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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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Park DY, Hu JR, Campbell G, Goldwag K, Kelsey MD, Altin SE, Gallegos-Kattán C, Nanna MG. Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101859. [PMID: 39131993 PMCID: PMC11307649 DOI: 10.1016/j.jscai.2024.101859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/06/2024] [Accepted: 02/20/2024] [Indexed: 08/13/2024]
Abstract
Background Patients with type 2 diabetes mellitus (DM) comprise more than a quarter of all patients undergoing percutaneous coronary intervention and are at higher risk of adverse events. We sought to reexamine the optimal duration of dual antiplatelet therapy (DAPT) postpercutaneous coronary intervention in patients with DM. Methods We systematically included randomized controlled trials comparing any 2 of 1, 3, 6, and 12 months of DAPT that reported major adverse cardiovascular events (MACE), net adverse clinical events (NACE), bleeding, or stent thrombosis in DM, and performed a frequentist network meta-analysis. We also performed a sensitivity analysis of trials that exclusively enrolled patients with acute coronary syndrome. Results In 16 randomized controlled trials comprising 16,376 adults with DM, there was no significant difference in NACE, MACE, stent thrombosis, or major bleeding between pairwise comparisons of 1, 3, 6, and 12 months of DAPT, except for a signal for lower bleeding with 3 months of DAPT compared to 12 (risk ratio, 0.72; 95% CI, 0.51-0.99). Sensitivity analysis of trials that solely included acute coronary syndrome similarly showed no significant difference in MACE between 1, 3, 6, and 12 months of DAPT. Conclusions Our study found no meaningful difference in NACE or MACE between pairwise comparisons of 1, 3, 6, and 12 months of DAPT by study-level meta-analysis of patients with DM, with lower bleeding risk observed with 3 months than with 12 months of DAPT. This finding may provide clinicians greater flexibility to personalize patients' DAPT duration based on other non-DM comorbidities that might affect bleeding or thrombosis risk.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Greta Campbell
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kiara Goldwag
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - S. Elissa Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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Ifthikar S, Savoj J, Singh H, Hu P. SARS-CoV-2: Current Tools to Fight COVID-19 ST-Elevation Myocardial Infarction. Cureus 2023; 15:e43539. [PMID: 37719620 PMCID: PMC10501174 DOI: 10.7759/cureus.43539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
The capacity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to wreak havoc on the inflammatory and coagulation pathways via the cytokine storm has led to over 6.3 million fatalities globally. Based on recent data, the mechanism predominately involves the formation of microvascular thrombosis when pertaining to cardiovascular disease. However, a subset of coronavirus disease-2019 (COVID-19)-positive patients present emergently with acute ST-elevation myocardial infarction (STEMI) are found to have severe epicardial thrombosis which is refractory to traditional coronary revascularization. We have noted mortality in these patients presenting to our facility to be as high as 90% and all angiographically confirmed to have thrombus which was refractory to traditional therapy. We present a case series of COVID-19-positive patients presenting with STEMI found to have epicardial thrombus who were treated with different traditional STEMI therapies but with fatal outcomes. Other possible techniques including mechanical thrombectomy, optimizing traditional and nontraditional anticoagulation therapy with the use of early hemodynamic support may prove more efficacious to destroy thrombus and potentially improve mortality.
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Affiliation(s)
- Syed Ifthikar
- Cardiology, HCA Healthcare Riverside, Riverside, USA
| | - Javad Savoj
- Cardiology, HCA Healthcare Riverside, Riverside, USA
| | - Harjeet Singh
- Internal Medicine, HCA Healthcare Riverside, Riverside, USA
| | - Patrick Hu
- Interventional Cardiology, HCA Healthcare Riverside, Riverside, USA
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Schilling U, Dingemanse J, Ufer M. Pharmacokinetics and Pharmacodynamics of Approved and Investigational P2Y12 Receptor Antagonists. Clin Pharmacokinet 2021; 59:545-566. [PMID: 32056160 DOI: 10.1007/s40262-020-00864-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronary artery disease remains the major cause of mortality worldwide. Antiplatelet drugs such as acetylsalicylic acid and P2Y12 receptor antagonists are cornerstone treatments for the prevention of thrombotic events in patients with coronary artery disease. Clopidogrel has long been the gold standard but has major pharmacological limitations such as a slow onset and long duration of effect, as well as weak platelet inhibition with high inter-individual pharmacokinetic and pharmacodynamic variability. There has been a strong need to develop potent P2Y12 receptor antagonists with more favorable pharmacological properties. Prasugrel and ticagrelor are more potent and have a faster onset of action; however, they have shown an increased bleeding risk compared with clopidogrel. Cangrelor is highly potent and has a very rapid onset and offset of effect; however, its indication is limited to P2Y12 antagonist-naïve patients undergoing percutaneous coronary intervention. Two novel P2Y12 receptor antagonists are currently in clinical development, namely vicagrel and selatogrel. Vicagrel is an analog of clopidogrel with enhanced and more efficient formation of its active metabolite. Selatogrel is characterized by a rapid onset of action following subcutaneous administration and developed for early treatment of a suspected acute myocardial infarction. This review article describes the clinical pharmacology profile of marketed P2Y12 receptor antagonists and those under development focusing on pharmacokinetic, pharmacodynamic, and drug-drug interaction liability.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
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Xu H, Bonaca MP, Goodrich E, Scirica BM, Morrow DA. Efficacy and safety of vorapaxar for secondary prevention in low body weight in patients with atherosclerosis: analyses from the TRA 2°P-TIMI 50 Trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:190–199. [PMID: 31642690 DOI: 10.1177/2048872619883354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/28/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vorapaxar inhibits the thrombin-mediated activation of platelets, reduces thrombotic events in patients with myocardial infarction or peripheral arterial disease while increasing bleeding. In the TRA 2°P-TIMI 50 trial, we observed a nominally significant interaction between low body weight and the reduced efficacy of vorapaxar. METHODS We investigated the relationship between body weight and the efficacy and safety of vorapaxar within a multinational, randomized, double-blind, placebo-controlled trial of vorapaxar in patients with atherosclerosis. This analysis was performed among 20,138 patients with a clinical indication for vorapaxar. RESULTS Compared with patients weighing 60 kg or more, patients weighing less than 60 kg were older, more frequently women, Asian and had renal insufficiency (each P<0.001). The efficacy of vorapaxar with respect to cardiovascular death, myocardial infarction and stroke showed a significant interaction with patients' weight (Pinteraction<0.03). However among patients younger than 65 years, vorapaxar reduced the primary endpoint regardless of weight (weight ≥60 kg: 6.4% vs. 8.1%, hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.65-0.86; weight <60 kg: 5.4% vs. 7.2%, HR 0.75, 95% CI 0.37-1.49, Pinteraction=0.98). Among patients aged 65 years and older, the efficacy of vorapaxar diminished in patients weighing less than 60 kg (high weight: 10.4% vs. 12.6%, HR 0.81, 95% CI 0.69-0.95; low weight: 16.1% vs. 9.0%, HR 1.62, 95% CI 0.95-2.76, Pinteraction=0.01). The relative increase in bleeding with vorapaxar was not modified by weight (all Pinteraction>0.05). CONCLUSIONS Vorapaxar reduced vascular events and improved net clinical outcome regardless of body weight in younger patients. Elderly patients with low weight may not be good candidates for aggressive secondary prevention with vorapaxar added to standard therapy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov Unique identifier: NCT00526474.
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Affiliation(s)
- Haiyan Xu
- TIMI Study Group, Brigham and Women's Hospital, USA
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Capranzano P, Angiolillo DJ. Antithrombotic Management of Elderly Patients With Coronary Artery Disease. JACC Cardiovasc Interv 2021; 14:723-738. [PMID: 33826494 DOI: 10.1016/j.jcin.2021.01.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/13/2023]
Abstract
Antithrombotic therapy represents the mainstay of treatment in patients with coronary artery disease (CAD), including elderly patients who are at increased risk for ischemic recurrences. However, the elderly population is also more vulnerable to bleeding complications. Numerous mechanisms, including abnormalities in the vasculature, thrombogenicity, comorbidities, and altered drug response, contribute to both increased thrombotic and bleeding risk. Age-related organ changes and drug-drug interactions secondary to polypharmacy lead to distinct pharmacokinetic and pharmacodynamic profiles of antithrombotic drugs. Overall these factors contribute to the risk-benefit profiles of antithrombotic therapies in elderly subjects and underscore the need for treatment regimens that can reduce bleeding while preserving efficacy. Given that the prevalence of CAD, as well as concomitant diseases with thromboembolic potential, such as atrial fibrillation, increases with age and that the elderly population is in continuous growth, understanding the safety and efficacy of different antithrombotic regimens is pivotal for patient-centered care. In the present overview the authors appraise the available data on the use of antithrombotic therapy in older patients with CAD to assist with the management of this high-risk population and define knowledge gaps that can set the basis for future research.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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Abstract
Patients with coronary artery disease (CAD) presenting with acute coronary syndrome or undergoing coronary stenting are indicated to treatment with dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 receptor inhibitor. The management of patients with CAD who present with a complex clinical profile due to multiple comorbidities, and/or undergoing complex interventional procedures, remains challenging as a high risk for both ischemic and bleeding events is often present; hence, the risk-benefit balance on the optimal DAPT duration is difficult to evaluate. The complexity of antiplatelet therapy in CAD patients is due to the fact that this complexity embraces several aspects: the coronary anatomy, the number of vascular districts at risk for atherothrombosis, and patient comorbidities, including global frailty. Recent randomized and epidemiological studies have highlighted subgroups that could benefit from prolonged antithrombotic treatment, as well as frail patients, who may be better suited to a shorter course of therapy. We provide an overview of the current knowledge regarding treatment with DAPT, along with suggestions on its management.
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Menichelli M, Neumann FJ, Ndrepepa G, Mayer K, Wöhrle J, Bernlochner I, Richardt G, Witzenbichler B, Sibbing D, Gewalt S, Angiolillo DJ, Lahu S, Hamm CW, Hapfelmeier A, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Age- and Weight-Adapted Dose of Prasugrel Versus Standard Dose of Ticagrelor in Patients With Acute Coronary Syndromes : Results From a Randomized Trial. Ann Intern Med 2020; 173:436-444. [PMID: 32687741 DOI: 10.7326/m20-1806] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The efficacy and safety of a reduced dose of prasugrel versus a standard dose of ticagrelor in elderly patients or those with a low body weight presenting with an acute coronary syndrome (ACS) are unknown. OBJECTIVE To investigate the effect of an age- and weight-adapted dose of prasugrel versus a standard dose of ticagrelor in patients with ACS. (ClinicalTrials.gov: NCT01944800). DESIGN Prespecified analysis of the multicenter, randomized ISAR-REACT 5 trial. SETTING 23 centers in Germany and Italy. PATIENTS 3997 patients with ACS planned for invasive management. INTERVENTION Participants were randomly assigned to receive a standard dose of ticagrelor or prasugrel (reduced dose in the elderly or low-weight group and standard dose in the neither elderly nor low-weight group). MEASUREMENTS The efficacy end point was a composite of death, myocardial infarction, or stroke, and the safety end point was bleeding, both at 12 months. RESULTS In the elderly or low-weight group, the efficacy end point occurred in 12.7% of patients assigned to receive prasugrel and 14.6% of those assigned to receive ticagrelor (hazard ratio [HR], 0.82 [95% CI, 0.60 to 1.14]); in the neither elderly nor low-weight group, the efficacy end point occurred in 4.8% of patients assigned to receive prasugrel and 7.3% of those assigned to receive ticagrelor (HR, 0.65 [CI, 0.48 to 0.88]; P for interaction > 0.2). In the elderly or low-weight group, Bleeding Academic Research Consortium type 3 to 5 bleeding occurred in 8.1% of patients assigned to receive prasugrel and 10.6% of those assigned to receive ticagrelor (HR, 0.72 [0.46 to 1.12]), and in 3.7% and 3.8%, respectively, of patients in the neither elderly nor low-weight group (HR, 0.98 [CI, 0.65 to 1.47]; P for interaction > 0.2). LIMITATION The study is a subgroup analysis. CONCLUSION In elderly or low-weight patients with ACS, a reduced dose of prasugrel compared with the standard dose of ticagrelor is associated with maintained anti-ischemic efficacy while protecting these patients against the excess risk for bleeding. PRIMARY FUNDING SOURCE German Center for Cardiovascular Research and Deutsches Herzzentrum München.
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Affiliation(s)
| | - Franz-Josef Neumann
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (F.N., D.T.)
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Katharina Mayer
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Jochen Wöhrle
- Medical Campus Lake Constance, Friedrichshafen, Germany (J.W.)
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (I.B.)
| | - Gert Richardt
- Heart Center Bad Segeberg, Bad Segeberg, Germany (G.R.)
| | | | - Dirk Sibbing
- Klinik der Universität München, Ludwig-Maximilians-Universität, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (D.S.)
| | - Senta Gewalt
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | | | - Shqipdona Lahu
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Christian W Hamm
- Heart Center, Campus Kerckhoff of Justus-Liebig-University, Giessen, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany (C.W.H.)
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute of Medical Informatics, Statistics and Epidemiology, Munich, Germany (A.H.)
| | - Dietmar Trenk
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (F.N., D.T.)
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (K.L.)
| | - Heribert Schunkert
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
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Maekawa Y, Furuie H, Kato M, Myobatake Y, Kamiyama E, Watanabe A, Shiosakai K, Taguchi T, Bass R, Zhou J, Dishy V, Warren V, Vashi V, Ishizuka H. Effect of DS-8500a, a Novel G Protein-Coupled Receptor 119 Agonist, on the Pharmacokinetics of Rosuvastatin and Atorvastatin in Healthy Subjects. Clin Drug Investig 2019; 39:967-978. [DOI: 10.1007/s40261-019-00825-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Moser BA, LaBell ES, Chigutsa E, Jakubowski JA, Small DS. Population Pharmacokinetic and Exposure-Response Analyses of Prasugrel in Pediatric Patients with Sickle Cell Anemia. Clin Pharmacokinet 2019; 57:243-254. [PMID: 28578536 DOI: 10.1007/s40262-017-0556-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVE Prasugrel, a P2Y12 adenosine diphosphate (ADP) receptor antagonist, inhibits ADP-mediated platelet activation and aggregation in patients with sickle cell anemia (SCA). We developed a population pharmacokinetic (popPK) model in pediatric patients from 2 to <18 years of age with SCA, and performed exposure-response evaluations to characterize the effects of prasugrel in a subset of these patients who weighed 19 kg or more and experienced at least two episodes of vaso-occlusive crises (VOC) in the past year. METHODS A three-compartment popPK model adapted from that used in adults with acute coronary syndrome was used to describe the relationship between plasma concentrations of prasugrel's active metabolite (Pras-AM) and time using data from phase II and III clinical studies in children. A VOC event rate model was developed from the phase III study to explore the exposure-response relationship between Pras-AM exposure and VOC, and included evaluation of covariates. RESULTS The final popPK model for children with SCA provided a reasonable fit to Pras-AM plasma concentrations over time, with estimates of apparent clearance (CL/F) (172 L/h) and apparent volume of distribution (Vd/F) (51.7 L) that were comparable to previous studies in adults. The final model included weight as a covariate on both CL/F and Vd/F, and age as a covariate on CL/F. Analyses of safety (bleeding events requiring medical intervention) and efficacy (VOC event rate) variables showed no apparent relationship to model-predicted Pras-AM exposure quartiles, and no statistically significant effects of intrinsic or extrinsic factors on the VOC event rate were identified in the VOC event rate model. The effect of post hoc exposures on the VOC event rate did not reach statistical significance. CONCLUSIONS A popPK model was developed that provided reasonable parameter estimates, goodness-of-fit diagnostics, and visual predictive checks when applied to Pras-AM plasma concentrations in pediatric patients with SCA. Post hoc exposures obtained from this model did not correlate with measures of VOC or bleeding events in this population.
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Affiliation(s)
- Brian A Moser
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA.
| | - Elizabeth S LaBell
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - Emmanuel Chigutsa
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - Joseph A Jakubowski
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - David S Small
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
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Ohya M, Shimada T, Osakada K, Kuwayama A, Miura K, Murai R, Amano H, Kubo S, Otsuru S, Habara S, Tada T, Tanaka H, Fuku Y, Katoh H, Goto T, Kadota K. In-Hospital Bleeding and Utility of a Maintenance Dose of Prasugrel 2.5 mg in High Bleeding Risk Patients With Acute Coronary Syndrome. Circ J 2018; 82:1874-1883. [DOI: 10.1253/circj.cj-18-0114] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Kohei Osakada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital
| | - Hidewo Amano
- Department of Cardiology, Kurashiki Central Hospital
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Suguru Otsuru
- Department of Cardiology, Kurashiki Central Hospital
| | - Seiji Habara
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
| | - Harumi Katoh
- Department of Cardiology, Kurashiki Central Hospital
| | - Tsuyoshi Goto
- Department of Cardiology, Kurashiki Central Hospital
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13
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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14
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Niijima S, Ohmori T, Kario K. Differential impact of diabetes mellitus on antiplatelet effects of prasugrel and clopidogrel. Thromb J 2018; 16:5. [PMID: 29568240 PMCID: PMC5853094 DOI: 10.1186/s12959-017-0159-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Although prasugrel exerts stronger antiplatelet effects compared with clopidogrel, the factors affecting platelet reactivity under prasugrel have not been fully determined. This study aimed to find the novel mechanistic differences between two thienopyridines and identify the factor that influence platelet reactivity to each drug. Methods Forty patients with stable angina who underwent elective percutaneous coronary intervention were randomly assigned to receive either prasugrel (20 mg) or clopidogrel (300 mg) as a loading dose. Platelet function (light transmission, laser light scattering, and vasodilator-stimulated phosphoprotein phosphorylation) and plasma active metabolite levels were measured after the loading dose. Results Prasugrel consistently inhibited adenosine diphosphate receptor P2Y12 signalling to abolish amplification of platelet aggregation. Prasugrel abolished even small platelet aggregates composed of less than 100 platelets. On the other hand, clopidogrel inhibited large aggregates but increased small and medium platelet aggregates. Diabetes was the only independent variable for determining antiplatelet effects and active metabolite concentration of prasugrel, but not clopidogrel. Sleep-disordered breathing was significantly correlated with platelet reactivity in patients who had clopidogrel. Conclusions Prasugrel efficiently abolishes residual P2Y12 signalling that causes small platelet aggregates, but these small aggregates are not inhibited by clopidogrel. Considering the differential effect of diabetes on antiplatelet effects between these two drugs, the pharmacokinetics of prasugrel, other than cytochrome P450 metabolism, might be affected by diabetes. Trial registration UMIN-CTR UMIN000017624, retrospectively registered 21 May 2015.
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Affiliation(s)
- Satoshi Niijima
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Tsukasa Ohmori
- 2Department of Biochemistry, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Kazuomi Kario
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
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15
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Choi HH, Lee JJ, Cho YD, Han MH, Cho WS, Kim JE, An SJ, Mun JH, Yoo DH, Kang HS. Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel. Neurosurgery 2017; 83:981-988. [PMID: 29301051 DOI: 10.1093/neuros/nyx591] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022] Open
Abstract
Abstract
BACKGROUND
The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized.
OBJECTIVE
To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms.
METHODS
This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group).
RESULTS
P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization.
CONCLUSION
Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Dongk-uk University Hospital, Dongkuk Unive-rsity College of Medicine, Ilsan, Korea
| | - Jung Jun Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Joon An
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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16
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Orban M, Massberg S, Sibbing D. Potent P2Y12 receptor inhibitors in patients with acute coronary syndrome. Hamostaseologie 2017; 33:9-15. [DOI: 10.5482/hamo-12-12-0022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 12/19/2012] [Indexed: 11/05/2022] Open
Abstract
SummaryBlood platelets are highly activated in the setting of an acute coronary syndrome (ACS). This fact mandates the need for potent platelet inhibition in ACS patients and especially in patients undergoing a percutaneous coronary intervention (PCI). The 2nd generation thienopyridine clopidogrel has been the standard of treatment in the past. Due to its pharmacological properties including a delayed onset of action, a large response variability and an insufficient antiplatelet action in some patients (low responsiveness or high on-treatment platelet reactivity), there was a need to develop, to study and to introduce more potent agents with a fast, reliable and potent antiplatelet action. With the 3rd generation thienopyridine prasugrel and with ticagrelor two potent agents for antiplatelet treatment of ACS patients are available now. Both drugs have demonstrated their superiority compared to clopidogrel in terms of thrombotic risk reduction in large-scale randomized trials. However, for these agents and in line with the expectations towards a more potent anti platelet treatment regimen, a higher risk for bleeding was observed for prasugrel and ticagrelor. Further on, the new anti platelet agents have their own and characteristic contraindications and numerous issues to be considered in clinical practice.This review aims to provide an overview on the state of the art P2Y12 receptor directed inhibition in ACS patients with a focus on patients undergoing a coronary stenting procedure.
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17
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Tamburino C, Capodanno D, Miccichè E, D’Urso L, Calvi V, Angiolillo D, Tamburino C, Capranzano P. Platelet function profiles in the elderly: Results of a pharmacodynamic study in patients on clopidogrel therapy and effects of switching to prasugrel 5 mg in patients with high platelet reactivity. Thromb Haemost 2017; 106:1149-57. [DOI: 10.1160/th11-05-0346] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 09/23/2011] [Indexed: 11/05/2022]
Abstract
SummaryStudies specifically designed to assess clopidogrel response in the elderly as well as treatment alternatives to improve platelet inhibition in this highrisk population are lacking. This study aimed to define phar-macodynamic (PD) profiles, including high platelet reactivity (HPR) rates, among elderly patients on maintenance clopidogrel therapy and to assess the PD effects of prasugrel 5 mg/day in elderly with HPR. This was a prospective observational PD study enrolling consecutive ≥75-year-old patients on maintenance clopidogrel therapy (75 mg/day) who were tested for clopidogrel response by the VerifyNow P2Y12 assay and light transmittance aggregometry (LTA). HPR rates were estimated using multiple definitions. HPR patients identified by the VerifyNow P2Y12 assay [P2Y12 reaction unit (PRU) ≥230] were switched to prasugrel 5 mg/day, and platelet function testing was performed after 15 days of treatment. PD testing was completed in 100 patients. The HPR prevalence varied between 25% and 32%, depending on the definition used. A PRU ≥230 was observed in 25 patients; of these, 20 switched to prasugrel 5 mg/day. This resulted in significant reduction in PRU mean values (279.8 ± 45.1 vs. 171.7 ± 65.2, p=0.0002) with an absolute between-treatment difference of 108.1 (95% confidence intervals 75.2–140.9). Accordingly, switching to prasugrel 5 mg/day overcame HPR in most (80%) patients. Consistently, all LTA measures were significantly lower after prasugrel compared with clopidogrel. In conclusion, a considerable proportion of elderly patients exhibit HPR while on standard clopidogrel therapy. Switching to 5 mg/day prasugrel in elderly patients with HPR is associated with enhanced platelet inhibition and overcomes HPR in the majority of these patients.
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18
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Darlington A, Tello-Montoliu A, Rollini F, Ueno M, Ferreiro JL, Patel R, Desai B, Guzman L, Bass T, Angiolillo D. Pharmacodynamic effects of standard dose prasugrel versus high dose clopidogrel in non-diabetic obese patients with coronary artery disease. Thromb Haemost 2017; 111:258-65. [DOI: 10.1160/th13-07-0529] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/17/2013] [Indexed: 01/22/2023]
Abstract
SummaryIncreased body weight is independently associated with impaired clopidogrel pharmacodynamic (PD) response. Prasugrel has more potent PD effects compared with clopidogrel, although its PD effects in obese patients are unknown. The aim of this prospective, randomised, study was to compare the PD effects of standard-dose prasugrel [60 mg loading dose (LD)/10 mg daily maintenance dose (MD)] with highdose clopidogrel (900 mg LD/150 mg daily MD) in non-diabetic obese [body mass index (BMI) ≥30 kg/m2] patients, with coronary artery disease (CAD) on aspirin therapy. PD assessments (baseline, 2 hours post-LD and 6 ± 2 days after MD) were conducted using four platelet function assays, and the platelet reactivity index (PRI) assessed by VASP was used for sample size estimation. A total of 42 patients with a BMI of 36.42 ± 5.6 kg/m2 completed the study. There were no differences in baseline PD measures between groups. At 2 hours post-LD, prasugrel was associated with lower PRI compared with clopidogrel (24.3 ± 5.5 vs 58.7 ± 5.7, p≤0.001), with consistent findings for all assays. At one-week, PRI values on prasugrel MD were lower than clopidogrel MD without reaching statistical significance (34.7 ± 5.8 vs 42.9 ± 5.8, p=0.32), with consistent findings for all assays. Accordingly, rates of high on-treatment platelet reactivity were markedly reduced after prasugrel LD, but not after MD. In conclusion, in non-diabetic obese patients with CAD, standard prasugrel dosing achieved more potent PD effects than high-dose clopidogrel in the acute phase of treatment, but this was not sustained during maintenance phase treatment. Whether an intensified prasugrel regimen is required in obese patients warrants investigation.
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19
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Bottorff MB, Bright DR, Kisor DF. Commentary: Should Pharmacogenomic Evidence Be Considered in Clinical Decision Making? Focus on Select Cardiovascular Drugs. Pharmacotherapy 2017; 37:1005-1013. [DOI: 10.1002/phar.1979] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Michael B. Bottorff
- Department of Pharmacy Practice; College of Pharmacy, Natural and Health Sciences; Manchester University; Fort Wayne Indiana
| | - David R. Bright
- Department of Pharmaceutical Sciences; College of Pharmacy; Ferris State University; Grand Rapids Michigan
| | - David F. Kisor
- Department of Pharmaceutical Sciences; College of Pharmacy, Natural and Health Sciences; Manchester University; Fort Wayne Indiana
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20
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Tamargo J, Rosano G, Walther T, Duarte J, Niessner A, Kaski JC, Ceconi C, Drexel H, Kjeldsen K, Savarese G, Torp-Pedersen C, Atar D, Lewis BS, Agewall S. Gender differences in the effects of cardiovascular drugs. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:163-182. [DOI: 10.1093/ehjcvp/pvw042] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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21
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Conran N, Rees DC. Prasugrel hydrochloride for the treatment of sickle cell disease. Expert Opin Investig Drugs 2017; 26:865-872. [PMID: 28562105 DOI: 10.1080/13543784.2017.1335710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Therapeutic options for sickle cell disease (SCD) are limited and, currently, only one drug (hydroxyurea) has FDA approval for the treatment of adult SCD. While this genetic disease is caused by hemoglobin polymerization, subsequent downstream events trigger platelet activation, vaso-occlusion and the disease's complex pathophysiology. Areas covered: The oral thienopyridine, prasugrel hydrochloride, irreversibly inhibits the P2Y12 receptors, inhibiting ADP-dependent platelet activation. We discuss recent clinical trials evaluating the pharmokinetics of prasugrel and its potential for use in SCD. Expert opinion: Prasugrel administration in SCD appears to be well tolerated and safe. However, although this drug modestly inhibits platelet activity in these patients, administration of prasugrel to a large group of children and adolescents for up to 24 months failed to convincingly reduce vaso-occlusive complications. Speculatively, prasugrel may be of occasional use for off-license purposes in patients unable or unwilling to take hydroxyurea (particularly in 12-17-year olds). Although there is currently no prospect of prasugrel being licensed for use in SCD, the success of on-going trials of other antiplatelet agents in SCD might lead to further trials of prasugrel in SCD.
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Affiliation(s)
- Nicola Conran
- a Hematology Center , University of Campinas - UNICAMP, Cidade Universitaria , Campinas-SP , Brazil
| | - David C Rees
- b Department of Paediatric Haematology , King's College Hospital , London , UK
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22
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Jakubowski JA, Erlinge D, Alexopoulos D, Small DS, Winters KJ, Gurbel PA, Angiolillo DJ. The Rationale for and Clinical Pharmacology of Prasugrel 5 mg. Am J Cardiovasc Drugs 2017; 17:109-121. [PMID: 27854064 DOI: 10.1007/s40256-016-0202-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prasugrel is a third-generation thienopyridine platelet P2Y12 adenosine diphosphate (ADP) receptor antagonist administered with aspirin for the treatment of patients with acute coronary syndrome (ACS) with planned percutaneous coronary intervention. Prasugrel is administered periprocedurally at an oral loading dose of 60 mg followed by daily maintenance doses (MDs) of 10 mg for most patients and 5 mg for patients weighing <60 kg or aged ≥75 years. Data from a prasugrel phase III study, TRITON-TIMI 38, suggested that a lower MD might be more suitable for patients weighing <60 kg or aged ≥75 years; subsequent pharmacokinetic and pharmacodynamic studies have indicated that prasugrel 5 mg reduced platelet reactivity in these populations to an extent similar to that of prasugrel 10 mg in heavier or younger patients. Clinical experience with prasugrel 5 mg is limited, and additional studies are needed to verify the clinical efficacy and safety of this dose in these challenging populations.
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Affiliation(s)
- Joseph A Jakubowski
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, 46285, USA.
| | - David Erlinge
- Department of Cardiology, Lund University, Lund, Sweden
| | - Dimitrios Alexopoulos
- Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - David S Small
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, 46285, USA
| | - Kenneth J Winters
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana, 46285, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Baltimore, MD, USA
| | - Dominick J Angiolillo
- Cardiovascular Research Center at University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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23
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Umemura K, Ikeda Y, Matsushima N, Kondo K. Platelet Aggregation Inhibitory Effects and Pharmacokinetics of Prasugrel Used in Combination With Aspirin in Healthy Japanese Subjects. Clin Pharmacol Drug Dev 2016; 6:398-407. [PMID: 27652589 PMCID: PMC5516194 DOI: 10.1002/cpdd.308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/12/2016] [Indexed: 11/17/2022]
Abstract
We evaluated the pharmacokinetics and pharmacodynamics of prasugrel used in combination with aspirin in healthy Japanese subjects. All subjects received aspirin 100 mg/day. Subsequently, in the single‐administration study, 23 subjects also received prasugrel 20 or 30 mg, and in the multiple‐administration study, 20 subjects received a loading dose of prasugrel 20 or 30 mg on day 1, followed by a maintenance dose of prasugrel 5 or 7.5 mg/day, respectively, on days 2–5. In both studies, the plasma concentration of the active metabolite of prasugrel, R‐138727, reached a maximum 0.5 hours after administration and rapidly decreased within 4 hours. In the single‐administration study, the inhibitory effect on adenosine diphosphate–induced platelet aggregation was significantly higher in the prasugrel 20‐ and 30‐mg groups than in the placebo group at all times (1–144 hours) after administration. In the multiple‐administration study, a similar antiplatelet effect was found after both the loading dose and the maintenance dose and was maintained for 3–6 days after the last administration. There were study drug‐related adverse events; however, all were mild, and none was clinically significant.
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Affiliation(s)
- Kazuo Umemura
- Department of Pharmacology, Hamamatsu University School of Medicine, Hamamatsu-shi, Shizuoka, Japan
| | - Yasuhiko Ikeda
- Department of Pharmacology, Hamamatsu University School of Medicine, Hamamatsu-shi, Shizuoka, Japan.,Shin-nakagawa Hospital, Yokohama-shi, Kanagawa, Japan
| | - Nobuko Matsushima
- Translational Medicine and Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd, Shinagawa-ku, Tokyo, Japan.,Clinical Pharmacology Department, Janssen Pharmaceutical K.K. , Chiyoda-ku, Tokyo, Japan
| | - Kazunao Kondo
- Department of Pharmacology, Fujita Health University School of Medicine, Toyoake-shi, Aichi, Japan
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Umemura K, Ikeda Y, Kondo K. Pharmacokinetics and pharmacodynamics of prasugrel in healthy Japanese subjects. Drug Metab Pharmacokinet 2016; 31:285-91. [PMID: 27474356 DOI: 10.1016/j.dmpk.2016.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 10/22/2022]
Abstract
This randomized double-blind and placebo-controlled study assessed the pharmacodynamics and pharmacokinetics of prasugrel in healthy adult Japanese male subjects after single (n = 50) and multiple (n = 40) oral administration. With a single administration of prasugrel (2-30 mg), the plasma concentration of the active metabolite increased rapidly, reached a maximum at 30 min after administration, and then decreased rapidly within 4 h. The 5 mg and higher doses prevented ADP-induced platelet aggregation in a dose-dependent manner. Further analyses showed that 30 mg prasugrel exhibited the peak inhibition, and 20 mg prasugrel showed a nearly equivalent effect. With multiple doses (2.5-10 mg), the pharmacokinetic parameters on Day 1 and Day 7 were similar, and no accumulation attributable to multiple dosing was observed. The inhibitory effect on ADP-induced platelet aggregation increased with doses from 2.5 to 7.5 mg, and reached the peak level at 7.5 mg. Regarding safety, all of the drug-related adverse events observed were mild, and there were no clinically significant bleeding-related adverse events. This study indicates that a single oral administration of prasugrel at a dose of up to 30 mg and a maintenance dose of up to 10 mg are tolerated in Japanese healthy subjects.
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Affiliation(s)
- Kazuo Umemura
- Department of Pharmacology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu-shi, Shizuoka, 431-3192, Japan.
| | - Yasuhiko Ikeda
- Department of Pharmacology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu-shi, Shizuoka, 431-3192, Japan; Shin-nakagawa Hospital, 3901 Ikenoya, Izumi-ku, Yokohama-shi, Kanagawa, 245-0001, Japan
| | - Kazunao Kondo
- Department of Pharmacology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake-shi, Aichi, 470-1192, Japan
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Greenhalgh J, Bagust A, Boland A, Dwan K, Beale S, Fleeman N, McEntee J, Dundar Y, Richardson M, Fisher M. Prasugrel (Efient®) with percutaneous coronary intervention for treating acute coronary syndromes (review of TA182): systematic review and economic analysis. Health Technol Assess 2016; 19:1-130. [PMID: 25896573 DOI: 10.3310/hta19290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute coronary syndromes (ACSs) are life-threatening conditions associated with acute myocardial ischaemia. There are three main types of ACS: ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (UA). One treatment for ACS is percutaneous coronary intervention (PCI) plus adjunctive treatment with antiplatelet drugs. Dual therapy antiplatelet treatment [aspirin plus either prasugrel (Efient(®), Daiichi Sankyo Company Ltd UK/Eli Lilly and Company Ltd), clopidogrel or ticagrelor (Brilique(®), AstraZeneca)] is standard in UK clinical practice. Prasugrel is the focus of this review. OBJECTIVES The remit is to appraise the clinical effectiveness and cost-effectiveness of prasugrel within its licensed indication for the treatment of ACS with PCI and is a review of National Institute for Health and Care Excellence technology appraisal TA182. DATA SOURCES Four electronic databases (MEDLINE, EMBASE, The Cochrane Library, PubMed) were searched from database inception to June 2013 for randomised controlled trials (RCTs) and to August 2013 for economic evaluations comparing prasugrel with clopidogrel or ticagrelor in ACS patients undergoing PCI. METHODS Clinical outcomes included non-fatal and fatal cardiovascular (CV) events, adverse effects of treatment and health-related quality of life (HRQoL). Cost-effectiveness outcomes included incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) gained. An independent economic model assessed four mutually exclusive subgroups: ACS patients treated with PCI for STEMI and with and without diabetes mellitus and ACS patients treated with PCI for UA or NSTEMI and with and without diabetes mellitus. RESULTS No new RCTs were identified beyond that reported in TA182. TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel Thrombolysis in Myocardial Infarction 38) compared prasugrel with clopidogrel in ACS patients scheduled for PCI. No relevant economic evaluations were identified. Our analyses focused on a key subgroup of patients: those aged < 75 years who weighed > 60 kg (no previous stroke or transient ischaemic attack). For the primary composite end point (death from CV causes, non-fatal myocardial infarction or non-fatal stroke) statistically significantly fewer events occurred in the prasugrel arm (8.3%) than in the clopidogrel arm (11%). No statistically significant difference in major bleeding events was noted. However, there was a significant difference in favour of clopidogrel when major and minor bleeding events were combined (3.0 vs. 3.9%). No conclusions could be drawn regarding HRQoL. The results of sensitivity analyses confirmed that it is likely that, for all four ACS subgroups, within 5-10 years prasugrel is a cost-effective treatment option compared with clopidogrel at a willingness-to-pay threshold of £20,000 to £30,000 per QALY gained. At the full 40-year time horizon, all estimates are < £10,000 per QALY gained. LIMITATIONS Lack of data precluded a clinical comparison of prasugrel with ticagrelor; the comparative effectiveness of prasugrel compared with ticagrelor therefore remains unknown. The long-term modelling exercise is vulnerable to major assumptions about the continuation of early health outcome gains. CONCLUSION A key strength of the review is that it demonstrates the cost-effectiveness of prasugrel compared with clopidogrel using the generic price of clopidogrel. Although the report demonstrates the cost-effectiveness of prasugrel compared with clopidogrel at a threshold of £20,000 to £30,000 per QALY gained, the long-term modelling is vulnerable to major assumptions regarding long-term gains. Lack of data precluded a clinical comparison of prasugrel with ticagrelor; the comparative effectiveness of prasugrel compared with ticagrelor therefore remains unknown. Well-audited data are needed from a long-term UK clinical registry on defined ACS patient groups treated with PCI who receive prasugrel, ticagrelor and clopidogrel. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005047. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Adrian Bagust
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Kerry Dwan
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Sophie Beale
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Nigel Fleeman
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Joanne McEntee
- North West Medicines Information Centre, Pharmacy Practice Unit, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Michael Fisher
- The Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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Xanthopoulou I, Davlouros P, Tsigkas G, Koutsogiannis N, Patsilinakos S, Deftereos S, Hahalis G, Alexopoulos D. Factors Affecting Platelet Reactivity 2 Hours After P2Y 12 Receptor Antagonist Loading in Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction – Impact of Pain-to-Loading Time –. Circ J 2016; 80:442-9. [DOI: 10.1253/circj.cj-15-0495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Serebruany VL, Tomek A, Pokov AN, Kim MH. Clopidogrel, prasugrel, ticagrelor or vorapaxar in patients with renal impairment: do we have a winner? Expert Rev Cardiovasc Ther 2015; 13:1333-44. [PMID: 26513059 DOI: 10.1586/14779072.2015.1101343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal utilization of antiplatelet therapy in patients with renal impairment (RI) following acute coronary syndromes (ACS) represents an urgent, unmet and yet unsolved need with regards to the choice of agents, duration of treatment and potential dose/regimen adjustment. The lack of any large randomized trials designed and powered specifically in such high-risk patients, absence of the uniformed efficacy and safety data reporting policy to the FDA and endless overoptimistic publications based on post hoc analyses of primary trials sometimes exaggerating benefits and hiding risks, clouds reality. In addition, triaging RI patients is problematic due to ongoing kidney deterioration and the fact that such patients are prone to both vascular occlusions and bleeding. The authors summarize available FDA-confirmed evidence from the latest trials with approved antiplatelet agents, namely clopidogrel (CAPRIE, CURE, CREDO, CLARITY, CHARISMA); prasugrel (TRITON, TRILOGY); ticagrelor (PLATO, and PEGASUS); and vorapaxar (TRACER and TRA2P) in RI patient cohorts on top of aspirin as part of dual antiplatelet therapy (DAPT). We deliberately avoided any results unless they were verified by the FDA, with the exception of the recent PEGASUS, since Agency reviews are not yet available. Despite differences among the trials and DAPT choices, RI patients universally experience much higher (HR = 1.3-3.1) rates of primary endpoint events, and bleeding risks (HR = 1.7-3.6). However, only ticagrelor increases creatinine and uric acid levels above that of clopidogrel; has the worst incidence of serious adverse events, more adverse events, and inferior outcomes in patients with severe (eGFR <30 ml/min), especially in the lowest (eGFR <15 ml/min) RI subsets. Clopidogrel, prasugrel and vorapaxar appear safer. Moreover, less aggressive half dose (5 mg/daily) prasugrel and strict DAPT, are well justified in RI, but not predominantly triple strategies with vorapaxar as tested in TRA2P and especially in TRACER. In conclusion, data from clinical trials, their sub-studies and affiliated FDA reviews indicate that RI cause more vascular occlusions and bleeding in ACS patients treated with DAPT. Among the novel antiplatelet agents, prasugrel and vorapaxar, but probably not ticagrelor, offer advantage in RI patients.
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Affiliation(s)
- Victor L Serebruany
- a Osler Medical Center , Towson , MD , USA.,b Department of Neurology , Johns Hopkins , Towson , MD , USA
| | - Ales Tomek
- c Department of Neurology , University of Prague , Prague , Czech Republic
| | | | - Moo Hyun Kim
- d Department of Cardiology , Dong-A University , Busan , Korea
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Guimarães PO, Tricoci P. Ticagrelor, prasugrel, or clopidogrel in ST-segment elevation myocardial infarction: which one to choose? Expert Opin Pharmacother 2015. [PMID: 26224244 DOI: 10.1517/14656566.2015.1074180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Clopidogrel, prasugrel, and ticagrelor are the currently available oral P2Y12 inhibitors for the treatment of ST-segment elevation myocardial infarction (STEMI), in association with aspirin. These agents bind the P2Y12 platelet receptor and thus inhibit platelet aggregation. Large randomized clinical trials have provided efficacy and safety data on P2Y12 inhibitors in STEMI patients. AREAS COVERED This review focuses on key pharmacologic and clinical aspects of clopidogrel, prasugrel, and ticagrelor, highlighting their differences. Results from the main clinical trials are discussed, as well as the current STEMI guideline recommendations, to help inform agent selection for patients presenting with STEMI. EXPERT OPINION Clinical trials studying newer P2Y12 inhibitors with increased potency have shown further reduction of cardiovascular events compared with clopidogrel, therefore suggesting the use of ticagrelor or prasugrel as a first-line agent for STEMI treatment. There are still clinical situations - such as fibrinolysis, high risk of bleeding, use of oral anticoagulant, and financial hurdles - in which clopidogrel maintains a role in the treatment of STEMI.
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Affiliation(s)
- Patrícia O Guimarães
- Duke Clinical Research Institute, Duke University Medical Center , 2400 Pratt Street, Durham, NC 27715-7969 , USA +1 919 668 7536 ; +1 919 668 7056 ;
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Alexopoulos D, Vogiatzi C, Stavrou K, Vlassopoulou N, Perperis A, Pentara I, Xanthopoulou I. Diabetes mellitus and platelet reactivity in patients under prasugrel or ticagrelor treatment: an observational study. Cardiovasc Diabetol 2015; 14:68. [PMID: 26025572 PMCID: PMC4453292 DOI: 10.1186/s12933-015-0232-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/23/2015] [Indexed: 01/17/2023] Open
Abstract
Background The influence of diabetes mellitus (DM) on platelet reactivity (PR) in prasugrel or ticagrelor treated patients is not well studied. Methods In an observational study involving 777 patients with acute coronary syndrome undergoing percutaneous coronary intervention treated by either prasugrel 10 mg od (n = 315) or ticagrelor 90 mg bid (n = 462), platelet function was assessed using the VerifyNow P2Y12 function assay (in PRU) at one month post intervention. Results In the overall population, ticagrelor and insulin-treated DM affected PR, with a decrease in log by 0.88 (corresponding to a 58 % decrease in PR) compared to prasugrel-treated patients (p < 0.001), and an increase in log by 0.26 (corresponding to a 30 % increase in PR) compared to non-diabetic patients (p = 0.01), respectively. PR in prasugrel-treated patients differed significantly by DM status: 70.0 (36.3-113.0) in non-diabetic vs 69.0 (44.5-115.3) in non insulin-treated diabetic vs 122.0 (69.0-161.0) in insulin-treated diabetic patients, p for trend = 0.01. No differences were observed in ticagrelor-treated patients. By multivariate analysis, in prasugrel-treated patients insulin-treated DM was the only factor predicting PR, with log of PR increased by 0.42 (corresponding to a 52 % increase in PR) compared to non-diabetic patients (p = 0.001). No factor was found to affect PR in ticagrelor-treated patients. Conclusions Patients with insulin-treated DM treated with prasugrel post PCI have higher PR, than patients without DM or non insulin-treated diabetic patients treated with this drug. Ticagrelor treated patients have overall lower PR than patients on prasugrel, independent of DM status or insulin treatment. Trial registration Clinical Trials Gov. NCT01774955
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Affiliation(s)
- Dimitrios Alexopoulos
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Chrysoula Vogiatzi
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Katerina Stavrou
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Niki Vlassopoulou
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Angelos Perperis
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Ioanna Pentara
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
| | - Ioanna Xanthopoulou
- Department of Cardiology, Patras University Hospital, University of Patras, Rion, Patras, Greece.
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Santilli F, Simeone P, Liani R, Davì G. Platelets and diabetes mellitus. Prostaglandins Other Lipid Mediat 2015; 120:28-39. [PMID: 25986598 DOI: 10.1016/j.prostaglandins.2015.05.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/21/2015] [Accepted: 05/05/2015] [Indexed: 01/13/2023]
Abstract
Platelet activation plays a key role in atherothrombosis in type 2 diabetes mellitus (T2DM) and increased in vivo platelet activation with enhanced thromboxane (TX) biosynthesis has been reported in patients with impairment of glucose metabolism even in the earlier stages of disease and in the preclinical phases. In this regards, platelets appear as addresses and players carrying and transducing metabolic derangement into vascular injury. The present review critically addresses key pathophysiological aspects including (i) hyperglycemia, glycemic variability and insulin resistance as determinants and predictors of platelet activation, (ii) inflammatory mediators derived from platelets, such as soluble CD40 ligand, soluble CD36, Dickkopf-1 and probably soluble receptor for advanced glycation-end-products (sRAGE), which expand the functional repertoire of platelets from players of hemostasis and thrombosis to powerful amplifiers of inflammation by promoting the release of cytokines and chemokines, cell activation, and cell-cell interactions; (iii) molecular mechanisms underpinning the less-than-expected antithrombotic protection by aspirin (ASA), despite regular antiplatelet prophylaxis at the standard dosing regimen, and (iv) stratification of patients deserving different antiplatelet strategies, based on the metabolic phenotype. Taken together, these pathophysiological aspects may contribute to the development of promising mechanism-based therapeutic strategies to reduce the progression of atherothrombosis in diabetic subjects.
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Affiliation(s)
- Francesca Santilli
- Internal Medicine and Center of Excellence on Aging, "G. D'Annunzio" University of Chieti, Italy
| | - Paola Simeone
- Internal Medicine and Center of Excellence on Aging, "G. D'Annunzio" University of Chieti, Italy
| | - Rossella Liani
- Internal Medicine and Center of Excellence on Aging, "G. D'Annunzio" University of Chieti, Italy
| | - Giovanni Davì
- Internal Medicine and Center of Excellence on Aging, "G. D'Annunzio" University of Chieti, Italy.
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Wagner H, Angiolillo DJ, Ten Berg JM, Bergmeijer TO, Jakubowski JA, Small DS, Moser BA, Zhou C, Brown P, James S, Winters KJ, Erlinge D. Higher body weight patients on clopidogrel maintenance therapy have lower active metabolite concentrations, lower levels of platelet inhibition, and higher rates of poor responders than low body weight patients. J Thromb Thrombolysis 2015; 38:127-36. [PMID: 24043374 DOI: 10.1007/s11239-013-0987-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Body weight is a predictor of clopidogrel response. However, no prospective studies have compared pharmacodynamic (PD) and pharmacokinetic (PK) data based on body weight. We compared PD and PK effects of clopidogrel 75 mg in low body weight (LBW, <60 kg) and higher body weight (HBW, ≥60 kg) patients with stable coronary artery disease. LBW (n = 34, 56.4 ± 3.7 kg) and HBW (n = 38, 84.7 ± 14.9 kg) aspirin-treated patients received clopidogrel 75 mg for 10-14 days. The area under the concentration-time curve of active metabolite (Clop-AM) calculated through the last quantifiable concentration up to 4 h postdose, AUC(0-tlast), was calculated by noncompartmental methods. Light transmission aggregometry (LTA) (maximum platelet aggregation and inhibition of platelet aggregation to 20 μM adenosine diphosphate (ADP), and residual platelet aggregation to 5 μM ADP), VerifyNow(®) P2Y12 reaction units (PRU), and vasodilator-associated stimulated phosphoprotein phosphorylation platelet reactivity index (VASP-PRI) were performed. Mean AUC(0-tlast) was lower in HBW than LBW patients: 12.8 versus 17.9 ng h/mL. HBW patients had higher platelet reactivity as measured by LTA (all p ≤ 0.01), PRU (207 ± 68 vs. 152 ± 57, p < 0.001), and VASP-PRI (56 ± 18 vs. 39 ± 17, p < 0.001). More HBW patients exhibited high on-treatment platelet reactivity (HPR) using PRU (35 vs. 9%) and VASP-PRI (65 vs. 27%). Body weight correlated with PRU and VASP-PRI (both p < 0.001), and inversely with log transformed AUC(0-tlast) (p < 0.001). In conclusion, HBW patients had lower levels of Clop-AM, and higher platelet reactivity and rates of HPR than LBW subjects, contributing to their suboptimal response to clopidogrel.
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Affiliation(s)
- Henrik Wagner
- Department of Cardiology, Skane University Hospital, Lund University, Getingevägen 4, 221 85, Lund, Sweden,
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Lhermusier T, Waksman R. Prasugrel hydrochloride for the treatment of acute coronary syndromes. Expert Opin Pharmacother 2015; 16:585-96. [DOI: 10.1517/14656566.2015.1005602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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De Luca L, Bolognese L, Valgimigli M, Ceravolo R, Danzi GB, Piccaluga E, Rakar S, Cremonesi A, Bovenzi FM, Abbate R, Andreotti F, Bolognese L, Biondi-Zoccai G, Bovenzi FM, Capodanno D, Caporale R, Capranzano P, Carrabba N, Casella G, Cavallini C, Ceravolo R, Colombo P, Conte MR, Cordone S, Cremonesi A, Danzi GB, Del Pinto M, De Luca G, De Luca L, De Servi S, Di Lorenzo E, Di Pasquale G, Esposito G, Farina R, Fiscella A, Formigli D, Galli S, Giudice P, Gonzi G, Greco C, Grieco NB, La Vecchia L, Lazzari M, Lettieri C, Lettino M, Limbruno U, Lupi A, Macchi A, Marini M, Marzilli M, Montinaro A, Musumeci G, Navazio A, Olivari Z, Oltrona Visconti L, Oreglia JA, Ottani F, Parodi G, Pasquetto G, Patti G, Perkan A, Perna GP, Piccaluga E, Piscione F, Prati F, Rakar S, Ravasio R, Ronco F, Rossini R, Rubboli A, Saia F, Sardella G, Satullo G, Savonitto S, Sbarzaglia P, Scorcu G, Signore N, Tarantini G, Terrosu P, Testa L, Tubaro M, Valente S, Valgimigli M, Varbella F, Vatrano M. ANMCO/SICI-GISE paper on antiplatelet therapy in acute coronary syndrome. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Cayla G, Cuisset T, Silvain J, Henry P, Leclercq F, Carrié D, Etienne CS, Belle L, Rangé G, Pouillot C, Varenne O, Van Belle E, Boueri Z, Motreff P, Elhadad S, Delarche N, El Mahmoud R, Vicaut E, Collet JP, Montalescot G. Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: design of the randomized antarctic study. Am Heart J 2014; 168:674-81. [PMID: 25440795 DOI: 10.1016/j.ahj.2014.07.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/18/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Elderly patients are at high risk for both ischemic and bleeding events. Platelet monitoring offers the opportunity to individualized antiplatelet therapy to optimize the therapeutic risk/benefit ratio. STUDY DESIGN The ANTARCTIC study is designed to demonstrate the superiority of a strategy of platelet function monitoring with dose and drug adjustment in patients initially on prasugrel 5 mg as compared with a more conventional strategy using prasugrel 5 mg without monitoring and without adjustment (Conventional Treatment Arm) to reduce the primary end point evaluated 1 year after stent percutaneous coronary intervention in elderly patients presenting with an acute coronary syndrome (ACS). ANTARCTIC is a multicenter, prospective, open-label study with 2 parallel arms. A total of 852 elderly patients (≥ 75 years) undergoing stent percutaneous coronary intervention for ACS are to be enrolled. The primary end point is the time to first occurrence of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, urgent revascularization, and bleeding complications (Bleeding Academic Research Consortium definition 2, 3, or 5). Platelet function analyses will be performed 14 days after randomization and repeated 14 days later in patients who require a change in treatment. CONCLUSION ANTARCTIC is a nationwide, prospective, open-label study testing a strategy of platelet function monitoring with dose and drug adjustment to reduce ischemic and bleeding complications in elderly ACS patients undergoing coronary stenting.
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Affiliation(s)
| | - Thomas Cuisset
- Departement de Cardiologie, Hôpital de la Timone, Marseille, France
| | - Johanne Silvain
- Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Patrick Henry
- Service de Cardiologie, Hôpital Lariboisière, Paris, France
| | | | | | | | - Loic Belle
- Service de Cardiologie, CH, Annecy, France
| | - Grégoire Rangé
- Service de Cardiologie, Hôpital Louis Pasteur, Le Coudray, France
| | | | | | | | | | | | - Simon Elhadad
- Service de Cardiologie, CH, de Lagny, Marne-la-Vallée, France
| | | | | | - Eric Vicaut
- Unité de Recherche Clinique Lariboisère, Hôpital Fernand Widal, Paris, France
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Diabetes mellitus and clopidogrel response variability. J Am Coll Cardiol 2014; 64:1015-8. [PMID: 25190237 DOI: 10.1016/j.jacc.2014.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/01/2014] [Indexed: 11/24/2022]
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Parodi G, Bellandi B, Comito V, Capodanno D, Valenti R, Marcucci R, Carrabba N, Migliorini A, Gensini GF, Abbate R, Antoniucci D. Residual platelet reactivity and outcomes with 5mg prasugrel therapy in elderly patients undergoing percutaneous coronary intervention. Int J Cardiol 2014; 176:874-7. [DOI: 10.1016/j.ijcard.2014.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/08/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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Jakubowski JA, Angiolillo DJ, Zhou C, Small DS, Moser BA, ten Berg JM, Brown PB, James S, Winters KJ, Erlinge D. The influence of body size on the pharmacodynamic and pharmacokinetic response to clopidogrel and prasugrel: A retrospective analysis of the FEATHER study. Thromb Res 2014; 134:552-7. [DOI: 10.1016/j.thromres.2014.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/22/2014] [Accepted: 05/13/2014] [Indexed: 11/25/2022]
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Gryn SE, Kim RB. Personalized medicine: importance of clinical interpretative skills for real-world patient care. Per Med 2014; 11:395-408. [PMID: 29783478 DOI: 10.2217/pme.14.16] [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: 11/21/2022]
Abstract
Sequencing of the human genome led to great hopes and expectations for a 'genomics revolution' where disease diagnosis as well as therapies would be based on an individual's genetic makeup. Although significant progress has been made, a number of challenging hurdles must be overcome prior to the broader adoption and implementation of pharmacogenomics and personalized medicine as a part of standard patient care. One aspect of pharmacogenomics-based personalized medicine that has not garnered as much attention, a key focus of this perspective, is the importance of interpreting pharmacogenomic test results in a patient-specific clinical context, and expert physicians and other allied health care providers with the requisite expertise in clinical pharmacology and genomics who are able to provide such services.
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Affiliation(s)
- Steven E Gryn
- Division of Clinical Pharmacology, Department of Medicine, Western University, London Health Sciences Centre-UH; 339 Windermere Road; London, ON. N6A 5A5; Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London Health Sciences Centre-UH; 339 Windermere Road; London, ON. N6A 5A5; Canada
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Bonhomme F, Fontana P, Reny JL. How to manage prasugrel and ticagrelor in daily practice. Eur J Intern Med 2014; 25:213-20. [PMID: 24529662 DOI: 10.1016/j.ejim.2014.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/13/2022]
Abstract
Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.
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Affiliation(s)
- Fanny Bonhomme
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of General Internal Medicine and Rehabilitation, Trois-Chêne, Geneva University Hospitals, Geneva, Switzerland
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Scott SA, Owusu Obeng A, Hulot JS. Antiplatelet drug interactions with proton pump inhibitors. Expert Opin Drug Metab Toxicol 2013; 10:175-89. [PMID: 24205916 DOI: 10.1517/17425255.2014.856883] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Non-aspirin antiplatelet agents (e.g., clopidogrel, prasugrel, ticagrelor) are commonly prescribed for the prevention of recurrent cardiovascular events among patients with acute coronary syndromes (ACS) and/or those undergoing percutaneous coronary intervention (PCI). In addition, combination therapy with proton pump inhibitors (PPIs) is often recommended to attenuate gastrointestinal bleeding risk, particularly during dual antiplatelet therapy (DAPT) with clopidogrel and aspirin. Importantly, a pharmacological interaction between clopidogrel and some PPIs has been proposed based on mutual CYP450-dependent metabolism, but available evidence is inconsistent. AREAS COVERED This article provides an overview of the currently approved antiplatelet agents and PPIs, including their metabolic pathways. Additionally, the CYP450 isoenzyme at the center of the drug interaction, CYP2C19, is described in detail, and the available evidence on both the potential pharmacological interaction and influence on clinical outcomes are summarized and evaluated. EXPERT OPINION Although concomitant DAPT and PPI use reduces clopidogrel active metabolite levels and ex vivo-measured platelet inhibition, the influence of the drug interaction on clinical outcomes has been conflicting and largely reported from non-randomized observational studies. Despite this inconsistency, a clinically important interaction cannot be definitively excluded, particularly among patient subgroups with higher overall cardiovascular risk and potentially among CYP2C19 loss-of-function allele carriers.
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Affiliation(s)
- Stuart A Scott
- Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences , One Gustave L. Levy Place, Box 1497, New York, NY 10029 , USA +1 212 241 3780 ; +1 212 241 0139 ;
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Pharmacology of the New P2Y12 Receptor Inhibitors: Insights on Pharmacokinetic and Pharmacodynamic Properties. Drugs 2013; 73:1681-709. [DOI: 10.1007/s40265-013-0126-z] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
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Erlinge D, Gurbel PA, James S, Lindahl TL, Svensson P, Ten Berg JM, Foley DP, Wagner H, Brown PB, Luo J, Zhou C, Moser BA, Jakubowski JA, Small DS, Winters KJ, Angiolillo DJ. Prasugrel 5 mg in the Very Elderly Attenuates Platelet Inhibition But Maintains Noninferiority to Prasugrel 10 mg in Nonelderly Patients. J Am Coll Cardiol 2013; 62:577-83. [DOI: 10.1016/j.jacc.2013.05.023] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 04/11/2013] [Accepted: 05/07/2013] [Indexed: 11/27/2022]
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Bliden KP, Baker BA, Nolin TD, Jeong YH, Bailey WL, Tantry US, Gurbel PA. Thienopyridine efficacy and cigarette smoking status. Am Heart J 2013; 165:693-703. [PMID: 23622905 DOI: 10.1016/j.ahj.2012.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 12/16/2012] [Indexed: 12/24/2022]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is an established regimen to reduce the risk of ischemic event occurrence in patients with high-risk cardiovascular (CV) disease. Cigarette smoking is an important cardiovascular risk factor. However, several investigators have reported what may be termed a "new" "smoker's paradox", whereby clopidogrel-treated nonsmokers appear to have either less or no CV-event reduction when compared to the substantial CV-event reduction in clopidogrel-treated smokers based on several large-scale trials. This "smoker's paradox" observed in multiple clinical outcome studies is also supported by emerging "real-world" data that also suggest clopidogrel nonsmokers do not fare as well as smokers treated with clopidogrel. In support of the new "smoker's paradox", pharmacodynamic studies have also shown that smoking status influences clopidogrel responsiveness in healthy volunteers, acute coronary syndrome patients, and patients treated with percutaneous coronary intervention. Finally, there is a substantial, albeit not entirely consistent, body of pharmacodynamic and clinical outcome data supporting a reduced antiplatelet effect of clopidogrel in non-smokers as compared to smokers. The clinical relevance of this interaction has never been demonstrated in a prospective trial. The focus of this review is to critically evaluate the reported interaction between cigarette smoking status and thienopyridine efficacy.
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Affiliation(s)
- Kevin P Bliden
- Sinai Center for Thrombosis Research, Baltimore, MD 21215, USA
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Riesmeyer JS, Salazar DE, Weerakkody GJ, Ni L, Wrishko RE, Ernest CS, Luo J, Li YG, Small DS, Rohatagi S, Macias WL. Relationship Between Exposure to Prasugrel Active Metabolite and Clinical Outcomes in the TRITON-TIMI 38 Substudy. J Clin Pharmacol 2013; 52:789-97. [DOI: 10.1177/0091270011406280] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Small DS, Li YG, Ernest CS, April JH, Farid NA, Payne CD, Winters KJ, Rohatagi S, Ni L. Integrated Analysis of Pharmacokinetic Data Across Multiple Clinical Pharmacology Studies of Prasugrel, a New Thienopyridine Antiplatelet Agent. J Clin Pharmacol 2013; 51:321-32. [DOI: 10.1177/0091270010367429] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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P2Y12 Receptor Inhibitors in Acute Coronary Syndromes: What Is New on the Horizon? Cardiol Res Pract 2013; 2013:195456. [PMID: 23533940 PMCID: PMC3590496 DOI: 10.1155/2013/195456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 12/21/2012] [Indexed: 01/31/2023] Open
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor represents the cornerstone therapy for patients with acute coronary syndromes or undergoing percutaneous interventions, leading to a reduction of subsequent ischemic events. Variable response to clopidogrel has received close attention, and pharmacokinetic, pharmacodynamic, and pharmacogenomic factors have been identified as culprits. This led to the introduction of newer, potentially safer, and more effective antiplatelet agents (prasugrel and ticagrelor). Additionally, several point-of-care assays of platelet function have been developed in recent years to rapidly screen individuals on antiplatelet therapy. While the routine use of platelet function testing is uncertain and not currently recommended, it may be useful in instances when the degree of platelet inhibition may be uncertain such as high-risk patients undergoing percutaneous coronary intervention or when there may be a suspected pharmacodynamic interaction with other drugs. The current paper focuses on the P2Y12 receptor inhibitors and their pharmacogenetics and indications in patients with acute coronary syndromes or receiving percutaneous coronary interventions as well as the applicability of platelet function testing in this clinical context.
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Platelet Function Testing in Patients with Acute Coronary Syndrome. J Cardiovasc Transl Res 2013; 6:371-7. [DOI: 10.1007/s12265-013-9450-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 01/25/2013] [Indexed: 12/18/2022]
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Alexopoulos D, Xanthopoulou I, Plakomyti TE, Theodoropoulos KC, Mavronasiou E, Damelou A, Hahalis G, Davlouros P. Pharmacodynamic effect of prasugrel 5 mg vs clopidogrel 150 mg in elderly patients with high on-clopidogrel platelet reactivity. Am Heart J 2013; 165:73-9. [PMID: 23237136 DOI: 10.1016/j.ahj.2012.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/05/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Elderly patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) frequently exhibit high platelet reactivity (HPR) while on clopidogrel. In the elderly cohort, either prasugrel is not recommended or, if used, halving of the dose has been suggested. We aimed to test the hypothesis that in elderly patients exhibiting HPR after standard treatment with clopidogrel, prasugrel-reduced dose (5 mg) could be more effective than high-dose (150 mg) clopidogrel. METHODS Consecutive elderly (≥75 years old) patients with ACS undergoing PCI and loaded with clopidogrel were considered for platelet reactivity (PR) assessment at 24 hours after PCI with the VerifyNow assay (Accumetrics Inc, San Diego, CA), measured in P2Y12 reaction units (PRU). Of 63 screened patients, 30 (47.6%) were found with HPR (defined as PRU ≥230) and 27 of them participated in a prospective, randomized, single-center, single-blind, investigator-initiated, crossover study of platelet inhibition by prasugrel 5 mg/d vs clopidogrel 150 mg/d, with a 15-day treatment period. RESULTS The primary end point of PR at the end of the 2 study periods was lower in patients receiving low-dose prasugrel than those receiving high-dose clopidogrel (least squares estimates 190.8 [95% CI 161.5-220.1] and 240.8 [95% CI 211.0-270.6], respectively; P = .008). The secondary end point of HPR rate at the end of treatment periods was lower for prasugrel (8/24; 33.3%) compared with clopidogrel (16/24; 66.7%), P = .02. CONCLUSIONS In elderly patients with ACS undergoing PCI and exhibiting HPR after standard clopidogrel treatment, prasugrel 5 mg/d is significantly more efficacious than clopidogrel 150 mg/d in reducing PR and HPR rate.
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