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Yang S, Xu Y, Zhang Y, Li D, Li X. Effectiveness and Safety of Different Oral Anticoagulants with P-glycoprotein/ CYP3A4 Inhibitors: A Network Meta-analysis. Curr Pharm Des 2024; 30:1167-1177. [PMID: 38523519 DOI: 10.2174/0113816128293940240315073345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Metabolism of oral anticoagulants (OAC) is affected by P-glycoprotein (P-gp)/ CYP3A4 enzyme. However, the P-gp/CYP3A4 inhibitors are unavoidably used with OACs. METHODS Medline, Cochrane, and Embase were systematically searched for randomized controlled trials and cohort studies from inception till 23rd November, 2022 to assess the safety and effectiveness of OACs when concomitantly used with P-gp/CYP3A4 inhibitors. The primary outcomes were major bleeding and gastrointestinal (GI) bleeding. Secondary outcomes were stroke/systemic embolism (SE), all-cause mortality, any bleeding as well as intracranial hemorrhage (ICH). We estimated summary odds ratios (OR) with 95% credible intervals (CI) using pairwise and network meta-analysis with random effects. RESULTS A total of 11 studies involving 37,973 patients were included. When concomitantly used with P-pg/ CYP3A4 inhibitors, network meta-analysis indicated that dabigatran, apixaban, and edoxaban were associated with significantly lower risk of major bleeding compared to rivaroxaban, with ORs of 0.56, 0.51 and 0.48, respectively. Rivaroxaban and dabigatran were associated with a significantly increased risk of GI bleeding than warfarin, apixaban and edoxaban. Dabigatran and apixaban were linked with significantly lower risk of any bleeding compared with warfarin (ORs were 0.75 and 0.68, respectively) or rivaroxaban (ORs were 0.67 and 0.60, respectively). Apixaban (OR 0.32) and edoxaban (OR 0.35) were associated with a lower risk of ICH compared with warfarin. There was no difference between any OACs in terms of stroke/SE or all-cause mortality. CONCLUSION When concomitantly used with P-gp/CYP3A4 inhibitors, apixaban and edoxaban were associated with a lower risk of bleeding, though no significant difference in effectiveness was observed among all OACs.
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Affiliation(s)
- Siyu Yang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ye Xu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yang Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Arbit B, Hsu JC. Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation and Associated Intracranial Hemorrhage: A Focused Review. Clin Cardiol 2015; 38:684-91. [PMID: 26173428 DOI: 10.1002/clc.22434] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and predisposes patients to an increased risk of embolic stroke. After nearly 60 years, warfarin is no longer the only effective therapeutic option for patients with AF. Large randomized trials have consistently shown that non-vitamin K oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban significantly reduce from the risk of intracranial hemorrhage (ICH) compared with warfarin. We provide a focused review regarding the NOACs and ICH in AF patients by summarizing findings of these large clinical trials, mechanisms of lower ICH, reversal strategies with specific agents, and monitoring strategies.
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Affiliation(s)
- Boris Arbit
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, La Jolla, California
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Abstract
To evaluate whether intravitreal thrombin activity is elevated in eyes with branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) in comparison to healthy controls. Prospective clinical case series of 19 patients with BRVO, 13 patients suffering from CRVO and nine participants serving as controls. Vitreous taps were extracted from the central vitreous body, 200 μl frozen/thawed sample was immediately stabilized with 200 μl 5% human albumin, and 200 μl mixture thereof was stabilized with 200 μl 2.5 mol/l arginine, pH 8.6. Thrombin activity was determined chromogenically. Intravitreal levels of vascular endothelial growth factor (VEGF) as a marker for blood-retina barrier (BRB) breakdown were measured by a commercial chemiluminescent enzyme immuno assay (R&D). Intravitreal thrombin activity and VEGF levels were 1.6 ± 1.2 mIU/ml (mean value ± SD; range: 0.2-4.2 mIU/ml) and 554 ± 568 pg/ml (range: 20-2005 pg/ml) in BRVO-affected eyes, 2.6 ± 1.2 mIU/ml (range: 0.8-5.2 mIU/ml) and 1332 ± 1350 pg/ml (range: 58-3943 pg/ml) in eyes suffering from CRVO as well as 0.8 ± 0.8 mIU/ml (range: 0.2-2.7 mIU/ml) and 115 ± 120 pg/ml (range: 32-431 pg/ml) in controls. There are significant differences of intravitreal thrombin activity and intravitreal VEGF levels between eyes with BRVO, CRVO, and controls (P = 0.007 and P = 0.003, Kruskal-Wallis test). Intravitreal thrombin activity is significantly correlated with intravitreal VEGF levels (r = 0656; P < 0.001, Pearson correlation). Intravitreal thrombin activity might serve as a new marker for BRB breakdown or macular fibrin deposition in ophthalmology. Significant differences of intravitreal thrombin activity between eyes with BRVO, CRVO, and healthy controls might offer new therapeutic strategies for RVO-affected eyes. The effect of oral and intravitrealy injected direct thrombin inhibitors needs to be evaluated in further investigations.
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Wittich CM, Burkle CM, Lanier WL. Ten common questions (and their answers) about off-label drug use. Mayo Clin Proc 2012; 87:982-90. [PMID: 22877654 PMCID: PMC3538391 DOI: 10.1016/j.mayocp.2012.04.017] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 04/11/2012] [Accepted: 04/16/2012] [Indexed: 11/18/2022]
Abstract
The term off-label drug use (OLDU) is used extensively in the medical literature, continuing medical education exercises, and the media. Yet, we propose that many health care professionals have an underappreciation of its definition, prevalence, and implications. This article introduces and answers 10 questions regarding OLDU in an effort to clarify the practice's meaning, breadth of application, acceptance, and liabilities. Off-label drug use involves prescribing medications for indications, or using a dosage or dosage form, that have not been approved by the US Food and Drug Administration. Since the Food and Drug Administration does not regulate the practice of medicine, OLDU has become common. It occurs in every specialty of medicine, but it may be more common in areas of medicine in which the patient population is less likely to be included in clinical trials (eg, pediatric, pregnant, or psychiatric patients). Pharmaceutical companies are not allowed to promote their medications for an off-label use, which has lead to several large settlements for illegal marketing. To limit liability, physicians should prescribe medications only for indications that they believe are in the best interest of the patient. In addition, health care professionals should educate themselves about OLDU to weigh the risks and benefits and provide the best possible care for their patients.
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Affiliation(s)
- Christopher M Wittich
- Department of Internal Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Ru San T, Chan MYY, Wee Siong T, Kok Foo T, Kheng Siang N, Lee SH, Chi Keong C. Stroke prevention in atrial fibrillation: understanding the new oral anticoagulants dabigatran, rivaroxaban, and apixaban. THROMBOSIS 2012; 2012:108983. [PMID: 22997573 PMCID: PMC3444866 DOI: 10.1155/2012/108983] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/01/2012] [Indexed: 12/21/2022]
Abstract
Unlike vitamin K antagonists (VKAs), the new oral anticoagulants (NOACs)-direct thrombin inhibitor, dabigatran, and direct activated factor X inhibitors, rivaroxaban, and apixaban-do not require routine INR monitoring. Compared to VKAs, they possess relatively rapid onset of action and short halflives, but vary in relative degrees of renal excretion as well as interaction with p-glycoprotein membrane transporters and liver cytochrome P450 metabolic enzymes. Recent completed phase III trials comparing NOACs with VKAs for stroke prevention in atrial fibrillation (AF)-the RE-LY, ROCKET AF, and ARISTOTLE trials-demonstrated at least noninferior efficacy, largely driven by significant reductions in haemorrhagic stroke. Major and nonmajor clinically relevant bleeding rates were acceptable compared to VKAs. Of note, the NOACs caused significantly less intracranial haemorrhagic events compared to VKAs, the mechanisms of which are not completely clear. With convenient fixed-dose administration, the NOACs facilitate anticoagulant management in AF in the community, which has hitherto been grossly underutilised. Guidelines should evolve towards simplicity in anticipation of greater use of NOACs among primary care physicians. At the same time, the need for caution with their use in patients with severely impaired renal function should be emphasised.
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Affiliation(s)
- Tan Ru San
- Department of Cardiology, National Heart Centre Singapore, 17 Third Hospital Avenue, Singapore 168752
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857
| | - Mark Yan Yee Chan
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074
| | - Teo Wee Siong
- Department of Cardiology, National Heart Centre Singapore, 17 Third Hospital Avenue, Singapore 168752
- Mount Elizabeth Medical Centre, 3 Mount Elizabeth No. 14-10, Singapore 228510
| | - Tang Kok Foo
- Mount Elizabeth Medical Centre, 3 Mount Elizabeth No. 14-01, Singapore 228510
| | - Ng Kheng Siang
- Gleneagles Medical Centre, 6 Napier Road No. 03-04, Singapore 25499
| | - Sze Huar Lee
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Ching Chi Keong
- Department of Cardiology, National Heart Centre Singapore, 17 Third Hospital Avenue, Singapore 168752
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857
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Hori M. [Series: Clinical study from Japan and its reflections RE-LY trial]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2012; 101:1432-1439. [PMID: 22693869 DOI: 10.2169/naika.101.1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Masatsugu Hori
- Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan
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Sun YX, Huang YX, Li FL, Wang HY, Fan C, Bao YL, Sun LG, Ma ZQ, Kong J, Li YX. IVSPlat 1.0: an integrated virtual screening platform with a molecular graphical interface. Chem Cent J 2012; 6:2. [PMID: 22222098 PMCID: PMC3264508 DOI: 10.1186/1752-153x-6-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 01/05/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The virtual screening (VS) of lead compounds using molecular docking and pharmacophore detection is now an important tool in drug discovery. VS tasks typically require a combination of several software tools and a molecular graphics system. Thus, the integration of all the requisite tools in a single operating environment could reduce the complexity of running VS experiments. However, only a few freely available integrated software platforms have been developed. RESULTS A free open-source platform, IVSPlat 1.0, was developed in this study for the management and automation of VS tasks. We integrated several VS-related programs into a molecular graphics system to provide a comprehensive platform for the solution of VS tasks based on molecular docking, pharmacophore detection, and a combination of both methods. This tool can be used to visualize intermediate and final results of the VS execution, while also providing a clustering tool for the analysis of VS results. A case study was conducted to demonstrate the applicability of this platform. CONCLUSIONS IVSPlat 1.0 provides a plug-in-based solution for the management, automation, and visualization of VS tasks. IVSPlat 1.0 is an open framework that allows the integration of extra software to extend its functionality and modified versions can be freely distributed. The open source code and documentation are available at http://kyc.nenu.edu.cn/IVSPlat/.
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Affiliation(s)
- Yin Xue Sun
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
- School of Computer Science and Information Technology, Northeast Normal University, Changchun 130117, P.R. China
| | - Yan Xin Huang
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
| | - Feng Li Li
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
- School of Computer Science and Information Technology, Northeast Normal University, Changchun 130117, P.R. China
| | - Hong Yan Wang
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
| | - Cong Fan
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
| | - Yong Li Bao
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
| | - Lu Guo Sun
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
| | - Zhi Qiang Ma
- School of Computer Science and Information Technology, Northeast Normal University, Changchun 130117, P.R. China
| | - Jun Kong
- School of Computer Science and Information Technology, Northeast Normal University, Changchun 130117, P.R. China
| | - Yu Xin Li
- National Engineering Laboratory for Druggable Gene and Protein Screening, Northeast Normal University, Changchun 130024, P.R. China
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