduction to 110 mg b.i.d. should be considered when coadministered with cobicistat.
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Affiliation(s)
- Karthik Lingineni
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Nashid Farhan
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Sarah Kim
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Rodrigo Cristofoletti
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Lori A Gordon
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy, National Institutes of Health, Bethesda, Maryland, USA
| | - Parag Kumar
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy, National Institutes of Health, Bethesda, Maryland, USA
| | - Scott Penzak
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy, National Institutes of Health, Bethesda, Maryland, USA
| | - Colleen Hadigan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jomy M George
- Clinical Pharmacokinetics Research Unit, Clinical Center Pharmacy, National Institutes of Health, Bethesda, Maryland, USA
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes & Policy, Center for Drug Evaluation & Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
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13
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Zubiaur P, Saiz-Rodríguez M, Ochoa D, Navares-Gómez M, Mejía G, Román M, Koller D, Soria-Chacartegui P, Almenara S, Abad-Santos F. Effect of Sex, Use of Pantoprazole and Polymorphisms in SLC22A1, ABCB1, CES1, CYP3A5 and CYP2D6 on the Pharmacokinetics and Safety of Dabigatran. Adv Ther 2020; 37:3537-3550. [PMID: 32564268 DOI: 10.1007/s12325-020-01414-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Dabigatran is a direct oral anticoagulant (DOAC) used for the treatment of several thrombotic conditions. To date, very few pharmacogenetic studies on dabigatran were published. We aimed to investigate the influence of 59 polymorphisms in 15 genes (including CES1, UGT and CYP that encode enzymes and ABCB1 and SLC that encode transporters), concomitant treatment with pantoprazole and demographic characteristics (including sex or race) on dabigatran pharmacokinetics and safety. METHODS This was a candidate gene pharmacogenetic study. The study population comprised 107 volunteers enrolled in two dabigatran bioequivalence clinical trials; they were genotyped with a ThermoFisher QuantStudio 12K Flex OpenArray instrument. SPSS software v.21 was used for statistical analysis. RESULTS Women showed a higher exposure to dabigatran compared to men. The concomitant treatment with pantoprazole was associated with a decreased exposure to the drug. CYP2D6 poor metabolizers (PMs) were related to lower clearance (Cl/F) (p = 0.049) and a tendency was observed towards higher area under the curve (AUC), maximum concentration (Cmax) and to lower volume of distribution (Vd/F) (p < 0.10). SLC22A1 haplotype was related to pharmacokinetic variability (p < 0.05). The remaining genes (including CYP, UGT1A1 and ABCB1) had no effect on dabigatran pharmacokinetics (p > 0.10). Women showed more adverse drug reactions (ADR) compared to men (0.40 ± 0.68 vs 0.15 ± 0.41 ADR per person, p = 0.03) and SLC22A1 mutant haplotype was related to a lower risk of nausea (p = 0.02). CONCLUSION Sex, concomitant use of pantoprazole and SLC22A1, CYP2D6 and CYP3A5 polymorphism had an effect on dabigatran pharmacokinetics and safety. Previously published pharmacogenetic predictors, namely CES1 or ABCB1 polymorphisms, had no effect on pharmacokinetics and safety. This study is of interest as it increases the scarce pharmacogenetic information on dabigatran.
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14
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Simultaneous Determination of Dabigatran, Rivaroxaban, and Apixaban in Human Plasma by Liquid Chromatography/Tandem Mass Spectrometry. Ther Drug Monit 2020; 42:473-480. [DOI: 10.1097/ftd.0000000000000744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Foerster KI, Hermann S, Mikus G, Haefeli WE. Drug-Drug Interactions with Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 59:967-980. [PMID: 32157630 PMCID: PMC7403169 DOI: 10.1007/s40262-020-00879-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A large body of evidence suggests that not only direct anticoagulant effects but also major bleeding events and stroke prevention depend on plasma concentrations of direct oral anticoagulants (DOACs). Concomitant drugs that cause drug–drug interactions (DDIs) alter DOAC exposure by increasing or decreasing DOAC bioavailability and/or clearance; hence, they might affect the efficacy and safety of DOAC therapy. Patients with renal impairment already receive smaller DOAC maintenance doses because avoidance of elevated DOAC exposure might prevent serious bleeding events. For other causes of increased exposure such as DDIs, management is often less well-defined. Considering that DOAC patients are often older and have multiple co-morbidities, polypharmacy is highly prevalent. However, the effect of multiple drugs on DOAC exposure, and especially the impact of DDIs when concurring with drug–disease interactions as observed in renal impairment, has not been thoroughly elucidated. In order to provide effective and safe anticoagulation with DOACs, understanding the mechanisms and magnitude of DDIs appears relevant. Instead of avoiding drug combinations with DOACs, more DDI trials should be conducted and new strategies such as dose adjustments based on therapeutic drug monitoring should be investigated. However, dose adjustments based on concentration measurements cannot currently be recommended because evidence-based data are missing.
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Affiliation(s)
- Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simon Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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16
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Cerny MA, Kalgutkar AS, Obach RS, Sharma R, Spracklin DK, Walker GS. Effective Application of Metabolite Profiling in Drug Design and Discovery. J Med Chem 2020; 63:6387-6406. [PMID: 32097005 DOI: 10.1021/acs.jmedchem.9b01840] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
At one time, biotransformation was a descriptive activity in pharmaceutical development, viewed simply as structural elucidation of drug metabolites, completed only once compounds entered clinical development. Herein, we present our strategic approach using structural elucidation to enable chemistry design/SAR development. The approach considers four questions that often present themselves to medicinal chemists optimizing their compounds for candidate selection: (1) What are the important clearance mechanisms that mediate the disposition of my molecule? (2) Can metabolic liabilities be modulated in a favorable way? (3) Does my compound undergo bioactivation to a reactive metabolite? (4) Do any of the metabolites possess activity, either on- or off-target? An additional question necessary to support compound development relates to metabolites in safety testing (MIST) and our approach also addresses this question. The value in structural elucidation is derived from its application to better design molecules, guide their clinical development, and underwrite patient safety.
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Affiliation(s)
- Matthew A Cerny
- Medicine Design, Pfizer Worldwide Research, Development and Medical, Eastern Point Road, Groton, Connecticut 06340, United States
| | - Amit S Kalgutkar
- Medicine Design, Pfizer Worldwide Research, Development and Medical, 1 Portland Street, Cambridge Massachusetts 02139, United States
| | - R Scott Obach
- Medicine Design, Pfizer Worldwide Research, Development and Medical, Eastern Point Road, Groton, Connecticut 06340, United States
| | - Raman Sharma
- Medicine Design, Pfizer Worldwide Research, Development and Medical, Eastern Point Road, Groton, Connecticut 06340, United States
| | - Douglas K Spracklin
- Medicine Design, Pfizer Worldwide Research, Development and Medical, Eastern Point Road, Groton, Connecticut 06340, United States
| | - Gregory S Walker
- Medicine Design, Pfizer Worldwide Research, Development and Medical, Eastern Point Road, Groton, Connecticut 06340, United States
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Abstract
BACKGROUND A liquid chromatography-mass spectrometry assay to determine plasma dabigatran concentrations has been available for routine clinical use at our tertiary institutions since 2017. The aim of the study was to describe (1) the use of the assay over time; (2) the indications for testing; and (3) subsequent dabigatran prescribing decisions. METHODS Patients for whom dabigatran concentrations were measured were identified using the laboratory database, and clinical data were extracted from the associated electronic health records. RESULTS There were 233 samples in 24 months. The use of dabigatran increased over time, with a mean (95% confidence interval) increase of +0.5 (0.3-0.7) samples per month. Dabigatran concentrations ranged from <1 to 1060 mcg/L. The main reasons for testing were uncertainty about impact on renal function and drug interactions (39%), to inform prescribing decisions after thromboembolic or bleeding events (21%), and for investigation following dose-adjustment (16%). Dabigatran dose was changed after 30% (68/233) of assay results. CONCLUSIONS The clinical use of the dabigatran assay has increased, with almost one-third of results associated with a subsequent change in dabigatran prescribing.
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Kustos SA, Fasinu PS. Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update. MEDICINES 2019; 6:medicines6040103. [PMID: 31618893 PMCID: PMC6963825 DOI: 10.3390/medicines6040103] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
Background: Over the last ten years, a new class of drugs, known as the direct-acting oral anticoagulants (DOACs), have emerged at the forefront of anticoagulation therapy. Like the older generation anticoagulants, DOACs require specific reversal agents in cases of life-threatening bleeding or the need for high-risk surgery. Methods: Published literature was searched, and information extracted to provide an update on DOACS and their reversal agents. Results: The DOACs include the direct thrombin inhibitor—dabigatran, and the factor Xa inhibitors—rivaroxaban, apixaban, edoxaban, and betrixaban. These DOACs all have a rapid onset of action and each has a predictable therapeutic response requiring no monitoring, unlike the older anticoagulants, such as warfarin. Two reversal agents have been approved within the last five years: idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban and apixaban. Additionally, ciraparantag, a potential “universal” reversal agent, is currently under clinical development. Conclusions: A new generation of anticoagulants, the DOACs, and their reversal agents, are gaining prominence in clinical practice, having demonstrated superior efficacy and safety profiles. They are poised to replace traditional anticoagulants including warfarin.
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Affiliation(s)
- Stephanie A Kustos
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
| | - Pius S Fasinu
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
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Patel SR. Bioanalytical challenges and strategies for accurately measuring acyl glucuronide metabolites in biological fluids. Biomed Chromatogr 2019; 34:e4640. [DOI: 10.1002/bmc.4640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/13/2019] [Accepted: 06/25/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Shefali R. Patel
- Drug metabolism and pharmacokinetics, Discovery Sciences, Janssen Research and Development Springhouse PA
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Moj D, Maas H, Schaeftlein A, Hanke N, Gómez-Mantilla JD, Lehr T. A Comprehensive Whole-Body Physiologically Based Pharmacokinetic Model of Dabigatran Etexilate, Dabigatran and Dabigatran Glucuronide in Healthy Adults and Renally Impaired Patients. Clin Pharmacokinet 2019; 58:1577-1593. [DOI: 10.1007/s40262-019-00776-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Meech R, Hu DG, McKinnon RA, Mubarokah SN, Haines AZ, Nair PC, Rowland A, Mackenzie PI. The UDP-Glycosyltransferase (UGT) Superfamily: New Members, New Functions, and Novel Paradigms. Physiol Rev 2019; 99:1153-1222. [DOI: 10.1152/physrev.00058.2017] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
UDP-glycosyltransferases (UGTs) catalyze the covalent addition of sugars to a broad range of lipophilic molecules. This biotransformation plays a critical role in elimination of a broad range of exogenous chemicals and by-products of endogenous metabolism, and also controls the levels and distribution of many endogenous signaling molecules. In mammals, the superfamily comprises four families: UGT1, UGT2, UGT3, and UGT8. UGT1 and UGT2 enzymes have important roles in pharmacology and toxicology including contributing to interindividual differences in drug disposition as well as to cancer risk. These UGTs are highly expressed in organs of detoxification (e.g., liver, kidney, intestine) and can be induced by pathways that sense demand for detoxification and for modulation of endobiotic signaling molecules. The functions of the UGT3 and UGT8 family enzymes have only been characterized relatively recently; these enzymes show different UDP-sugar preferences to that of UGT1 and UGT2 enzymes, and to date, their contributions to drug metabolism appear to be relatively minor. This review summarizes and provides critical analysis of the current state of research into all four families of UGT enzymes. Key areas discussed include the roles of UGTs in drug metabolism, cancer risk, and regulation of signaling, as well as the transcriptional and posttranscriptional control of UGT expression and function. The latter part of this review provides an in-depth analysis of the known and predicted functions of UGT3 and UGT8 enzymes, focused on their likely roles in modulation of levels of endogenous signaling pathways.
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Affiliation(s)
- Robyn Meech
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Dong Gui Hu
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ross A. McKinnon
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Siti Nurul Mubarokah
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Alex Z. Haines
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Pramod C. Nair
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Andrew Rowland
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Peter I. Mackenzie
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Lee KC, Hsu WF, Hsieh YC, Chan CC, Yang YY, Huang YH, Hou MC, Lin HC. Dabigatran Reduces Liver Fibrosis in Thioacetamide-Injured Rats. Dig Dis Sci 2019; 64:102-112. [PMID: 30288660 DOI: 10.1007/s10620-018-5311-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 09/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Liver fibrosis can progress to cirrhosis, hepatocellular carcinoma, or liver failure. Unfortunately, the antifibrotic agents are limited. Thrombin activates hepatic stellate cells (HSCs). Therefore, we investigated the effects of a direct thrombin inhibitor, dabigatran, on liver fibrosis. METHODS Adult male Sprague-Dawley rats were injected intraperitoneally with thioacetamide (TAA, 200 mg/kg twice per week) for 8 or 12 weeks to induce liver fibrosis. The injured rats were assigned an oral gavage of dabigatran etexilate (30 mg/kg/day) or vehicle in the last 4 weeks of TAA administration. Rats receiving an injection of normal saline and subsequent oral gavage of dabigatran etexilate or vehicle served as controls. RESULTS In the 8-week TAA-injured rats, dabigatran ameliorated fibrosis, fibrin deposition, and phosphorylated ERK1/2 in liver, without altering the transcript expression of thrombin receptor protease-activated receptor-1. In vitro, dabigatran inhibited thrombin-induced HSC activation. Furthermore, dabigatran reduced intrahepatic angiogenesis and portal hypertension in TAA-injured rats. Similarly, in the 12-week TAA-injured rats, a 4-week treatment with dabigatran reduced liver fibrosis and portal hypertension. CONCLUSIONS By inhibiting thrombin action, dabigatran reduced liver fibrosis and intrahepatic angiogenesis. Dabigatran may be a promising therapeutic agent for treatment of liver fibrosis.
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Affiliation(s)
- Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Fan Hsu
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Hepato-Gastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yun-Cheng Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Che-Chang Chan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ying-Ying Yang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan.,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, #201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. .,Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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23
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He C, Wan H. Drug metabolism and metabolite safety assessment in drug discovery and development. Expert Opin Drug Metab Toxicol 2018; 14:1071-1085. [DOI: 10.1080/17425255.2018.1519546] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Chunyong He
- Department of DMPK/Tox, Shanghai Hengrui Pharmaceutical Co., Ltd., Shanghai, P. R. China
| | - Hong Wan
- Department of DMPK/Tox, Shanghai Hengrui Pharmaceutical Co., Ltd., Shanghai, P. R. China
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24
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Padrini R. Clinical Pharmacokinetics and Pharmacodynamics of Direct Oral Anticoagulants in Patients with Renal Failure. Eur J Drug Metab Pharmacokinet 2018; 44:1-12. [DOI: 10.1007/s13318-018-0501-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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25
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Ryder TF, Calabrese MF, Walker GS, Cameron KO, Reyes AR, Borzilleri KA, Delmore J, Miller R, Kurumbail RG, Ward J, Kung DW, Brown JA, Edmonds DJ, Eng H, Wolford AC, Kalgutkar AS. Acyl Glucuronide Metabolites of 6-Chloro-5-[4-(1-hydroxycyclobutyl)phenyl]-1 H-indole-3-carboxylic Acid (PF-06409577) and Related Indole-3-carboxylic Acid Derivatives are Direct Activators of Adenosine Monophosphate-Activated Protein Kinase (AMPK). J Med Chem 2018; 61:7273-7288. [PMID: 30036059 DOI: 10.1021/acs.jmedchem.8b00807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Studies on indole-3-carboxylic acid derivatives as direct activators of human adenosine monophosphate-activated protein kinase (AMPK) α1β1γ1 isoform have culminated in the identification of PF-06409577 (1), PF-06885249 (2), and PF-06679142 (3) as potential clinical candidates. Compounds 1-3 are primarily cleared in animals and humans via glucuronidation. Herein, we describe the biosynthetic preparation, purification, and structural characterization of the glucuronide conjugates of 1-3. Spectral characterization of the purified glucuronides M1, M2, and M3 indicated that they were acyl glucuronide derivatives. In vitro pharmacological evaluation revealed that all three acyl glucuronides retained selective activation of β1-containing AMPK isoforms. Inhibition of de novo lipogenesis with representative parent carboxylic acids and their respective acyl glucuronide conjugates in human hepatocytes demonstrated their propensity to activate cellular AMPK. Cocrystallization of the AMPK α1β1γ1 isoform with 1-3 and M1-M3 provided molecular insights into the structural basis for AMPK activation by the glucuronide conjugates.
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Affiliation(s)
- Tim F Ryder
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Matthew F Calabrese
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Gregory S Walker
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | | | - Kris A Borzilleri
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | | | - Ravi G Kurumbail
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | - Daniel W Kung
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Janice A Brown
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | - Heather Eng
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Angela C Wolford
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
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26
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Burchell SR, Tang J, Zhang JH. Hematoma Expansion Following Intracerebral Hemorrhage: Mechanisms Targeting the Coagulation Cascade and Platelet Activation. Curr Drug Targets 2018; 18:1329-1344. [PMID: 28378693 DOI: 10.2174/1389450118666170329152305] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/20/2016] [Accepted: 03/14/2017] [Indexed: 01/04/2023]
Abstract
Hematoma expansion (HE), defined as a greater than 33% increase in intracerebral hemorrhage (ICH) volume within the first 24 hours, results in significant neurological deficits, and enhancement of ICH-induced primary and secondary brain injury. An escalation in the use of oral anticoagulants has led to a surge in the incidences of oral anticoagulation-associated ICH (OAT-ICH), which has been associated with a greater risk for HE and worse functional outcomes following ICH. The oral anticoagulants in use include vitamin K antagonists, and direct thrombin and factor Xa inhibitors. Fibrinolytic agents are also frequently administered. These all act via differing mechanisms and thus have varying degrees of impact on HE and ICH outcome. Additionally, antiplatelet medications have also been increasingly prescribed, and result in increased bleeding risks and worse outcomes after ICH. Aspirin, thienopyridines, and GPIIb/IIIa receptor blockers are some of the most common agents in use clinically, and also have different effects on ICH and hemorrhage growth, based on their mechanisms of action. Recent studies have found that reduced platelet activity may be more effective in predicting ICH risk, hemorrhage expansion, and outcomes, than antiplatelet agents, and activating platelets may thus be a novel target for ICH therapy. This review explores how dysfunctions or alterations in the coagulation and platelet cascades can lead to, and/or exacerbate, hematoma expansion following intracerebral hemorrhage, and describe the mechanisms behind these effects and the drugs that induce them. We also discuss potential future therapy aimed at increasing platelet activity after ICH.
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Affiliation(s)
- Sherrefa R Burchell
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology, Loma Linda University School of Medicine, Loma Linda CA, USA.,Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda CA, USA
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27
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Havig SM, Lea D, Krpo M, Skari RM, Gustavsen I, Høiseth G. Fatal Adverse Event with Dabigatran in Elderly Patient with Reduced Kidney Function. Basic Clin Pharmacol Toxicol 2018; 123:221-226. [DOI: 10.1111/bcpt.12985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/04/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Stine Marie Havig
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Dordi Lea
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - Maja Krpo
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ragnhild Margrete Skari
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ingebjørg Gustavsen
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Gudrun Høiseth
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Department of Psychopharmacology; Diakonhjemmet Hospital; Oslo Norway
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Yamamura N, Stangier J, Reilly P, Clemens A, Härtter S. Pharmacokinetics and pharmacodynamics in Japanese and Caucasian subjects after oral administration of dabigatran etexilate. Thromb Haemost 2017; 107:260-9. [DOI: 10.1160/th11-08-0551] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/10/2011] [Indexed: 11/05/2022]
Abstract
SummaryEthnic differences in drug disposition may potentially influence therapeutic response to dabigatran, a reversible direct thrombin inhibitor used for the prevention and/or treatment of various thromboembolic disorders. This analysis of data from 18 clinical studies in healthy volunteers and patients with non-valvular atrial fibrillation (AF) or undergoing knee or hip arthroplasty investigated whether there were any clinically relevant differences in the pharmacokinetics and pharmacodynamics of dabigatran, the active form of dabigatran etexilate, between Japanese and Caucasian subjects. In pooled data from 14 phase I trials, total exposure (i.e. area under the plasma concentration-time curve [AUC]) after administration of dabigatran 150 mg once or twice-daily was on average 20% higher in Japanese than Caucasian subjects (median [10th to 90th percentile] 1,110 [644–1,824] vs. 924 [420–1,654] ng·h/ml) although the difference between the groups was not significant. Within-trial comparisons in subjects treated with dabigatran 150 mg twice-daily showed that AUC and maximum plasma concentration differed by less than 10% between the two groups. In patients with AF, trough concentrations after administration of 150 mg twice-daily were similar in Japanese and Caucasian subjects (80.1 [34.5–193.8] vs. 71.0 [34.0–190] ng/ml). Various factors, including body weight and renal clearance, may explain these observed pharmacokinetic differences. The relationship between plasma concentration and coagulation markers was similar and indicative of no difference in the exposure-pharmacodynamic response between these two groups. In conclusion, the results of this analysis show that the pharmacokinetics and pharmacodynamics of dabigatran are similar in Japanese and Caucasian subjects and suggest that there is no need for dose adjustment of dabigatran in Japanese subjects.
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30
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Hanisch S, Paulke A, Toennes SW. 11-nor-9-carboxy-Δ 9 -tetrahydrocannabinol glucuronide exhibits acyl-migration isomers. J Pharm Biomed Anal 2017; 146:261-265. [DOI: 10.1016/j.jpba.2017.08.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/26/2017] [Accepted: 08/28/2017] [Indexed: 12/24/2022]
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31
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Camilleri P, Buch A, Soldo B, Hutt AJ. The influence of physicochemical properties on the reactivity and stability of acyl glucuronides. Xenobiotica 2017; 48:958-972. [DOI: 10.1080/00498254.2017.1384967] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Akshay Buch
- Aerpio Therapeutics, Inc., Cincinnati, OH, USA, and
| | - Brandi Soldo
- Aerpio Therapeutics, Inc., Cincinnati, OH, USA, and
| | - Andrew J. Hutt
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, College Lane, Hatfield, UK
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O'connor CT, Kiernan TJ, Yan BP. The genetic basis of antiplatelet and anticoagulant therapy: A pharmacogenetic review of newer antiplatelets (clopidogrel, prasugrel and ticagrelor) and anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban). Expert Opin Drug Metab Toxicol 2017; 13:725-739. [PMID: 28571507 DOI: 10.1080/17425255.2017.1338274] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The study of pharmacogenomics presents the possibility of individualised optimisation of drug therapy tailored to each patients' unique physiological traits. Both antiplatelet and anticoagulant drugs play a key role in the management of cardiovascular disease. Despite their importance, there is a substantial volume of literature to suggest marked person-to-person variability in their effect. Areas covered: This article reviews the data available for the genetic cause for this inter-patient variability of antiplatelet and anticoagulant drugs. The genetic basis for traditional antiplatelets (i.e. aspirin) is compared with the newly available antiplatelet medicines (clopidogrel, prasugrel and ticagrelor). Similarly, the pharmacogenetics of warfarin is compared with the newer direct oral anticoagulants (DOACs) in detail. Expert Opinion: We identify strengths and weaknesses in the research thus far; including shortcomings in trial design and a review of newer analytical techniques. The direction of this research and its real-world implications are discussed.
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Affiliation(s)
- Cormac T O'connor
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Thomas J Kiernan
- a Cardiology Department , University Hospital Limerick , Limerick , Ireland
| | - Bryan P Yan
- b Division of Cardiology, Department of Medicine and Therapeutics , The Chinese University of Hong Kong, Prince of Wales Hospital , Hong Kong SAR , China
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Pearson D, Weiss HM, Jin Y, Jaap van Lier J, Erpenbeck VJ, Glaenzel U, End P, Woessner R, Eggimann F, Camenisch G. Absorption, Distribution, Metabolism, and Excretion of the Oral Prostaglandin D2 Receptor 2 Antagonist Fevipiprant (QAW039) in Healthy Volunteers and In Vitro. Drug Metab Dispos 2017; 45:817-825. [PMID: 28442499 DOI: 10.1124/dmd.117.075358] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/20/2017] [Indexed: 11/22/2022] Open
Abstract
Fevipiprant is a novel oral prostaglandin D2 receptor 2 (DP2; also known as CRTh2) antagonist, which is currently in development for the treatment of severe asthma and atopic dermatitis. We investigated the absorption, distribution, metabolism, and excretion properties of fevipiprant in healthy subjects after a single 200-mg oral dose of [14C]-radiolabeled fevipiprant. Fevipiprant and metabolites were analyzed by liquid chromatography coupled to tandem mass spectrometry and radioactivity measurements, and mechanistic in vitro studies were performed to investigate clearance pathways and covalent plasma protein binding. Biotransformation of fevipiprant involved predominantly an inactive acyl glucuronide (AG) metabolite, which was detected in plasma and excreta, representing 28% of excreted drug-related material. The AG metabolite was found to covalently bind to human plasma proteins, likely albumin; however, in vitro covalent binding to liver protein was negligible. Excretion was predominantly as unchanged fevipiprant in urine and feces, indicating clearance by renal and possibly biliary excretion. Fevipiprant was found to be a substrate of transporters organic anion transporter 3 (OAT3; renal uptake), multidrug resistance gene 1 (MDR1; possible biliary excretion), and organic anion-transporting polypeptide 1B3 (OATP1B3; hepatic uptake). Elimination of fevipiprant occurs via glucuronidation by several uridine 5'-diphospho glucuronosyltransferase (UGT) enzymes as well as direct excretion. These parallel elimination pathways result in a low risk of major drug-drug interactions or pharmacogenetic/ethnic variability for this compound.
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Affiliation(s)
- David Pearson
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - H Markus Weiss
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Yi Jin
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Jan Jaap van Lier
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Veit J Erpenbeck
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Ulrike Glaenzel
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Peter End
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Ralph Woessner
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Fabian Eggimann
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
| | - Gian Camenisch
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, Basel, Switzerland (D.P., H.M.W., Y.J., V.J.E., U.G., P.E., R.W., F.E., G.C.); PRA International, Early Development Services, Zuidlaren, the Netherlands (J.J.v.L.)
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Boonen K, Schmitz E, Rozestraten F, van den Heuvel D, Brunsveld L, van der Voort P, van de Kerkhof D. Real life dabigatran and metabolite concentrations, focused on inter-patient variability and assay differences in patients with atrial fibrillation. ACTA ACUST UNITED AC 2017; 55:2002-2009. [DOI: 10.1515/cclm-2016-0681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/06/2017] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Dabigatran is prescribed to increasing numbers of patients with atrial fibrillation (AF). Although routine monitoring is not considered to be useful, measuring drug concentrations can be clinically relevant in specific situations. The aim of this study was the comparison of different functional and non-functional assays for determination of dabigatran concentrations at different timepoints in a real-life patient population with AF. We focused on the differences between assays in identifying patients with low drug concentrations. Furthermore, we studied the effect of glucuronidation on the established concentration as determined with different assays.Methods:This study established dabigatran concentration ranges in 40 real-life AF patients by an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) reference method and compared these with results from coagulation assays (Hemoclot dTT, LD-dTT and ECA). Samples were taken just before and 2 and 4 h after taking the drug.Results:A wide range of concentrations at different time points was found in this patient group. Coagulation assays correlate best with UPLC-MS/MS results that include the glucuronidated metabolites, showing that the pharmacologically active glucuronides are also measured in coagulation testing. The LD-dTT has the best agreement with UPLC-MS/MS and combines good sensitivity with high specificity. Several patients show consistently low or high drug concentrations, implying that drug exposure differs between patients.Conclusions:Based on the association of dabigatran concentrations with bleeding and thromboembolic risk, we believe that dabigatran monitoring could be beneficial for further optimizing anticoagulation therapy in AF.
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Dosage Adjustment of Dabigatran Etexilate Based on Creatinine Clearance in Patients With Cardioembolic Stroke or Atrial Fibrillation. Ther Drug Monit 2016; 38:670-676. [DOI: 10.1097/ftd.0000000000000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chai F, Sun L, Ding Y, Liu X, Zhang Y, Webster TJ, Zheng C. A solid self-nanoemulsifying system of the BCS class IIb drug dabigatran etexilate to improve oral bioavailability. Nanomedicine (Lond) 2016; 11:1801-16. [DOI: 10.2217/nnm-2016-0138] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To develop dabigatran etexilate (DE)-loaded self-nanoemulsifying drug delivery systems (SNEDDS) for the prevention of stroke and thromboembolism. Materials & methods: SNEDDS were optimized by ternary phase diagrams and then further solidified into dispersible tablets. In vitro dissolution was analyzed by a phase distribution study. In situ absorption and in vivo pharmacokinetic studies were tested in male Sprague-Dawley rats. Results: The phase distribution study showed that more than 60% of DE was retained in the oil phase. Dissolution rate was dramatically enhanced without significant precipitation (<30%) in simulated intestinal fluid. Optimized SNEDDS had 531.80% relative bioavailability compared with Pradaxa® capsules (a commercial DE product). Conclusion: The developed SNEDDS are promising materials for improving the dissolution and oral bioavailability of BCS class IIb drugs.
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Affiliation(s)
- Fujuan Chai
- Pharmaceutical Research Institute, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Linlin Sun
- Wenzhou Institute of Biomaterials & Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, 325001, China
- Department of Chemical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Yafei Ding
- Jiangsu Hengrui Medicine Co., Ltd., 7 Kunshan Road, Lianyungang 222047, China
| | - Xiaoqing Liu
- Pharmacy Department, Shanghai Pudong New District Zhoupu Hospital, 1500 Zhouyuan Road, Pudong New District, Shanghai, China
| | - Yajie Zhang
- Pharmaceutical Research Institute, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Thomas J Webster
- Wenzhou Institute of Biomaterials & Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, 325001, China
- Department of Chemical Engineering, Northeastern University, Boston, MA 02115, USA
- Center of Excellence for Advanced Materials Research, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Chunli Zheng
- Pharmaceutical Research Institute, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
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Latli B, Kiesling R, Aßfalg S, Chevliakov M, Hrapchak M, Campbell S, Gonnella N, Busacca CA, Senanayake CH. Carbon-13 and carbon-14 labeled dabigatran etexilate and tritium labeled dabigatran. J Labelled Comp Radiopharm 2016; 59:648-656. [PMID: 27146196 DOI: 10.1002/jlcr.3402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 03/08/2016] [Accepted: 03/28/2016] [Indexed: 01/10/2023]
Abstract
Dabigatran etexilate or pradaxa, a novel oral anticoagulant, is a reversible, competitive, direct thrombin inhibitor. It is used to prevent strokes in patients with atrial fibrillation and the formation of blood clots in the veins (deep venous thrombosis) in adults who have had an operation to replace a hip or a knee. Pradaxa is the only novel oral anticoagulant available with both proven superiority to warfarin and a specific reversal agent for use in rare emergency situations. The detailed description of the synthesis of carbon-13 and carbon-14 labeled dabigatran etexilate, and tritium labeled dabigatran is described. The synthesis of carbon-13 dabigatran etexilate was accomplished in eight steps and in 6% overall yield starting from aniline-13 C6 . Ethyl bromoacetate-1-14 C was the reagent of choice in the synthesis of carbon-14 labeled dabigatran etexilate in six steps and 17% overall yield. Tritium labeled dabigatran was prepared using either direct tritium incorporation under Crabtree's catalytic conditions or tritium-dehalogenation of a diiodo-precursor of dabigatran.
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Affiliation(s)
- Bachir Latli
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Ralf Kiesling
- DMPK, Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Strasse 65, D-88397, Biberach, Germany
| | - Stefan Aßfalg
- DMPK, Boehringer Ingelheim Pharma GmbH & Co. KG, Birkendorfer Strasse 65, D-88397, Biberach, Germany
| | - Max Chevliakov
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Matt Hrapchak
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Scot Campbell
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Nina Gonnella
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Carl A Busacca
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
| | - Chris H Senanayake
- Chemical Development, Boehringer Ingelheim Pharmaceuticals, Inc., 900 Ridgebury Road, P.O. Box 368, Ridgefield, CT, 06877-0368, USA
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Brunetti L, Sanchez-Catanese B, Kagan L, Wen X, Liu M, Buckley B, Luyendyk JP, Aleksunes LM. Evaluation of the chromogenic anti-factor IIa assay to assess dabigatran exposure in geriatric patients with atrial fibrillation in an outpatient setting. Thromb J 2016; 14:10. [PMID: 27158246 PMCID: PMC4858862 DOI: 10.1186/s12959-016-0084-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 04/22/2016] [Indexed: 01/08/2023] Open
Abstract
Background Dabigatran etexilate may be underutilized in geriatric patients because of inadequate clinical experience in individuals with severe renal impairment and post-marketing reports of bleeding events. Assessing the degree of anticoagulation may improve the risk:benefit ratio for dabigatran. The aim of this prospective study was to identify whether therapeutic drug monitoring of dabigatran anticoagulant activity using a chromogenic anti-factor IIa assay is a viable option for therapy individualization. Methods Plasma dabigatran concentration was assessed in nine patients with nonvalvular atrial fibrillation aged 75 years or older currently receiving dabigatran etexilate for prevention of stroke, using an anti-factor IIa chromogenic assay and HPLC-MS/MS. Trough concentrations were evaluated on two separate occasions to determine intrapatient variation. Results Blood was collected at 13.1 ± 2.3 h (mean ± SD) post dose from patients prescribed dabigatran etexilate 150 mg twice daily (5/9 patients) or dabigatran etexilate 75 mg twice daily (4/9 patients). Results from the anti-factor IIa chromogenic assay correlated with dabigatran concentrations as assessed by HPLC-MS/MS (r2 = 0.81, n = 16). There was no correlation between dabigatran trough values taken at separate visits (r2 = 0.002, n = 7). Furthermore, there was no correlation found between the drug concentrations and patients’ renal function determined by both creatinine and cystatin-C based equations. None of the patients enrolled in the study were in the proposed on-therapy trough range during at least one visit. Conclusion The chromogenic anti-factor IIa assay demonstrated similar performance in quantifying dabigatran plasma trough concentrations to HPLC-MS/MS. Single measurement of dabigatran concentration by either of two methods during routine visits may not be reliable in identifying patients at consistently low or high dabigatran concentrations. Electronic supplementary material The online version of this article (doi:10.1186/s12959-016-0084-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, USA
| | - Betty Sanchez-Catanese
- Department of Medicine, Robert Wood Johnson University Hospital-Somerset, Somerville, USA
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, USA
| | - Xia Wen
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, USA
| | - Min Liu
- Chemical Analytical Core Laboratory, Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey, Piscataway, USA
| | - Brian Buckley
- Chemical Analytical Core Laboratory, Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey, Piscataway, USA
| | - James P Luyendyk
- Pathology and Diagnostic Inv., Michigan State University, East Lansing, USA
| | - Lauren M Aleksunes
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, USA
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Awad NI, Brunetti L, Juurlink DN. Enhanced elimination of dabigatran through extracorporeal methods. J Med Toxicol 2015; 11:85-95. [PMID: 25448250 DOI: 10.1007/s13181-014-0448-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Several pharmacokinetic studies have suggested that dabigatran possesses a number of ideal properties for expedited removal via extracorporeal methods. However, this practice has not been prospectively evaluated in patients with life-threatening bleeding or requiring emergency surgery secondary to dabigatran-associated coagulopathy. The purpose of this literature review is to evaluate the published evidence surrounding extracorporeal removal of dabigatran in the setting of emergency surgery or life-threatening bleeding. A query of MEDLINE, Web of Science, International Pharmaceutical Abstracts, and Google Scholar using the terms dabigatran, dabigatran etexilate, hemodialysis, renal replacement therapy, hemorrhage, and atrial fibrillation was used to retrieve relevant literature. Furthermore, a manual search of the references of the identified literature was performed to capture additional data. Current evidence suggests that extracorporeal removal of dabigatran may play a role in the setting of life-threatening bleeding and emergent surgery. Conflicting evidence exists with regard to the potential for redistribution based on serum dabigatran concentrations. In addition, a number of practicalities must be considered before incorporating this technique in the clinical setting. Extracorporeal removal of dabigatran may be a treatment modality in selected patients who require emergency reversal.
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Affiliation(s)
- Nadia I Awad
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Room 423, Piscataway, NJ, USA,
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Zhong S, Jones R, Lu W, Schadt S, Ottaviani G. A New Rapid In Vitro Assay for Assessing Reactivity of Acyl Glucuronides. Drug Metab Dispos 2015; 43:1711-7. [DOI: 10.1124/dmd.115.066159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/12/2015] [Indexed: 01/31/2023] Open
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Chin PKL, Wright DFB, Patterson DM, Doogue MP, Begg EJ. A proposal for dose-adjustment of dabigatran etexilate in atrial fibrillation guided by thrombin time. Br J Clin Pharmacol 2015; 78:599-609. [PMID: 24592851 DOI: 10.1111/bcp.12364] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/21/2013] [Indexed: 12/30/2022] Open
Abstract
Dabigatran is an oral anticoagulant that is increasingly used for atrial fibrillation (AF). Presently, many authorities state that routine laboratory coagulation monitoring is not required. However, data have recently been published demonstrating that higher trough plasma dabigatran concentrations are associated with lower thromboembolic and higher haemorrhagic event rates. Using these data, we simulate a range of AF patients with varying risks for these events and derive a target range of trough plasma dabigatran concentrations (30-130 μg l(-1) ). Finally, we propose that a conventional screening coagulation assay, the thrombin time (TT), can be used to discern whether or not patients are within this range of dabigatran concentrations.
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Affiliation(s)
- Paul K L Chin
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
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Chin PKL, Patterson DM, Zhang M, Jensen BP, Wright DFB, Barclay ML, Begg EJ. Coagulation assays and plasma fibrinogen concentrations in real-world patients with atrial fibrillation treated with dabigatran. Br J Clin Pharmacol 2015; 78:630-8. [PMID: 24592919 DOI: 10.1111/bcp.12366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 02/26/2014] [Indexed: 11/29/2022] Open
Abstract
AIMS In patients with atrial fibrillation prescribed dabigatran, the aim was to examine the correlation between plasma dabigatran concentrations and the three screening coagulation assays [international normalized ratio (INR), activated partial thromboplastin time (aPTT) and thrombin time (TT)] as well as the dilute thrombin time (dTT) and to examine the contribution of plasma fibrinogen concentrations to the variability in TT results. METHODS Plasma from patients with atrial fibrillation on dabigatran were analysed for clotting times and concentrations of fibrinogen and dabigatran. Correlation plots (and associated r(2) values) were generated using these data. The variability in TT results explained by fibrinogen concentrations was quantified using linear regression. RESULTS Fifty-two patients (38-94 years old) contributed 120 samples, with plasma dabigatran concentrations ranging from 9 to 408 μg l(-1) . The r(2) values of INR, aPTT, TT and dTT against plasma dabigatran concentrations were 0.49, 0.54, 0.70 and 0.95, respectively. Plasma fibrinogen concentrations explained some of the residual variability in TT values after taking plasma dabigatran concentrations into account (r(2) = 0.12, P = 0.02). CONCLUSIONS Of the screening coagulation assays, the TT correlated best with plasma dabigatran concentrations. Variability in fibrinogen concentrations accounts for some of the variability in the TT.
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Affiliation(s)
- Paul K L Chin
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand; Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
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Quantification of dabigatran and indirect quantification of dabigatran acylglucuronides in human plasma by LC–MS/MS. Bioanalysis 2015; 7:957-66. [DOI: 10.4155/bio.15.32] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: An assay for the quantification of dabigatran and its active metabolites, dabigatran acylglucuronides, has not previously been described in detail. Results: For the quantification of total dabigatran concentration (free dabigatran and acylglucuronides), samples were subjected to alkaline hydrolysis. For the quantification of free dabigatran, samples were acidified with ammonium formate. Following acetonitrile protein precipitation, the samples were analyzed by LC–MS/MS using gradient elution to ensure separation of dabigatran from dabigatran acylglucuronides. Mean recoveries ≥98% were achieved. The assay was validated over the range 2.5–1000 ng/ml dabigatran, imprecision was <9% CV (<15% at LLOQ) and accuracy was 101–114%. Conclusion: An assay for dabigatran with indirect quantification of dabigatran acylglucuronides in plasma was developed, validated and applied.
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Nouman EG, Al-Ghobashy MA, Lotfy HM. Development and validation of LC–MSMS assay for the determination of the prodrug dabigatran etexilate and its active metabolites in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2015; 989:37-45. [DOI: 10.1016/j.jchromb.2015.02.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 12/14/2022]
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Chin PKL, Wright DFB, Zhang M, Wallace MC, Roberts RL, Patterson DM, Jensen BP, Barclay ML, Begg EJ. Correlation between trough plasma dabigatran concentrations and estimates of glomerular filtration rate based on creatinine and cystatin C. Drugs R D 2015; 14:113-23. [PMID: 24797400 PMCID: PMC4070467 DOI: 10.1007/s40268-014-0045-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIMS Dabigatran is largely cleared by renal excretion. Renal function is thus a major determinant of trough dabigatran concentrations, which correlate with the risk of thromboembolic and haemorrhagic outcomes. Current dabigatran dosing guidelines use the Cockcroft-Gault (CG) equation to gauge renal function, instead of contemporary equations including the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations employing creatinine (CKD-EPI_Cr), cystatin C (CKD-EPI_Cys) and both renal biomarkers (CKD-EPI_CrCys). METHODS A linear regression model including the dabigatran etexilate maintenance dose rate, relevant interacting drugs and genetic polymorphisms (including CES1), was used to analyse the relationship between the values from each renal function equation and trough steady-state plasma dabigatran concentrations. RESULTS The median dose-corrected trough steady-state plasma dabigatran concentration in 52 patients (38-94 years) taking dabigatran etexilate was 60 µg/L (range 9-279). The dose-corrected trough concentration in a patient on phenytoin and phenobarbitone was >3 standard deviations below the cohort mean. The CG, CKD-EPI_Cr, CKD-EPI_Cys and CKD-EPI_CrCys equations explained (R (2), 95 % CI) 32 % (9-55), 37 % (12-60), 41 % (16-64) and 47 % (20-69) of the variability in dabigatran concentrations between patients, respectively. One-way analysis of variance (ANOVA) comparing the R (2) values for each equation was not statistically significant (p = 0.74). DISCUSSION Estimates of renal function using the four equations accounted for 32-47 % of the variability in dabigatran concentrations between patients. We are the first to provide evidence that co-administration of phenytoin/phenobarbitone with dabigatran etexilate is associated with significantly reduced dabigatran exposure.
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Affiliation(s)
- Paul K L Chin
- Department of Clinical Pharmacology, Christchurch Hospital, 2 Riccarton Avenue, Christchurch, 8011, New Zealand,
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Schmohl M, Gansser D, Moschetti V, Stangier J. Measurement of dabigatran plasma concentrations by calibrated thrombin clotting time in comparison to LC-MS/MS in human volunteers on dialysis. Thromb Res 2015; 135:532-6. [PMID: 25600440 DOI: 10.1016/j.thromres.2014.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/05/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Dabigatran etexilate is an oral direct thrombin inhibitor. Although routine anticoagulation monitoring with dabigatran is not usually required, a simple and precise laboratory test to measure dabigatran concentrations in patient plasma may be useful in certain clinical circumstances, such as emergency situations. The HEMOCLOT(®) Thrombin Inhibitors assay has demonstrated accurate and precise determination of dabigatran concentrations within a range of 50-500 ng/ml. The objective of this study was to assess comparability of dabigatran concentrations determined by HEMOCLOT(®) and by liquid chromatography/tandem mass spectrometry (LC-MS/MS) in plasma samples from human volunteers with end-stage renal disease (ESRD) undergoing regular haemodialysis (HD) during a Phase I study. MATERIALS AND METHODS Overall, 304 plasma samples were obtained from seven ESRD patients in dabigatran steady-state for measurement by HEMOCLOT(®) (calibrated diluted thrombin time [dTT]) and by LC-MS/MS. Agreement of dabigatran concentrations was assessed by regression analysis and difference plots. RESULTS The measurements of calibration standards of the HEMOCLOT(®) assay showed excellent precision with coefficients of variation <5%. Accuracy determined by analysis of two quality control samples was 90% and 111%. HEMOCLOT(®)-derived dabigatran plasma concentrations paralleled those obtained by LC-MS/MS. The mean ratio of the LC-MS/MS and dTT-derived concentrations was 0.955 (67% limits of agreement: 0.771-1.18). CONCLUSIONS The HEMOCLOT(®) Thrombin Inhibitors assay is suitable for measuring dabigatran plasma concentrations in volunteers with ESRD undergoing haemodialysis. The agreement between dabigatran concentrations determined by the HEMOCLOT(®) assay and the LC-MS/MS reference method met bioanalytical acceptance criteria.
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Affiliation(s)
- Michael Schmohl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Dietmar Gansser
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
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Hu DG, Meech R, McKinnon RA, Mackenzie PI. Transcriptional regulation of human UDP-glucuronosyltransferase genes. Drug Metab Rev 2014; 46:421-58. [PMID: 25336387 DOI: 10.3109/03602532.2014.973037] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Glucuronidation is an important metabolic pathway for many small endogenous and exogenous lipophilic compounds, including bilirubin, steroid hormones, bile acids, carcinogens and therapeutic drugs. Glucuronidation is primarily catalyzed by the UDP-glucuronosyltransferase (UGT) 1A and two subfamilies, including nine functional UGT1A enzymes (1A1, 1A3-1A10) and 10 functional UGT2 enzymes (2A1, 2A2, 2A3, 2B4, 2B7, 2B10, 2B11, 2B15, 2B17 and 2B28). Most UGTs are expressed in the liver and this expression relates to the major role of hepatic glucuronidation in systemic clearance of toxic lipophilic compounds. Hepatic glucuronidation activity protects the body from chemical insults and governs the therapeutic efficacy of drugs that are inactivated by UGTs. UGT mRNAs have also been detected in over 20 extrahepatic tissues with a unique complement of UGT mRNAs seen in almost every tissue. This extrahepatic glucuronidation activity helps to maintain homeostasis and hence regulates biological activity of endogenous molecules that are primarily inactivated by UGTs. Deciphering the molecular mechanisms underlying tissue-specific UGT expression has been the subject of a large number of studies over the last two decades. These studies have shown that the constitutive and inducible expression of UGTs is primarily regulated by tissue-specific and ligand-activated transcription factors (TFs) via their binding to cis-regulatory elements (CREs) in UGT promoters and enhancers. This review first briefly summarizes published UGT gene transcriptional studies and the experimental models and tools utilized in these studies, and then describes in detail the TFs and their respective CREs that have been identified in the promoters and/or enhancers of individual UGT genes.
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Affiliation(s)
- Dong Gui Hu
- Department of Clinical Pharmacology and Flinders Centre for Innovation in Cancer, Flinders University School of Medicine, Flinders Medical Centre , Bedford Park, SA , Australia
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Measurement of the Direct Oral Anticoagulants Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in Human Plasma Using Turbulent Flow Liquid Chromatography With High-Resolution Mass Spectrometry. Ther Drug Monit 2014; 36:597-605. [DOI: 10.1097/ftd.0000000000000059] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Wilson JAS, Goralski KB, Soroka SD, Morrison M, Mossop P, Sleno L, Wang Y, Anderson DR. An evaluation of oral dabigatran etexilate pharmacokinetics and pharmacodynamics in hemodialysis. J Clin Pharmacol 2014; 54:901-9. [PMID: 24846496 DOI: 10.1002/jcph.335] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/20/2014] [Indexed: 11/10/2022]
Abstract
Dabigatran etexilate represents a possible improved alternative to warfarin for anticoagulation in hemodialysis patients with atrial fibrillation (AF). The objective was to determine dabigatran plasma concentrations and anticoagulant effects following administration of a single 110 mg oral dose of dabigatran etexilate to 10 adult patients immediately prior to starting hemodialysis. Mass spectrometry and the Hemoclot® assay were used, respectively, to determine free (unconjugated) dabigatran concentrations and thrombin time (TT) in plasma samples collected intermittently over 48 hours. The median time (tmax ) to reach the maximum plasma-free dabigatran concentration (Cmax ) was 2 hours (range 1-3 hours). The mean free dabigatran Cmax was 95.5 ± 33.4 ng/mL. The mean elimination half-lives on and off hemodialysis were, respectively, 2.6 ± 1.3 and 30.2 ± 7.8 hours. Hemodialysis effectively removed dabigatran with an extraction ratio of 0.63 ± 0.07. The maximal TT ratio was 2.1 and the TT ratio demonstrated a strong linear dependence on free dabigatran concentration (r(2) = 0.741). A 110 mg oral dabigatran dose prior to hemodialysis was rapidly absorbed and achieved therapeutic concentrations. Hemodialysis effectively removed dabigatran from the plasma and may be an effective means of accelerating the elimination of dabigatran in circumstances of excessive anticoagulation.
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Affiliation(s)
- Jo-Anne S Wilson
- College of Pharmacy, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Nephrology, Department of Medicine, Capital District Health Authority, Halifax, Nova Scotia, Canada
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Strunets A, Mirza M, Sra J, Jahangir A. Novel anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly. Expert Rev Clin Pharmacol 2014; 6:677-89. [DOI: 10.1586/17512433.2013.842125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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