1
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Liu Y, Kuang Y, Hai M, Cui C, Liu D, Yang G. Model-Informed Dosing Regimen of Ticagrelor in Chinese Patients With Acute Coronary Syndrome. Clin Pharmacol Ther 2023; 114:1342-1349. [PMID: 37702259 DOI: 10.1002/cpt.3048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 08/28/2023] [Indexed: 09/14/2023]
Abstract
The exposure to ticagrelor (BRILINTA) is higher in the East Asian population compared with the White population, thus, East Asians have an increased risk of bleeding. We developed a population pharmacokinetic (PopPK) model of ticagrelor based on a randomized 3 × 3 crossover study in healthy subjects. The area under the concentration-time curve (AUC) of Chinese patients with acute coronary syndrome was simulated based on this model. Following this, eight machine learning (ML) methods were used to construct bleeding risk models. Variables included in the final bleeding risk model were age, hypertension, body weight, AUC, drinking status, calcium channel blockers, antidiabetic medications, β-blockers, peripheral vascular disease, diabetes, transient ischemic attack, sex, and proton pump inhibitor. In terms of F1 scores and area under the curve of receiver operating characteristic curve (ROC-AUC), the Random Forest model performed best among all models, with an F1 score of 0.73 and ROC-AUC of 0.81. Moreover, the PopPK model and ML algorithm were used to bridge the real-world data to build a bleeding risk prediction model based on drug exposure and clinical information. Using this model, a ticagrelor regimen that is associated with a lower risk of bleeding in individuals can be obtained. This model should be further validated prospectively in clinical settings.
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Affiliation(s)
- Yaxin Liu
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yun Kuang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Min Hai
- Drug Clinical Trial Center, Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
| | - Cheng Cui
- Drug Clinical Trial Center, Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Center of Clinical Medical Research, Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Cardiovascular Receptors Research, Peking University Third Hospital, Beijing, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
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2
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Dong C, Zhang X, Zhang Y, Ouyang W, Peng D, Li X, Li D, Qin Q. Pharmacokinetics, bioequivalence and safety of two formulations of ticagrelor in healthy Chinese subjects: Effects of food. Basic Clin Pharmacol Toxicol 2023; 132:313-320. [PMID: 36617810 DOI: 10.1111/bcpt.13830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023]
Abstract
Ticagrelor is the first reversible ADP P2Y12 receptor antagonist approved to treat acute coronary syndrome. To investigate the effects of food on the pharmacokinetics (PK), bioequivalence and safety of ticagrelor tablets in healthy Chinese volunteers, 32 healthy subjects were randomly assigned to an open-labelled, single-centre, two-preparation, two-sequence, two-cycle, double-crossover trial under fasting and fed conditions, with a washout period of 7 days. Plasma concentrations of ticagrelor and AR-C124910XX were determined using LC-MS/MS. The Cmax , AUC0-t and AUC0-∞ of the reference and test tablets were determined using ANOVA and the USFDA bioequivalence statistical criterion of 90% CI for the 80%-125% range (p ≤ 0.05) of the geometric mean ratios. Adverse events (AEs) were observed and recorded. Food consumption increased the AUC0-t and AUC0-∞ (p < 0.01) of ticagrelor, lowered the Cmax (p < 0.01) and prolonged the t12z (p < 0.05) of AR-C124910XX. The effects of food on the reference preparations were comparable. Formulation, time and sequence had no significant effects on the PK parameters (p ≧ 0.05). The test formulation was bioequivalent to the reference formulation as the geometric mean ratios under fasting and fed conditions were within equivalence limits (80%-125%). No serious AEs were reported. Thus, test and reference ticagrelor are bioequivalent in Chinese subjects under fasting and fed conditions.
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Affiliation(s)
- Chengmei Dong
- National Institution of Drug Clinical Trial, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,International Science and Technology Innovation Cooperation Base for Early Clinical Trials of Biological Agents in Hunan Province, Changsha, China
| | - Xiaonan Zhang
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yalan Zhang
- First People's Hospital of Chongqing Liangjiang New Area, Chongqing, China
| | - Wenjuan Ouyang
- Xiangya Changde Hospital, Central South University, Changde, China
| | - Daizhuang Peng
- National Institution of Drug Clinical Trial, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,International Science and Technology Innovation Cooperation Base for Early Clinical Trials of Biological Agents in Hunan Province, Changsha, China
| | - Xiaomin Li
- National Institution of Drug Clinical Trial, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Phase I Clinical Research Center, Xiangya Hospital, Central South University, Changsha, China
| | - Dai Li
- National Institution of Drug Clinical Trial, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Phase I Clinical Research Center, Xiangya Hospital, Central South University, Changsha, China
| | - Qun Qin
- National Institution of Drug Clinical Trial, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,International Science and Technology Innovation Cooperation Base for Early Clinical Trials of Biological Agents in Hunan Province, Changsha, China
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3
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Ma J, Chalasani NP, Schwantes-An L, Björnsson ES. Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:52-71. [PMID: 36373544 DOI: 10.1111/apt.17297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.
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Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Linus Schwantes-An
- Indiana University School of Medicine, Medical & Molecular Genetics, Indianapolis, Indiana, USA
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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4
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Schilling U, Hsin CH, Delahaye S, Krause A, Wuelfrath H, Halabi A, Dingemanse J. Influence of hepatic impairment on the pharmacokinetics and pharmacodynamics of the P2Y12 receptor antagonist selatogrel. Clin Transl Sci 2022; 15:1906-1915. [PMID: 35583936 PMCID: PMC9372424 DOI: 10.1111/cts.13298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/18/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022] Open
Abstract
Selatogrel is a potent and selective reversible P2Y12 receptor antagonist in development for early treatment of acute myocardial infarction via subcutaneous (s.c.) self‐injection. Selatogrel is almost exclusively eliminated via the hepatobiliary route. Hepatic impairment is associated with reduced drug clearance and primary hemostasis. This single‐center, open‐label study investigated the effect of mild and moderate hepatic impairment on pharmacokinetics (PK) and pharmacodynamics (PD) of a single s.c. dose of selatogrel (16 mg). The study included groups of eight subjects with mild and moderate hepatic impairment, and matched healthy control subjects. Compared to healthy subjects, exposure to selatogrel in subjects with mild and moderate hepatic impairment was 30% and 108% (maximum plasma concentration [Cmax]) and 47% and 212% (area under the concentration‐time curve from zero to infinity [AUC0–∞]) higher, respectively. Hepatic impairment was associated with lower clearance and volume of distribution, whereas plasma protein binding was not affected. Marked inhibition of platelet aggregation (IPA > 80%) was attained within 30 min in all subjects and hepatic impairment prolonged IPA duration. Area under the effect curve was 60% and 160% higher in subjects with mild and moderate hepatic impairment, respectively. PK/PD modeling identified a change in the relationship between exposure and IPA, with a steeper concentration‐effect relationship in healthy subjects compared to subjects with hepatic impairment. The combination of higher exposure and lower half‐maximum inhibitory concentration resulted in longer lasting effect. In conclusion, hepatic impairment alters the PK/PD relationship leading to prolonged effects. Therefore, dose adjustments may be warranted in subjects with moderate hepatic impairment.
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Affiliation(s)
- Uta Schilling
- Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
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5
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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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6
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Hepatic Interactions in Atherosclerotic Heart Disease. Am J Med Sci 2021; 363:104-113. [PMID: 34547286 DOI: 10.1016/j.amjms.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/19/2021] [Accepted: 07/16/2021] [Indexed: 12/20/2022]
Abstract
Atherosclerotic heart disease remains a major cause of morbidity and mortality worldwide. The past few decades have seen the emergence of chronic inflammation as a mediator of atherosclerosis. Although the heart and vascular system remain the organ systems most affected in the atherosclerotic process, chronic inflammation and ischemia trigger a systemic multi-organ response. The liver is a critical organ for systemic hemostasis and recent developments have established an important role of the liver in response to atherosclerosis and myocardial ischemia. In addition, the rapid emergence of systemic liver diseases has unraveled a pathophysiological link with heart disease with therapeutic implications. In this review, we explore the relationship between the liver and the heart in myocardial ischemia, describe epidemiological associations between various liver pathologies and coronary heart disease, and elucidate practical challenges in the clinical management of patients with concomitant coronary heart disease and hepatic abnormalities.
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7
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Krakowiak A, Kuleta J, Plech I, Zarębiński M, Wojciechowska M, Wretowski D, Cudnoch-Jędrzejewska A. Ticagrelor-Related Severe Dyspnoea: Mechanisms, Characteristic Features, Differential Diagnosis and Treatment. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2020; 13:1179547620956634. [PMID: 33100831 PMCID: PMC7550933 DOI: 10.1177/1179547620956634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/13/2020] [Indexed: 11/17/2022]
Abstract
With a growing number of patients on ticagrelor therapy after stent
implantation, we observe many cases of side effects of the drug,
mostly dyspnoea and bradycardia. In our article we present 2 patients,
in which the symptoms were particularly severe. Then we describe
possible mechanisms of these complications, explain how to carry out
differential diagnosis, discuss when to switch ticagrelor to other
antiplatelet drug and finally we present the way to deal with the
symptoms.
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Affiliation(s)
- Alicja Krakowiak
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Kuleta
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Plech
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Zarębiński
- Invasive Cardiology Unit, Independent Public Specialist Western Hospital John Paul II in Grodzisk Mazowiecki, Poland
| | - Małgorzata Wojciechowska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.,Invasive Cardiology Unit, Independent Public Specialist Western Hospital John Paul II in Grodzisk Mazowiecki, Poland
| | - Dominik Wretowski
- Department of Internal Medicine and Cardiology with the Centre for Management of Venous Thromboembolic Disease, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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8
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Chen J, Wang S, Zhang J, Ying H, Zheng H, Dong X, Che J, Chen X, Cheng G. Design, Synthesis and Pharmacokinetic Study of Deuterated Ticagrelor Derivatives. ChemistrySelect 2020. [DOI: 10.1002/slct.202002605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jing Chen
- College of Pharmaceutical Sciences Zhejiang Chinese Medicinal University Hangzhou 311400 China
| | - Siyu Wang
- ZJU-ENS Joint Laboratory of Medicinal Chemistry Hangzhou Institute of Innovative Medicine College of Pharmaceutical Sciences Zhejiang University Hangzhou China
| | - Jianjun Zhang
- Department of pharmacy Zhejiang Provincial Hospital of Traditional Chinese Medicine Hangzhou China
| | - Huazhou Ying
- ZJU-ENS Joint Laboratory of Medicinal Chemistry Hangzhou Institute of Innovative Medicine College of Pharmaceutical Sciences Zhejiang University Hangzhou China
| | - Hao Zheng
- Zhejiang Yongning Pharmaceutical Co. Ltd. Taizhou 318020 China
| | - Xiaowu Dong
- ZJU-ENS Joint Laboratory of Medicinal Chemistry Hangzhou Institute of Innovative Medicine College of Pharmaceutical Sciences Zhejiang University Hangzhou China
| | - Jinxin Che
- ZJU-ENS Joint Laboratory of Medicinal Chemistry Hangzhou Institute of Innovative Medicine College of Pharmaceutical Sciences Zhejiang University Hangzhou China
| | - Xin Chen
- Zhejiang Yongning Pharmaceutical Co. Ltd. Taizhou 318020 China
| | - Gang Cheng
- College of Pharmaceutical Sciences Zhejiang Chinese Medicinal University Hangzhou 311400 China
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9
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Abstract
Antithrombotic therapy is common in the arthroplasty patient population; the preoperative management of chronic antithrombotic medications requires coordination among the medical team. It is estimated that approximately 250,000 or 10% of patients on chronic antithrombotic medication undergo treatment interruption for surgical procedures annually in North America. Although the description of postoperative anticoagulation management after arthroplasty is extensive, orthopaedic literature describing the preoperative management of antithrombotic therapy is lacking. The goal of this guideline is to provide practicing orthopaedic surgeons concise recommendations for the preoperative management of common contemporary antithrombotics in the setting of elective arthroplasty using evidence-based guidelines from other medical specialties. All arthroplasty procedures are considered high bleeding risk in accordance with collaborative AAOS and ACC guidelines. Orthopaedic surgeons should collaborate with their colleagues in cardiology, anesthesia, and other specialties when planning perioperative antithrombotic interruption, particularly in the case of medically complex patients such as those with known risk factors for bleeding and clotting disorders. Resumption of antithrombotic therapy after arthroplasty is beyond the scope of this discussion; this should be performed in accordance with cardiology and anesthesia recommendations.
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10
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Ticagrelor induces paraoxonase-1 (PON1) and better protects hypercholesterolemic mice against atherosclerosis compared to clopidogrel. PLoS One 2019; 14:e0218934. [PMID: 31242230 PMCID: PMC6594647 DOI: 10.1371/journal.pone.0218934] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/12/2019] [Indexed: 12/20/2022] Open
Abstract
Ticagrelor (TIC), a P2Y purinoceptor 12 (P2Y12)-receptor antagonist, has been widely used to treat patients with acute coronary syndrome. Although animal studies suggest that TIC protects against atherosclerosis, it remains unknown whether it does so through its potent platelet inhibition or through other pathways. Here, we placed hypercholesterolemic Ldlr-/-Apobec1-/- mice on a high-fat diet and treated them with either 25 mg/kg/day of clopidogrel (CLO) or 180 mg/kg/day of TIC for 16 weeks and evaluated the extent of atherosclerosis. Both treatments equally inhibited platelets as determined by ex vivo platelet aggregation assays. The extent of atherosclerosis, however, was significantly less in the TIC group than in the CLO group. Immunohistochemical staining and ELISA showed that TIC treatment was associated with less macrophage infiltration to the atherosclerotic intima and lower serum levels of CCL4, CXCL10, and TNFα, respectively, than CLO treatment. Treatment with TIC, but not CLO, was associated with higher serum activity and tissue level of paraoxonase-1 (PON1), an anti-atherosclerotic molecule, suggesting that TIC might exert greater anti-atherosclerotic activity, compared with CLO, through its unique ability to induce PON1. Although further studies are needed, TIC may prove to be a viable strategy in the prevention and treatment of chronic stable human atherosclerosis.
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11
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Zhang M, You X, Ke M, Jiao Z, Wu H, Huang P, Lin C. Prediction of Ticagrelor and its Active Metabolite in Liver Cirrhosis Populations Using a Physiologically Based Pharmacokinetic Model Involving Pharmacodynamics. J Pharm Sci 2019; 108:2781-2790. [PMID: 30928308 DOI: 10.1016/j.xphs.2019.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/14/2022]
Abstract
Ticagrelor, a P2Y12 receptor antagonist, has been highly recommended for use in acute coronary syndrome. The major active metabolite (AM) is similar to the parent drug, which exhibits antiplatelet activity. The inhibition of platelet aggregation (IPA) is used as an assay to demonstrate the anticoagulant efficacy of ticagrelor. In this study, we developed a physiologically based pharmacokinetic (PBPK) model to predict the pharmacokinetics of ticagrelor and its AM and combined this model with a pharmacodynamics model to reflect potential pharmacodynamic alterations in liver cirrhosis populations. The simulated results obtained using the PBPK model were validated by fold error values, which were all smaller than 2. Comparisons of exposure in different classifications of liver cirrhosis indicated that exposure to ticagrelor increased significantly with an increase in the degree of cirrhosis severity, whereas exposure to AM was decreased. The total concentration of ticagrelor and AM was related to the IPA included in the Sigmoid Emax model. The PBPK model of ticagrelor and AM could predict the pharmacokinetics of all populations, and a combination of PD models was used to extrapolate for predicting unknown scenarios. Liver cirrhosis may result in prolonged IPA, depending on the severity degree of this disease. The combined PBPK model including IPA can reveal changes in pharmacokinetics and pharmacodynamics in populations affected by liver cirrhosis and indicate the risk potential.
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Affiliation(s)
- Min Zhang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China
| | - Xiang You
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China
| | - Meng Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital of Fudan University, 12 Wu Lu Mu Qi M. Rd, Shanghai 20040, People's Republic of China.
| | - Hongwei Wu
- Department of Antibiotics, Xiamen Institute for Food and Drug Quality Control, 33 Hai Shan. Rd, Xiamen 361012, People's Republic of China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China.
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12
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Xu X, Ding X, Yuan B, Li W, Wang Y, Jin Y, Xu H. Validated liquid chromatography-tandem mass spectrometry method for quantification of ticagrelor and its active metabolite in human plasma. Biomed Chromatogr 2019; 33:e4498. [PMID: 30675914 DOI: 10.1002/bmc.4498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/13/2018] [Accepted: 01/13/2019] [Indexed: 12/13/2022]
Abstract
A rapid, simple and sensitive LC-MS/MS method was established and validated for simultaneous quantification of ticagrelor and its active metabolite AR-C124910XX in human plasma. After plasma samples were deproteinized with acetonitrile, the post-treatment samples were chromatographed on a Dikma C18 column interfaced with a triple quadrupole tandem mass spectrometer. Electrospray negative ionization mode and multiple reaction monitoring were adopted to assay ticagrelor and AR-C124910XX. Acetonitrile and 5 mΜ ammonium acetate was used as the mobile phase with a gradient elution at a flow rate of 0.5 mL/min. The method was linear in the range of 0.781-800 ng/mL for both ticagrelor and AR-C124910XX with a correlation coefficient ≥0.994. The intra- and inter-day precisions were within 12.61% in terms of relative standard deviation and the accuracy was within ±7.88% in terms of relative error. The LC-MS/MS method was fully validated for its sensitivity, selectivity, stability, matrix effect and recovery. This convenient and specific LC-MS/MS method was successfully applied to the pharmacokinetic study of ticagrelor and AR-C124910XX in healthy volunteers after an oral dose of 90 mg ticagrelor.
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Affiliation(s)
- Xiaomin Xu
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaohong Ding
- Drug Research and Development Center, Shandong Drug and Food Vocational College, Weihai, China
| | - Bo Yuan
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
| | - Weiwei Li
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
| | - Yimei Wang
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
| | - Yi Jin
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
| | - Haiyan Xu
- Department of Pharmaceutical Analysis, Pharmacy School, Shenyang Pharmaceutical University, Shenyang, China
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13
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Shiba-Ishii A, Hong J, Hirokawa T, Kim Y, Nakagawa T, Sakashita S, Sakamoto N, Kozuma Y, Sato Y, Noguchi M. Stratifin Inhibits SCFFBW7 Formation and Blocks Ubiquitination of Oncoproteins during the Course of Lung Adenocarcinogenesis. Clin Cancer Res 2019; 25:2809-2820. [DOI: 10.1158/1078-0432.ccr-18-3631] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/11/2018] [Accepted: 01/17/2019] [Indexed: 11/16/2022]
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14
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Adamski P, Buszko K, Sikora J, Niezgoda P, Barańska M, Ostrowska M, Paciorek P, Navarese EP, Gorog DA, Kubica J. Metabolism of ticagrelor in patients with acute coronary syndromes. Sci Rep 2018; 8:11746. [PMID: 30082687 PMCID: PMC6078957 DOI: 10.1038/s41598-018-29619-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 07/03/2018] [Indexed: 11/10/2022] Open
Abstract
Ticagrelor is a state-of-the-art antiplatelet agent used for the treatment of patients with acute coronary syndromes (ACS). Unlike remaining oral P2Y12 receptor inhibitors ticagrelor does not require metabolic activation to exert its antiplatelet action. Still, ticagrelor is extensively metabolized by hepatic CYP3A enzymes, and AR-C124910XX is its only active metabolite. A post hoc analysis of patient-level (n = 117) pharmacokinetic data pooled from two prospective studies was performed to identify clinical characteristics affecting the degree of AR-C124910XX formation during the first six hours after 180 mg ticagrelor loading dose in the setting of ACS. Both linear and multiple regression analyses indicated that ACS patients presenting with ST-elevation myocardial infarction or suffering from diabetes mellitus are more likely to have decreased rate of ticagrelor metabolism during the acute phase of ACS. Administration of morphine during ACS was found to negatively influence transformation of ticagrelor into AR-C124910XX when assessed with linear regression analysis, but not with multiple regression analysis. On the other hand, smoking appears to increase the degree of ticagrelor transformation in ACS patients. Mechanisms underlying our findings and their clinical significance warrant further research.
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Affiliation(s)
- Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Joanna Sikora
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Malwina Barańska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Paciorek
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Inova Heart and Vascular Institute, Inova Center for Thrombosis Research and Drug Development, Fairfax, VA, USA.,SIRIO MEDICINE research network, Inova Heart and Vascular Institute, Inova Center for Thrombosis Research and Drug Development, Fairfax, VA, USA
| | - Diana A Gorog
- National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Li GF, Yu G, Li Y, Zheng Y, Zheng QS, Derendorf H. Quantitative Estimation of Plasma Free Drug Fraction in Patients With Varying Degrees of Hepatic Impairment: A Methodological Evaluation. J Pharm Sci 2018. [DOI: 10.1016/j.xphs.2018.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Teng R, Muldowney S, Zhao Y, Berg JK, Lu J, Khan ND. Pharmacokinetics and pharmacodynamics of ticagrelor in subjects on hemodialysis and subjects with normal renal function. Eur J Clin Pharmacol 2018; 74:1141-1148. [PMID: 29850937 PMCID: PMC6096709 DOI: 10.1007/s00228-018-2484-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/14/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE This single-dose, randomized, open-label, parallel-group, and crossover study assessed pharmacokinetics (PK), pharmacodynamics (PD), and safety of ticagrelor in subjects on hemodialysis versus healthy subjects. METHODS Hemodialysis subjects were randomized, receiving a single ticagrelor 90-mg dose 1 day post-hemodialysis or just before hemodialysis, with an intervening washout of ≥ 7 days. Healthy subjects (creatinine clearance ≥ 90 mL/min) received a single ticagrelor 90-mg dose. PK, PD (P2Y12 reaction units [PRU], inhibition of platelet aggregation [IPA]), and safety were evaluated. RESULTS Twenty-seven subjects (14 hemodialysis, 13 healthy) received ticagrelor. The mean maximum plasma concentration (Cmax) and area under the plasma concentration curve from time zero to infinity (AUC0-∞) of ticagrelor were 598.4 ng/mL and 3256.1 ng·h/mL, respectively, in pre-hemodialysis subjects; 560.3 ng/mL and 3015.1 ng·h/mL, respectively, in post-hemodialysis subjects; and 370.8 ng/mL and 2188.8 ng·h/mL, respectively, in healthy subjects. Cmax and AUC0-∞ of AR-C124910XX, the active metabolite, were 152.3 ng/mL and 1144.2 ng·h/mL, respectively, in pre-hemodialysis subjects; 130.8 ng/mL and 1127.8 ng·h/mL, respectively, in post-hemodialysis subjects; and 111.7 ng/mL and 1000.4 ng·h/mL, respectively, in healthy subjects. Mean IPA time curves over 24 h post-dose were almost indistinguishable for all three treatments. The greatest reduction in mean PRU occurred approximately 2 h post-dose for all three treatments. No safety or tolerability issues were identified. CONCLUSION Hemodialysis resulted in modestly higher exposure to ticagrelor and AR-C124910XX, with no clinically significant effect on PD or tolerability. Accordingly, no dose adjustment is required for hemodialysis patients. Timing of hemodialysis has little impact on ticagrelor PK, or the effect of ticagrelor on IPA.
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Affiliation(s)
- Renli Teng
- AstraZeneca, Gaithersburg, MD, USA. .,Careceutics LLC, 2016 Saint Andrews Dr, Berwyn, PA, 19312, USA.
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17
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Rosa GM, Bianco D, Valbusa A, Massobrio L, Chiarella F, Brunelli C. Pharmacokinetics and pharmacodynamics of ticagrelor in the treatment of cardiac ischemia. Expert Opin Drug Metab Toxicol 2016; 12:1491-1502. [PMID: 27715344 DOI: 10.1080/17425255.2016.1244524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Gian Marco Rosa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Daniele Bianco
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Alberto Valbusa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Laura Massobrio
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Francesco Chiarella
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
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A Prediction Model of Drug Exposure in Cirrhotic Patients According to Child-Pugh Classification. Clin Pharmacokinet 2016; 54:1245-58. [PMID: 26070946 DOI: 10.1007/s40262-015-0288-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Prediction of drug clearance in liver cirrhosis patients is currently based on in vitro-in vivo extrapolation and physiologically-based pharmacokinetic models. No static model for this purpose has been described. The objectives of this study were to (1) derive a static model for predicting drug exposure in cirrhotic patients, and (2) to evaluate the model on a large set of published data. METHODS The impact of cirrhosis was characterized by the ratio of the total and unbound drug area under the concentration-time curve (AUC) in cirrhotic patients to the AUC measured in healthy subjects These ratios were predicted for Child-Pugh classes A, B, and C. The AUC ratios observed in published data were compared with AUC ratios predicted by the model. RESULTS Among 171 drugs examined, 83 published AUC ratios for 45 drugs in cirrhotic patients were available for analysis. The mean ± standard deviation relative prediction error for the total and unbound AUC ratios was 0.22 ± 0.58 and 0.24 ± 0.56, respectively. There were four outliers among the 83 predicted values. Simulations showed that the prediction error was negligible provided that the hepatic extraction coefficient was less than 0.8. CONCLUSIONS For mild and moderate cirrhosis (classes A and B), the predicted unbound AUC ratio is typically approximately 2 and 3.5, respectively, for most drugs. In the absence of data in cirrhotic patients, the drug dose might be empirically reduced by these factors. In severe cirrhosis (class C), our model may help clinicians to adjust their prescriptions.
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20
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Li H, Guo J, Carlson GF, Teng R. Pharmacodynamics, pharmacokinetics, and safety of ticagrelor in Chinese patients with stable coronary artery disease. Br J Clin Pharmacol 2016; 82:352-61. [PMID: 27038001 DOI: 10.1111/bcp.12950] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/08/2016] [Accepted: 03/28/2016] [Indexed: 01/03/2023] Open
Abstract
AIM The aim of the study was to assess ticagrelor's effects on inhibition of platelet aggregation (IPA), P2Y12 reaction units (PRU, measure of platelet P2Y12 receptor blockade), pharmacokinetic (PK) parameters and safety in Chinese patients with stable coronary artery disease (CAD). METHODS This was an open label, single centre, randomized study. Thirty-six patients on low dose aspirin (75-100 mg day(-1) ) received ticagrelor 45, 60 or 90 mg (single dose, days 1 and 7; twice daily, days 3-6). IPA (final extent), PRU and ticagrelor and AR-C124910XX plasma concentrations were determined. RESULTS On day 1, peak IPA >80% occurred 2-6 h post-dose (all doses). PRU was markedly reduced at 1 h vs. baseline (all doses). With ticagrelor 45 and 90 mg twice daily, maximum IPA (mean, SD) was 91% (13%), and 99% (3%), and maximum PRU reduction from baseline (mean, SD) was 82% (17%) and 92% (9%), respectively. Approximate dose-proportional increases (mean [%CV]; 45 vs. 90 mg twice daily) in ticagrelor Cmax (616 [37] vs. 1273 [43] ng ml(-1) ) and AUC (3882 [42] vs. 8206 [51] ng ml(-1) h) and AR-C124910XX parameters were seen. Pharmacodynamic and PK differences between 45 and 60 mg were small. No safety issues were identified. CONCLUSIONS In Chinese patients with CAD, ticagrelor (45, 60 and 90 mg) markedly reduced platelet aggregation. The IPA and PRU magnitude increased generally with increasing doses. However, the mean pharmacodynamic differences between 45 and 60 mg doses were small. Following single and multiple doses, the mean Cmax and AUC values of ticagrelor and AR-C124910XX increased approximately dose proportionally between 45 and 90 mg doses.
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Affiliation(s)
- Haiyan Li
- Peking University Third Hospital, Haidian District, Beijing, China and
| | - Jingchuan Guo
- Peking University Third Hospital, Haidian District, Beijing, China and
| | | | - Renli Teng
- AstraZeneca LP, Gaithersburg, Maryland, USA
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21
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Abstract
Despite advancements in treatments for acute coronary syndromes over the last 10 years, they continue to be life-threatening disorders. Currently, the standard of treatment includes dual antiplatelet therapy consisting of aspirin plus a P2Y12 receptor antagonist. The thienopyridine class of P2Y12 receptor antagonists, clopidogrel and prasugrel, have demonstrated efficacy. However, their use is associated with several limitations, including the need for metabolic activation and irreversible P2Y12 receptor binding causing prolonged recovery of platelet function. In addition, response to clopidogrel is variable and efficacy is reduced in patients with certain genotypes. Although prasugrel is a more consistent inhibitor of platelet aggregation than clopidogrel, it is associated with an increased risk of life-threatening and fatal bleeding. Ticagrelor is an oral antiplatelet agent of the cyclopentyltriazolopyrimidine class and also acts through the P2Y12 receptor. In contrast to clopidogrel and prasugrel, ticagrelor does not require metabolic activation and binds rapidly and reversibly to the P2Y12 receptor. In light of new data, this review provides an update on the pharmacokinetic, pharmacodynamic and pharmacogenetic profiles of ticagrelor in different study populations. Recent studies report that no dose adjustment for ticagrelor is required on the basis of age, gender, ethnicity, severe renal impairment or mild hepatic impairment. The non-P2Y12 actions of ticagrelor are reviewed, showing indirect positive effects on cellular adenosine concentration and biological activity, by inhibition of equilibrative nucleoside transporter-1 independently of the P2Y12 receptor. CYP2C19 and ABCB1 genotypes do not appear to influence ticagrelor pharmacodynamics. A summary of drug interactions is also presented.
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22
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Monitillo F, Iacoviello M, Caldarola P, Valle R, Chiatto M, Aspromonte N. Pharmacokinetics and pharmacodynamics of ticagrelor when treating non-ST elevation acute coronary syndromes. Expert Opin Drug Metab Toxicol 2015; 11:977-93. [DOI: 10.1517/17425255.2015.1037279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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23
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015; 40:182-212. [DOI: 10.1097/aap.0000000000000223] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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24
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Dobesh PP, Oestreich JH. Ticagrelor: pharmacokinetics, pharmacodynamics, clinical efficacy, and safety. Pharmacotherapy 2014; 34:1077-90. [PMID: 25164528 PMCID: PMC4282310 DOI: 10.1002/phar.1477] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dual antiplatelet therapy, composed of aspirin plus a P2Y12-receptor antagonist, is the cornerstone of treatment for patients with acute coronary syndrome (ACS). A number of U.S. Food and Drug Administration–approved P2Y12-receptor antagonists are available for treating patients with ACS, including the thienopyridine compounds clopidogrel and prasugrel. Ticagrelor, the first of a new class of antiplatelet agents, is a noncompetitive, direct-acting P2Y12-receptor antagonist. Unlike the thienopyridine compounds, ticagrelor does not require metabolism for activity. Also, whereas clopidogrel and prasugrel are irreversible inhibitors of the P2Y12 receptor, ticagrelor binds reversibly to inhibit receptor signaling and subsequent platelet activation. In pharmacodynamic studies, ticagrelor demonstrated faster onset and more potent inhibition of platelet aggregation than clopidogrel. These properties of ticagrelor may contribute to reduced rates of thrombotic outcomes compared with clopidogrel, as demonstrated in a phase III clinical trial. However, in addition to bleeding, distinctive adverse effects of this new chemical entity have not been reported with the thienopyridine P2Y12-receptor inhibitors. Although ticagrelor represents an advancement in P2Y12-receptor inhibition therapy, a thorough understanding of this compound as an antiplatelet therapy remains to be elucidated.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
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25
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Benzon H, Avram M, Green D, Bonow R. New oral anticoagulants and regional anaesthesia. Br J Anaesth 2013; 111 Suppl 1:i96-113. [DOI: 10.1093/bja/aet401] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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26
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Lisman T, Kamphuisen PW, Northup PG, Porte RJ. Established and new-generation antithrombotic drugs in patients with cirrhosis - possibilities and caveats. J Hepatol 2013; 59:358-66. [PMID: 23548197 DOI: 10.1016/j.jhep.2013.03.027] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/25/2013] [Accepted: 03/22/2013] [Indexed: 12/16/2022]
Abstract
Until recently, it was widely accepted that patients with cirrhosis have a bleeding tendency related to the changes in the hemostatic system that occur as a consequence of the disease. However, it has now been well established that patients with cirrhosis are at risk for both bleeding and thrombotic complications. These thrombotic complications include portal vein thrombosis, deep vein thrombosis and pulmonary embolism, and coronary or cerebrovascular infarctions. Antithrombotic drugs to prevent or treat thrombotic complications in patients with cirrhosis have been used only minimally in the past due to the perceived bleeding risk. As the thrombotic complications and the necessity of antithrombotic treatment in these patients are increasingly recognized, the use of antithrombotic drugs in this population is likely increasing. Moreover, given the rising incidence of fatty liver disease and generally longer survival times of patients with chronic liver diseases, it would be reasonable to presume that some of these thrombotic complications may be increasing in incidence over time. In this review, we will outline the indications for antithrombotic treatment in patients with cirrhosis. Furthermore, we will discuss the available antithrombotic drugs and indicate possible applications, advantages, and caveats. Since for many of these drugs very little experience in patients with cirrhosis exists, these data are essential in the design of future clinical and laboratory studies on mechanisms, efficacy, and safety of the various antithrombotic strategies in these patients.
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Affiliation(s)
- Ton Lisman
- Department of Surgery, Section of Hepatobiliairy Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Davis EM, Knezevich JT, Teply RM. Advances in antiplatelet technologies to improve cardiovascular disease morbidity and mortality: a review of ticagrelor. Clin Pharmacol 2013; 5:67-83. [PMID: 23650452 PMCID: PMC3640601 DOI: 10.2147/cpaa.s41859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Antiplatelet therapy is widely used with proven benefit for the prevention of further ischemic cardiac complications in patients with acute coronary syndrome. Treatment guidelines for acute coronary syndrome and percutaneous coronary intervention now recommend the use of oral antiplatelet agents including ticagrelor, prasugrel, or clopidogrel in combination with aspirin to comprise dual antiplatelet therapy for the prevention of recurrent ischemic events. The limitations of conventional antiplatelet therapy with clopidogrel or prasugrel include the potential for low response to clopidogrel identified through platelet reactivity or genetic testing, increased risk of bleeding with prasugrel, or slower return to normal platelet activity in patients who received either prasugrel or clopidogrel prior to emergent or planned surgical procedures. This review will discuss the pharmacokinetic and pharmacodynamic properties of ticagrelor in comparison to conventional P2Y12 receptor inhibitors and its utility in patients identified as low responders to clopidogrel. Completed clinical studies and substudies comparing ticagrelor to clopidogrel and ongoing clinical trials evaluating ticagrelor in acute coronary syndrome patients will also be reviewed.
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Affiliation(s)
- Estella M Davis
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - Jon T Knezevich
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - Robyn M Teply
- Department of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
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Butler K, Teng R. Pharmacokinetics, Pharmacodynamics, and Safety of Ticagrelor in Volunteers With Severe Renal Impairment. J Clin Pharmacol 2013; 52:1388-98. [DOI: 10.1177/0091270011415526] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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Burgess S, Mallard TA, Juergens CP. Review of ticagrelor in the management of acute coronary syndromes. Expert Opin Drug Metab Toxicol 2012; 8:1315-25. [PMID: 22924796 DOI: 10.1517/17425255.2012.717931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Ticagrelor, an oral P2Y(12) receptor antagonist used as part of dual antiplatelet therapy in the treatment of acute coronary syndromes (ACS), has many favorable characteristics when compared with the more frequently used P2Y(12) receptor antagonist clopidogrel. Ticagrelor binds reversibly, with a rapid onset and offset of action, and produces high levels of platelet inhibition without variation secondary to genetic polymorphism. Ticagrelor produces increased platelet inhibition and an overall reduction in adverse cardiac events compared with clopidogrel. Clinically relevant side effects include an increase in non-CABG-related bleeding events as well as off-target adverse effects including ventricular pauses and dyspnea. AREAS COVERED This article details ticagrelor's pharmacokinetic and pharmacodynamic characteristics, development and chemical properties. The authors review relevant clinical trials looking at the efficiency and safety of ticagrelor focusing predominantly on the management of patients with ACS. Finally, the review article concludes with discussion of ticagrelor's current role and future integration into clinical practice. EXPERT OPINION Ticagrelor is a promising P2Y(12) receptor antagonist with characteristics that offer advantages for patients beyond those currently demonstrated by other P2Y(12) receptor antagonists. The challenge for prescribers is to identify those most likely to benefit from ticagrelor treatment while minimizing unnecessary bleeding events for 'real-world' ACS patients.
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Affiliation(s)
- Sonya Burgess
- Department of Cardiology, Liverpool Hospital, Liverpool NSW, Australia
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31
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Teng R. Pharmacokinetic, Pharmacodynamic and Pharmacogenetic Profile of the Oral Antiplatelet Agent Ticagrelor. Clin Pharmacokinet 2012; 51:305-18. [DOI: 10.2165/11630960-000000000-00000] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Cheng JWM. Ticagrelor: oral reversible P2Y(12) receptor antagonist for the management of acute coronary syndromes. Clin Ther 2012; 34:1209-20. [PMID: 22521881 DOI: 10.1016/j.clinthera.2012.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 03/15/2012] [Accepted: 04/06/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND The clinical benefits of dual antiplatelet treatment (aspirin + clopidogrel) in the management of acute coronary syndromes (ACS) are well established. However, clopidogrel is a prodrug that requires hepatic activation. Concerns regarding its delayed onset of action, variability in antiplatelet effects, and prolonged recovery of platelet function after discontinuation have prompted the development of P2Y(12) receptor antagonists. Ticagrelor is the most recently developed P2Y(12) receptor antagonist available in the United States. Ticagrelor is a nonthienopyridine antiplatelet agent and is the first reversible oral antagonist of the P2Y(12) receptors. OBJECTIVE This article reviews the pharmacology, clinical efficacy, and tolerability of ticagrelor use in management of ACS. METHODS Peer-reviewed clinical trials, review articles, and relevant treatment guidelines published from 1966 to March 15, 2012, were identified from the MEDLINE and Current Content databases using the search terms ticagrelor, ACS, pharmacokinetics, pharmacodynamics, pharmacoeconomics, and cost-effectiveness. Citations from available articles were also reviewed for additional references. RESULTS Nine pharmacokinetics/pharmacodynamics studies in humans and 1 clinical study were identified. In addition, the findings from 6 subanalyses based on the clinical study were included. Compared with clopidogrel, ticagrelor was associated with a significantly reduced composite rate of death from cardiovascular causes, myocardial infarction, or stroke (ticagrelor, 9.8%; clopidogrel, 11.7%; hazard ratio [HR] = 0.84; 95% CI, 0.77-0.92; P < 0.001). The difference in the rates of major bleeding was not significant (ticagrelor, 11.6%; clopidogrel, 11.2%). Ticagrelor was associated with a higher rate of non-coronary artery bypass graft surgery related major bleeding (4.5% vs 3.8%; P = 0.03), including fatal intracranial bleeding (0.1% vs 0.01%; P = 0.02), and fewer cases of other types of fatal bleeding (0.1% vs 0.3%; P = 0.03). Other adverse events reported with ticagrelor use included dyspnea (13.8%), headache (6.5%), and bradyarrhythmia (5.8%). The effects of ticagrelor have not been compared to those of other antiplatelet agents, including prasugrel. CONCLUSIONS Based on the findings from the present review, ticagrelor provides reversible inhibition of adenosine diphosphate-induced platelet aggregation, with a faster onset of action than clopidogrel, and is effective in the treatment of patients with ACS. More data are required to definitively position ticagrelor with respect to other antiplatelet agents, including prasugrel.
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Affiliation(s)
- Judy W M Cheng
- Massachusetts College of Pharmacy and Health Sciences, Brigham and Women's Hospital, Boston, MA 02115-5896, USA.
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Oh EY, Abraham T, Saad N, Rapp JH, Vastey FL, Balmir E. A comprehensive comparative review of adenosine diphosphate receptor antagonists. Expert Opin Pharmacother 2012; 13:175-91. [PMID: 22216937 DOI: 10.1517/14656566.2012.647683] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Thrombosis risk necessitates dual antiplatelet therapy with aspirin and an adenosine diphosphate (ADP) receptor antagonist, in patients who have acute coronary syndrome. Current guidelines emphasize the critical role of dual antiplatelet therapy in both medical management and invasive strategy, especially in patients undergoing percutaneous coronary intervention. With the availability of multiple ADP-receptor antagonists, it is crucial to select the most appropriate agent for each patient. AREAS COVERED The pertinent trials were identified through a MEDLINE search, in addition to a manual search from the articles retrieved. This review examines the differences between clopidogrel, prasugrel and ticagrelor in terms of their pharmacological/pharmacokinetic properties, clinical efficacy, drug interactions and safety parameters. EXPERT OPINION Prasugrel and ticagrelor exhibit greater platelet inhibition and superior efficacy compared with clopidogrel, at the expense of higher bleeding risk. Prasugrel and ticagrelor should be preferred over clopidogrel in patients who are at a high risk of thrombotic events with low risk of bleeding. Additionally, these two agents may offer advantage over clopidogrel in those patients who might have risk for drug resistance due to CYP2C19 polymorphism. In selecting the ideal agent for patients, clinicians should tailor the antiplatelet regimen by considering individual risk factors and medication characteristics.
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Affiliation(s)
- Erin Y Oh
- New York Methodist Hospital, Pharmacy Department, 506 Sixth Street, Brooklyn, NY 11215, USA.
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Dennis JC, Levien TL, Danial EB. Ticagrelor. Hosp Pharm 2012. [DOI: 10.1310/hpj4701-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. Subscribers to The Formulary Monograph Service also receive access to a pharmacy bulletin board, The Formulary Information Exchange (The F.I.X.). All topics pertinent to clinical and hospital pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The January 2012 monograph topics are on clobazam, ruxolitinib, bupivacaine liposome injection suspension, ivacaftor, and teriflunomide. The DUE/MUE is on clobazam.
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Affiliation(s)
| | - Terri L. Levien
- Drug Information Center, Washington State University, Spokane, Washington
| | - E. Baker Danial
- Drug Information Center, and College of Pharmacy, Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495
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Nawarskas JJ, Snowden SS. Critical appraisal of ticagrelor in the management of acute coronary syndrome. Ther Clin Risk Manag 2011; 7:473-88. [PMID: 22241944 PMCID: PMC3253754 DOI: 10.2147/tcrm.s19835] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Ticagrelor is a novel P2Y₁₂ receptor antagonist which, like clopidogrel and prasugrel, functions by blocking adenosine diphosphate-mediated platelet aggregation. However, unlike the aforementioned agents, the binding of ticagrelor to this receptor is reversible. Ticagrelor is also believed to mediate some of its beneficial effects by augmenting the effects of adenosine, which is another unique pharmacologic property of this drug. In terms of antiplatelet effect, ticagrelor is more potent than clopidogrel and produces a faster and stronger inhibition of platelet aggregation. This may also be an advantage of ticagrelor over prasugrel, but this has not been adequately studied. Due to the reversible nature of the binding of ticagrelor to the platelet receptor, ticagrelor has a relatively fast offset of effect, with platelet aggregation approaching pretreatment levels about 3 days after discontinuation of therapy. This has advantages in patients requiring invasive procedures, but also makes medication adherence very important in order to be able to maintain an effective antiplatelet effect. Ticagrelor has been shown to be clinically superior to clopidogrel when given to patients with an acute coronary syndrome, resulting in significantly lower rates of myocardial infarction and vascular death. However, ticagrelor is indicated to be administered with aspirin, and the clinical benefits of ticagrelor may be less when daily dosages of aspirin exceed 100 mg. As expected, bleeding is the most common adverse effect with ticagrelor, although it occurs at rates comparable with those seen for clopidogrel with the exception of noncoronary artery bypass graft-related major bleeding and fatal intracranial bleeds, the latter of which occurs only rarely. Dyspnea is another common adverse effect with ticagrelor, although this is usually not severe and resolves with drug discontinuation. Unlike clopidogrel, there are no known pharmacogenomic concerns with ticagrelor, and emerging data suggest ticagrelor to be effective in patients resistant to clopidogrel, although more study is needed on this topic. While preliminary data suggest ticagrelor to be cost effective when compared with generic clopidogrel, the acquisition cost of ticagrelor is not insignificant and this will likely be an issue for many health care organizations. Currently, ticagrelor is well positioned to assume an active role in the treatment of coronary artery disease due to an impressive efficacy profile and reasonable safety. Its ultimate role in therapy will continue to evolve as studies on this drug continue eg, (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin, PEGASUS) and more information hopefully becomes available on its use in clopidogrel nonresponders and relative safety and efficacy compared with prasugrel.
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Teng R, Mitchell PD, Butler K. Lack of significant food effect on the pharmacokinetics of ticagrelor in healthy volunteers. J Clin Pharm Ther 2011; 37:464-8. [PMID: 21967645 DOI: 10.1111/j.1365-2710.2011.01307.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Ticagrelor is the first reversibly binding oral P2Y(12) receptor antagonist and has been approved in the European Union and the USA for the reduction of clinical thrombotic events in patients with acute coronary syndromes. This study aimed to assess the effect of food on ticagrelor pharmacokinetics. METHODS The study was an open-label, randomized, 2-period crossover single-centre trial; 26 healthy volunteers received a single 270 mg (3×90 mg tablets) ticagrelor dose orally following: (i) a 10-h overnight fast; and (ii) after a standard high-fat, high-calorie breakfast. Ticagrelor and AR-C124910XX (a major pharmacologically active metabolite) plasma concentrations were quantified for pharmacokinetic analysis. RESULTS Ticagrelor median time to maximum concentration (t(max); 2·5 h vs. 1·5 h) was slightly delayed in the fed vs. fasting state. Maximum concentration of ticagrelor (C(max)) was comparable between the two states with 95% confidence intervals (CI) of the geometric least-squares (GLS) mean ratio (0·85-1·03) being within no-effect limits (0·80-1·25). Ticagrelor exposure was slightly higher with food intake; area under the plasma concentration-time curve from zero to infinity (AUC) was 21% higher compared with fasting state (95% CI of GLS mean ratio=1·13-1·30). For AR-C124910XX, AUC (95% CI of GLS mean ratio=0·93-1·07) was unaffected by food consumption. Median t(max) of the metabolite was slightly longer in the fed than fasting state (3·5 h vs. 1·5 h). Mean C(max) for AR-C124910XX was slightly lower (22%) with food intake vs. fasting (95% CI of GLS mean ratio 0·69-0·88). WHAT IS NEW AND CONCLUSION Food effects on ticagrelor AUC and AR-C124910XX C(max) were small and are considered to be of minimal clinical significance. Thus, ticagrelor can be administered with or without food.
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Affiliation(s)
- R Teng
- AstraZeneca LP, Wilmington, DE 19850-5437, USA.
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Wijeyeratne YD, Heptinstall S. Anti-platelet therapy: ADP receptor antagonists. Br J Clin Pharmacol 2011; 72:647-57. [PMID: 21518389 PMCID: PMC3187865 DOI: 10.1111/j.1365-2125.2011.03999.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 04/18/2011] [Indexed: 12/13/2022] Open
Abstract
The P2Y(12) receptor on platelets with which ADP interacts has an important role in promoting platelet function and thereby platelet involvement in both haemostasis and thrombosis. Agents that act as antagonists at this receptor are thus likely to provide effective antithrombotic therapy, provided that there are no adverse effects on haemostasis. Here we describe the ADP receptor antagonists that are available and in development. We also consider their mode of action and ask whether there are additional mechanisms through which they exert their inhibitory effects on platelet function.
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