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Fox LP, Tunehag KR, Nguyen A, Reed S, Shastri D, Quig N, Stouffer GA, Solander S, Lee CR. Real-world evaluation of CYP2C19 guided antiplatelet therapy in patients undergoing intracranial aneurysm repair. Pharmacogenomics 2024:1-11. [PMID: 39360670 DOI: 10.1080/14622416.2024.2406213] [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: 07/19/2024] [Accepted: 09/16/2024] [Indexed: 10/04/2024] Open
Abstract
Aim: To evaluate the feasibility and impact of using CYP2C19 genotype to guide selection of antiplatelet therapy in patients undergoing intracranial aneurysm treatment with a flow diversion stent in a real-world clinical setting.Patients & methods: A single-center, retrospective, observational cohort study was conducted in 112 patients undergoing intracranial aneurysm repair with flow-diversion stenting from 2014 to 2021. Data were abstracted from health records. The frequency of clopidogrel or alternative therapy (ticagrelor or prasugrel) use was compared across CYP2C19 status (intermediate or poor metabolizer [IM/PM] vs. normal, rapid, or ultrarapid metabolizer [NM/RM/UM]).Results: In the study population, CYP2C19 genotype testing was performed on 110 (98.2%) patients; of these, 106 (97.2%) had results available prior to the stent procedure and 28 (25.5%) were IM/PMs. Alternative therapy was used more frequently in IM/PMs compared with NM/RM/UMs (57.1 vs. 8.5%, respectively, p < 0.0001). The frequency of thromboembolic events over 12 months did not significantly differ across clopidogrel-treated IM/PMs, clopidogrel-treated NM/RM/UMs and patients on alternative therapy (p = 0.352); although, event numbers were low.Conclusion: A pre-emptive CYP2C19 genotyping strategy to guide antiplatelet therapy selection in intracranial aneurysm repair patients is feasible in a real-world clinical setting. Larger studies are needed to assess the impact on clinical outcomes.
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Affiliation(s)
- Layna P Fox
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Kayla R Tunehag
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Anh Nguyen
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Samuel Reed
- Department of Neurosurgery, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Darshan Shastri
- Department of Neurosurgery, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Nathan Quig
- Department of Neurosurgery, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - George A Stouffer
- Division of Cardiology, Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sten Solander
- Department of Radiology, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Craig R Lee
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Division of Cardiology, Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Cavallari LH, Coons JC. Genetic Determinants of Response to P2Y 12 Inhibitors and Clinical Implications. Interv Cardiol Clin 2024; 13:469-481. [PMID: 39245547 DOI: 10.1016/j.iccl.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
The CYP2C19 enzyme metabolizes clopidogrel, a prodrug, to its active form. Approximately 30% of individuals inherit a loss-of-function (LoF) polymorphism in the CYP2C19 gene, leading to reduced formation of the active clopidogrel metabolite. Reduced clopidogrel effectiveness has been well documented in patients with an LoF allele following an acute coronary syndrome or percutaneous coronary intervention. Prasugrel or ticagrelor is recommended in those with an LoF allele as neither is affected by CYP2C19 genotype. Although data demonstrate improved outcomes with a CYP2C19-guided approach to P2Y12 inhibitor selection, genotyping has not yet been widely adopted in clinical practice.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, 1333 Center Drive, PO Box 100486, Gainesville, FL 32610, USA.
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh, 9058 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261, USA
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Delabays B, Trajanoska K, Walonoski J, Mooser V. Cardiovascular Pharmacogenetics: From Discovery of Genetic Association to Clinical Adoption of Derived Test. Pharmacol Rev 2024; 76:791-827. [PMID: 39122647 DOI: 10.1124/pharmrev.123.000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 04/24/2024] [Accepted: 05/28/2024] [Indexed: 08/12/2024] Open
Abstract
Recent breakthroughs in human genetics and in information technologies have markedly expanded our understanding at the molecular level of the response to drugs, i.e., pharmacogenetics (PGx), across therapy areas. This review is restricted to PGx for cardiovascular (CV) drugs. First, we examined the PGx information in the labels approved by regulatory agencies in Europe, Japan, and North America and related recommendations from expert panels. Out of 221 marketed CV drugs, 36 had PGx information in their labels approved by one or more agencies. The level of annotations and recommendations varied markedly between agencies and expert panels. Clopidogrel is the only CV drug with consistent PGx recommendation (i.e., "actionable"). This situation prompted us to dissect the steps from discovery of a PGx association to clinical translation. We found 101 genome-wide association studies that investigated the response to CV drugs or drug classes. These studies reported significant associations for 48 PGx traits mapping to 306 genes. Six of these 306 genes are mentioned in the corresponding PGx labels or recommendations for CV drugs. Genomic analyses also highlighted the wide between-population differences in risk allele frequencies and the individual load of actionable PGx variants. Given the high attrition rate and the long road to clinical translation, additional work is warranted to identify and validate PGx variants for more CV drugs across diverse populations and to demonstrate the utility of PGx testing. To that end, pre-emptive PGx combining genomic profiling with electronic medical records opens unprecedented opportunities to improve healthcare, for CV diseases and beyond. SIGNIFICANCE STATEMENT: Despite spectacular breakthroughs in human molecular genetics and information technologies, consistent evidence supporting PGx testing in the cardiovascular area is limited to a few drugs. Additional work is warranted to discover and validate new PGx markers and demonstrate their utility. Pre-emptive PGx combining genomic profiling with electronic medical records opens unprecedented opportunities to improve healthcare, for CV diseases and beyond.
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Affiliation(s)
- Benoît Delabays
- Canada Excellence Research Chair in Genomic Medicine, Victor Phillip Dahdaleh Institute of Genomic Medicine, Department of Human Genetics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada (B.D., K.T., V.M.); and Medeloop Inc., Palo Alto, California, and Montreal, QC, Canada (J.W.)
| | - Katerina Trajanoska
- Canada Excellence Research Chair in Genomic Medicine, Victor Phillip Dahdaleh Institute of Genomic Medicine, Department of Human Genetics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada (B.D., K.T., V.M.); and Medeloop Inc., Palo Alto, California, and Montreal, QC, Canada (J.W.)
| | - Joshua Walonoski
- Canada Excellence Research Chair in Genomic Medicine, Victor Phillip Dahdaleh Institute of Genomic Medicine, Department of Human Genetics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada (B.D., K.T., V.M.); and Medeloop Inc., Palo Alto, California, and Montreal, QC, Canada (J.W.)
| | - Vincent Mooser
- Canada Excellence Research Chair in Genomic Medicine, Victor Phillip Dahdaleh Institute of Genomic Medicine, Department of Human Genetics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada (B.D., K.T., V.M.); and Medeloop Inc., Palo Alto, California, and Montreal, QC, Canada (J.W.)
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4
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Pereira NL, Cresci S, Angiolillo DJ, Batchelor W, Capers Q, Cavallari LH, Leifer D, Luzum JA, Roden DM, Stellos K, Turrise SL, Tuteja S. CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e129-e150. [PMID: 38899464 PMCID: PMC11300169 DOI: 10.1161/cir.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.
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Cavallari LH, Lee CR, Franchi F, Keeley EC, Rossi JS, Thomas CD, Gong Y, McDonough CW, Starostik P, Al Saeed MJ, Been L, Kulick N, Malave J, Mulrenin IR, Nguyen AB, Terrell JN, Tillotson G, Beitelshees AL, Winterstein AG, Stouffer GA, Angiolillo DJ. Precision Antiplatelet Therapy after Percutaneous Coronary Intervention (Precision PCI) Registry - Informing optimal antiplatelet strategies. Clin Transl Sci 2024; 17:e70004. [PMID: 39150361 PMCID: PMC11328342 DOI: 10.1111/cts.70004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) is indicated after percutaneous coronary intervention (PCI) to reduce the risk of atherothrombotic events. Approximately 30% of the US population has a CYP2C19 no-function allele that reduces the effectiveness of clopidogrel, but not prasugrel or ticagrelor, after PCI. We have shown improved outcomes with the integration of CYP2C19 genotyping into clinical care to guide the selection of prasugrel or ticagrelor in CYP2C19 no-function allele carriers. However, the influence of patient-specific demographic, clinical, and other genetic factors on outcomes with genotype-guided DAPT has not been defined. In addition, the impact of genotype-guided de-escalation from prasugrel or ticagrelor to clopidogrel in patients without a CYP2C19 no-function allele has not been investigated in a diverse, real-world clinical setting. The Precision Antiplatelet Therapy after Percutaneous Coronary Intervention (Precision PCI) Registry is a multicenter US registry of patients who underwent PCI and clinical CYP2C19 testing. The registry is enrolling a diverse population, assessing atherothrombotic and bleeding events over 12 months, collecting DNA samples, and conducting platelet function testing in a subset of patients. The registry aims to define the influence of African ancestry and other patient-specific factors on clinical outcomes with CYP2C19-guided DAPT, evaluate the safety and effectiveness of CYP2C19-guided DAPT de-escalation following PCI in a real-world setting, and identify additional genetic influences of clopidogrel response after PCI, with the ultimate goal of establishing optimal strategies for individualized antiplatelet therapy that improves outcomes in a diverse, real-world population.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Joseph S. Rossi
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine; College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Maryam J. Al Saeed
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Latonya Been
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jean Malave
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Ian R. Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Joshua N. Terrell
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Grace Tillotson
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and Safety, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
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Rajachandran M, Lange RA. Role of Cyp2c19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Curr Cardiol Rep 2024; 26:675-680. [PMID: 38806977 DOI: 10.1007/s11886-024-02071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Identification of a reliable discriminatory test to accurately stratify patient responses to antiplatelet therapy following coronary revascularization has become increasingly desirable to optimize therapeutic efficacy and safety. RECENT FINDINGS The expansion of platelet function testing to include genotype assessment has been an evolutionary journey, initially fraught with confounding results. However, more recent and rigorous data analysis suggests that genotype testing- guided, tailored antiplatelet therapy may hold promise in optimizing treatment of patients after coronary intervention. Current evidence increasingly supports the use of genotype guided CYP2C19 testing to better match the post coronary intervention patient with the most efficacious and least risky antiplatelet inhibitor. The risk stratification of poor, intermediate, and good metabolizers of these drugs with such testing promises to yield clinical dividends in terms of morbidity, mortality and cost control, in this growing patient population.
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Affiliation(s)
- Manu Rajachandran
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
| | - Richard A Lange
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA
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Kim J, Shin BS, Kim DH, Shin DI, Ahn SH, Kim JG, Ryu SH, Moon HR, Kang HG, Jeong H, Yum KS, Chae HY, Kim DH, Kang K, Kim J. Molecular genomic and epigenomic characteristics related to aspirin and clopidogrel resistance. BMC Med Genomics 2024; 17:166. [PMID: 38902747 PMCID: PMC11188263 DOI: 10.1186/s12920-024-01936-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Mediators, genomic and epigenomic characteristics involving in metabolism of arachidonic acid by cyclooxygenase (COX) and lipoxygenase (ALOX) and hepatic activation of clopidogrel have been individually suggested as factors associated with resistance against aspirin and clopidogrel. The present multi-center prospective cohort study evaluated whether the mediators, genomic and epigenomic characteristics participating in arachidonic acid metabolism and clopidogrel activation could be factors that improve the prediction of the aspirin and clopidogrel resistance in addition to cardiovascular risks. METHODS We enrolled 988 patients with transient ischemic attack and ischemic stroke who were evaluated for a recurrence of ischemic stroke to confirm clinical resistance, and measured aspirin (ARU) and P2Y12 reaction units (PRU) using VerifyNow to assess laboratory resistance 12 weeks after aspirin and clopidogrel administration. We investigated whether mediators, genotypes, and promoter methylation of genes involved in COX and ALOX metabolisms and clopidogrel activation could synergistically improve the prediction of ischemic stroke recurrence and the ARU and PRU levels by integrating to the established cardiovascular risk factors. RESULTS The logistic model to predict the recurrence used thromboxane A synthase 1 (TXAS1, rs41708) A/A genotype and ALOX12 promoter methylation as independent variables, and, improved sensitivity of recurrence prediction from 3.4% before to 13.8% after adding the mediators, genomic and epigenomic variables to the cardiovascular risks. The linear model we used to predict the ARU level included leukotriene B4, COX2 (rs20417) C/G and thromboxane A2 receptor (rs1131882) A/A genotypes with the addition of COX1 and ALOX15 promoter methylations as variables. The linear PRU prediction model included G/A and prostaglandin I receptor (rs4987262) G/A genotypes, COX2 and TXAS1 promoter methylation, as well as cytochrome P450 2C19*2 (rs4244285) A/A, G/A, and *3 (rs4986893) A/A genotypes as variables. The linear models for predicting ARU (r = 0.291, R2 = 0.033, p < 0.01) and PRU (r = 0.503, R2 = 0.210, p < 0.001) levels had improved prediction performance after adding the genomic and epigenomic variables to the cardiovascular risks. CONCLUSIONS This study demonstrates that different mediators, genomic and epigenomic characteristics of arachidonic acid metabolism and clopidogrel activation synergistically improved the prediction of the aspirin and clopidogrel resistance together with the cardiovascular risk factors. TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov ; Unique identifier: NCT03823274.
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Grants
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
- YMC037 Yuhan Corporation, South Korea
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Affiliation(s)
- Jei Kim
- Department of Neurology, College of Medicine and Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Chungnam National University, Daejeon, South Korea.
- Department of Anatomy, College of Medicine, Chungnam National University, 266 Moonhwaro, Joongku, Daejeon, 35015, South Korea.
| | - Byoung-Soo Shin
- Department of Neurology, Research Institute of Clinical Medicine and Biomedical Research Institute, Medical School and Hospital, Jeonbuk National University, Jeonju, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Busan Regional Cardiocerebrovascular Disease Center, Dong-A University Hospital, Busan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk Regional Cardiocerebrovascular Disease Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University Hospital, Gwangju, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Su Hyun Ryu
- Department of Neurology, College of Medicine and Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Chungnam National University, Daejeon, South Korea
| | - Hye Rin Moon
- Department of Neurology, College of Medicine and Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Chungnam National University, Daejeon, South Korea
| | - Hyun Goo Kang
- Department of Neurology, Research Institute of Clinical Medicine and Biomedical Research Institute, Medical School and Hospital, Jeonbuk National University, Jeonju, South Korea
| | - Hyeseon Jeong
- Department of Neurology, College of Medicine and Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Chungnam National University, Daejeon, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk Regional Cardiocerebrovascular Disease Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Hee-Yun Chae
- Department of Neurology, Chungbuk Regional Cardiocerebrovascular Disease Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Do-Hyung Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Keunsoo Kang
- Department of Microbiology, College of Science & Technology, Dankook University, Cheonan, South Korea
| | - Jeeyeon Kim
- Department of Neurology, College of Medicine and Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Chungnam National University, Daejeon, South Korea
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Tunehag KR, Thomas CD, Franchi F, Rossi JS, Keeley EC, Anderson RD, Beitelshees AL, Duarte JD, Gong Y, Kerensky RA, McDonough CW, Nguyen AB, Ortega‐Paz L, Venkatesh S, Wang Y, Johnson JA, Winterstein AG, Stouffer GA, Angiolillo DJ, Cavallari LH, Lee CR. CYP2C19 Genotype Is Associated With Adverse Cardiovascular Outcomes in Black Patients Treated With Clopidogrel Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e033791. [PMID: 38874073 PMCID: PMC11255757 DOI: 10.1161/jaha.123.033791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/13/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Cytochrome P450 2C19 (CYP2C19) intermediate and poor metabolizer patients exhibit diminished clopidogrel clinical effectiveness after percutaneous coronary intervention (PCI). However, outcome studies to date have lacked racial diversity. Thus, the impact of CYP2C19 genotype on cardiovascular outcomes in patients treated with clopidogrel who identify as Black or African American remains unclear. METHODS AND RESULTS Adults among 5 institutions who self-identified as Black or African American, underwent PCI and clinical CYP2C19 genotyping, and were treated with clopidogrel were included. Data were abstracted from health records. Major atherothrombotic (composite of death, myocardial infarction, ischemic stroke, stent thrombosis, or revascularization for unstable angina) and bleeding event rates within 1 year after PCI were compared across CYP2C19 metabolizer groups using multivariable Cox regression adjusted for potential confounders and baseline variables meeting a threshold of P<0.10. The population included 567 Black patients treated with clopidogrel (median age, 62 years; 46% women; 70% with an acute coronary syndrome indication for PCI). Major atherothrombotic events rates were significantly higher among clopidogrel-treated intermediate and poor metabolizers (24 of 125 [19.2%]) versus patients treated with clopidogrel without a no function allele (43 of 442 [9.7%]; 35.1 versus 15.9 events per 100 person-years; adjusted hazard ratio, 2.00 [95% CI, 1.20-3.33], P=0.008). Bleeding event rates were low overall (23 of 567 [4.1%]) and did not differ among the metabolizer groups. CONCLUSIONS Black patients with CYP2C19 intermediate and poor metabolizer phenotypes who are treated with clopidogrel exhibit increased risk of adverse cardiovascular outcomes after PCI in a real-world clinical setting. Bleeding outcomes should be interpreted cautiously. Prospective studies are needed to determine whether genotype-guided use of prasugrel or ticagrelor in intermediate and poor metabolizers improves outcomes in Black patients undergoing PCI.
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Affiliation(s)
- Kayla R. Tunehag
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Cameron D. Thomas
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Francesco Franchi
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Joseph S. Rossi
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Ellen C. Keeley
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - R. David Anderson
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Amber L. Beitelshees
- University of Maryland School of MedicineDepartment of Medicine and Program for Personalized and Genomic MedicineBaltimoreMDUSA
| | - Julio D. Duarte
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Yan Gong
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Richard A. Kerensky
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Luis Ortega‐Paz
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Sanjay Venkatesh
- Division of Cardiology, Duke Department of MedicineDuke University School of MedicineDurhamNCUSA
| | - Yehua Wang
- Department of Pharmaceutical Outcomes & Policy, Department of Epidemiology, and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFLUSA
| | - Julie A. Johnson
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy, Department of Epidemiology, and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFLUSA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Aquilante CL, Trinkley KE, Lee YM, Crooks KR, Hearst EC, Heckman SM, Hess KW, Kudron EL, Martin JL, Swartz CT, Kao DP. Implementation of clopidogrel pharmacogenetic clinical decision support for a preemptive return of results program. Am J Health Syst Pharm 2024; 81:555-562. [PMID: 38253063 DOI: 10.1093/ajhp/zxae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 01/24/2024] Open
Abstract
PURPOSE To describe our experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support (CDS) tools over time in the setting of a large health system-wide, preemptive pharmacogenomics program. SUMMARY Clopidogrel-treated patients who are genetically predicted cytochrome P450 isozyme 2C19 (CYP2C19) intermediate or poor metabolizers have an increased risk of atherothrombotic events, some of which can be life-threatening. The Clinical Pharmacogenetics Implementation Consortium provides guidance for the use of clopidogrel based on CYP2C19 genotype in patients with cardiovascular and cerebrovascular diseases. Our multidisciplinary team implemented an automated, interruptive alert that fires when clopidogrel is ordered or refilled for biobank participants with structured CYP2C19 intermediate or poor metabolizer genomic indicators in the electronic health record. The implementation began with a narrow cardiovascular indication and setting and was then scaled in 4 primary dimensions: (1) clinical indication; (2) availability across health-system locations; (3) care venue (e.g., inpatient vs outpatient); and (4) provider groups (eg, cardiology and neurology). We iterated our approach over time based on evolving clinical evidence and proactive strategies to optimize CDS maintenance and sustainability. A key facilitator of expansion was socialization of the broader pharmacogenomics initiative among our academic medical center community, accompanied by clinician acceptance of pharmacogenetic alerts in practice. CONCLUSION A multidisciplinary collaboration is recommended to facilitate the use of CYP2C19 genotype-guided antiplatelet therapy in patients with cardiovascular and cerebrovascular diseases. Evolving clopidogrel pharmacogenetic evidence necessitates thoughtful iteration of implementation efforts and strategies to optimize long-term maintenance and sustainability.
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Affiliation(s)
- Christina L Aquilante
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katy E Trinkley
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Yee Ming Lee
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristy R Crooks
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Pathology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Emily C Hearst
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- UCHealth, Aurora, CO, USA
| | | | | | - Elizabeth L Kudron
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Biomedical Informatics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James L Martin
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - David P Kao
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Kim JH, Lee SJ, Cha JJ, Park JH, Hong SJ, Ahn TH, Kim BK, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Jeong YH, Kim HS, Kim MH, Shin ES, Lim DS. Prognostic Impact of CYP2C19 Genotypes on Long-Term Clinical Outcomes in Older Patients After Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e032248. [PMID: 38761068 PMCID: PMC11179831 DOI: 10.1161/jaha.123.032248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Carriers of CYP2C19 loss-of-function alleles have increased adverse events after percutaneous coronary intervention, but limited data are available for older patients. We aimed to evaluate the prognostic impact of CYP2C19 genotypes on clinical outcomes in older patients after percutaneous coronary intervention. METHODS AND RESULTS The study included 1201 older patients (aged ≥75 years) who underwent percutaneous coronary intervention and received clopidogrel-based dual antiplatelet therapy in South Korea. Patients were grouped on the basis of CYP2C19 genotypes. The primary outcome was 3-year major adverse cardiac events, defined as a composite of cardiac death, myocardial infarction, and stent thrombosis. Older patients were grouped into 3 groups: normal metabolizer (36.6%), intermediate metabolizer (48.1%), and poor metabolizer (15.2%). The occurrence of the primary outcome was significantly different among the groups (3.1, 7.0, and 6.2% in the normal metabolizer, intermediate metabolizer, and poor metabolizer groups, respectively; P=0.02). The incidence rate of all-cause death at 3 years was greater in the intermediate metabolizer and poor metabolizer groups (8.1% and 9.2%, respectively) compared with that in the normal metabolizer group (3.5%, P=0.03) without significant differences in major bleeding. In the multivariable analysis, the intermediate metabolizer and poor metabolizer groups were independent predictors of 3-year clinical outcomes. CONCLUSIONS In older patients, the presence of any CYP2C19 loss-of-function allele was found to be predictive of a higher incidence of major adverse cardiac events within 3 years following percutaneous coronary intervention. This finding suggests a need for further investigation into an optimal antiplatelet strategy for older patients. REGISTRATION URL: https://clinicaltrials.gov. Identifier: NCT04734028.
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Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | | | - Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Tae Hoon Ahn
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | | | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine College of Medicine, Catholic University of Korea Seoul South Korea
| | - Yongwhi Park
- Department of Internal Medicine Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital Changwon South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Sung Gyun Ahn
- Department of Cardiology Yonsei University Wonju Severance Christian Hospital Wonju South Korea
| | - Jung-Won Suh
- Department of Cardiology, Department of Internal Medicine Seoul National University Bundang Hospital, Seoul National University College of Medicine Seoul South Korea
| | - Sang Yeub Lee
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital Hallym University College of Medicine Seoul South Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine Kangwon National University School of Medicine Chuncheon South Korea
| | - Young-Hoon Jeong
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Moo Hyun Kim
- Department of Cardiology Dong-A University Hospital Busan South Korea
| | - Eun-Seok Shin
- Division of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
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11
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Bedair KF, Smith B, Palmer CNA, Doney ASF, Pearson ER. Pharmacogenetics at scale in real-world bioresources: CYP2C19 and clopidogrel outcomes in UK Biobank. Pharmacogenet Genomics 2024; 34:73-82. [PMID: 38179710 DOI: 10.1097/fpc.0000000000000519] [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: 01/06/2024]
Abstract
OBJECTIVE The impact of CYP2C19 genotype on clopidogrel outcomes is one of the most well established pharmacogenetic interactions, supported by robust evidence and recommended by the Food and Drug Administration and clinical pharmacogenetics implementation consortium. However, there is a scarcity of large-scale real-world data on the extent of this pharmacogenetic effect, and clinical testing for the CYP2C19 genotype remains infrequent. This study utilizes the UK Biobank dataset, including 10 365 patients treated with clopidogrel, to offer the largest observational analysis of these pharmacogenetic effects to date. METHODS Incorporating time-varying drug exposure and repeated clinical outcome, we adopted semiparametric frailty models to detect and quantify exposure-based effects of CYP2C19 (*2,*17) variants and nongenetic factors on the incidence risks of composite outcomes of death or recurrent hospitalizations due to major adverse cardiovascular events (MACE) or hemorrhage in the entire cohort of clopidogrel-treated patients. RESULTS Out of the 10 365 clopidogrel-treated patients, 40% (4115) experienced 10 625 MACE events during an average follow-up of 9.23 years. Individuals who received clopidogrel (coverage >25%) with a CYP2C19*2 loss-of-function allele had a 9.4% higher incidence of MACE [incidence rate ratios (IRR), 1.094; 1.044-1.146], but a 15% lower incidence of hemorrhage (IRR, 0.849; 0.712-0.996). These effects were stronger with high clopidogrel exposure. Conversely, the gain-of-function CYP2C19*17 variant was associated with a 5.3% lower incidence of MACE (IRR, 0.947; 0.903-0.983). Notably, there was no evidence of *2 or *17 effects when clopidogrel exposure was low, confirming the presence of a drug-gene interaction. CONCLUSION The impact of CYP2C19 on clinical outcomes in clopidogrel-treated patients is substantial, highlighting the importance of incorporating genotype-based prescribing into clinical practice, regardless of the reason for clopidogrel use or the duration of treatment. Moreover, the methodology introduced in this study can be applied to further real-world investigations of known drug-gene and drug-drug interactions and the discovery of novel interactions.
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Affiliation(s)
- Khaled F Bedair
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
- Department of Statistics & Mathematics, Tanta University, Tanta, Egypt
| | - Blair Smith
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Colin N A Palmer
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Alex S F Doney
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan R Pearson
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
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12
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Fang HY, Lee WC. Author's Reply to Kow et al.: "Comparison of Clinical Outcomes between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study". Am J Cardiovasc Drugs 2024; 24:327-328. [PMID: 38270841 DOI: 10.1007/s40256-023-00627-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Jen-Ai Hospital, Taichung, Taiwan
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan.
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, No. 901, Zhonghua Rd., Yongkang Dist., Tainan, Taiwan.
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13
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Luan Y, Zhu X, Jiao Y, Liu H, Huang Z, Pei J, Xu Y, Yang Y, Ren K. Cardiac cell senescence: molecular mechanisms, key proteins and therapeutic targets. Cell Death Discov 2024; 10:78. [PMID: 38355681 PMCID: PMC10866973 DOI: 10.1038/s41420-023-01792-5] [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: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Cardiac aging, particularly cardiac cell senescence, is a natural process that occurs as we age. Heart function gradually declines in old age, leading to continuous heart failure, even in people without a prior history of heart disease. To address this issue and improve cardiac cell function, it is crucial to investigate the molecular mechanisms underlying cardiac senescence. This review summarizes the main mechanisms and key proteins involved in cardiac cell senescence. This review further discusses the molecular modulators of cellular senescence in aging hearts. Furthermore, the discussion will encompass comprehensive descriptions of the key drugs, modes of action and potential targets for intervention in cardiac senescence. By offering a fresh perspective and comprehensive insights into the molecular mechanisms of cardiac senescence, this review seeks to provide a fresh perspective and important theoretical foundations for the development of drugs targeting this condition.
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Affiliation(s)
- Yi Luan
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China
| | - Xiaofan Zhu
- Genetic and Prenatal Diagnosis Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China
| | - Yuxue Jiao
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China
| | - Hui Liu
- School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, 453003, P. R. China
| | - Zhen Huang
- School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, 453003, P. R. China
| | - Jinyan Pei
- Quality Management Department, Henan No.3 Provincial People's Hospital, Zhengzhou, 450052, P. R. China
| | - Yawei Xu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China.
| | - Yang Yang
- Clinical Systems Biology Laboratories, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China.
| | - Kaidi Ren
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, P. R. China.
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, 450052, P. R. China.
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14
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Shubbar Q, Alchakee A, Issa KW, Adi AJ, Shorbagi AI, Saber-Ayad M. From genes to drugs: CYP2C19 and pharmacogenetics in clinical practice. Front Pharmacol 2024; 15:1326776. [PMID: 38420192 PMCID: PMC10899532 DOI: 10.3389/fphar.2024.1326776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
The CYP2C19 gene is frequently included in different pharmacogenomic panels tested in clinical practice, due to its involvement in the metabolism of a myriad of frequently prescribed medications. Accordingly, CYP2C19 genotyping can promote precise therapeutic decisions and avoid the occurrence of significant drug-drug-gene interactions in the clinical setting. A comprehensive examination of the role of the CYP2C19 gene in real-world medical settings is presented in this review. This review summarizes the most recent information on how genetic variants in CYP2C19 affect drug metabolism and therapeutic outcomes. It goes into the wide range of CYP2C19 phenotypes, with different degrees of metabolizing activity, and their implications for customized medication response through a review of the literature. The review also analyzes the clinical significance of CYP2C19 in several medical specialties, including cardiology, psychiatry, and gastro-enterology clinics, and illuminates how it affects pharmacological efficacy, safety, and adverse effects. Finally, CYP2C19-supported clinical decision-making is outlined, highlighting the possibility of improving therapeutic outcomes and achieving more affordable treatment options, a step towards optimizing healthcare provision through precision medicine.
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Affiliation(s)
- Qamar Shubbar
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Aminah Alchakee
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Khaled Walid Issa
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Abdul Jabbar Adi
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Maha Saber-Ayad
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
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15
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Akkaif MA, Daud NAA, Noor DAM, Sha'aban A, Kader MASA, Ibrahim B. The Impact of CYP2C19 Genotype on the Platelet Reactivity Index (PRI) among Chronic Coronary Syndromes (CCS) Patients Undergoing Percutaneous Coronary Intervention (PCI): Affectability of Rapid Genetic Testing. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07544-6. [PMID: 38224415 DOI: 10.1007/s10557-024-07544-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND In the Asian population, the presence of the CYP2C19 loss-of-function (LOF) allele is a known genetic variation. This allele is associated with a reduced capacity to metabolize clopidogrel into its active forms through the CYP2C19 enzyme, resulting in diminished platelet inhibition and an elevated risk of recurrent cardiovascular events. Regulatory authorities have recommended an alternative P2Y12 inhibitor, ticagrelor, for individuals carrying the LOF allele. Consequently, this study seeks to assess the impact of the CYP2C19 genotype on the Platelet reactivity index (PRI) using a rapid genetic testing approach in Asian patients with chronic coronary syndromes (CCS) who undergo percutaneous coronary intervention (PCI). METHODS This prospective study employed a parallel design, single-center design, and randomized approach. Genotyping for the CYP2C19*2 and *3 polymorphisms was conducted using the Nested Allele-Specific Multiplex PCR (NASM-PCR) technique. Patients meeting the inclusion criteria underwent genotyping for CYP2C19 polymorphisms. Following PCI, patients were randomly assigned to receive either ticagrelor or clopidogrel. PRI assessments were performed four hours after loading dose administration. The trial was registered with ClinicalTrials.gov under the identifier NCT05516784. RESULTS Among the 94 patients recruited for the study, 40 (42.55%) were identified as carriers of the LOF allele for CYP2C19*2 and *3 (*1/*2, *2/*2, *1/*3). Out of the 84 patients evaluated for PRI (44 receiving clopidogrel and 40 receiving ticagrelor), 21 (47.7%) of the clopidogrel group and 39 (97.5%) of the ticagrelor group exhibited a favorable response to antiplatelet therapy (PRI < 50). Patients treated with ticagrelor demonstrated superior antiplatelet responses compared to those receiving clopidogrel, regardless of LOF carrier status (P = 0.005 and < 0.001 for non-LOF and LOF carriers, respectively). CONCLUSION NASM-PCR as a rapid genetic test holds promise for personalizing antiplatelet therapy in Asian CCS patients.
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Affiliation(s)
- Mohammed Ahmed Akkaif
- Department of Cardiology, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People's Republic of China.
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, 11800, Malaysia.
| | | | | | - Abubakar Sha'aban
- School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK
| | | | - Baharudin Ibrahim
- Faculty of Pharmacy, University of Malaya, Federal Territory Malaysia, Kuala Lumpur, 50603, Malaysia.
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Tan CK, Wu DBC, Joseph Tan SY, Imran SS, Wee XT, Tan SYD. Validating the Prognostic Utility of the ABCD-GENE Score in Asian Patients with Acute Coronary Syndrome Patients on Clopidogrel. Eur Cardiol 2023; 18:e60. [PMID: 38023338 PMCID: PMC10658354 DOI: 10.15420/ecr.2023.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background The ABCD-GENE score, which links cytochrome P450 2C19 (CYP2C19) phenotype and high platelet reactivity (HPR) to the risk of major adverse cardiovascular events (MACE) in clopidogrel users, has been validated in white and Japanese populations. The prognostic implications of the score in other Asian cohorts, however, have been largely unchartered. The aim of this study was to validate the prognostic utility of the ABCD-GENE score in a heterogeneous Asian acute coronary syndrome (ACS) cohort. Methods and Results In this single-centre, retrospective cohort evaluation of 423 ACS patients, the objectives were to characterise the best cut-off score for MACE prognostication by comparing the adjusted 1-year risk of MACE between groups above and below the candidate cut-off scores using Cox regression; and for on-clopidogrel HPR prediction using receiver operating characteristic (ROC) analysis and Youden's index. In the adjusted Cox model, an ABCD-GENE score cut-off at 10 points significantly predicts the 1-year risk of MACE (adjusted HR 3.771; 95% CI [1.041-13.661]). Female sex, baseline LDL, history of ACS and angiotensin receptor blocker use were additional independent predictors of MACE. On ROC analysis the ideal cut-off for HPR prediction was 7 points. However, that did not independently predict the 1-year risk of MACE (adjusted HR 1.595; 95% CI [0.425-5.989]). Conclusion The original ABCD-GENE score 10-point cut-off moderately predicts MACE in a heterogeneous, Asian ACS population at 1 year. Additional predictors of MACE were also identified in the present cohort, and these findings should be prospectively validated in larger ACS cohorts.
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Affiliation(s)
| | - David Bin-Chia Wu
- Saw Swee Hock School of Public Health, National University of SingaporeSingapore
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17
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Chanfreau-Coffinier C, Friede KA, Plomondon ME, Lee KM, Lu Z, Lynch JA, DuVall SL, Vassy JL, Waldo SW, Cleator JH, Maddox TM, Rader DJ, Assimes TL, Damrauer SM, Tsao PS, Chang KM, Voora D, Giri J, Tuteja S. CYP2C19 Polymorphisms and Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) in the Million Veterans Program. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.25.23297578. [PMID: 37961335 PMCID: PMC10635203 DOI: 10.1101/2023.10.25.23297578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background CYP2C19 loss-of-function (LOF) alleles decrease the antiplatelet effect of clopidogrel following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). The impact of genotype in stable ischemic heart disease (SIHD) is unclear. Objectives Determine the association of CYP2C19 genotype with major adverse cardiac events (MACE) after PCI for ACS or SIHD. Methods Million Veterans Program (MVP) participants age <65 years with a PCI documented in the VA Clinical Assessment, Reporting and Tracking (CART) Program between 1/1/2009 to 9/30/2017, treated with clopidogrel were included. Time to MACE defined as the composite of all-cause death, stroke or myocardial infarction within 12 months following PCI. Results Among 4,461 Veterans (mean age 59.1 ± 5.1 years, 18% Black); 44% had ACS, 56% had SIHD and 29% carried a CYP2C19 LOF allele. 301 patients (6.7%) experienced MACE while being treated with clopidogrel, 155 (7.9%) in the ACS group and 146 (5.9%) in the SIHD group. Overall, MACE was not significantly different between LOF carriers vs. noncarriers (adjusted hazard ratio [HR] 1.18, confidence interval [95%CI] 0.97-1.45, p=0.096). Among patients presenting with ACS, MACE risk in LOF carriers versus non-carriers was numerically higher (HR 1.30, 95%CI 0.98-1.73, p=0.067). There was no difference in MACE risk in patients with SIHD (HR 1.09, 95%CI 0.82-1.44; p=0.565). Conclusions CYP2C19 LOF carriers presenting with ACS treated with clopidogrel following PCI experienced a numerically greater elevated risk of MACE events. CYP2C19 LOF genotype is not associated with MACE among patients presenting with SIHD.
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Affiliation(s)
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mary E. Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Kyung Min Lee
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Zhenyu Lu
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Julie A. Lynch
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott L. DuVall
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jason L. Vassy
- VA Boston Healthcare System, Harvard Medical School, and Brigham and Women’s Hospital, Boston, MA
| | - Stephen W. Waldo
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
- Rocky Mountain Regional VA Medical Center and University of Colorado School of Medicine, Aurora, CO
| | | | - Thomas M. Maddox
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel J. Rader
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Scott M. Damrauer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Philip S. Tsao
- VA Palo Alto Healthcare System and Stanford University, Palo Alto, CA
| | - Kyong-Mi Chang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Deepak Voora
- Durham VA Healthcare System and Duke University, Durham, NC
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Preys CL, Blout Zawatsky CL, Massmann A, Heukelom JV, Green RC, Hajek C, Hickingbotham MR, Zoltick ES, Schultz A, Christensen KD. Attitudes about pharmacogenomic testing vary by healthcare specialty. Pharmacogenomics 2023; 24:539-549. [PMID: 37458095 PMCID: PMC10621761 DOI: 10.2217/pgs-2023-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023] Open
Abstract
Aim: To understand how attitudes toward pharmacogenomic (PGx) testing among healthcare providers varies by specialty. Methods: Providers reported comfort ordering PGx testing and its perceived utility on web-based surveys before and after genetics education. Primary quantitative analyses compared primary care providers (PCPs) to specialty providers at both timepoints. Results: PCPs were more likely than specialty care providers to rate PGx testing as useful at both timepoints. Education increased comfort ordering PGx tests, with larger improvements among PCPs than specialty providers. Over 90% of cardiology and internal medicine providers rated PGx testing as useful at pre- and post-education. Conclusion: PCPs overwhelmingly perceive PGx to be useful, and provider education is particularly effective for improving PCPs' confidence. Education for all specialties will be essential to ensure appropriate integration into routine practice.
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Affiliation(s)
- Charlene L Preys
- MGH Institute of Health Professions, Charlestown, MA 02129, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Carrie L Blout Zawatsky
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Ariadne Labs, Boston, MA 02215, USA
| | - Amanda Massmann
- Sanford Imagenetics, Sanford Health, Sioux Falls, SD 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermilion, SD 57069, USA
| | - Joel Van Heukelom
- Sanford Imagenetics, Sanford Health, Sioux Falls, SD 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermilion, SD 57069, USA
| | - Robert C Green
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Ariadne Labs, Boston, MA 02215, USA
- Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA
| | - Catherine Hajek
- Sanford Imagenetics, Sanford Health, Sioux Falls, SD 57105, USA
- Helix OpCo, LLC, San Diego, CA 92121, USA
| | - Madison R Hickingbotham
- Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA
| | - Emilie S Zoltick
- Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA
| | - April Schultz
- Sanford Imagenetics, Sanford Health, Sioux Falls, SD 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermilion, SD 57069, USA
| | - Kurt D Christensen
- Ariadne Labs, Boston, MA 02215, USA
- Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA 02115, USA
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19
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [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: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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20
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Rocca B, Patrono C. Precision antiplatelet therapy. Res Pract Thromb Haemost 2023; 7:100138. [PMID: 37215094 PMCID: PMC10193296 DOI: 10.1016/j.rpth.2023.100138] [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: 01/03/2023] [Revised: 02/23/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
A State of the Art lecture titled "Personalizing Antiplatelet Therapy Based on Platelet Turnover and Metabolic Phenotype" was presented by Bianca Rocca at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2022. Increased variability in drug response may be associated with serious, mechanism-based and off-target side effects, especially in the case of drugs that do not routinely undergo therapeutic drug monitoring, such as antiplatelet drugs or direct oral anticoagulants. Precision pharmacology can be defined as the identification of a drug regimen that maximizes the benefit/risk balance at the level of an individual patient. Key tools for identifying relevant sources of variability and developing precision drug dosing are represented by genetic, biochemical, and pharmacological biomarkers recognized as a valid surrogate or strong predictor of major clinical complications. Pharmacodynamic, pharmacokinetic, and/or disease-related biomarkers are central to identifying the right population to be targeted, characterizing the sources of variability in drug response, guiding precision treatments that maximize benefits and minimize risks, and designing precision dosing trials. Another valuable tool for guiding precision pharmacology is represented by in silico pharmacokinetic/pharmacodynamic models and simulations instructed by real-world data of validated biomarkers. This review critically analyzes the tools for precision dosing and exemplifies conditions in which precision dosing can considerably optimize the efficacy and safety of antiplatelet drugs, namely aspirin and P2Y12 receptor blockers, used alone and in combination. Finally, we summarize relevant new data on this topic presented during the 2022 ISTH Congress.
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Affiliation(s)
- Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine and Fondazione Policlinico Universitario Agostino Gemelli and Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Carlo Patrono
- Section of Pharmacology, Catholic University School of Medicine and Fondazione Policlinico Universitario Agostino Gemelli and Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
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21
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van den Broek WWA, Mani N, Azzahhafi J, Ten Berg JM. CYP2C9 Polymorphisms and the Risk of Cardiovascular Events in Patients Treated with Clopidogrel: Combined Data from the POPular Genetics and POPular AGE Trials. Am J Cardiovasc Drugs 2023; 23:165-172. [PMID: 36787094 PMCID: PMC10006245 DOI: 10.1007/s40256-022-00565-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND The cytochrome P450 (CYP) 2C9 enzyme plays a role in the metabolization of clopidogrel. Carriage of a CYP2C9 loss-of-function (LoF) allele has been associated with attenuated pharmacokinetics, leading to a diminished pharmacodynamic response and increased risk for developing stent thrombosis in patients treated with clopidogrel. METHODS In this study, we aimed to determine the effect of the CYP2C9*2 and *3 LoF alleles on thrombotic events. Therefore, a post hoc analysis was performed in 878 patients with available CYP2C9 genotype status included in the POPular Genetics and POPular Age trials, which enrolled patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, respectively. The primary thrombotic outcome was a composite of cardiovascular death, myocardial infarction or stroke. RESULTS A total of 526 (60%) patients were CYP2C9 LoF allele noncarriers and 352 (40%) were CYP2C9 LoF allele (*2 or *3) carriers. After correction for differences in baseline characteristics, there were no significant differences between CYP2C9 LoF allele carriers and noncarriers for the combined thrombotic outcome (6.3% vs. 5.9%, hazard ratio 1.16 [0.67-2.0], p = 0.60), or the individual thrombotic outcomes. Moreover, no differences were seen in the event rates for clinically relevant bleeding (Bleeding Academic Research Consortium [BARC] 2-5 bleeding) as well as major bleeding (BARC 3 or 5 bleeding). CONCLUSIONS Carriers of a CYP2C9 *2 or *3 LoF allele presenting with acute coronary syndrome and treated with clopidogrel did not have an increased risk for thrombotic events compared with noncarriers. Given the limited number of poor metabolizers, no firm conclusions could be drawn with regard to the thrombotic risk for patients carrying two CYP2C9 LoF alleles.
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Affiliation(s)
| | - Nabil Mani
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
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22
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Cavallari LH, Limdi NA, Beitelshees AL, Lee JC, Duarte JD, Franchi F, Tuteja S, Giri J, Empey PE, Kreutz RP, Skaar TC, Allen JM, Coons JC, Gong Y, McDonough CW, Stevenson JM, Thomas CD, Johnson JA, Stouffer GA, Angiolillo DJ, Lee CR. Evaluation of Potential Racial Disparities in CYP2C19-Guided P2Y 12 Inhibitor Prescribing After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2023; 113:615-623. [PMID: 36306392 PMCID: PMC9957848 DOI: 10.1002/cpt.2776] [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] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/21/2022] [Indexed: 01/16/2023]
Abstract
Black patients suffer worse outcomes after percutaneous coronary intervention (PCI) than White patients. Inequities in antiplatelet prescribing may contribute to this health disparity. We compared P2Y12 inhibitor prescribing by race following CYP2C19 genotyping to guide antiplatelet therapy selection after PCI. Patients from 9 sites that performed clinical CYP2C19 genotyping after PCI were included. Alternative therapy (e.g., prasugrel or ticagrelor) was recommended for CYP2C19 no-function allele carriers, in whom clopidogrel is predicted to be less effective. The primary outcome was choice of P2Y12 inhibitor (clopidogrel vs. alternative therapy) based on genotype. Of 3,342 patients included, 2,448 (73%) were White, and 659 (20%) were Black. More Black than White patients had a no-function allele (34.3% vs. 29.7%, P = 0.024). At hospital discharge following PCI, 44.2% of Black and 44.0% of White no-function allele carriers were prescribed alternative therapy. At the time of the last follow-up within 12 months, numerically fewer Black (51.8%) than White (56.7%) no-function allele carriers were prescribed alternative therapy (P = 0.190). However, the difference was not significant after accounting for other factors associated with P2Y12 inhibitor selection (odds ratio 0.79, 95% confidence interval 0.58-1.08). Alternative therapy use did not differ between Black (14.3%) and White (16.7%) patients without a no-function allele (P = 0.232). Among real-world patients who received CYP2C19 testing after PCI, P2Y12 inhibitor prescribing rates did not differ between Black and White patients. Our data suggest an absence of racial disparity in genotype-guided antiplatelet prescribing among patients receiving CYP2C19 testing.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Nita A. Limdi
- Department of Neurology, Program for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, AL
| | - Amber L. Beitelshees
- University of Maryland School of Medicine, Department of Medicine and Program for Personalized and Genomic Medicine, Baltimore, MD
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | - John M. Allen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, FL
| | - James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
| | | | - Craig R. Lee
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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23
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Thomas CD, Williams AK, Lee CR, Cavallari LH. Pharmacogenetics of P2Y 12 receptor inhibitors. Pharmacotherapy 2023; 43:158-175. [PMID: 36588476 PMCID: PMC9931684 DOI: 10.1002/phar.2758] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Oral P2Y12 inhibitors are commonly prescribed for cardiovascular disease and include clopidogrel, prasugrel, and ticagrelor. Each of these drugs has its strengths and weaknesses. Prasugrel and ticagrelor are more potent inhibitors of platelet aggregation and were shown to be superior to clopidogrel in preventing major adverse cardiovascular events after an acute coronary syndrome and percutaneous coronary intervention (PCI) in the absence of genotyping. However, both are associated with an increased risk for non-coronary artery bypass-related bleeding. Clopidogrel is a prodrug requiring bioactivation, primarily via the CYP2C19 enzyme. Approximately 30% of individuals have a CYP2C19 no function allele and decreased or no CYP2C19 enzyme activity. Clopidogrel-treated carriers of a CYP2C19 no function allele have decreased exposure to the clopidogrel active metabolite and lesser inhibition of platelet aggregation, which likely contributed to reduced clopidogrel efficacy in clinical trials. The pharmacogenetic data for clopidogrel are most robust in the setting of PCI, but evidence is accumulating for other indications. Guidance is available from expert consensus groups and regulatory agencies to assist with integrating genetic information into P2Y12 inhibitor prescribing decisions, and CYP2C19 genotype-guided antiplatelet therapy after PCI is one of the most common examples of clinical pharmacogenetic implementation. Herein, we review the evidence for pharmacogenetic associations with clopidogrel response and outcomes with genotype-guided P2Y12 inhibitor selection and describe guidance to assist with pharmacogenetic implementation. We also describe processes for applying genotype data for P2Y12 inhibitor therapy selection and remaining gaps in the field. Ultimately, consideration of both clinical and genetic factors may guide selection of P2Y12 inhibitor therapy that optimally balances the atherothrombotic and bleeding risks.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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24
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Abstract
Inter-individual variability in drug response, be it efficacy or safety, is common and likely to become an increasing problem globally given the growing elderly population requiring treatment. Reasons for this inter-individual variability include genomic factors, an area of study called pharmacogenomics. With genotyping technologies now widely available and decreasing in cost, implementing pharmacogenomics into clinical practice - widely regarded as one of the initial steps in mainstreaming genomic medicine - is currently a focus in many countries worldwide. However, major challenges of implementation lie at the point of delivery into health-care systems, including the modification of current clinical pathways coupled with a massive knowledge gap in pharmacogenomics in the health-care workforce. Pharmacogenomics can also be used in a broader sense for drug discovery and development, with increasing evidence suggesting that genomically defined targets have an increased success rate during clinical development.
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25
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Application of Pharmacogenetics for the Use of Antiplatelet and Anticoagulant Drugs. CURRENT CARDIOVASCULAR RISK REPORTS 2023. [DOI: 10.1007/s12170-022-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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26
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Azzahhafi J, Broek WWAVD, Chan Pin Yin DRPP, Harmsze AM, van Schaik RHN, Ten Berg JM. The Clinical Implementation of CYP2C19 Genotyping in Patients with an Acute Coronary Syndrome: Insights From the FORCE-ACS Registry. J Cardiovasc Pharmacol Ther 2023; 28:10742484231210704. [PMID: 37899583 DOI: 10.1177/10742484231210704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Guidelines recommend prasugrel or ticagrelor for acute coronary syndrome (ACS) patients. However, these P2Y12 inhibitors increase bleeding risk compared to clopidogrel. Although genotype-guided P2Y12-inhibitor selection has been shown to reduce bleeding risk, data on its clinical implementation is lacking. METHODS The study included ACS patients receiving genotype-guided antiplatelet therapy, utilising either a point-of-care (POC) device or laboratory-based testing. We aimed to collect qualitative and quantitative data on genotyping, eligibility for de-escalation, physician adherence to genotype results, time to de-escalation and cost reduction. RESULTS Of the 1,530 patients included in the ACS registry from 2021 to 2023, 738 ACS patients treated with ticagrelor received a CYP2C19 genotype test. The median turnover time of genotyping was 6.3 hours (interquartile range [IQR], 3.2-16.7), with 82.3% of the genotyping results known within 24 hours after admission. POC genotyping exhibited significantly shorter turnaround times compared to laboratory-based testing (with respective medians of 5.7 vs 47.8 hours; P < .001). Of the genotyped patients, 81.7% were eligible for de-escalation which was carried out within 24 hours in 70.9% and within 48 h in 93.0%. The time to de-escalation was significantly shorter using POC (25.4 hours) compared to laboratory-based testing (58.9 hours; P < .001). Implementing this strategy led to a reduction of €211,150.50 in medication costs. CONCLUSIONS CYP2C19 genotype-guided-de-escalation in an all-comers ACS population is feasible. POC genotyping leads to shorter turnaround times and quicker de-escalation. Time to de-escalation from ticagrelor to clopidogrel in noncarriers was short, with high physician adherence to genotype results.
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Affiliation(s)
- Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Ankie M Harmsze
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, the Netherlands
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27
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Cascorbi I. Polypharmazie – Interaktionen bei älteren Menschen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1911-8015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ZusammenfassungThrombozytenaggregationshemmer und Antikoagulanzien sind wichtige Standardmedikationen in der Prophylaxe und Therapie kardiovaskulärer Erkrankungen. Die oft multiple Medikation und durch
zusätzliche Begleiterkrankungen notwendige weitere Medikation birgt besonders bei älteren Patienten ein hohes Risiko von Arzneimittelwechselwirkungen. Diese können das Blutungsrisiko oder im
Fall des Wirkungsverlusts das Risiko thromboembolischer Ereignisse erhöhen. In diesem Artikel werden klinisch relevante Interaktionen von COX-Hemmern (COX: Cyclooxygenase) und
Adenosinrezeptorantagonisten sowie von Vitamin-K-Antagonisten und direkten oralen Antikoagulanzien (DOAK) wie auch Strategien zur Vermeidung unerwünschter Wirkungen diskutiert.
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Affiliation(s)
- Ingolf Cascorbi
- Institut für Experimentelle und Klinische Pharmakologie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Deutschland
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28
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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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29
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van den Broek WWA, Ten Berg JM. Is a genotype-guided therapy the optimal strategy to personalize anti-thrombotic management in patients with acute coronary syndrome? Eur Heart J 2022; 43:4599-4600. [PMID: 35678582 DOI: 10.1093/eurheartj/ehac219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Wout W A van den Broek
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Utrecht 3435 CM, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Utrecht 3435 CM, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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30
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Lu HF, Liu TY, Chou YP, Chang SS, Hsieh YW, Chang JG, Tsai FJ. Comprehensive characterization of pharmacogenes in a Taiwanese Han population. Front Genet 2022; 13:948616. [PMID: 36092904 PMCID: PMC9452738 DOI: 10.3389/fgene.2022.948616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Abstract
Pharmacogenetic (PGx) testing has not been well adopted in current clinical practice. The phenotypic distribution of clinically relevant pharmacogenes remains to be fully characterized in large population cohorts. In addition, no study has explored actionable PGx alleles in the East Asian population at a large scale. This study comprehensively analyzed 14 actionable pharmacogene diplotypes and phenotypes in 172,854 Taiwanese Han individuals by using their genotype data. Furthermore, we analyzed data from electronic medical records to investigate the effect of the actionable phenotypes on the individuals. The PGx phenotype frequencies were comparable between our cohort and the East Asian population. Overall, 99.9% of the individuals harbored at least one actionable PGx phenotype, and 29% of them have been prescribed a drug to which they may exhibit an atypical response. Our findings can facilitate the clinical application of PGx testing and the optimization of treatment and dosage individually.
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Affiliation(s)
- Hsing-Fang Lu
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Ting-Yuan Liu
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Pao Chou
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Yow-Wen Hsieh
- Department of Pharmacy, China Medical University Hospital, Taichung, Taiwan
- School of Pharmacy, College of Pharmacy, China Medical University, Taichung, Taiwan
| | - Jan-Gowth Chang
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
- Epigenome Research Center, China Medical University Hospital, Taichung, Taiwan
- *Correspondence: Jan-Gowth Chang, ; Fuu-Jen Tsai,
| | - Fuu-Jen Tsai
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
- Division of Medical Genetics, Children’s Hospital of China Medical University, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
- *Correspondence: Jan-Gowth Chang, ; Fuu-Jen Tsai,
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31
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Nguyen AB, Cavallari LH, Rossi JS, Stouffer GA, Lee CR. Evaluation of race and ethnicity disparities in outcome studies of CYP2C19 genotype-guided antiplatelet therapy. Front Cardiovasc Med 2022; 9:991646. [PMID: 36082121 PMCID: PMC9445150 DOI: 10.3389/fcvm.2022.991646] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022] Open
Abstract
Dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin remains the standard of care for all patients undergoing percutaneous coronary intervention (PCI). It is well-established that patients carrying CYP2C19 no function alleles have impaired capacity to convert clopidogrel into its active metabolite and thus, are at higher risk of major adverse cardiovascular events (MACE). The metabolism and clinical effectiveness of prasugrel and ticagrelor are not affected by CYP2C19 genotype, and accumulating evidence from multiple randomized and observational studies demonstrates that CYP2C19 genotype-guided antiplatelet therapy following PCI improves clinical outcomes. However, most antiplatelet pharmacogenomic outcome studies to date have lacked racial and ethnic diversity. In this review, we will (1) summarize current guideline recommendations and clinical outcome evidence related to CYP2C19 genotype-guided antiplatelet therapy, (2) evaluate the presence of potential racial and ethnic disparities in the major outcome studies supporting current genotype-guided antiplatelet therapy recommendations, and (3) identify remaining knowledge gaps and future research directions necessary to advance implementation of this precision medicine strategy for dual antiplatelet therapy in diverse, real-world clinical settings.
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Affiliation(s)
- Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, United States
| | - Joseph S. Rossi
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - George A. Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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32
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Thomas CD, Franchi F, Keeley EC, Rossi JS, Winget M, David Anderson R, Dempsey AL, Gong Y, Gower MN, Kerensky RA, Kulick N, Malave JG, McDonough CW, Mulrenin IR, Starostik P, Beitelshees AL, Johnson JA, Stouffer GA, Winterstein AG, Angiolillo DJ, Lee CR, Cavallari LH. Impact of the ABCD-GENE Score on Clopidogrel Clinical Effectiveness after PCI: A Multi-Site, Real-World Investigation. Clin Pharmacol Ther 2022; 112:146-155. [PMID: 35429163 PMCID: PMC9233085 DOI: 10.1002/cpt.2612] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
The Age, Body mass index, Chronic kidney disease, Diabetes mellitus, and CYP2C19 GENEtic variants (ABCD-GENE) score was developed to identify patients at risk for diminished antiplatelet effects with clopidogrel after percutaneous coronary intervention (PCI). The objective of this study was to validate the ability of the ABCD-GENE score to predict the risk for atherothrombotic events in a diverse, real-world population of clopidogrel-treated patients who underwent PCI and received clinical CYP2C19 genotyping to guide antiplatelet therapy. A total of 2,341 adult patients who underwent PCI, were genotyped for CYP2C19, and received treatment with clopidogrel across four institutions were included (mean age 64 ± 12 years, 35% women, and 20% Black). The primary outcome was major atherothrombotic events, defined as the composite of all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or revascularization for unstable angina within 12 months following PCI. Major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, myocardial infarction, ischemic stroke, or stent thrombosis, was assessed as the secondary outcome. Outcomes were compared between patients with an ABCD-GENE score ≥ 10 vs. < 10. The risk of major atherothrombotic events was higher in patients with an ABCD-GENE score ≥ 10 (n = 505) vs. < 10 (n = 1,836; 24.6 vs. 14.7 events per 100 patient-years, adjusted hazard ratio (HR) 1.66, 95% confidence interval (CI), 1.23-2.25, P < 0.001). The risk for MACE was also higher among patients with a score ≥ 10 vs. < 10 (16.7 vs. 10.1 events per 100 patient-years, adjusted HR 1.59, 95% CI 1.11-2.30, P = 0.013). Our diverse, real-world data demonstrate diminished clopidogrel effectiveness in post-PCI patients with an ABCD-GENE score ≥ 10.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marshall Winget
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R David Anderson
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Alyssa L Dempsey
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Megan N Gower
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard A Kerensky
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jean G Malave
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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