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Decaix T, Kemache K, Gay P, Ketz F, Laprévote O, Pautas É. Pharmacokinetics and pharmacodynamics of drug‒drug interactions in hospitalized older adults treated with direct oral anticoagulants. Aging Clin Exp Res 2024; 36:113. [PMID: 38776005 PMCID: PMC11111557 DOI: 10.1007/s40520-024-02768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Polypharmacy is a frequent situation in older adults that increases the risk of drug-drug interactions (DDIs), both pharmacokinetic (PK) and pharmacodynamic (PD). Direct oral anticoagulants (DOACs) are frequently prescribed in older adults, mainly because of the high prevalence of atrial fibrillation (AF). DOACs are subject to cytochrome P450 3A4 (CYP3A4)- and/or P-glycoprotein (P-gp)-mediated PK DDIs and PD DDIs when co-administered with drugs that interfere with platelet function. The aim of our study was to assess the prevalence of DDIs involving DOACs in older adults and the associated risk factors at admission and discharge. METHODS This was a cross-sectional study conducted in an acute geriatric unit between January 1, 2018 and December 31, 2022, including patients over 75 years of age treated with DOACs at admission and/or discharge, for whom a comprehensive collection of co-medications was performed. RESULTS From 909 hospitalizations collected, the prevalence of PK DDIs involving DOACs was 16.9% at admission and 20.7% at discharge, and the prevalence of PD DDIs was 20.7% at admission and 20.2% at discharge. Factors associated with DDIs were bleeding history [adjusted odds ratio (ORa) 1.74, 95% confidence interval (CI) 1.13-2.68], number of drugs > 6 (ORa 2.54, 95% CI 1.88-3.46) and reduced dose of DOACs (ORa 0.39, 95% CI 0.28-0.54) at admission and age > 87 years (ORa 0.74, 95% CI 0.55-0.99), number of drugs > 6 (ORa 2.01, 95% CI 1.48-2.72) and reduced dose of DOACs (ORa 0.41, 95% CI 0.30-0.57) at discharge. CONCLUSION This study provides an indication of the prevalence of DDIs as well as the profile of DDIs and patients treated with DOACs.
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Affiliation(s)
- Théodore Decaix
- Geriatrics department, APHP Paris Cité University, Lariboisière-Fernand Widal Hospital, Paris, France.
- Paris-Cité University, CNRS, Paris, F-75006, CitCoM, France.
- Faculty of Pharmacy, Paris-Cité University, 4 avenue de l'Observatoire, Paris, 75006, France.
| | - Kenza Kemache
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Pierre Gay
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Flora Ketz
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Olivier Laprévote
- Paris-Cité University, CNRS, Paris, F-75006, CitCoM, France
- Department of biology, National Hospital Center Of ophthalmology, 15-20, F-75012, Paris, France
| | - Éric Pautas
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
- Therapeutic innovations in hemostasis, Paris-Cité University, UMR-S 1140, Inserm, Paris, France
- Medical school, Sorbonne University, Paris, France
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Douketis JD, Yi Q, Bhatt DL, Muehlhofer E, Wang MK, Connolly S, Yusuf S, Maggioni AP, Eikelboom JW. Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. J Thromb Haemost 2024:S1538-7836(24)00257-5. [PMID: 38729576 DOI: 10.1016/j.jtha.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. OBJECTIVE To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. METHODS Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. RESULTS There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. CONCLUSION In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Michael K Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Stuart Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Salim Yusuf
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Yamashita Y, Hira D, Morita M, Katsube Y, Takakura M, Tomotaki H, Tomotaki S, Xiong W, Shiomi H, Horie T, Ueshima S, Mizuno T, Terada T, Ono K. Potential treatment option of rivaroxaban for breastfeeding women: A case series. Thromb Res 2024; 237:141-144. [PMID: 38593524 DOI: 10.1016/j.thromres.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Abstract
The use of direct oral anticoagulants (DOACs) in breastfeeding women is currently challenging due to limited safety data for breastfeeding infants, and there have been no previous studies on the drug concentration in breastfeeding infants. We treated 2 patients (one case was twin pregnancy) with venous thromboembolisms in breastfeeding women administered rivaroxaban at our institution. Blood samples from the mothers and breastmilk samples were collected at time 0 and 2 h after the rivaroxaban administration, breastfeeding was conducted 2 h after the rivaroxaban administration, and blood samples from the infants were collected 2 h after breastfeeding (4 h after maternal rivaroxaban administration). The milk-to-plasma (M:P) ratios were 0.27 in Case 1 and 0.32 in Case 2. The estimated relative infant dose (RID) was 0.82 % in Case 1 Children 1 and 2, and 1.27 % in Case 2. The rivaroxaban concentration in the infant plasma was below the lower limit of quantification in all infants. In addition, even in the high-exposure case simulation based on 5 days of breastfeeding in Case 2, the infant plasma concentration level was below the lower limit of quantification. At 3 months of follow-up, breastfeeding was continued, and all infants grew and developed without any health problems including bleeding events. The current case series showed that there were no pharmacokinetic or clinical concerns for breastfeeding women or breastfed infants, and provides support for rivaroxaban as a safe treatment option for these patients.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Makiko Morita
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Yurie Katsube
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Masahito Takakura
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroko Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seiichi Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Horie
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Ueshima
- College of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, OH, USA
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Rohr BS, Krohmer E, Foerster KI, Burhenne J, Schulz M, Blank A, Mikus G, Haefeli WE. Time Course of the Interaction Between Oral Short-Term Ritonavir Therapy with Three Factor Xa Inhibitors and the Activity of CYP2D6, CYP2C19, and CYP3A4 in Healthy Volunteers. Clin Pharmacokinet 2024; 63:469-481. [PMID: 38393578 PMCID: PMC11052790 DOI: 10.1007/s40262-024-01350-x] [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] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND We investigated the effect of a 5-day low-dose ritonavir therapy, as it is used in the treatment of COVID-19 with nirmatrelvir/ritonavir, on the pharmacokinetics of three factor Xa inhibitors (FXaI). Concurrently, the time course of the activities of the cytochromes P450 (CYP) 3A4, 2C19, and 2D6 was assessed. METHODS In an open-label, fixed sequence clinical trial, the effect and duration of a 5-day oral ritonavir (100 mg twice daily) treatment on the pharmacokinetics of three oral microdosed FXaI (rivaroxaban 25 µg, apixaban 25 µg, and edoxaban 50 µg) and microdosed probe drugs (midazolam 25 µg, yohimbine 50 µg, and omeprazole 100 µg) was evaluated in eight healthy volunteers. The plasma concentrations of all drugs were quantified using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods and pharmacokinetics were analysed using non-compartmental analyses. RESULTS Ritonavir increased the exposure of apixaban, edoxaban, and rivaroxaban, but to a different extent the observed area under the plasma concentration-time curve (geometric mean ratio 1.29, 1.46, and 1.87, respectively). A strong CYP3A4 inhibition (geometric mean ratio > 10), a moderate CYP2C19 induction 2 days after ritonavir (0.64), and no alteration of CYP2D6 were observed. A CYP3A4 recovery half-life of 2.3 days was determined. CONCLUSION This trial with three microdosed FXaI suggests that at most the rivaroxaban dose should be reduced during short-term ritonavir, and only in patients receiving high maintenance doses. Thorough time series analyses demonstrated differential effects on three different drug-metabolising enzymes over time with immediate profound inhibition of CYP3A4 and only slow recovery after discontinuation. CLINICAL TRIAL REGISTRATION EudraCT number: 2021-006643-39.
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Affiliation(s)
- Brit S Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Evelyn Krohmer
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Martin Schulz
- Drug Commission of German Pharmacists and Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Decaix T, Kemache K, Gay P, Laprévote O, Ketz F, Pautas É. Prevalence and factors associated with inappropriate dosing of apixaban and rivaroxaban in hospitalized older adults with atrial fibrillation: a cross-sectional study. Drugs Aging 2024; 41:55-64. [PMID: 37957440 DOI: 10.1007/s40266-023-01081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) is a common condition among older adults, requiring anticoagulation therapy to prevent thromboembolic events. Direct oral anticoagulants (DOACs) are now recommended as first-line therapy for this purpose. Apixaban and rivaroxaban are two direct-factor Xa inhibitors whose dosing is based on various factors (age, weight, creatinine, and creatinine clearance) that can affect the pharmacokinetics of the medication. This study aimed to evaluate factors associated with inappropriate dosing of apixaban or rivaroxaban based on the summary of product characteristics. METHODS A retrospective, single-center study included 777 hospitalizations of patients treated with apixaban or rivaroxaban for AF between 1 January 2018 and 31 December 2022. Primary endpoint assessed whether the dose of apixaban or rivaroxaban was within the summary of product characteristics used by European Medicine Agency (EMA). RESULTS Inappropriate dosing of apixaban or rivaroxaban is noted for approximately 30% of hospitalizations mostly underdosing. Factors associated with the risk of inappropriate dosing were the presence of cognitive impairment [adjusted odds ratio (OR*) 1.65, 95% confidence interval (CI) 1.19-2.29, p value (p) = 0.002], weight per kilogram increase (OR* 1.03, 95% CI 1.01-1.04, p < 0.0001), and history of bleeding under apixaban or rivaroxaban (OR* 1.94, 95% CI 1.24-3.03, p = 0.003). CONCLUSION This study highlighted the high prevalence of inappropriate apixaban or rivaroxaban doses in older adults, particularly underdosing, which increases the risk of thromboembolism.
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Affiliation(s)
- Théodore Decaix
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France.
- CNRS, CitCoM, Paris-Cité University, 75006, Paris, France.
| | - Kenza Kemache
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Pierre Gay
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Olivier Laprévote
- CNRS, CitCoM, Paris-Cité University, 75006, Paris, France
- Department of biology, 15-20 National Hospital Center of Ophtalmology, Paris, France
| | - Flora Ketz
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
| | - Éric Pautas
- Acute Geriatrics Unit, Charles Foix Hospital, APHP Sorbonne University, Ivry-sur-Seine, France
- Therapeutic Innovations in Hemostasis, Inserm UMR-S 1140, Paris-Cité University, Paris, France
- Medical School, Sorbonne University, Paris, France
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Hany M, Bedewy AML, Torensma B. Practical Issues with Using Direct Oral Anticoagulant After Bariatric Metabolic Surgery. Obes Surg 2023:10.1007/s11695-023-06591-6. [PMID: 37074527 DOI: 10.1007/s11695-023-06591-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 03/18/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561, Alexandria, Egypt.
- Consultant of Bariatric Surgery at Madina Women's Hospital, Alexandria, Egypt.
| | | | - Bart Torensma
- Clinical Epidemiologist, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Research progress of nephrotic syndrome accompanied by thromboembolism. Int Urol Nephrol 2023:10.1007/s11255-023-03474-8. [PMID: 36757656 DOI: 10.1007/s11255-023-03474-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
Thromboembolism (TE) is a common and serious complication of nephrotic syndrome (NS). NS is associated with hypercoagulability, which may be induced by changes in coagulation, anticoagulant, and fibrinolytic factors. Moreover, accumulating evidence supports the hypothesis that the complex interactions between genetic and acquired risk factors in TE should be considered and that genetic susceptibility should not be ignored. Extracellular vesicles (EVs) also play unique roles. Further research on EVs may provide new insights into the discovery and treatment of TE associated with NS. The occurrence of NS accompanied by TE may be associated with various risk factors. Preventive anticoagulant therapy can not only reduce the risk of TE in patients but also aggravate the risk of bleeding. Heparin and vitamin K antagonists (VKAs), traditional anticoagulant drugs, have been extensively applied in the prevention and treatment of thromboembolic diseases, and emerging direct oral anticoagulants (DOACs) also provide an alternative choice. Owing to the particularity of NS, the safe application of DOACs still needs to be addressed. This review aimed to comprehensively describe the pathophysiology of TE in NS, as well as analyze the associated risk factors, the opportunity for preventive anticoagulation, and current anticoagulant information.
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Deitelzweig S, Keshishian A, Kang A, Jenkins A, Atreja N, Schuler P, Jiang J, Yuce H, Sun X, Lip GYH. Delaying clinical events among patients with non-valvular atrial fibrillation treated with oral anticoagulants: Insights from the ARISTOPHANES study. Eur J Intern Med 2023; 108:37-42. [PMID: 36456387 DOI: 10.1016/j.ejim.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral anticoagulants (OACs) mitigate stroke and systemic embolism (SE) risk in non-valvular atrial fibrillation (AF) patients but can increase the risk of major bleeding (MB). This study analyzed the gains in event-free time for these outcomes among OAC treatment options represented in the ARISTOPHANES study. METHODS This sub-analysis consisted of NVAF patients who initiated warfarin, apixaban, dabigatran, or rivaroxaban from 01JAN2013-30SEP2015, with data pooled from Medicare and 4 US commercial claims databases. Propensity score matching was conducted between non-vitamin K antagonist OAC (NOAC) and warfarin cohorts in each database and results were pooled. Laplace regression was used to evaluate the delay in time to stroke/SE and MB events between NOACs and warfarin and between NOACs after the first 12-months of follow-up. RESULTS The population included 466,991 patients (167,413 warfarin; 108,852 apixaban; 37,724 dabigatran; and 153,002 rivaroxaban). Event-free time gain (95% confidence interval) for apixaban versus warfarin was 101 days (78- 124) for stroke/SE and 116 (103- 130) days for MB. The gain in event-free time for dabigatran versus warfarin was 45 days (3- 87) for stroke/SE and 92 (68- 116) days for MB. The gain in event-free time for rivaroxaban versus warfarin was 63 days (42- 84) for stroke/SE but event-free time decreased by 18 (-31-6) days for MB. CONCLUSIONS Over 12 months after initiation, apixaban and dabigatran conferred progressive increases in event free time for stroke/SE and MB vs warfarin, whereas rivaroxaban conferred an increase in stroke/SE-free time but a loss in MB-free time vs warfarin.
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, LA, USA and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Nipun Atreja
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Hügl B, Horlitz M, Fischer K, Kreutz R. Clinical significance of the rivaroxaban-dronedarone interaction: insights from physiologically based pharmacokinetic modelling. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead004. [PMID: 36820238 PMCID: PMC9938521 DOI: 10.1093/ehjopen/oead004] [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: 07/22/2022] [Revised: 01/06/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023]
Abstract
Patients with atrial fibrillation may require rhythm control therapy in addition to anticoagulation therapy for the prevention of stroke. Since 2012, the European Society of Cardiology and European Heart Rhythm Association guidelines have recommended non-vitamin K antagonist oral anticoagulants, including rivaroxaban, for the prevention of stroke in patients with atrial fibrillation. During the same period, these guidelines have also recommended dronedarone or amiodarone as second-line rhythm control agents in certain patients with atrial fibrillation and no contraindications. Amiodarone and dronedarone both strongly inhibit P-glycoprotein, while dronedarone is a moderate and amiodarone a weak inhibitor of cytochrome P450 3A4 (CYP3A4). Based on these data and evidence from physiologically based pharmacokinetic modelling, amiodarone and dronedarone are expected to have similar effects on rivaroxaban exposure resulting from P-glycoprotein and CYP3A4 inhibition. However, the rivaroxaban label recommends against the concomitant use of dronedarone, but not amiodarone, citing a lack of evidence on the concomitant use of rivaroxaban and dronedarone as the reason for the different recommendations. In this report, we discuss evidence from clinical studies and physiologically based pharmacokinetic modelling on the potential for increased rivaroxaban exposure resulting from drug-drug interaction between rivaroxaban and dronedarone or amiodarone. The current evidence supports the same clinical status and concomitant use of either amiodarone or dronedarone with rivaroxaban, which could be considered in future recommendations.
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Affiliation(s)
| | - Marc Horlitz
- Klinik für Kardiologie, Elektrophysiologie und Rhythmologie, Krankenhaus Porz am Rhein, Universität Witten/Herdecke, Köln, Germany
| | - Kerstin Fischer
- Bayer AG, Research & Development, Pharmaceuticals Therapeutic Opportunity Expansion, Berlin, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Clinical Pharmacology and Toxicology, Charité University Medicine, Berlin, Germany
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Foulon-Pinto G, Lafuente-Lafuente C, Jourdi G, Guen JL, Tall F, Puymirat E, Delrue M, Rivière L, Ketz F, Gouin-Thibault I, Mullier F, Gaussem P, Pautas E, Lecompte T, Curis E, Siguret V. Assessment of DOAC in GEriatrics (Adage Study): Rivaroxaban/Apixaban Concentrations and Thrombin Generation Profiles in NVAF Very Elderly Patients. Thromb Haemost 2023; 123:402-414. [PMID: 36395818 PMCID: PMC10060059 DOI: 10.1055/a-1981-1763] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although a growing number of very elderly patients with atrial fibrillation (AF), multiple conditions, and polypharmacy receive direct oral anticoagulants (DOACs), few studies specifically investigated both apixaban/rivaroxaban pharmacokinetics and pharmacodynamics in such patients. AIMS To investigate: (1) DOAC concentration-time profiles; (2) thrombin generation (TG); and (3) clinical outcomes 6 months after inclusion in very elderly AF in-patients receiving rivaroxaban or apixaban. METHODS Adage-NCT02464488 was an academic prospective exploratory multicenter study, enrolling AF in-patients aged ≥80 years, receiving DOAC for at least 4 days. Each patient had one to five blood samples at different time points over 20 days. DOAC concentrations were determined using chromogenic assays. TG was investigated using ST-Genesia (STG-ThromboScreen, STG-DrugScreen). RESULTS We included 215 patients (women 71.1%, mean age: 87 ± 4 years), 104 rivaroxaban and 111 apixaban, and 79.5% receiving reduced-dose regimen. We observed important inter-individual variabilities (coefficient of variation) whatever the regimen, at C max [49-46%] and C min [75-61%] in 15 mg rivaroxaban and 2.5 mg apixaban patients, respectively. The dose regimen was associated with C max and C min plasma concentrations in apixaban (p = 0.0058 and p = 0.0222, respectively), but not in rivaroxaban samples (multivariate analysis). Moreover, substantial variability of thrombin peak height (STG-ThromboScreen) was noticed at a given plasma concentration for both xabans, suggesting an impact of the underlying coagulation status on TG in elderly in-patients. After 6-month follow-up, major bleeding/thromboembolic event/death rates were 6.7%/1.0%/17.3% in rivaroxaban and 5.4%/3.6%/18.9% in apixaban patients, respectively. CONCLUSION Our study provides original data in very elderly patients receiving DOAC in a real-life setting, showing great inter-individual variability in plasma concentrations and TG parameters. Further research is needed to understand the potential clinical impact of these findings.
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Affiliation(s)
- Geoffrey Foulon-Pinto
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Carmelo Lafuente-Lafuente
- Service de gériatrie à orientation cardiologique et neurologique, AP-HP, Sorbonne Université, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France.,CEpiA Team (Clinical Epidemiology and Ageing), Université Paris Est Créteil, INSERM, IMRB, Créteil, France
| | - Georges Jourdi
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Research Center, Institut de Cardiologie de Montréal - Université de Montréal, Montréal, QC, Canada
| | - Julien Le Guen
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Fatoumata Tall
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Rothschild, Paris, France
| | - Etienne Puymirat
- Service de Cardiologie, AP-HP. Université de Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Maxime Delrue
- Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Léa Rivière
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Flora Ketz
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Isabelle Gouin-Thibault
- INSERM, CIC 1414 (Centre d'Investigation Clinique de Rennes), Université de Rennes, CHU de Rennes, Rennes, France.,Service d'Hématologie Biologique, CHU de Rennes, Rennes, France
| | - François Mullier
- Department of Laboratory Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, Yvoir, Belgium.,Hematology-Hemostasis Laboratory, CHU UCL Namur, Yvoir, Belgium
| | - Pascale Gaussem
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Eric Pautas
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Thomas Lecompte
- Service d'Hématologie Biologique, CHU de Rennes, Rennes, France.,Université de Lorraine, Faculté de médecine de Nancy, Nancy, France
| | - Emmanuel Curis
- Université de Paris Cité, UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie, Paris, France
| | - Virginie Siguret
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
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11
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Leong R, Chu DK, Crowther MA, Mithoowani S. Direct oral anticoagulants after bariatric surgery-What is the evidence? J Thromb Haemost 2022; 20:1988-2000. [PMID: 35844166 DOI: 10.1111/jth.15823] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Obesity is a global epidemic and bariatric surgery is used with increasing frequency to treat its complications. The extent to which bariatric surgery alters the efficacy, safety, and pharmacokinetics of direct oral anticoagulants (DOACs) is unknown. AIMS In this review, we summarize the evidence supporting the use of DOACs after bariatric surgery and apply our findings to resolve several clinical cases. MATERIALS & METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, CINAHL and ClinicalTrials.gov from January 1, 2000, to June 15, 2021 for randomized and non-randomized studies evaluating the use of DOACs for any indication after bariatric surgery. Two reviewers independently screened titles, abstracts, and full-text articles. Clinical and pharmacokinetic outcomes were pooled by random-effects meta-analysis with inverse variance weighting. We used the Newcastle-Ottawa scale to assess risk of bias in non-randomized studies and assessed the certainty of evidence with GRADE. RESULTS From 2519 records, we included 28 studies (n = 3229 patients): no randomized trials, 7 cohort studies, 6 case series, and 15 case reports. Incidence rates for arterial thromboembolism, venous thromboembolism and major bleeding were: 0.73 (95% confidence interval [CI]: 0.01-5.10), 2.45 (95% CI: 0.40-7.94), and 3.40 (95% CI: 0.80-9.36) events per 100 patient-years, respectively. The pooled proportion of peak direct oral anticoagulant drug levels within the expected range was 58% (95% CI: 39%-74%). CONCLUSION There appears be substantial risk of DOAC malabsorption after bariatric surgery that could affect clinical outcomes, however the certainty of evidence was very low. PROSPERO CRD42020202636.
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Affiliation(s)
- Russell Leong
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Siraj Mithoowani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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12
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Direct oral Xa inhibitors for the treatment of venous thromboembolism after bariatric surgery. Blood Adv 2022; 7:224-226. [PMID: 35640233 PMCID: PMC9841032 DOI: 10.1182/bloodadvances.2021006696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 01/21/2023] Open
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13
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Tracy AL, Goggs R, Brooks MB, Lynch AM. Clinical features and posttreatment monitoring of dogs administered rivaroxaban (2018-2020): 19 cases. J Vet Emerg Crit Care (San Antonio) 2022; 32:629-636. [PMID: 35442563 DOI: 10.1111/vec.13199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe a population of sick dogs administered rivaroxaban monitored with a rivaroxaban-calibrated anti-Xa activity assay (aXa). DESIGN Descriptive retrospective study. SETTING Two veterinary teaching hospitals. ANIMALS Client-owned dogs administered rivaroxaban and monitored with aXa from January 2018 to January 2020 were eligible for study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed and 19 dogs with a variety of underlying disease processes were identified. Rivaroxaban was administered to 12 of 19 dogs (63%) with confirmed thrombosis, 4 of 19 dogs (21%) with a strong clinical suspicion of thrombosis, and in 3 of 19 dogs (16%) with no current evidence of thrombosis. The median rivaroxaban dose administered was 0.96 mg/kg/day (0.62-1.58 mg/kg/day), with 15 of 19 dogs (79%) receiving rivaroxaban once daily. Clopidogrel was concurrently administered to 11 of 19 dogs (58%). Complete or partial thrombus resolution was identified in 5 of 12 (42%) and 3 of 12 (25%) dogs, respectively. Rivaroxaban appeared safe, with only 1 of 19 dogs (5%), concurrently administered clopidogrel, developing evidence of mild hematuria. Posttreatment monitoring revealed that 8 of 19 dogs (42%) had aXa below the target (aXa range of 150-250 ng/ml associated with effective treatment and prevention of venous thrombosis in people). The remaining 3 to 19 dogs (16%) achieved this range, and 8 of 19 dogs (42%) exceeded the range. No significant relationship between the initial rivaroxaban dose administered and the corresponding aXa result was identified. There were also no significant differences in baseline clinicopathological variables in dogs in which aXa fell within or outside this range. CONCLUSIONS aXa was most commonly measured in dogs receiving rivaroxaban with confirmed or suspected thrombosis. Dogs in this study received a range of rivaroxaban dosages and attained variable aXa values that were not directly correlated with dosage.
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Affiliation(s)
- Alyxandra L Tracy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Marjory B Brooks
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Alex M Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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14
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Ansari U, Asghar Z, Oswald M, Ng H. Apixaban-Induced Hepatotoxicity. Cureus 2022; 14:e23879. [PMID: 35402115 PMCID: PMC8985735 DOI: 10.7759/cureus.23879] [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] [Accepted: 04/06/2022] [Indexed: 11/05/2022] Open
Abstract
Apixaban is widely used to prevent and manage thromboembolic disease. Due to it being fairly new in the market, we are still understanding its complete risk profile. We present a case of a 61-year-old female with no prior history of liver disease, who developed severe transaminitis shortly after the initiation of apixaban and started trending down after its discontinuation.
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15
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Baksam VK, Saritha N, Devineni SR, Jain M, Kumar P, Shandilya S, Kumar P. A Critical N-Nitrosamine Impurity of Anticoagulant Drug, Rivaroxaban: Synthesis, Characterization, Development of LC–MS/MS Method for Nanogram Level Quantification. Chromatographia 2022. [DOI: 10.1007/s10337-021-04115-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Alalawneh M, Awaisu A, Rachid O. Rivaroxaban Pharmacokinetics in Obese Subjects: A Systematic Review. Clin Pharmacokinet 2022; 61:1677-1695. [PMID: 36201149 PMCID: PMC9734246 DOI: 10.1007/s40262-022-01160-z] [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] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a leading cause of morbidity and mortality globally. The direct oral anticoagulants, including rivaroxaban, are relatively novel therapeutic options in the treatment and prevention of VTE. There is a conflicting and inconclusive evidence surrounding the pharmacokinetics (PK) of rivaroxaban in patients with VTE who are obese. OBJECTIVES We conducted a systematic review to provide an overview, and to synthesize the available evidence in the current literature pertaining to rivaroxaban PK in obese subjects who are healthy or diseased. METHODS The PubMed, Embase, ScienceDirect, Rayyan, and Cochrane Library databases were systematically searched from 1 May 2021 through 28 February 2022. Studies investigating rivaroxaban PK in adult obese subjects were included in the review. Pertinent data, including anthropometric parameters, rivaroxaban dosage regimen, PK parameters, PK model, and outcome measures were extracted. Reference values of rivaroxaban PK parameters in the general population were used for comparison purposes. The review protocol was registered in the PROSPERO database (CRD42020177770). RESULTS In the 11 studies included in this systematic review, over 7140 healthy or diseased subjects received rivaroxaban therapy, with varying clinical indications in the diseased population. The reported PK parameters of rivaroxaban in obese subjects compared with reference values in the general population were variable. The reported values of the volume of distribution (Vd) among obese subjects (73.4-82.8 L) fell within the range of values reported/calculated for the general population (59.4-104 L), assuming complete bioavailability. However, some of the reported values of clearance (CL) in obese subjects (7.86-16.8 L.h-1) do not fall within the range of values reported/calculated for the general population (5.57-11.3 L.h-1). The reported maximum plasma concentrations in obese subjects versus the general population following a 10 mg dose were 149 vs. 143-180 µg.L-1, and following a 20 mg dose were 214-305 vs. 299-360 µg.L-1, respectively. The area under the plasma concentration versus time curves (AUC) over different intervals in obese subjects versus the general population following a 10 mg dose were 1155 (AUC from time zero to infinity [AUC∞]) vs. 1029 (AUC∞) µg.h.L-1; and 1204-2800 (AUC from time zero to 24 h [AUC24]) vs. 3200 (AUC24) µg.h.L-1, respectively, following a 20 mg dose. The reported values of half-life and time to reach the maximum plasma concentration in obese subjects versus the general population were not consistent across studies. CONCLUSION Variable changes and inconsistencies in different rivaroxaban PK parameters were reported in obese subjects. Further well-designed studies are warranted to better characterize the PK and clinical outcomes of rivaroxaban in subjects with obesity.
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Affiliation(s)
| | - Ahmed Awaisu
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | - Ousama Rachid
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
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17
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Pretelín-Castillo G, Silva Miranda M, Espitia C, Chávez-Santos RM, Suárez-Castro A, Chacón-García L, Aguayo-Ortiz R, Martinez R. ( 2Z)-3-Hydroxy-3-(4-R-Phenyl)-Prop-2-Enedithioic Acids as New Antituberculosis Compounds. Infect Drug Resist 2021; 14:4323-4332. [PMID: 34707377 PMCID: PMC8543028 DOI: 10.2147/idr.s328132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis. Compounds including a sulfur-containing scaffold have been shown to be key scaffolds in various antituberculosis agents. Interestingly, the 3-hydroxy-3-phenyl-prop-2-enedithioic acids 11a-j have, to the best of our knowledge, not been previously described as antituberculosis agents. Purpose In the present study, we investigated the role of substituents attached to the phenyl ring of a 3-hydroxy-3-phenyl-prop-2-enedithioic acid scaffold (compounds 11a–j) in inhibiting the growth of M. tuberculosis strain H37Rv. Methods (Z)-3-hydroxy-3-(4-R-phenyl)-prop-2-enedithioic acids 11b–j, with R groups including various electron-donating or electron-withdrawing groups, were designed by structurally modifying the lead compound 11a. The syntheses of 11a–j involved each one-step procedure starting from the corresponding substituted acetophenone. Compounds 11a–j were tested against M. tuberculosis strain H37Rv to evaluate their bacterial growth inhibitory activities. ADMET profiles were predicted by employing three different methods. In addition, molecular docking studies were carried out, based on the molecular similarities of the synthesized compounds with ethionamide (5), on the active site of the M. tuberculosis H37Rv (3R)-hydroxyacyl-ACP (HadAB) dehydratase heterodimer. Results The antituberculosis activities of compounds 11a–j could be explained in terms of the presence of electron-donating or electron-withdrawing substituents on the aromatic ring of the substituted 3-hydroxy-3-phenyl)-prop-2-enedithioic acid core. The activity and selectivity index (SI) value of (Z)-3-hydroxy-3-(4-nitrophenyl)-prop-2-enedithioic acid 11e suggested that this compound could be used for the design of novel antituberculosis agents. Most of the synthesized molecules showed an acceptable ADME profile and a low probability of being toxic. Docking studies of 11d and 11e showed them forming hydrogen bonds with the ACys61 residue of the HadAB enzyme. Conclusion Our results suggested that the antituberculosis compound 11e could be used for the design of novel antituberculosis agents.
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Affiliation(s)
- Gustavo Pretelín-Castillo
- Instituto de Química, Universidad Nacional Autónoma de México, Circuito Exterior, Ciudad Universitaria, Cd. México, 04510, México
| | - Mayra Silva Miranda
- Catedrática CONACYT adscrita al Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Cd. México, 04510, México.,Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Departamento de Inmunología, Ciudad Universitaria, Cd. México, 04510, México
| | - Clara Espitia
- Catedrática CONACYT adscrita al Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Cd. México, 04510, México.,Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Departamento de Inmunología, Ciudad Universitaria, Cd. México, 04510, México
| | - Rosa María Chávez-Santos
- Instituto de Química, Universidad Nacional Autónoma de México, Circuito Exterior, Ciudad Universitaria, Cd. México, 04510, México
| | - Abel Suárez-Castro
- Instituto de Investigaciones Químico-Biológicas, Universidad Michoacana de San Nicolás de Hidalgo, Edificio B-1, Ciudad Universitaria, Morelia Michoacán, 58030, México
| | - Luis Chacón-García
- Instituto de Investigaciones Químico-Biológicas, Universidad Michoacana de San Nicolás de Hidalgo, Edificio B-1, Ciudad Universitaria, Morelia Michoacán, 58030, México
| | - Rodrigo Aguayo-Ortiz
- Departamento de Farmacia, Facultad de Química, Universidad Nacional Autónoma de México, Circuito Exterior, Ciudad Universitaria, Cd. México, 04510, México
| | - Roberto Martinez
- Instituto de Química, Universidad Nacional Autónoma de México, Circuito Exterior, Ciudad Universitaria, Cd. México, 04510, México
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18
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Ballerie A, Nguyen Van R, Lacut K, Galinat H, Rousseau C, Pontis A, Nédelec-Gac F, Lescoat A, Belhomme N, Guéret P, Mahé G, Couturaud F, Jégo P, Gouin-Thibault I. Apixaban and rivaroxaban in obese patients treated for venous thromboembolism: Drug levels and clinical outcomes. Thromb Res 2021; 208:39-44. [PMID: 34689080 DOI: 10.1016/j.thromres.2021.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/24/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) use remains challenging in obese patients treated for Venous-Thrombo-Embolism (VTE) due to the paucity of prospective and dedicated studies. OBJECTIVE To assess rivaroxaban and apixaban concentrations at different time-points after intake, in obese patients followed at a thrombosis center and treated for VTE; to define factors associated with DOAC levels outside the on-therapy ranges; and to evaluate bleeding and thrombosis rates during follow-up. METHODS Observational prospective study in two French University hospitals. Apixaban or rivaroxaban concentrations were measured after the first visit, regardless of last intake in obese patients receiving DOAC for VTE. Concentrations were compared to published reference values for non-obese patients. Demographic, clinical, biological and therapeutic data were collected. Univariate and multivariate analyses were performed to identify factors associated to DOAC concentrations outside the on-therapy ranges. RESULTS Out of the 146 patients included, 22 (15%) had DOAC concentrations outside the on-therapy ranges, mainly in the rivaroxaban group (n = 17). Age ≤ 63 years, use of rivaroxaban and time since last intake ≤8 h were associated with DOAC concentrations outside the on-therapy ranges, in multivariable analysis. During the median follow-up of 16 months, two (1%) patients receiving apixaban had recurrent VTE. No patient had major bleeding, 11 (8%) patients had minor bleeding. CONCLUSION In this specific prospective bi-centric study dedicated to VTE obese patients, use of DOACs at fixed doses led to concentrations similar to those of non-obese patients in a high proportion of patients, without any effect of the BMI, and with risk-benefit profile comparable to non-obese patients.
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Affiliation(s)
- Alice Ballerie
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Rémi Nguyen Van
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Karine Lacut
- Department of Internal Medecine and Chest Diseases, Brest University Hospital, Bretagne Occidentale University, EA 3878, CIC INSERM 1412, Brest, FCRIN INNOVTE, France
| | - Hubert Galinat
- Hematology Laboratory, Brest University Hospital, Bretagne Occidentale University, EA 3878, Brest, France
| | - Chloé Rousseau
- Clinical Investigation Center INSERM 1414, Department of Clinical Pharmacology, Rennes University Hospital, F-35033, France
| | - Adeline Pontis
- Hematology Laboratory, Rennes University Hospital, Rennes, France
| | | | - Alain Lescoat
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Nicolas Belhomme
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Pierre Guéret
- Hematology Laboratory, Rennes University Hospital, Rennes, France
| | - Guillaume Mahé
- Vascular Medicine Unit, Rennes University Hospital, INSERM CIC 1414, Clinical Investigation Center, Univ Rennes, M2S - EA 7470, F-35033 Rennes, France
| | - Francis Couturaud
- Department of Internal Medecine and Chest Diseases, Brest University Hospital, Bretagne Occidentale University, EA 3878, CIC INSERM 1412, Brest, FCRIN INNOVTE, France
| | - Patrick Jégo
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Isabelle Gouin-Thibault
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France; Hematology Laboratory, Rennes University Hospital, Rennes, France.
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19
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Grześk G, Rogowicz D, Wołowiec Ł, Ratajczak A, Gilewski W, Chudzińska M, Sinkiewicz A, Banach J. The Clinical Significance of Drug-Food Interactions of Direct Oral Anticoagulants. Int J Mol Sci 2021; 22:8531. [PMID: 34445237 PMCID: PMC8395160 DOI: 10.3390/ijms22168531] [Citation(s) in RCA: 17] [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: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug-food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John's wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.
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Affiliation(s)
- Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Agnieszka Ratajczak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Małgorzata Chudzińska
- Department of Nutrition and Dietetics, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dębowa 3 Street, 85-626 Bydgoszcz, Poland;
| | - Anna Sinkiewicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Joanna Banach
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
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20
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Transfer of Apixaban into Human Milk. Obstet Gynecol 2021; 137:1080-1082. [PMID: 33957661 DOI: 10.1097/aog.0000000000004388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/04/2021] [Indexed: 11/26/2022]
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21
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Gronich N, Stein N, Muszkat M. Association Between Use of Pharmacokinetic-Interacting Drugs and Effectiveness and Safety of Direct Acting Oral Anticoagulants: Nested Case-Control Study. Clin Pharmacol Ther 2021; 110:1526-1536. [PMID: 34287842 PMCID: PMC9290518 DOI: 10.1002/cpt.2369] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022]
Abstract
Concomitant use of direct oral anticoagulants (DOACs) and medications with inhibition/induction effect on P-gp/CYP3A might increase risk of bleeding/treatment failure, respectively. We designed a nested case-control study within a Clalit cohort of patients with atrial fibrillation (AF) and a cohort of patients with venous thromboembolism, new users of a DOAC (January 1, 2010 to August 24, 2020). Propensity scores were constructed from demographic/clinical characteristics, and medications at cohort entry. Each case of: (i) serious bleeding event; (ii) stroke/systemic emboli (SE) in patients with AF; (iii) recurrent thromboembolism in patients with thromboembolism, was matched by age, sex, length of follow-up, year of cohort entry, DOAC type, and DOAC indication, to up to 20 controls. Within 89,284 patients with AF and venous thromboembolism and 126,302 patient-years of follow-up, there were 1,587 serious bleeding events. Risk of serious bleeding increased in association with concurrent prescription of P-gp/CYP3A4 inhibitors. Specifically, higher bleeding risk was associated with dabigatran-verapamil, rivaroxaban-verapamil, and rivaroxaban-amiodarone concurrent prescriptions: adjusted odds ratios (ORs) 2.29 (1.13-4.60), 2.18 (1.07-4.40), and 1.68 (1.14-2.49), respectively. There were 1,116 events of stroke/SE, in 79,302 DOAC-treated patients with AF and 118,124 patient-years of follow-up. Concomitant use of phenytoin, carbamazepine, valproic acid, or levetiracetam was associated with risk for stroke/SE: adjusted OR 2.18 (1.55-3.10). Risk of recurrent venous thromboembolism could not be assessed due to the low number of cases. Concurrent prescriptions of dabigatran or rivaroxaban with verapamil, and of rivaroxaban with amiodarone, are associated with increased risk for serious bleeding. Higher risk for stroke/SE in patients with AF is associated with concurrent prescriptions of DOACs with phenytoin, carbamazepine, valproic acid, or levetiracetam.
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Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nili Stein
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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22
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Rohr BS, Foerster KI, Blank A, Burhenne J, Mahmoudi M, Haefeli WE, Mikus G. Perpetrator Characteristics of Azole Antifungal Drugs on Three Oral Factor Xa Inhibitors Administered as a Microdosed Cocktail. Clin Pharmacokinet 2021; 61:97-109. [PMID: 34273071 PMCID: PMC8761715 DOI: 10.1007/s40262-021-01051-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/05/2023]
Abstract
Background Factor Xa inhibitors (FXaIs) are increasingly used without having sufficient drug–drug interaction data. Using a microdosed cocktail methodology could support filling the knowledge gap quickly. Methods In a randomised crossover trial, we investigated the drug–drug interactions between six oral azole antifungals and a microdosed FXaI cocktail containing 25 µg rivaroxaban, 25 µg apixaban, and 50 µg edoxaban. Additionally, different enzyme activities were also monitored using a microdosed cocktail approach. The six different azole antifungals were administered in therapeutic doses over a 24 h period, while the microdosed cocktails were administered 1 h after administration of the azole antifungals. Results Ketoconazole and posaconazole were the strongest perpetrators, showing similar increases as apixaban (area under the concentration–time curve ratio [AUCR] 1.64 and 1.62, respectively) and edoxaban (AUCR 2.08 and 2.1, respectively), whereas ketoconazole increased rivaroxaban 2.32-fold but only increased posaconazole 1.37-fold. All other azole antifungals showed less perpetrator effects on the FXaIs. Cytochrome P450 (CYP) 3A inhibition was confirmed using microdosed midazolam, with ketoconazole also the most potent perpetrator (8.42-fold). Conclusion Drug–drug interactions for three victim drugs of the same drug class (FXaIs) with different clearance mechanisms can be studied using a microdosed cocktail approach. Using members of the azole antifungal drug class as perpetrators, multiple interactions can be studied in one trial, and a more detailed insight into the underlying interaction mechanisms is possible. Clinical Trial Registration EudraCT number: 2017-004453-16. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01051-9.
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Affiliation(s)
- Brit Silja Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin Isabelle Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mazyar Mahmoudi
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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23
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Bosch FTM, Candeloro M, Potere N, Porreca E, Di Nisio M, Kamphuisen PW. Effect of dexamethasone on direct Xa-inhibitor oral anticoagulant plasma levels in patients with COVID-19. Thromb Res 2021; 205:106-109. [PMID: 34293538 PMCID: PMC8278828 DOI: 10.1016/j.thromres.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/20/2021] [Accepted: 07/12/2021] [Indexed: 10/28/2022]
Affiliation(s)
- Floris T M Bosch
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands; Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam University, Medical Centres, University of Amsterdam, Amsterdam, the Netherlands.
| | - Matteo Candeloro
- Department of Medicine and Ageing Sciences, Gabriele D'Annunzio University, Chieti, Italy
| | - Nicola Potere
- Department of Medicine and Ageing Sciences, Gabriele D'Annunzio University, Chieti, Italy; Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Gabriele D'Annunzio University, Chieti, Italy
| | - Pieter W Kamphuisen
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands; Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam University, Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
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24
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Gebreyohannes EA, Salter S, Chalmers L, Bereznicki L, Lee K. Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence. Am J Cardiovasc Drugs 2021; 21:419-433. [PMID: 33369718 DOI: 10.1007/s40256-020-00457-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.
| | - Sandra Salter
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Leanne Chalmers
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, WA, Australia
| | - Luke Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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25
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Benamouzig R, Guenoun M, Deutsch D, Fauchier L. Review Article: Gastrointestinal Bleeding Risk with Direct Oral Anticoagulants. Cardiovasc Drugs Ther 2021; 36:973-989. [PMID: 34143317 DOI: 10.1007/s10557-021-07211-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared with vitamin K antagonists (VKAs) remains controversial. Accordingly, we aimed to provide a focused overview of the risk of gastrointestinal bleeding associated with dabigatran, rivaroxaban, apixaban and edoxaban and its management. METHODS We reviewed published studies reporting on DOACs with gastrointestinal bleeding as an outcome, including randomised controlled trials (RCTs), retrospective database studies and large-scale prospective cohort studies. RESULTS Cumulative evidence confirms no notable difference in major gastrointestinal bleeding risk between DOACs and VKAs. Moreover, gastrointestinal bleeding in DOAC-treated patients seems less severe and requires less intensive management. The main cause of upper gastrointestinal bleeding in DOAC-treated patients appears to be gastroduodenal ulcers, whereas lower gastrointestinal bleedings are mainly due to diverticula followed by angiodysplasia and haemorrhoids. The lack of head-to-head RCTs with DOACs precludes drawing conclusions on the DOAC with the lowest gastrointestinal bleeding risk. Prescribing physicians should be aware of risk factors for DOAC-related gastrointestinal bleeding (e.g. age > 65, heavy alcohol use, uncontrolled hypertension, hepatic or renal dysfunction, active cancer, anaemia) and adopt preventive measures accordingly. Management of DOAC-associated major gastrointestinal bleeding involves temporary discontinuation of the DOAC, investigation of the bleeding source and treatment of bleeding with fluid resuscitation combined with transfusion and endoscopic haemostasis. CONCLUSION DOACs as a class do not increase the risk of major gastrointestinal bleeding compared to VKAs, which supports their continued use for different anticoagulant indications.
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Affiliation(s)
- Robert Benamouzig
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France.
| | - Maxime Guenoun
- Department of Cardiology, Clinique Bouchard, Marseille, France
| | - David Deutsch
- Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France
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26
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Clifford CR, Jung RG, Hibbert B, Chong AY, Lordkipanidzé M, Tanguay JF, So DYF. Dual antiplatelet therapy (PEGASUS) vs. dual pathway (COMPASS): a head-to-head in vitro comparison. Platelets 2021; 33:298-303. [PMID: 33856269 DOI: 10.1080/09537104.2021.1904134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is prescribed for 1-year after myocardial infarction. Two clinical strategies are considered at 1-year: continuation of DAPT or "Dual Pathway" (DP), using aspirin and rivaroxaban. No head-to-head comparative studies exist. In our in-vitro study, 24 samples of donor blood were treated with clinically proven concentrations of 5 antithrombotic regimens: aspirin, ticagrelor, rivaroxaban, DAPT, and DP. Thrombosis was analyzed using the Total Thrombus Analysis System (T-TAS) to measure both antiplatelet and anticoagulant effects. Flow cytometry was performed to quantify platelet activation. DAPT was the most potent antiplatelet regimen, delaying thrombus onset (p < .0001) and reducing thrombogenicity (p < .0001), relative to control. DP did not delay thrombus formation relative to aspirin alone (p = .69). DP was the most potent anticoagulant regimen, delaying thrombus onset (p < .0001) and reducing thrombogenicity (p < .0001), relative to control. DP showed synergistic antithrombotic effects by delaying thrombus onset (p < .0001) and reducing thrombogenicity (p = .0003), relative to rivaroxaban alone. Flow cytometry showed only DAPT (p = .0023) reduced platelet activation. DP treatment demonstrated synergistic antithrombotic effects over rivaroxaban alone, but no additional antiplatelet synergism over aspirin alone.
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Affiliation(s)
- Cole R Clifford
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Richard G Jung
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun Yeong Chong
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marie Lordkipanidzé
- Montreal Heart Institute Research Center, Montreal, Qc, Canada.,Faculty of Pharmacy, Université De Montréal, Montreal, Qc, Canada
| | - Jean-Francois Tanguay
- Montreal Heart Institute Research Center, Montreal, Qc, Canada.,Faculty of Medicine, Université De Montréal, Montreal, Qc, Canada
| | - Derek Y F So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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27
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Reinecke I, Solms A, Willmann S, Spiro TE, Peters G, Weitz JI, Mueck W, Garmann D, Schmidt S, Zhang L, Fox KAA, Berkowitz SD. Associations between model-predicted rivaroxaban exposure and patient characteristics and efficacy and safety outcomes in the prevention of venous thromboembolism. J Thromb Thrombolysis 2021; 50:12-19. [PMID: 32323190 PMCID: PMC7293976 DOI: 10.1007/s11239-020-02078-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Anticoagulant plasma concentrations and patient characteristics might affect the benefit–risk balance of therapy. The study objective was to assess the impact of model-predicted rivaroxaban exposure and patient characteristics on outcomes in patients receiving rivaroxaban for venous thromboembolism (VTE) prophylaxis (VTE-P) after hip/knee replacement surgery. Post hoc exposure–response analyses were conducted using data from the phase 3 RECORD1–4 studies, in which 12,729 patients were randomized to rivaroxaban 10 mg once daily or enoxaparin for ≤ 39 days. Multivariate regression approaches were used to correlate model-predicted individual rivaroxaban exposures and patient characteristics with outcomes. In the absence of measured rivaroxaban exposure, exposure estimates were predicted based on individual increases in prothrombin time (PT) and by making use of the known correlation between rivaroxaban plasma concentration and dynamics of PT. No significant associations between rivaroxaban exposure and total VTE or major bleeding were identified. A significant association between exposure and a composite of major or non-major clinically relevant (NMCR) bleeding from day 4 after surgery was observed. The relationship was shallow, with an approximate predicted absolute increase in a composite of major or NMCR bleeding from 1.08 [95% confidence interval (CI) 0.76–1.54] to 2.18% (95% CI 1.51–3.17) at the 5th and 95th percentiles of trough plasma concentration, respectively. In conclusion, based on the underlying data and analysis, no reliable target window for exposure with improved benefit–risk could be identified within the investigated exposure range. Hence, monitoring rivaroxaban levels is unlikely to be beneficial in VTE-P.
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Affiliation(s)
| | | | | | - Theodore E Spiro
- Bayer U.S., LLC, Research & Development, Pharmaceuticals, 100 Bayer Boulevard, Whippany, NJ, 07981, USA
| | - Gary Peters
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Dirk Garmann
- Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Liping Zhang
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Keith A A Fox
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Scott D Berkowitz
- Bayer U.S., LLC, Research & Development, Pharmaceuticals, 100 Bayer Boulevard, Whippany, NJ, 07981, USA.
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28
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Associations between model-predicted rivaroxaban exposure and patient characteristics and efficacy and safety outcomes in the treatment of venous thromboembolism. J Thromb Thrombolysis 2021; 50:1-11. [PMID: 32323191 PMCID: PMC7293979 DOI: 10.1007/s11239-020-02073-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Anticoagulant plasma concentrations and patient characteristics might affect the benefit–risk balance of therapy. This study assessed the impact of model-predicted rivaroxaban exposure and patient characteristics on outcomes in patients receiving rivaroxaban for venous thromboembolism treatment (VTE-T) using data from the phase 3 EINSTEIN–DVT and EINSTEIN–PE studies. In the absence of measured rivaroxaban exposure, exposure estimates were predicted based on individual increases in prothrombin time (PT) and the known correlation between rivaroxaban plasma concentrations and PT dynamics. The composite efficacy outcomes evaluated were recurrent deep-vein thrombosis (DVT) and pulmonary embolism (PE) and recurrent DVT, PE and all-cause death; safety outcomes were major bleeding and the composite of major or non-major clinically relevant (NMCR) bleeding. Exposure–response relationships were evaluated using multivariate logistic and Cox regression for the twice-daily (BID) and once-daily (OD) dosing periods, respectively. Predicted rivaroxaban exposure and CrCl were significantly associated with both efficacy outcomes in the BID period. In the OD period, exposure was significantly associated with recurrent DVT and PE but not recurrent DVT, PE and all-cause death. The statistically significant exposure–efficacy relationships were shallow. Exposure–safety relationships were absent within the investigated exposure range. During both dosing periods, low baseline hemoglobin and prior bleeding were associated with the composite of major or NMCR bleeding. In conclusion, based on the underlying data and analysis, no reliable target window for exposure with improved benefit–risk could be identified within the investigated exposure range. Therefore, monitoring rivaroxaban levels is unlikely to be beneficial in VTE-T.
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29
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Iqbal M, Ullah Z, Ezzeldin E, Khalil NY, Al-Shakliah NS, Alrasheed A, Ahmad I, Albehlal L. A simple and sensitive HILIC-based UHPLC-MS/MS method for quantifying of rivaroxaban in dried blood spots: Application in comparison with the plasma sample method. J Pharm Biomed Anal 2021; 198:114023. [PMID: 33744464 DOI: 10.1016/j.jpba.2021.114023] [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: 12/02/2020] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Rivaroxaban, indicated for the treatment of atrial fibrillation, deep vein thrombosis, pulmonary embolism, and coronary or peripheral artery disease, is one of the most frequently used direct oral anticoagulants. Therapeutic drug monitoring [TDM] is essential to minimize bleeding and thrombosis during personalized rivaroxaban treatment. An efficient and reliable analytical technique is required to quatify the rivaroxaban during its therapeutic indication. Dried blood spots (DBSs) sampling is a convenient bioanalytical method with minimal invasive blood drawing, long-term stability, and low shipment and storage costs. Therfore, DBS sampling technique is growing rapidly for TDM of drugs in medical care. This study developed an ultra high performance liquid chromatography-tandem mass spectrometry method of quantitating rivaroxaban in DBSs samples using the isotopic labeled analog (rivaroxaban-d4) as an internal standard (IS). Rivaroxaban and IS were separated on an Acquity HILIC column and eluted with a mobile-phase composition of acetonitrile and 20 mM ammonium acetate in the ratio of 95:5 at a flow rate of 0.3 mL/min. The precursor-to-product ion transitions of 436.03 ˃ 144.9 for rivaroxaban and 440.04 ˃ 144.9 for IS were used to quantify in multiple reaction monitoring mode. The method was accurate and precise in the 2.06-1000 ng/mL calibration range without hematocrit and blood spot volume effects. Rivaroxaban was stable in DBSs samples under different anticipated storage and temperature conditions. We observed good correlation between the plasma concentration and the DBSs concentration, indicating that the proposed DBSs method is suitable for monitoring the rivaroxaban concentration using a simple and convenient sample collection procedure.
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Affiliation(s)
- Muzaffar Iqbal
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia; Bioavailability Unit, Central Lab, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia.
| | - Zabih Ullah
- Scientific Research Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; Department of Pharmacy, College of Dentistry and Pharmacy, Buraydah Colleges, Alqassim, Saudi Arabia
| | - Essam Ezzeldin
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia; Bioavailability Unit, Central Lab, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia
| | - Nasr Y Khalil
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia
| | - Nasser S Al-Shakliah
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, PO Box No. 2457, Riyadh, Saudi Arabia
| | | | - Ishtiaque Ahmad
- Scientific Research Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Luluh Albehlal
- Scientific Research Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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30
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Kumano O, Akatsuchi K, Amiral J. Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants. Biomedicines 2021; 9:biomedicines9030264. [PMID: 33799956 PMCID: PMC7998518 DOI: 10.3390/biomedicines9030264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant drugs have been used to prevent and treat thrombosis. However, they are associated with risk of hemorrhage. Therefore, prior to their clinical use, it is important to assess the risk of bleeding and thrombosis. In case of older anticoagulant drugs like heparin and warfarin, dose adjustment is required owing to narrow therapeutic ranges. The established monitoring methods for heparin and warfarin are activated partial thromboplastin time (APTT)/anti-Xa assay and prothrombin time – international normalized ratio (PT-INR), respectively. Since 2008, new generation anticoagulant drugs, called direct oral anticoagulants (DOACs), have been widely prescribed to prevent and treat several thromboembolic diseases. Although the use of DOACs without routine monitoring and frequent dose adjustment has been shown to be safe and effective, there may be clinical circumstances in specific patients when measurement of the anticoagulant effects of DOACs is required. Recently, anticoagulation therapy has received attention when treating patients with coronavirus disease 2019 (COVID-19). In this review, we discuss the mechanisms of anticoagulant drugs—heparin, warfarin, and DOACs and describe the methods used for the measurement of their effects. In addition, we discuss the latest findings on thrombosis mechanism in patients with COVID-19 with respect to biological chemistry.
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Affiliation(s)
- Osamu Kumano
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
- Protein Technology, Engineering 1, Sysmex Corporation, Kobe 651-2271, Japan
- Correspondence: ; Tel.: +81-78-991-2203
| | - Kohei Akatsuchi
- R&D Division, Sysmex R&D Center Americas, Inc., Mundelein, IL 60060, USA;
| | - Jean Amiral
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
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31
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On Absorption Modeling and Food Effect Prediction of Rivaroxaban, a BCS II Drug Orally Administered as an Immediate-Release Tablet. Pharmaceutics 2021; 13:pharmaceutics13020283. [PMID: 33672439 PMCID: PMC7923293 DOI: 10.3390/pharmaceutics13020283] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/17/2022] Open
Abstract
The present work evaluates the food effect on the absorption of rivaroxaban (Riva), a BCS II drug, from the orally administered commercial immediate-release tablet (Xarelto IR) using physiologically based pharmacokinetic (PBPK) and conventional in vitro-in vivo correlation (IVIVC) models. The bioavailability of Riva upon oral administration of Xarelto IR tablet is reported to exhibit a positive food effect. The PBPK model for Riva was developed and verified using the previously reported in vivo data for oral solution (5 and 10 mg) and Xarelto IR tablet (5 and 10 mg dose strength). Once the PBPK model was established, the in vivo performance of the tablet formulation with the higher dose strength (Xarelto IR tablet 20 mg in fasted and fed state) was predicted using the experimentally obtained data of in vitro permeability, biorelevant solubility and in vitro dynamic dissolution data using United States Pharmacopeia (USP) IV flow-through cell apparatus. In addition, the mathematical IVIVC model was developed using the in vitro dissolution and in vivo profile of 20 mg strength Xarelto IR tablet in fasted condition. Using the developed IVIVC model, the pharmacokinetic (PK) profile of the Xarelto IR tablet in fed condition was predicted and compared with the PK parameters obtained via the PBPK model. A virtual in vivo PK study was designed using a single-dose, 3-treatment cross-over trial in 50 subjects to predict the PK profile of the Xarelto® IR tablet in the fed state. Overall, the results obtained from the IVIVC model were found to be comparable with those from the PBPK model. The outcome from both models pointed to the positive food effect on the in vivo profile of the Riva. The developed models thus can be effectively extended to establish bioequivalence for the marketed and novel complex formulations of Riva such as amorphous solid dispersions.
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Effect of Enzyme-Inducing Antiseizure Medications on the Risk of Sub-Therapeutic Concentrations of Direct Oral Anticoagulants: A Retrospective Cohort Study. CNS Drugs 2021; 35:305-316. [PMID: 33595834 PMCID: PMC8332574 DOI: 10.1007/s40263-021-00795-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Stroke and thromboembolic events occurring among patients taking direct oral anticoagulants (DOACs) have been associated with low concentrations of DOACs. Enzyme-inducing antiseizure medications (EI-ASMs) are associated with enhanced cytochrome-P450-mediated metabolism and enhanced P-glycoprotein-mediated transport. OBJECTIVE The aim of this study was to evaluate the effect of concomitant EI-ASM use on DOAC peak concentrations in patients treated in clinical care. METHODS We performed a retrospective cohort study of patients treated with DOACs for atrial fibrillation and venous thromboembolic disease in an academic general hospital. In total, 307 patients treated with DOACs between August 2015 and January 2020 were reviewed. Clinical characteristics and peak DOAC plasma concentrations of patients co-treated with an EI-ASM were compared with those of patients not treated with an EI-ASM. An apixaban dose score (ADS) was defined to account for apixaban dosage and the number of apixaban dose-reduction criteria. RESULTS In total, 177 peak DOAC plasma concentrations (including apixaban, rivaroxaban, and dabigatran) from 131 patients were measured, including 24 patients co-treated with an EI-ASM and 107 controls not treated with an EI-ASM. The proportion of patients with DOAC concentrations below the expected range was significantly higher among EI-ASM users than among patients not taking an EI-ASM (37.5 vs. 9.3%, respectively; p = 0.0004; odds ratio 5.82; 95% confidence interval [CI] 2.03-16.66). Most of these patients were treated with apixaban (85%); however, sensitivity analysis results were also significant (p = 0.031) for patients with non-apixaban DOACs. In patients co-treated with apixaban and an EI-ASM, median apixaban peak concentration was 106 ng/mL (interquartile range [IQR] 71-181) compared with 150 ng/mL (IQR 94-222) in controls (p = 0.019). In multivariable analysis, EI-ASM use was associated with 6.26-fold increased odds for apixaban concentration below the expected range (95% CI 2.19-17.90; p = 0.001). Apixaban concentrations were significantly associated with EI-ASM use, moderate enzyme inhibitor use, and ADS. CONCLUSIONS Concurrent EI-ASM and DOAC use presents a possible risk for DOAC concentrations below the expected range. The clinical significance of the interaction is currently unclear.
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Paul C, Baby M, Anthraper AR, K K. NOACs: an emerging class of oral anticoagulants-a review article. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2020. [DOI: 10.1186/s43094-020-00114-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AbstractBackgroundNOACs, commonly known as novel oral anticoagulants, are the non-vitamin K antagonist oral anticoagulants which are relatively newer in the market. It has displaced vitamin K antagonists, notably warfarin, for many indications. These agents are dabigatran, rivaroxaban, apixaban, and edoxaban.Main bodyThe drugs are licenced to prevent stroke and also systemic embolism in patients on treatment for atrial fibrillation and prevent venous thromboembolism. Rivaroxaban and apixaban are approved for prophylaxis of thrombus following surgical hip or knee arthroplasty. The recent surveys reveal that use of NOACs has steeply increased due to its safety profile and convenience to use. Also, the studies have shown that NOACs have lesser bleeding complications and associated mortality in contrast to traditional anticoagulants. The upcoming years are known to be NOACs’ age due to the significant findings in this area.ConclusionTherefore, a basic understanding on these drugs is highly recommended to provide a better service to the patients. This article aims to provide quick and brief information on the novel class of drugs. It equips an overview of NOAC and deals with the following areas: (i) pharmacology, (ii) laboratory methods, (iii) peri-operative management, (iv) advantages, (v) challenges, and (vi) future.
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Are apixaban and rivaroxaban distributed into human breast milk to clinically relevant concentrations? Blood 2020; 136:1783-1785. [DOI: 10.1182/blood.2020006231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/11/2020] [Indexed: 01/16/2023] Open
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Microdosed Cocktail of Three Oral Factor Xa Inhibitors to Evaluate Drug-Drug Interactions with Potential Perpetrator Drugs. Clin Pharmacokinet 2020; 58:1155-1163. [PMID: 30828771 DOI: 10.1007/s40262-019-00749-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to prove the suitability of simultaneously administered microdoses of the factor Xa inhibitors (FXaIs) rivaroxaban, apixaban and edoxaban (100 µg in total). To evaluate drug-drug interactions, the impact of ketoconazole, a known strong inhibitor of cytochrome P450 3A4 and P-glycoprotein, was studied. METHODS In a crossover clinical trial, 18 healthy volunteers were randomized to the two treatments using microdoses of rivaroxaban, apixaban and edoxaban alone and when coadministered with ketoconazole. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay with a lower limit of quantification of 2.5 pg/ml. RESULTS The microdosed FXaI cocktail showed similar pharmacokinetic parameters compared with published data, using normal therapeutic doses of each FXaI. Ketoconazole significantly increased exposure, with geometric mean AUC ratios of 1.90 (apixaban), 2.35 (edoxaban) and 2.27 (rivaroxaban). CONCLUSION The microdosed FXaI cocktail approach was able to precisely predict the drug interaction with ketoconazole. This is the first study that has been conducted to evaluate drug-drug interactions with a drug class, and the low administered doses also allow evaluation in vulnerable target populations. STUDY PROTOCOL EudraCT 2016-003024-23.
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Conversy B, Blais MC, Dunn M, Gara-Boivin C, Del Castillo JRE. Corrigendum to "Anticoagulant activity of oral rivaroxaban in healthy dogs" [Vet. J. 223 (2017) 5-11]. Vet J 2020; 263:105522. [PMID: 32928491 DOI: 10.1016/j.tvjl.2020.105522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Bérénice Conversy
- Department of Clinical Sciences, Université de Montréal, Saint-Hyacinthe, J2S 2M2, QC, Canada.
| | - Marie-Claude Blais
- Department of Clinical Sciences, Université de Montréal, Saint-Hyacinthe, J2S 2M2, QC, Canada
| | - Marilyn Dunn
- Department of Clinical Sciences, Université de Montréal, Saint-Hyacinthe, J2S 2M2, QC, Canada
| | - Carolyn Gara-Boivin
- Department of Pathology and Microbiology, Université de Montréal, Saint-Hyacinthe, J2S 2M2, QC, Canada
| | - Jérôme R E Del Castillo
- Department of Veterinary Biomedicine, Université de Montréal, Saint-Hyacinthe, J2S 2M2, QC, Canada
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Duthoit G, Silvain J, Marijon E, Ducrocq G, Lepillier A, Frere C, Dimby SF, Popovic B, Lellouche N, Martin-Toutain I, Spaulding C, Brochet E, Attias D, Mansourati J, Lorgis L, Klug D, Zannad N, Hauguel-Moreau M, Braik N, Deltour S, Ceccaldi A, Wang H, Hammoudi N, Brugier D, Vicaut E, Juliard JM, Montalescot G. Reduced Rivaroxaban Dose Versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure. Circ Cardiovasc Interv 2020; 13:e008481. [DOI: 10.1161/circinterventions.119.008481] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background:
Percutaneous left atrial appendage closure (LAAC) exposes to the risk of device thrombosis in patients with atrial fibrillation who frequently have a contraindication to full anticoagulation. Thereby, dual antiplatelet therapy (DAPT) is usually preferred. No randomized study has evaluated nonvitamin K antagonist oral anticoagulant after LAAC, and we decided to evaluate the efficacy and safety of reduced doses of rivaroxaban after LAAC.
Methods:
ADRIFT (Assessment of Dual Antiplatelet Therapy Versus Rivaroxaban in Atrial Fibrillation Patients Treated With Left Atrial Appendage Closure) is a multicenter, phase IIb study, which randomized 105 patients after successful LAAC to either rivaroxaban 10 mg (R
10
, n=37), rivaroxaban 15 mg (R
15
, n=35), or DAPT with aspirin 75 mg and clopidogrel 75 mg (n=33). The primary end point was thrombin generation (prothrombin fragments 1+2) measured 2 to 4 hours after drug intake, 10 days after treatment initiation. Thrombin-antithrombin complex, D-dimers, rivaroxaban concentrations were also measured at 10 days and 3 months. Clinical end points were evaluated at 3-month follow-up.
Results:
The primary end point was reduced with R
10
(179 pmol/L [interquartile range (IQR), 129–273],
P
<0.0001) and R
15
(163 pmol/L [IQR, 112–231],
P
<0.0001) as compared with DAPT (322 pmol/L [IQR, 218–528]). We observed no significant reduction of the primary end point between R
10
and R
15
while rivaroxaban concentrations increased significantly from 184 ng/mL (IQR, 127–290) with R
10
to 274 ng/mL (IQR, 192–377) with R
15
,
P
<0.0001. Thrombin-antithrombin complex and D-dimers were numerically lower with both rivaroxaban doses than with DAPT. These findings were all confirmed at 3 months. The clinical end points were not different between groups. A device thrombosis was noted in 2 patients assigned to DAPT.
Conclusions:
Thrombin generation measured after LAAC was lower in patients treated by reduced rivaroxaban doses than DAPT, supporting an alternative to the antithrombotic regimens currently used after LAAC and deserves further evaluation in larger studies.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03273322.
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Affiliation(s)
- Guillaume Duthoit
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Eloi Marijon
- European Georges Pompidou Hospital, APHP; Paris Descartes University, INSERM U 970, France (E.M., C.S.)
| | - Grégory Ducrocq
- Département de Cardiologie, Hôpital Bichat, AP-HP, Université Paris-Diderot, Inserm U1148, France (G.D., E.B., J.-M.J.)
| | - Antoine Lepillier
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France (A.L., D.A.)
| | - Corinne Frere
- Sorbonne Université, Department of Haematology Biologic, APHP Pitié-Salpêtrière Hospital; INSERM UMRS 1166, Institute of Cardiometabolism And Nutrition, Paris, France (C.F., I.M.-T.)
| | - Solohaja-Faniaha Dimby
- Unité de Recherche Clinique, ACTION Study Group, Hôpital Fernand Widal (AP-HP), SAMM - Statistique, Analyse et Modélisation Multidisciplinaire EA 4543, Université Paris 1 Panthéon Sorbonne, France (S.-F.D., E.V.)
| | - Batric Popovic
- Université de Lorraine, Département de Cardiologie, Centre Hospitalier Universitaire Brabois, Nancy, France (B.P.)
| | - Nicolas Lellouche
- Département de Cardiologie, CHU Henri Mondor, Créteil, France (N.L.)
| | - Isabelle Martin-Toutain
- Sorbonne Université, Department of Haematology Biologic, APHP Pitié-Salpêtrière Hospital; INSERM UMRS 1166, Institute of Cardiometabolism And Nutrition, Paris, France (C.F., I.M.-T.)
| | - Christian Spaulding
- European Georges Pompidou Hospital, APHP; Paris Descartes University, INSERM U 970, France (E.M., C.S.)
| | - Eric Brochet
- Département de Cardiologie, Hôpital Bichat, AP-HP, Université Paris-Diderot, Inserm U1148, France (G.D., E.B., J.-M.J.)
| | - David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France (A.L., D.A.)
| | - Jacques Mansourati
- Département de Cardiologie, CHRU Brest, Université de Bretagne Occidentale, EA 4324 (J.M.)
| | - Luc Lorgis
- Department of Cardiology, Laboratory of Cerebro-Vascular Pathophysiology and epidemiology (PEC2) EA 7460, University of Burgundy, Dijon, France (L.L.)
| | - Didier Klug
- Univ. Lille CHU Lille, F-59000 Lille, France (D.K.)
| | - Noura Zannad
- Département de Cardiologie, CHR Metz-Thionville, France (N.Z.)
| | - Marie Hauguel-Moreau
- Université de Versailles-Saint Quentin, Department of Cardiology, Ambroise Paré Hospital (AP-HP), INSERM U-1018, Boulogne, France (M.H.-M.)
| | - Nassim Braik
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Sandrine Deltour
- Sorbonne Université, Urgences Cerebro-Vasculaires Pitié-Salpêtrière Hospital (AP-HP), INSERM UMR U-942, Paris, France (S.D.)
| | - Alexandre Ceccaldi
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Hui Wang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China (H.W.)
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Delphine Brugier
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
| | - Eric Vicaut
- Unité de Recherche Clinique, ACTION Study Group, Hôpital Fernand Widal (AP-HP), SAMM - Statistique, Analyse et Modélisation Multidisciplinaire EA 4543, Université Paris 1 Panthéon Sorbonne, France (S.-F.D., E.V.)
| | - Jean-Michel Juliard
- Département de Cardiologie, Hôpital Bichat, AP-HP, Université Paris-Diderot, Inserm U1148, France (G.D., E.B., J.-M.J.)
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group (Allies in Cardiovascular Trials, Initiatives and Organized Networks), INSERM UMRS1166, ICAN, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (G.D., J.S., N.B., A.C., N.H., D.B., G.M.)
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Wongcharoen W, Pacharasupa P, Norasetthada L, Gunaparn S, Phrommintikul A. Anti-Factor Xa Activity of Standard and Japan-Specific Doses of Rivaroxaban in Thai Patients With Non-Valvular Atrial Fibrillation. Circ J 2020; 84:1075-1082. [PMID: 32461505 DOI: 10.1253/circj.cj-20-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recommended rivaroxaban doses for stroke prevention in atrial fibrillation (SPAF) are 20 and 15 mg/day in patients with normal and reduced renal function, respectively, but lower doses (15 and 10 mg) have been tested and approved in Japan. It is not known whether 15 and 10 mg rivaroxaban are appropriate in other Asian populations. This study compared the anti-Factor Xa (FXa) activity of 20 and 15 mg rivaroxaban in Thai patients with normal renal function and 15 and 10 mg rivaroxaban in patients with reduced renal function.Methods and Results:Sixty non-valvular atrial fibrillation patients receiving rivaroxaban (mean [±SD] age 69.3±9.1 years, mean creatinine clearance 59.2±22.7 mL/min) were enrolled. The anti-FXa activity of standard rivaroxaban and Japan-specific doses was measured at peak and trough concentrations. Median anti-FXa activity at peak concentrations was significantly higher for the standard than Japan-specific dose. Median anti-FXa activity measured at the trough was significantly higher for the standard dose only in those with impaired renal function. A higher proportion of patients receiving the Japan-specific rather than standard dose had anti-FXa activity at peak concentrations within the expected range (87.7% vs. 64.4%; P=0.001). One-third of those receiving the standard dose had anti-FXa activity higher than the expected range. CONCLUSIONS A significantly higher proportion of Thai patients receiving the Japan-specific dose of rivaroxaban had anti-FXa activity at peak concentrations within the expected range.
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Affiliation(s)
- Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Phongsathon Pacharasupa
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Lalita Norasetthada
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
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39
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Affiliation(s)
- Robert Diep
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - David Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
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40
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Mahmoudpour SH, Valerio L, Douxfils J, Mahan CE, Jankowski M, Quitzau K, Konstantinides SV, Barco S. Potential Drug Interactions between Recombinant Interleukin-2 and Direct Oral Anticoagulants: Indirect Evidence from In Vivo Animal Studies. Hamostaseologie 2020; 40:679-686. [PMID: 32325520 DOI: 10.1055/a-1120-4064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Recombinant interleukin-2 (rIL-2) is indicated for metastatic renal cell carcinoma and melanoma. Over recent years low-dose rIL-2 has been studied for the treatment of autoimmune diseases and acute coronary syndrome because of its ability to expand and activate T regulatory (Treg) cells. However, several medical conditions potentially benefiting from rIL-2 administrations are characterized by an intrinsic prothrombotic risk, thus requiring concurrent anticoagulation. In our systematic review of the literature, we investigated the potential for drug interactions between oral anticoagulants and rIL-2 by assessing the influence of rIL-2 administration on transporters and cytochromes determining the pharmacokinetics of (direct) oral anticoagulants. We extracted data from 12 studies, consisting of 11 animal studies and one study in humans. Eight studies investigated the pharmacokinetics of P-glycoprotein (P-gp) substrates and reported that the intraperitoneal rIL-2 administration may inhibit intestinal P-gp. Four studies on hepatic cytochrome P450 yielded conflicting results. The only human study included in this systematic review concluded that rIL-2 suppresses the hepatic cytochrome P450, but only if given at higher doses. Based on the results from animal studies, the co-administration of rIL-2 and dabigatran etexilate, a substrate of intestinal P-gp, may lead to higher dabigatran plasma concentrations and bioavailability. Human studies should confirm whether this potential interaction is clinically relevant.
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Affiliation(s)
- Seyed Hamidreza Mahmoudpour
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Biometry and Bioinformatics, Institute for Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Charles E Mahan
- Presbyterian Healthcare Services, University of New Mexico, Albuquerque, United States
| | - Marius Jankowski
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Kurt Quitzau
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital and University of Zurich, Zurich, Switzerland
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Shaikh K, Mungantiwar A, Halde S, Pandita N. Liquid chromatography-tandem mass spectrometry method for determination of rivaroxaban in human plasma and its application to a pharmacokinetic study. EUROPEAN JOURNAL OF MASS SPECTROMETRY (CHICHESTER, ENGLAND) 2020; 26:91-105. [PMID: 31514543 DOI: 10.1177/1469066719875014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A high-performance liquid chromatography tandem mass spectrometric method for the determination of Rivaroxaban in human plasma has been developed and validated using Rivaroxaban D4 as an internal standard. The extraction of analyte and internal standard was accomplished by solid phase extraction technique. The method has been validated over a concentration range of 5.96-801 ng/mL. Chromatographic separations were achieved using Gemini C18, 150 mm × 4.6 mm, 5 µm, column eluted at flow rate of 1.5 mL/min with mobile phase (acetonitrile: ammonium acetate buffer (80:20 v/v)). The overall run time of method was about 1.8 min with elution times of Rivaroxaban and its internal standard Rivaroxaban D4 at around 1.18 min. The multiple reaction monitoring transitions were set at 436/145 (m/z) and 440/145 (m/z) for Rivaroxaban and Rivaroxaban D4, respectively. The calibration curves were linear (r2 ≥ 0.99) over the range of 5.96-801 ng/mL with lower limit of quantitation validated at 5.96 ng/mL. Extraction recoveries were >88% for both rivaroxaban and its stable labeled internal standard rivaroxaban D4. The inter-day/between run precisions were ranged from 1.08% to 3.75%, while accuracy ranged from 96.3% to 102%. The presented method was used in pharmacokinetic study in healthy volunteers. Results of incurred sample reanalysis were within the acceptance range of ±20% of original value, for 98.3% of samples reanalyzed. This indicated good assay precision of target analytes in their real matrix at the employed experimental conditions. The applicability of the assay for the determination of the pharmacokinetic parameters was demonstrated.
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Affiliation(s)
- Khurshid Shaikh
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India
- Department of Chemistry, Sunandan Divatia School of Science, NMIMS University, Mumbai, India
| | - Ashish Mungantiwar
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India
| | - Supriya Halde
- Department of Bioequivalence, Research & Development Centre, Macleods Pharmaceuticals Limited, Mumbai, India
| | - Nancy Pandita
- Department of Chemistry, Sunandan Divatia School of Science, NMIMS University, Mumbai, India
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Ischemic and Thrombotic Events Associated with Concomitant Xa-inhibiting Direct Oral Anticoagulants and Antiepileptic Drugs: Analysis of the FDA Adverse Event Reporting System (FAERS). CNS Drugs 2019; 33:1223-1228. [PMID: 31686406 DOI: 10.1007/s40263-019-00677-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Factor Xa-inhibiting direct oral anticoagulants (FXa-DOACs) undergo hepatic metabolism via cytochrome P-450 (CYP450). Concomitant use of rifampicin, an inducer of these enzymes, with FXa-DOACs, has been shown to decrease FXa-DOAC concentrations in healthy subjects. Several common antiepileptic drugs (AEDs) are known to induce CYP450 enzymes as well. However, little is known regarding the impact of this potential interaction on treatment outcomes with FXa-DOACs. METHODS We analyzed adverse event cases submitted to the Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) from January 2013 to December 2018. We compared the proportion of cases reporting thromboembolic and ischemic adverse events (TAIAEs) with the concomitant use of FXa-DOACs and enzyme-inducing AEDs to the proportion of cases with FXa-DOACs and other AEDs. RESULTS During this period, 9693 adverse event cases reported concomitant use of FXa-DOACs and AEDs. Almost all reports (> 99%) involved the use of rivaroxaban or apixaban. Compared with other AEDs, enzyme-inducing AEDs were associated with an 86% increase in the odds of reporting TAIAEs [reporting odds ratio (ROR) 1.86, 95% confidence interval (CI) 1.61-2.15; p < 0.0001]. In secondary separate analyses of rivaroxaban and apixaban, enzyme-inducing AEDs were similarly associated with increased reporting of a TAIAE (ROR 1.79, 95% CI 1.50-2.12, and ROR 1.88, 95% CI 1.41-2.48, respectively). CONCLUSION Using real world data, we observed an increase in the odds of reporting anticoagulation treatment failure among patients treated with FXa-DOACs and concomitant enzyme-inducing AEDs compared to those treated with other AEDs.
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Siguret V, Abdoul J, Delavenne X, Curis E, Carlo A, Blanchard A, Salem JE, Gaussem P, Funck-Brentano C, Azizi M, Mismetti P, Loriot MA, Lecompte T, Gouin-Thibault I. Rivaroxaban pharmacodynamics in healthy volunteers evaluated with thrombin generation and the active protein C system: Modeling and assessing interindividual variability. J Thromb Haemost 2019; 17:1670-1682. [PMID: 31215111 DOI: 10.1111/jth.14541] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/21/2019] [Accepted: 06/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rivaroxaban is a direct factor Xa inhibitor with substantial inter-individual pharmacokinetic (PK) variability. Pharmacodynamic (PD) variability, especially assessed with thrombin generation (TG), has been less documented. OBJECTIVES (i) To assess TG parameter time profiles in healthy volunteers, with TG being studied under different conditions and (ii) to model the relationship between rivaroxaban concentrations and TG parameters and subsequently estimate interindividual variability. METHODS Sixty healthy male volunteers (DRIVING-NCT01627665) received a single 40-mg rivaroxaban dose. Blood sampling was performed at baseline and 10 predefined time points over 24 h. The TG was investigated with the fully automated ST-Genesia system (Stago), using two tissue-factor (TF) concentrations, in the absence (-), or presence (+) of thrombomodulin (TM) for the lowest one. The PD models were built to characterize the relationships between plasma rivaroxaban concentrations and endogenous thrombin potential (ETP) or peak height induced by the lowest TF concentration. RESULTS Thrombin generation parameter time profiles with the lowest TF concentration showed a good sensitivity to rivaroxaban, especially +TM (active protein C negative feedback). The relationship between rivaroxaban concentrations and TG parameters was modeled with a sigmoidal relation. Mean rivaroxaban concentrations halving the baseline value of ETP and peak height (-TM) (C50 ) were of 284 and 33.2 ng/mL, respectively: +TM, C50 declined to 19.4 and 13.8 ng/mL, reflecting a powerful inhibitory effect. The estimated C50 population coefficients of variation were of 12.2% (-TM) and 31.3% (+TM) with the peak height models, 34.8% (+TM) with the ETP model. CONCLUSIONS This low-rivaroxaban to moderate-rivaroxaban PD variability in healthy volunteers contrasts with the substantial PK variability and deserves to be studied in different patient settings.
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Affiliation(s)
- Virginie Siguret
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Lariboisière, Paris, France
| | - Johan Abdoul
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Xavier Delavenne
- Laboratoire de Pharmacologie -Toxicologie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
- Groupe de Recherche sur la Thrombose, Université Jean Monnet, Saint-Etienne, France
| | - Emmanuel Curis
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Laboratoire de biomathématiques, plateau iB2, EA 7537 BioSTM, Faculté de pharmacie de Paris, Paris, France
- Service de biostatistiques et informatique médicale, Hôpital Saint-Louis, AP-HP, Paris, France
| | | | - Anne Blanchard
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Centre d'Investigation Clinique INSERM CIC-1418, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Joe-Elie Salem
- Département de Pharmacologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Paris, France
- INSERM, CIC-1421, Institut de Cardio-métabolisme et Nutrition (ICAN), UMR ICAN_1166, Sorbonne Universités, Paris, France
| | - Pascale Gaussem
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Funck-Brentano
- Département de Pharmacologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Paris, France
- INSERM, CIC-1421, Institut de Cardio-métabolisme et Nutrition (ICAN), UMR ICAN_1166, Sorbonne Universités, Paris, France
| | - Michel Azizi
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Centre d'Investigation Clinique INSERM CIC-1418, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
- Unité d'Hypertension Artérielle, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint Étienne, Saint Étienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalier Universitaire de Saint Étienne, Saint Étienne, France
| | - Marie-Anne Loriot
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service de Biochimie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
- INSERM UMR_S1147, Centre Universitaire des Saints-Pères, Paris, France
| | - Thomas Lecompte
- Unité d'Hémostase, Département de Médecine, Hôpitaux Universitaires de Genève (HUG) and GpG, Faculté de médecine, Université de Genève, Geneva, Switzerland
| | - Isabelle Gouin-Thibault
- Laboratoire d'Hématologie Biologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
- INSERM, CIC-1414, Université de Rennes, Rennes, France
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Liquid chromatographic methods for the determination of direct oral anticoagulant drugs in biological samples: A critical review. Anal Chim Acta 2019; 1076:18-31. [DOI: 10.1016/j.aca.2019.03.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
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Zaman JAB, Bhandari AK. Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease. J Cardiovasc Pharmacol Ther 2019; 24:499-508. [PMID: 31284744 DOI: 10.1177/1074248419858116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The role of oral anticoagulants (OAC) in atrial fibrillation (AF) is well established. However, none of the randomized controlled trials included patients with end-stage renal disease (ESRD) leaving a lack of evidence in this large, challenging and unique patient group. Patients on hemodialysis (HD) with AF have additional risk factors for stroke due to vascular comorbidities, HD treatment, age, and diabetes. Conversely, they are also at increased risk of major bleeding due to uremic platelet impairment. Anticoagulants increase bleeding risk in patients with ESRD and HD up to 10-fold compared with non chronic kidney disease (CKD) patients on warfarin. There are conflicting data and recommendations regarding use of OACs in ESRD which will be reviewed in this article. We conclude by proposing a modified strategy for OAC use in ESRD based on the latest evidence.
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Affiliation(s)
- Junaid A B Zaman
- 1 Department of Cardiology, Good Samaritan Hospital, Los Angeles, CA, USA
| | - Anil K Bhandari
- 1 Department of Cardiology, Good Samaritan Hospital, Los Angeles, CA, USA
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The daily practice of direct oral anticoagulant use in patients with atrial fibrillation; an observational cohort study. PLoS One 2019; 14:e0217302. [PMID: 31170727 PMCID: PMC6554016 DOI: 10.1371/journal.pone.0217302] [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: 01/02/2019] [Accepted: 05/08/2019] [Indexed: 01/17/2023] Open
Abstract
Background Direct oral anticoagulants (DOACs) are administered in fixed doses without monitoring. There is still little published data on the impact of the absence of monitoring on adherence to medication and stability of DOAC plasma levels over time. Objectives To explore adherence and stability of DOAC plasma levels over time in patients with atrial fibrillation (NVAF) recently started on DOAC therapy. Patients and methods A prospective observational cohort study with structured follow up including assessment of adherence to medication, plasma levels at baseline, 3,6 and 12 months and adverse events. Results We included 164 patients; 89% were previous users of a vitamin K antagonist (VKA). One-year adherence was reasonably good: Morisky adherence measurement scores of 6–8 in 92%. The majority of DOAC plasma levels were within reported on-therapy ranges; dabigatran (median 104.4 ng/ml, IQR 110.2), rivaroxaban (median 185.2 ng/ml, IQR 216.1) and on average levels were not different for full and adjusted doses. There was significant variation between patients, but no significant differences over time within individuals. A substantial proportion of patients starting in the upper-or lower 20th percentiles remained there during the entire follow up. Seventeen bleedings (16 minor, 1 major) were reported, no ischemic events and bleeding or thrombotic events were not associated with DOAC plasma levels. Conclusions Adherence was reasonably good in the majority of patients. Our data confirm the stability of DOAC plasma levels over time. Knowledge of such data may, in the individual patient, contribute to optimal drug and dose selection.
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Park SH, Seo YH, Park PW, Kim KH, Seo JY, Lee HT, Kwoun WJ, Ahn JY. Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution. J Clin Lab Anal 2019; 33:e22869. [PMID: 30860622 PMCID: PMC6595315 DOI: 10.1002/jcla.22869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Apixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on-therapy ranges using conventional tests. METHODS A total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti-factor Xa chromogenic assay. PT, APTT, antithrombin, D-dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On-therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs. RESULTS Anti-factor Xa chromogenic assay-based DOACs levels were 26.0-279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9-565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3-395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6-494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6-431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On-therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32-1.52 for apixaban 2.5 mg BID, 1.12-1.75 for apixaban 5 mg BID, 1.11-1.78 for rivaroxaban 15 mg OD, 1.09-1.64 for rivaroxaban 20 mg OD, and 1.22-1.81 for rivaroxaban 20 mg BID. CONCLUSIONS Apixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.
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Affiliation(s)
- Soon Ho Park
- Department of Laboratory Medicine, Hongcheon Asan Hospital, Gangwon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung-Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jae Kwoun
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Sharp CR, deLaforcade AM, Koenigshof AM, Lynch AM, Thomason JM. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 4-Refining and monitoring antithrombotic therapies. J Vet Emerg Crit Care (San Antonio) 2019; 29:75-87. [PMID: 30654420 DOI: 10.1111/vec.12794] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/08/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To systematically review the evidence for therapeutic monitoring of antithrombotic drugs in small animals, develop guidelines regarding antithrombotic monitoring, and identify knowledge gaps in the field. DESIGN First, a standardized, systematic literature review was conducted to address predefined PICO (Population/Patient, Intervention, Control, Outcome) questions, with categorization of relevant articles according to level of evidence and quality. Preliminary guidelines were developed by PICO worksheet authors and the domain chair. Thereafter, a Delphi-style survey was used to develop consensus on guidelines regarding therapeutic monitoring of antithrombotics in dogs and cats. SETTING Academic and referral veterinary medical centers. RESULTS PICO questions regarding the utility of therapeutic monitoring were developed for 6 different antithrombotic drugs or drug classes, including aspirin, clopidogrel, warfarin, unfractionated heparin, the low molecular weight heparins, and rivaroxaban, The majority of the literature pertaining to therapeutic monitoring of antithrombotic drugs was either performed in experimental animal models of disease or involved studies of drug pharmacokinetics and pharmacodynamics in healthy laboratory animals. There was a paucity of high level of evidence studies directly addressing the PICO questions, which limited the strength of recommendations that could be provided. The final guidelines recommend that therapeutic monitoring should be performed when using warfarin or unfractionated heparin in dogs and cats at risk of thrombosis. There is insufficient evidence to make strong recommendations for therapeutic monitoring of aspirin or low molecular weight heparin in dogs and cats at this time. CONCLUSIONS As in other CURATIVE domains, significant knowledge gaps were highlighted, indicating the need for substantial additional research in this field. Ongoing investigation of the role of therapeutic monitoring of antithrombotic therapies will undoubtedly facilitate improved outcomes for dogs and cats at risk of thrombosis.
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Affiliation(s)
- Claire R Sharp
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA, Australia
| | - Armelle M deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA
| | - Amy M Koenigshof
- College of Veterinary Medicine, Michigan State University, East Lansing, MI
| | - Alex M Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, MS
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Mehta A, Burkland D, Mathuria N. Isolated hemopericardium after initiation of rivaroxaban: Implications and potential mechanisms. Clin Pract 2019; 9:1096. [PMID: 30815244 PMCID: PMC6371059 DOI: 10.4081/cp.2019.1096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/17/2019] [Indexed: 02/05/2023] Open
Abstract
Direct oral anticoagulants have become increasingly used for atrial fibrillation and venothromboembolic disease. Thus far, there have been a few published cases of pericardial effusion associated with rivaroxban. However, there has been little published regarding the effects of concurrent medications and their effect on the cytochrome enzyme systems involved in rivaroxaban metabolism. We present a case of a 76-year-old female who develops a spontaneous haemopericardium after initiating rivaroxaban. After thorough medical reconciliation, we offer pharmacokinetic mechanisms that may have contributed to the haemopericardium. This case demonstrates the importance of reviewing patients medication lists and utilizing basic pharmacokinetics to prevent adverse events.
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Affiliation(s)
| | - David Burkland
- Texas Heart Institute.,Baylor College of Medicine, Texas, USA
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Kanuri SH, Kreutz RP. Pharmacogenomics of Novel Direct Oral Anticoagulants: Newly Identified Genes and Genetic Variants. J Pers Med 2019; 9:jpm9010007. [PMID: 30658513 PMCID: PMC6463033 DOI: 10.3390/jpm9010007] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/01/2023] Open
Abstract
Direct oral anticoagulants (DOAC) have shown an upward prescribing trend in recent years due to favorable pharmacokinetics and pharmacodynamics without requirement for routine coagulation monitoring. However, recent studies have documented inter-individual variability in plasma drug levels of DOACs. Pharmacogenomics of DOACs is a relatively new area of research. There is a need to understand the role of pharmacogenomics in the interpatient variability of the four most commonly prescribed DOACs, namely dabigatran, rivaroxaban, apixaban, and edoxaban. We performed an extensive search of recently published research articles including clinical trials and in-vitro studies in PubMed, particularly those focusing on genetic loci, single nucleotide polymorphisms (SNPs), and DNA polymorphisms, and their effect on inter-individual variation of DOACs. Additionally, we also focused on commonly associated drug-drug interactions of DOACs. CES1 and ABCB1 SNPs are the most common documented genetic variants that contribute to alteration in peak and trough levels of dabigatran with demonstrated clinical impact. ABCB1 SNPs are implicated in alteration of plasma drug levels of rivaroxaban and apixaban. Studies conducted with factor Xa, ABCB1, SLCOB1, CYP2C9, and VKORC1 genetic variants did not reveal any significant association with plasma drug levels of edoxaban. Pharmacokinetic drug-drug interactions of dabigatran are mainly mediated by p-glycoprotein. Strong inhibitors and inducers of CYP3A4 and p-glycoprotein should be avoided in patients treated with rivaroxaban, apixaban, and edoxaban. We conclude that some of the inter-individual variability of DOACs can be attributed to alteration of genetic variants of gene loci and drug-drug interactions. Future research should be focused on exploring new genetic variants, their effect, and molecular mechanisms that contribute to alteration of plasma levels of DOACs.
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Affiliation(s)
- Sri H Kanuri
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Rolf P Kreutz
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA.
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