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van Uden RCAE, Sulaiman B, Pols PAM, Meijer K, van den Bemt PMLA, Becker ML. Antithrombotic Questionnaire Tool for Evaluation of Combined Antithrombotic Therapy in Community Pharmacies. J Patient Saf 2024; 20:404-409. [PMID: 38920416 DOI: 10.1097/pts.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVE The objective of this paper is to assess the diagnostic value of an antithrombotic questionnaire tool compared with the hospital's medical record information tool. The hypothesis of this study was that the antithrombotic questionnaire tool could identify patients with potentially incorrect antithrombotic therapy. METHODS This cross-sectional study was conducted in eight community pharmacies in the Netherlands. A standardized questionnaire was developed as antithrombotic questionnaire tool. The pharmacist assessed whether the antithrombotic therapy was correct or potentially incorrect based on answers given by patients and based on the medical record. The primary outcome of the study was the sensitivity and specificity of the antithrombotic questionnaire tool to identify patients with potentially incorrect antithrombotic therapy. RESULTS For 95 patients, the pharmacist assessed that in 81 (85%) the antithrombotic therapy was correct and in 14 (15%) potentially incorrect. Based on the medical record, 86 patients (91%) were assessed as correct and 9 (9%) as potentially incorrect. The sensitivity of the tool was 100% and the specificity 94%. CONCLUSIONS This study demonstrated that the antithrombotic questionnaire tool is a suitable tool to assess whether the patient's antithrombotic therapy is potentially incorrect. It can be applied to identify patients with potentially incorrect antithrombotic therapy.
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Affiliation(s)
| | - Barzo Sulaiman
- From the Pharmacy Foundation of Haarlem Hospitals, Haarlem, the Netherlands
| | | | - Karina Meijer
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Flora GD, Nayak MK, Ghatge M, Chauhan AK. Metabolic targeting of platelets to combat thrombosis: dawn of a new paradigm? Cardiovasc Res 2023; 119:2497-2507. [PMID: 37706546 PMCID: PMC10676458 DOI: 10.1093/cvr/cvad149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/29/2023] [Accepted: 07/18/2023] [Indexed: 09/15/2023] Open
Abstract
Current antithrombotic therapies used in clinical settings target either the coagulation pathways or platelet activation receptors (P2Y12 or GPIIb/IIIa), as well as the cyclooxygenase (COX) enzyme through aspirin. However, they are associated with bleeding risk and are not suitable for long-term use. Thus, novel strategies which provide broad protection against platelet activation with minimal bleeding risks are required. Regardless of the nature of agonist stimulation, platelet activation is an energy-intensive and ATP-driven process characterized by metabolic switching toward a high rate of aerobic glycolysis, relative to oxidative phosphorylation (OXPHOS). Consequently, there has been considerable interest in recent years in investigating whether targeting metabolic pathways in platelets, especially aerobic glycolysis and OXPHOS, can modulate their activation, thereby preventing thrombosis. This review briefly discusses the choices of metabolic substrates available to platelets that drive their metabolic flexibility. We have comprehensively elucidated the relevance of aerobic glycolysis in facilitating platelet activation and the underlying molecular mechanisms that trigger this switch from OXPHOS. We have provided a detailed account of the antiplatelet effects of targeting vital metabolic checkpoints such as pyruvate dehydrogenase kinases (PDKs) and pyruvate kinase M2 (PKM2) that preferentially drive the pyruvate flux to aerobic glycolysis. Furthermore, we discuss the role of fatty acids and glutamine oxidation in mitochondria and their subsequent role in driving OXPHOS and platelet activation. While the approach of targeting metabolic regulatory mechanisms in platelets to prevent their activation is still in a nascent stage, accumulating evidence highlights its beneficial effects as a potentially novel antithrombotic strategy.
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Affiliation(s)
- Gagan D Flora
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, IA, USA
| | - Manasa K Nayak
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, IA, USA
| | - Madankumar Ghatge
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, IA, USA
| | - Anil K Chauhan
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, IA, USA
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Mathews L, Hu X, Ding N, Ishigami J, Al Rifai M, Hoogeveen RC, Coresh J, Ballantyne CM, Selvin E, Matsushita K. Growth Differentiation Factor 15 and Risk of Bleeding Events: The Atherosclerosis Risk in Communities Study. J Am Heart Assoc 2023; 12:e023847. [PMID: 36927042 PMCID: PMC10111534 DOI: 10.1161/jaha.121.023847] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/05/2023] [Indexed: 03/18/2023]
Abstract
Background GDF15 (growth differentiation factor 15) is a potent predictor of bleeding in people with cardiovascular disease. However, whether GDF15 is associated with bleeding in individuals without a history of cardiovascular disease is unknown. Methods and Results The study population was from the ARIC (Atherosclerosis Risk in Communities) study. We studied the association of GDF15 with hospitalized bleeding events among 9205 participants (1993-1995) without prior bleeding and cardiovascular disease (mean age 60 years, 57% women, 21% Black). Plasma levels of GDF15 were measured in relative fluorescence units using DNA-based aptamer technology. Bleeding was ascertained using discharge codes. We examined hazard ratios (HRs) of incident bleeding using Cox models and risk prediction with the addition of GDF15 to clinical predictors of bleeding. There were 1328 hospitalizations with bleeding during a median follow-up of 22.5 years. The majority (76.5%) were because of gastrointestinal bleeding. The absolute incidence rate of bleeding per 1000 person-years was 11.64 in the highest quartile of GDF15 versus 5.22 in the lowest quartile. The highest versus lowest quartile of GDF15 demonstrated an adjusted HR of 2.00 (95% CI, 1.69-2.35) for total bleeding. The findings were consistent when we examined bleeding as the primary discharge diagnosis. The addition of GDF15 to clinical predictors of bleeding improved the C-statistic by 0.006 (0.002-0.011) from 0.684 to 0.690, P=0.008. Conclusions Higher levels of GDF15 were associated with bleeding events and improved the risk prediction beyond clinical predictors in individuals without cardiovascular disease.
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Affiliation(s)
- Lena Mathews
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Division of CardiologyCiccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of MedicineBaltimoreMD
| | - Xiao Hu
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Ning Ding
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Junichi Ishigami
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Mahmoud Al Rifai
- Division of CardiologyCiccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of MedicineBaltimoreMD
- Houston Methodist DeBakey Heart & Vascular CenterHoustonTX
| | - Ron C. Hoogeveen
- Department of Medicine, Section of Cardiovascular Research HoustonBaylor College of MedicineHoustonTX
| | - Josef Coresh
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Christie M. Ballantyne
- Department of Medicine, Section of Cardiovascular Research HoustonBaylor College of MedicineHoustonTX
| | - Elizabeth Selvin
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Kunihiro Matsushita
- Department of Epidemiology, Welch Center Department of Epidemiology, Prevention and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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Dzhioeva ON, Rogozhkina EA, Drapkina OM. Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2022-12-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Currently, antithrombotic therapy is the basis of the pathogenetic treatment of many cardiovascular diseases, such as coronary heart disease, stroke, peripheral vascular disease, as well as mechanical heart valves, heart rhythm disturbances, venous thromboembolism. At the same time, chronic use of antiplatelet and/or anticoagulant drugs is a complicating factor in invasive and surgical procedures, as it increases the risk of bleeding. In this regard, a fundamentally important and complex question arises: how to minimize the risk of periprocedural bleeding without exposing the patient to an increased risk of ischemic and thromboembolic complications? Perioperative management of patients who take antithrombotic drugs for a long time is a complex problem that depends on many factors - the risk of surgery, anesthesia, cardiovascular risks, and the urgency of surgery. Each clinical situation should be assessed individually, collegially, with the participation of surgeons, anesthesiologists, and therapists. The introduction of a checklist into clinical practice for each planned surgical patient will allow us to calculate the individual risk of bleeding and thromboembolic complications, and provide an optimal preventive strategy for perioperative management of the patient. The algorithms and schemes presented in the article for the perioperative management of patients with non-cardiac interventions are aimed at standardizing the management of patients before non-cardiac surgical interventions, which will reduce hemorrhagic risks in the presence of the necessary antithrombotic therapy.
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Affiliation(s)
- O. N. Dzhioeva
- National Medical Research Center for Therapy and Preventive Medicine;
A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - E. A. Rogozhkina
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine;
A.I. Yevdokimov Moscow State University of Medicine and Dentistry
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Djordjevic N. Genotyping genetic variants of CYP2C19 for precision antiplatelet dosing: state of the art and future perspectives. Expert Opin Drug Metab Toxicol 2022; 18:817-830. [PMID: 36606363 DOI: 10.1080/17425255.2022.2166486] [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: 01/07/2023]
Abstract
INTRODUCTION Clopidogrel is the only antiplatelet agent whose activity is significantly affected by CYP2C19 polymorphism. AREAS COVERED This review has summarized the available evidence on the clinically significant association between CYP2C19 polymorphism and clopidogrel-based therapy; reviewed the current recommendations for clinical use of CYP2C19 genotype test results in patients on clopidogrel treatment; and discussed possible pitfalls of routine application, and future perspectives of antiplatelets pharmacogenetics. EXPERT OPINION The available body of evidence, reflected in several meta-analyses and high-quality clinical practice guidelines, shows that the presence of CYP2C19 LOF alleles, especially CYP2C19*2, correlates with impaired activation of clopidogrel and variable platelet inhibition, followed by minimal or no antiplatelet effect, and higher risk of treatment failure. In combination with other known risk factors, CYP2C19 genetic testing could be very valuable in predicting low clopidogrel efficacy. At the same time, it could be very successful in selecting patients who will most probably benefit from the clopidogrel-based therapy, thus decreasing the pool of those who might need more expensive and otherwise riskier antiplatelet alternatives.
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Affiliation(s)
- Natasa Djordjevic
- Faculty of Medical Sciences, Department of Pharmacology and Toxicology, University of Kragujevac, Svetozara Markovica 69, 34 000 Kragujevac, Serbia
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van Uden RCAE, van den Broek MPH, Houtenbos I, Jaspers TCC, Harmsze AM, Kingma HJ, Odekerken DAM, Meijer K, van den Bemt PMLA, Becker ML. Unintentional guideline deviations in hospitalized patients with two or more antithrombotic agents: an intervention study. Eur J Clin Pharmacol 2021; 77:1919-1926. [PMID: 34319470 PMCID: PMC8585825 DOI: 10.1007/s00228-021-03185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/29/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE Treatment schedules for antithrombotic therapy are complex, and there is a risk of inappropriate prescribing or continuation of antithrombotic therapy beyond the intended period of time. The primary aim of this study was to determine the frequency of unintentional guideline deviations in hospitalized patients. Secondary aims were to determine whether the frequency of unintentional guideline deviations decreased after intervention by a pharmacist, to determine the acceptance rate of the interventions and to determine the type of interventions. METHODS We performed a non-controlled prospective intervention study in three teaching hospitals in the Netherlands. We examined whether hospitalized patients who used the combination of an anticoagulant plus at least one other antithrombotic agent had an unintentional guideline deviation. In these cases, the hospital pharmacist contacted the physician to assess whether this deviation was intentional. If the deviation was unintentional, a recommendation was provided how to adjust the antithrombotic regimen according to guideline recommendations. RESULTS Of the 988 included patients, 407 patients had an unintentional guideline deviation (41.2%). After intervention, this was reduced to 22 patients (2.2%) (p < 0.001). The acceptance rate of the interventions was 96.6%. The most frequently performed interventions were discontinuation of an low molecular weight heparin in combination with a direct oral anticoagulant and discontinuation of an antiplatelet agent when there was no indication for the combination of an antiplatelet agent and an anticoagulant. CONCLUSION A significant number of hospitalized patients who used an anticoagulant plus one other antithrombotic agent had an unintentional guideline deviation. Intervention by a pharmacist decreased unintentional guideline deviations.
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Affiliation(s)
- Renate C A E van Uden
- Pharmacy Foundation of Haarlem Hospitals, Haarlem, The Netherlands.
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands.
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | | | - Ilse Houtenbos
- Department of Internal Medicine, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
| | - Tessa C C Jaspers
- Department of Clinical Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ankie M Harmsze
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Hylke J Kingma
- Pharmacy Foundation of Haarlem Hospitals, Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
| | - Diego A M Odekerken
- Department of Cardiology, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
| | - Karina Meijer
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Haarlem, The Netherlands
- Department of Clinical Pharmacy, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
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