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Shi HT, Chen YY, Li XY, Luo JH, Zhong GH, Hu JJ, Zhang M, Zhou BR. The Dynamic Effect of Non-CYP3A4-Metabolized and CYP3A4-Metabolized Statins on Clopidogrel Resistance in Patients With Cerebral Infarction. Front Pharmacol 2021; 12:738562. [PMID: 34690774 PMCID: PMC8526974 DOI: 10.3389/fphar.2021.738562] [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: 08/05/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the treatment effect of statins used together with clopidogrel on cerebral infarction (CI). Methods: One hundred and thirty non-clopidogrel resistant patients were divided into a dynamic clopidogrel resistant (DCR) group and a continuous Non clopidogrel resistance (NCR) group. Patients were randomly assigned to AC group (atorvastatin 40 mg/d + clopidogrel, 51 patients) and RC group (rosuvastatin 20 mg/d + clopidogrel, 47 patients). The patient’s platelet aggregation rate (PAR) was measured on visit 0 (baseline), visit 1 (1 week after clopidogrel alone treatment), and visits 2 to 4 (one, three, and 6 months after clopidogrel plus statins treatment). The platelet reactivity index (PRI) was assessed on visits 0, 2, and 4, and clopidogrel thiol metabolite (H4) levels was measured on visits 2 and 4. DNA sequencing was used to determine CYP3A4, CYP2C9, and CYP2C19 genotypes in all patients. Results: PAR, PRI, and H4 levels, DCR ratio, and the genotype frequencies of CYP2C9*3εC, CYP2C19*2εA, and CYP2C19*3εA of both groups were similar (p > 0.05). CYP2C19εA *2 and *3 were independent risk factors for DCR (p < 0.05). Conclusion: Clopidogrel combined with atorvastatin does not affect platelet inhibition and does not increase the incidence of DCR. The incidence of DCR in the Chinese population is high and is related to CYP2C19εA.
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Affiliation(s)
- Hong Ting Shi
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yong Yuan Chen
- Department of Neurology, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiao Ying Li
- Department of Neurology, The Shunde Affiliated Hospital of Jinan University, Shunde, China
| | - Jian Hua Luo
- Department of Neurology, Yangchun People Hospital, Yangchun, China
| | | | - Jia Jia Hu
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Min Zhang
- Department of Epidemiology and Health Statistics, Guangdong Pharmaceutical University, Guangzhou, China
| | - Bo Rong Zhou
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Xu H, Yu Q, Zhou H, Yang J, Zheng N, Xu Z, Su J. Polymorphisms in the GCK gene increase the risk of clopidogrel resistance in stable coronary artery disease (SCAD) patients. ACTA ACUST UNITED AC 2021; 26:447-452. [PMID: 34165031 DOI: 10.1080/16078454.2021.1945789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Diabetes mellitus is a major factor in clopidogrel resistance (CR), and the glucokinase (GCK) gene plays a pivotal role in glucose homeostasis. This study investigated the contribution of GCK polymorphisms to CR risk. METHODS Two hundred SCAD patients were recruited, and their platelet functions were detected by the Verify-Now P2Y12 assay. The polymorphisms of GCK were tested based on the methods of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). We investigated the associations of GCK polymorphisms and CR. Multivariate logistic regression was performed to analyse the correlations between GCK polymorphisms and clinical values. RESULTS Our study found that the SNPs rs4607517 and rs6975024 were associated with CR. Additionally, patients with the G allele of rs4607517had a greater CR risk, but the C allele of rs6975024 might be a protective factor. Finally, logistic regression revealed that CC + TC (rs6975024) as well as the values of albumin were correlated with a decreased risk of CR, and higher levels of uric acid (UA) may be positively associated with CR. CONCLUSION The GCK gene polymorphisms might increase the CR risk in SCAD patients. Meanwhile, higher albumin levels and lower UA values might decrease the risk.
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Affiliation(s)
- Hongyu Xu
- Department of Geratology, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
| | - Qinglin Yu
- Department of Traditional Chinese Internal Medicine, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
| | - Honglin Zhou
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
| | - Jin Yang
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
| | - Nan Zheng
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
| | - Zhifeng Xu
- Department of Cardiology, Zhenhai People's Hospital of Zhejiang Province, Ningbo, People's Republic of China
| | - Jia Su
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, People's Republic of China
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA
| | - Robert A. Harrington
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
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Zhu KX, Song PY, He-Li, Li MP, Du YX, Ma QL, Peng LM, Chen XP. Association of FMO3 rs1736557 polymorphism with clopidogrel response in Chinese patients with coronary artery disease. Eur J Clin Pharmacol 2020; 77:359-368. [PMID: 33089397 DOI: 10.1007/s00228-020-03024-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Dual antiplatelet therapy with aspirin and clopidogrel is commonly used for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention to prevent stent thrombosis and ischemic events. However, some patients show high on-treatment platelet reactivity (HTPR) during clopidogrel therapy. Genetic factors such as loss-of-function variants of CYP2C19 are validated to increase the risk of HTPR. Flavin-containing monooxygenase 3 (FMO3) is reported to be associated with potency of platelet responsiveness and thrombosis. This study aimed to explore the association between FMO3 rs1736557 polymorphism and clopidogrel response. METHODS Five hundred twenty-two Chinese CAD patients treated with dual antiplatelet therapy were recruited from Xiangya Hospital. After oral administration of 300 mg loading dose (LD) clopidogrel for 12-24 h or 75 mg daily maintenance dose (MD) clopidogrel for at least 5 days, the platelet reaction index (PRI) was determined by vasodilator-stimulated phosphoprotein-phosphorylation assay. FMO3 rs1736557, CYP2C19*2, and CYP2C19*3 polymorphisms were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). RESULTS Mean PRI value was significantly higher in CYP2C19 poor metabolizers (PMs) and intermediate metabolizers (IMs) than the extensive metabolizers (EMs) (p < 0.001). In addition, FMO3 rs1736557 AA homozygotes showed significantly lower PRI as compared with carriers of the major rs1736557 G allele in the entire cohort and in the MD cohort (p = 0.011, p = 0.008, respectively). The risk of HTPR was decreased significantly in carriers of the rs1736557 A allele (AA vs GG: OR = 0.316, 95% CI: 0.137-0.726, p = 0.005; AA vs GA: OR = 0.249, 95% CI: 0.104-0.597, p = 0.001; AA vs GG+GA: OR = 0.294, 95% CI: 0.129-0.669, p = 0.002), and the association was observed mainly in patients carrying the CYP2C19 LOF allele and in those administered with MD. CONCLUSION The FMO3 rs1736557 AA genotype was related to an increased the antiplatelet potency of clopidogrel in Chinese CAD patients. Additional studies are required to verify this finding.
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Affiliation(s)
- Kong-Xiang Zhu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China
| | - Pei-Yuan Song
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China
| | - He-Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China
| | - Mu-Peng Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China
| | - Yin-Xiao Du
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China
| | - Qi-Lin Ma
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Li-Ming Peng
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China. .,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China. .,Department of Cardiology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.
| | - Xiao-Ping Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China. .,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410008, Hunan, People's Republic of China. .,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.
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Zhao X, Li Q, Tu C, Zeng Y, Ye Y. High glycated albumin is an independent predictor of low response to clopidogrel in ACS patients: a cross-sectional study. Cardiovasc Diabetol 2020; 19:171. [PMID: 33036613 PMCID: PMC7545941 DOI: 10.1186/s12933-020-01146-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/29/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Glycated albumin (GA) is a marker of short-term glycemic control and is strongly associated with the occurrence of diabetes. Previous studies have shown an association between GA and the effect of clopidogrel therapy on ischemic stroke. However, limited information is available regarding this relationship in acute coronary syndrome (ACS) patients. In this study, we evaluated the effect of GA on platelet P2Y12 inhibition by clopidogrel in patients with ACS. METHODS Consecutive Chinese patients with ACS who received loading or maintenance doses of clopidogrel in addition to aspirin were recruited. At least 12 h after the patient had taken the clopidogrel dose, thromboelastography (TEG) and light transmittance aggregometry (LTA) were used to calculate the quantitative platelet inhibition rate to determine clopidogrel-induced antiplatelet reactivity. A prespecified cutoff of the maximum amplitude of adenosine diphosphate (ADP)-induced platelet-fibrin clot strength > 47 mm plus an ADP-induced platelet inhibition rate < 50% assessed by TEG or ADP-induced platelet aggregation > 40% assessed by LTA to indicate low responsiveness to clopidogrel were applied for evaluation. Patients were categorized into two groups based on a GA level of 15.5%, the cutoff point indicating the development of early-phase diabetes. Multivariate linear regression analysis was used to assess the interaction of GA with clopidogrel antiplatelet therapy. RESULTS A total of 1021 participants were evaluated, and 28.3% of patients (289 of 1021) had low responsiveness to clopidogrel assessed by TEG. In patients with elevated GA levels, low responsiveness to clopidogrel assessed by TEG was observed in 33.7% (139 of 412) of patients, which was a significantly higher rate than that in the lower-GA-level group (24.6%, P = 0.002). According to multivariate linear regression analysis, a GA level > 15.5% was independently associated with low responsiveness to clopidogrel after adjustment for age, sex and other conventional confounding factors. This interaction was not mediated by a history of diabetes mellitus. A GA level ≤ 15.5% was associated with a high positive value [75.4%, 95% CI 73.0-77.6%] for predicting a normal responsiveness to clopidogrel. CONCLUSIONS GA could be a potential biomarker to predict the effects of clopidogrel antiplatelet therapy in ACS patients and might be a clinical biomarker to guide DAPT de-escalation.
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Affiliation(s)
- Xiliang Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Quan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Chenchen Tu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Yong Zeng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Yicong Ye
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
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Gairolla J, Ahluwalia J, Khullar M, Kler R, Kishore K, Medhi B, Modi M, Kumar M, Kumar A, Khurana D. Clopidogrel response in ischemic stroke patients: Is polymorphism or gender more important? Results of the CRISP study. J Clin Neurosci 2020; 76:81-86. [PMID: 32317191 DOI: 10.1016/j.jocn.2020.04.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/05/2020] [Indexed: 11/16/2022]
Abstract
Clopidogrel (CLP) is a second generation thienopyridine drug commonly used in secondary prevention of ischemic stroke (IS). Its antiplatelet response maybe variable due to genetic and non-genetic factors. Adipokines may affect platelet aggregation through ADP mediated platelet signalling. However, the combined effect of CYP genetic variants and adipokines on antiplatelet response of clopidogrel is unclear. Patients of IS/Transient ischemic attack (TIAs) within 3 months were prospectively screened following clopidogrel treatment. Major exclusions were cardioembolic and non atherosclerotic strokes. Antiplatelet effect of clopidogrel along with adipokine (Leptin and adiponectin) levels and genotyping of CYP, P2Y12 gene were investigated. Rare genetic variants were confirmed by DNA sequencing. 204 patients with ischemic stroke/TIAs were screened and 163 were recruited. 85 (52.1%) patients were poor responders to clopidogrel. Antiplatelet response to clopidogrel was weaker in females [Median 8.0 (IQR: 3.0-14.0)] compared to males [Median 5.0 (IQR: 2.0-10.0)]. In female subgroup analysis, association was found among high leptin levels and PPI (+) usage in poor responders. None of the genetic variants (CYP2C19*2,*3,*4*, CYP2C9*3, CYP2B6 and P2Y12) were found to influence the antiplatelet effects (p > 0.05). On multivariable logistic regression, a poor clopidogrel response was associated with female gender (Adjusted OR 2.55, 95% CI: 1.05-6.18) and PPI usage (Adjusted OR 2.42, 95% CI: 1.09-5.34). Despite a high prevalence of clopidogrel resistance in the North Indian stroke patients, female gender rather than genetic polymorphisms of CYP and P2Y12 genes may influence its antiplatelet effect. Further research may ascertain the role of gender on clopidogrel response.
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Affiliation(s)
- Jitender Gairolla
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Madhu Khullar
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rupinder Kler
- Molecular Genetics Lab, R&D Centre, Dayanand Medical College & Hospital, Ludhiana 141001, Punjab, India
| | - Kamal Kishore
- Department of Biostatistics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Mukesh Kumar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ashok Kumar
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Verdoia M, Rolla R, Negro F, Tonon F, Pergolini P, Nardin M, Marcolongo M, De Luca G. Homocysteine levels and platelet reactivity in coronary artery disease patients treated with ticagrelor. Nutr Metab Cardiovasc Dis 2020; 30:292-299. [PMID: 31780401 DOI: 10.1016/j.numecd.2019.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/17/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Recurrent atherothrombotic events have been reported in certain higher risk subsets of patients even with ticagrelor, a potent first-line antiplatelet agent for the management of patients with acute coronary syndrome (ACS). Hyperhomocysteinemia is a known determinant of platelet function abnormalities. Therefore, the aim of our study was to evaluate the impact of homocysteine (Hcy) levels on platelet reactivity in patients receiving Ticagrelor. METHODS AND RESULTS Patients with ACS undergoing percutaneous coronary revascularization and on dual antiplatelet therapy with ASA + Ticagrelor (90mg/twice a day) were scheduled for platelet function assessment 30-90 days post-discharge. Aggregation tests were performed by Multiple Electrode Aggregometry (MEA). Suboptimal platelet inhibition HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). We included 432 patients, divided according to Hcy tertiles. Higher Hcy levels were associated with age, renal failure, creatinine levels and use diuretics (p < 0.001). Patients with higher Hcy levels displayed a higher platelet reactivity at COL test (p = 0.002), and ADP test (p = 0.04), with a linear relationship between Hcy and platelet aggregation after stimulation with collagen (r = 0.202, p < 0.001), thrombin receptor peptide (r = 0.104, p = 0.05) and ADP (r = 0.145, p = 0.006). However, Hcy levels did not significantly affect the rate of HRPR with Ticagrelor (9.9% vs 13.7% vs 10.7%, p = 0.89; adjusted OR [95% CI] = [0.616-1.51], p = 0.99). CONCLUSIONS Among patients with ACS, despite the elevated platelet reactivity associated to hyperhomocysteinemia, DAPT with ticagrelor could overcome such phenomenon, achieving an adequate platelet inhibition in the majority of the patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Roberta Rolla
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Francesco Tonon
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Patrizia Pergolini
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Department of Internal Medicine, ASST Spedali Civili, Brescia, Italy
| | - Marco Marcolongo
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Wang JY, Zhang YJ, Li H, Hu XL, Li MP, Song PY, Ma QL, Peng LM, Chen XP. CRISPLD1 rs12115090 polymorphisms alters antiplatelet potency of clopidogrel in coronary artery disease patients in Chinese Han. Gene 2018; 678:226-232. [DOI: 10.1016/j.gene.2018.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/29/2018] [Accepted: 08/06/2018] [Indexed: 11/28/2022]
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Pharmacogenetic and clinical predictors of response to clopidogrel plus aspirin after acute coronary syndrome in Egyptians. Pharmacogenet Genomics 2018; 28:207-213. [PMID: 30188374 PMCID: PMC9903350 DOI: 10.1097/fpc.0000000000000349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel reduces the risk for recurrent cardiovascular events after acute coronary syndrome (ACS). However, there is significant variation in response to DAPT that may be influenced by both genetic and nongenetic factors. This study aimed to assess the effect of genetic polymorphisms in PON-1, PEAR-1, P2Y12, CES1, and CYP2C19, along with clinical, demographic, and social factors, on variation in response to DAPT in Egyptians. PARTICIPANTS AND METHODS This study included 230 Egyptians treated with clopidogrel 75 mg/day and aspirin 81 mg/day for at least 12 months following their first ACS. Simple and multivariable logistic regression analyses were carried out to identify factors associated with major adverse cardiovascular events (MACE), defined as the occurrence of recurrent ACS, ischemic stroke, stent-related revascularization, or death, in clopidogrel-treated participants. RESULTS Using multivariable logistic regression analysis, the CYP2C19*2 polymorphism was the only genetic predictor of MACE [odds ratio (OR): 2.23, 95% confidence interval (CI): 1.15-4.33, P=0.01]. In addition, proton pump inhibitor use (OR: 4.77, 95% CI: 1.47-15.54, P=0.009) and diabetes (OR: 1.83, 95% CI: 1.03-3.26, P=0.03) were associated with higher cardiovascular risk, whereas statin use was associated with lower risk (OR: 0.43, 95% CI: 0.25-0.76, P=0.003). The contribution of these four genetic and nongenetic factors explained 19% of the variability in risk for MACE in Egyptians treated with DAPT. CONCLUSION These results highlight that CYP2C19*2, along with diabetes, and use of proton pump inhibitor and statin are important factors jointly associated with variability in clinical response to DAPT following ACS in Egyptians.
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Abstract
Since the human genome project in 2003, the view of personalized medicine to improve diagnosis and cure diseases at the molecular level became more real. Sequencing the human genome brought some benefits in medicine such as early detection of diseases with a genetic predisposition, treating patients with rare diseases, the design of gene therapy and the understanding of pharmacogenetics in the metabolism of drugs. This review explains the concepts of pharmacogenetics, polymorphisms, mutations, variations, and alleles, and how this information has helped us better understand the metabolism of drugs. Multiple resources are presented to promote reducing the gap between scientists, physicians, and patients in understanding the use and benefits of pharmacogenetics. Some of the most common clinical examples of genetic variants and how pharmacogenetics was used to determine treatment options for patients having these variants were discussed. Finally, we evaluated some of the challenges of implementing pharmacogenetics in a clinical setting and proposed actions to be taken to make pharmacogenetics a standard diagnostic tool in personalized medicine.
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Affiliation(s)
- J T Oates
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute and Technology Enterprise (BRITE), College of Arts and Sciences, North Carolina Central University, USA
| | - D Lopez
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute and Technology Enterprise (BRITE), College of Arts and Sciences, North Carolina Central University, USA
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Danielak D, Karaźniewicz-Łada M, Komosa A, Burchardt P, Lesiak M, Kruszyna Ł, Graczyk-Szuster A, Główka F. Influence of genetic co-factors on the population pharmacokinetic model for clopidogrel and its active thiol metabolite. Eur J Clin Pharmacol 2017; 73:1623-1632. [PMID: 28914344 PMCID: PMC5684285 DOI: 10.1007/s00228-017-2334-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/06/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE A high interindividual variability is observed in the pharmacokinetics of clopidogrel, a widely used antiplatelet drug. In the present study, a joint parent-metabolite population pharmacokinetic model was developed to adequately describe observed concentrations of clopidogrel and its active thiol metabolite (H4). METHODS The study included 63 patients undergoing elective coronarography or percutaneous coronary intervention. The population pharmacokinetic model was developed in the NONMEM 7.3 software, and first-order conditional estimation method with interaction was applied. Also, the influence of covariates was evaluated (age, weight, body mass index (BMI), obesity defined as BMI ≥ 30 kg/m2, sex, diabetes mellitus, co-administration of PPI or statins, presence of CYP2C19*2, CYP2C19*17, CYP3A4*1G alleles, and ABCB1 3435 TT genotype). RESULTS It was found that the only significant covariate was the presence of CYP2C19*2 allele, which had an impact on lower conversion of clopidogrel to H4. As a result, predicted area under the time-concentration curve values was lower in carriers of this allele, with median 5.94 ng h/ml (interquartile range 3.92-12.51 [ng∙h/ml]) vs. 12.70 ng h/ml in non-carriers (interquartile range, 7.00-19.39 [ng∙h/ml]), respectively (p = 0.004). CONCLUSIONS Developed model predicts that the only significant covariate influencing the observed concentrations and therefore the exposure to the active H4 metabolite is the presence of CYP2C19*2 allele.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland.
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
| | - Anna Komosa
- First Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Paweł Burchardt
- Department of Biology and Environmental Sciences, Poznan University of Medical Sciences, Poznań, Poland
- Department of Cardiology, J. Struś Hospital, Poznań, Poland
| | - Maciej Lesiak
- First Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Łukasz Kruszyna
- Department of General and Vascular Surgery, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
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Xiao FY, Luo JQ, Liu M, Chen BL, Cao S, Liu ZQ, Zhou HH, Zhou G, Zhang W. Effect of carboxylesterase 1 S75N on clopidogrel therapy among acute coronary syndrome patients. Sci Rep 2017; 7:7244. [PMID: 28775293 PMCID: PMC5543069 DOI: 10.1038/s41598-017-07736-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 07/04/2017] [Indexed: 02/06/2023] Open
Abstract
Carboxylesterase 1 (CES1) hydrolyzes the prodrug clopidogrel to an inactive carboxylic acid metabolite. The effects of CES1 S75N (rs2307240,C>T) on clopidogrel response among 851 acute coronary syndrome patients who came from the north, central and south of China were studied. The occurrence ratios of each endpoint in the CC group were significantly higher than in the CT + TT group for cerebrovascular events (14% vs 4.8%, p < 0.001, OR = 0.31), acute myocardial infarction (15.1% vs 6.1%, p < 0.001, OR = 0.37) and unstable angina (62.8% vs 37.7%, p < 0.001, OR = 0.36). The results showed that there was a significant association between CES1 S75N (rs2307240) and the outcome of clopidogrel therapy. Moreover, the frequency of the T allele of rs2307240 in acute coronary syndrome patients (MAF = 0.22) was more than four times higher than that in the general public (MAF = 0.05).
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Affiliation(s)
- Fei-Yan Xiao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China
| | - Jian-Quan Luo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China
| | - Min Liu
- Department of cardiovascular, Zhengzhou central hospital, Zhengzhou University, Zhengzhou, China
| | - Bi-Lian Chen
- Department of Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Shan Cao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China
| | - Zhao-Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China
| | - Gan Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China.
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China.
- National institution of drug clinical trial, Xiangya Hospital, Central South University, Changsha, China.
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, China.
- Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, China.
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13
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Danielak D, Karaźniewicz-Łada M, Wiśniewska K, Bergus P, Burchardt P, Komosa A, Główka F. Impact of CYP3A4*1G Allele on Clinical Pharmacokinetics and Pharmacodynamics of Clopidogrel. Eur J Drug Metab Pharmacokinet 2017; 42:99-107. [PMID: 26891871 PMCID: PMC5306247 DOI: 10.1007/s13318-016-0324-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Resistance to the antiplatelet treatment with clopidogrel has both genetic and non-genetic causes. Polymorphic variants of cytochrome P450 3A4 isoenzyme involved in the bioactivation of clopidogrel might have an influence on responsiveness to the drug. The aim of this study was to evaluate the influence of CYP3A4*1G (IVS10+12G>A, rs2242480) on the pharmacokinetics and pharmacodynamics of clopidogrel. METHODS CYP3A4*1G polymorphism was determined in a group of 82 patients undergoing percutaneous coronary intervention and taking 75 mg of clopidogrel daily. Concentrations of clopidogrel and its metabolites, inactive carboxylic acid derivative and two diastereoisomers of active thiol metabolite: H3 and H4, were determined by a validated HPLC-MS/MS method. Pharmacodynamic effect was measured by an impedance method with a Multiplate analyzer. Moreover, an effect of factors, such as CYP2C19 phenotype, age, gender, body mass index and interactions with drugs metabolized by CYP3A4 were also investigated. RESULTS In the studied group allele frequencies were: wt-0.921, *1G-0.079. Pharmacokinetic parameters of clopidogrel and its metabolites were not significantly different in carriers of *1G allele, comparing to wt/wt homozygotes. Platelet aggregation was higher in heterozygotes than in wt/wt carriers; however, the difference was not statistically significant (p = 0.484). In a multivariate analysis, which included age, body mass index, co-morbidities and coadministered drugs, CYP3A4*1G was not a predictor of values of H3 and H4 pharmacokinetic parameters and platelet aggregation. CONCLUSION CYP3A4*1G might not be a significant contributor to the variability in pharmacokinetic and pharmacodynamic response to clopidogrel therapy.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 61-781, Poznan, Poland.
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 61-781, Poznan, Poland
| | - Karolina Wiśniewska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 61-781, Poznan, Poland
| | - Piotr Bergus
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 61-781, Poznan, Poland
| | - Paweł Burchardt
- Department of Biology and Environmental Sciences, Poznan University of Medical Sciences, Poznan, Poland
- Department of Cardiology, J. Strus Hospital, Poznan, Poland
| | - Anna Komosa
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 61-781, Poznan, Poland
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14
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Luchessi AD, Concheiro M, Germano JDF, Silbiger VN, Bortolin RH, Cruz A, Quintela O, Brion M, Carracedo A, Iñiguez A, Bravo M, López-Rivadulla M, Hirata RDC, Sousa AGMR, Hirata MH. ABCC3 Polymorphisms and mRNA Expression Influence the Concentration of a Carboxylic Acid Metabolite in Patients on Clopidogrel and Aspirin Therapy. Basic Clin Pharmacol Toxicol 2017; 120:466-474. [PMID: 27862978 DOI: 10.1111/bcpt.12703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/06/2016] [Indexed: 12/13/2022]
Abstract
Acetylsalicylic acid (ASA) and clopidogrel combined therapy has been reported to be beneficial in patients with acute coronary syndrome (ACS). Antiplatelet drug resistance, especially to clopidogrel, is a multifactorial phenomenon that affects a large number of ACS patients. The genetic contribution to this drug response is not fully elucidated. We investigated the relationship of ABC-type efflux subfamily C member 3 (ABCC3) polymorphisms and mRNA expression with plasma concentrations of clopidogrel, salicylic acid (SA) and a carboxylic acid metabolite (CAM). Clopidogrel, CAM and SA plasma concentrations were measured simultaneously by liquid chromatography-tandem mass spectrometry (LCMS/MS) from 83 ACS patients undergoing percutaneous coronary intervention. ABCC3 (rs757421, rs733392 and rs739923) and CYP2C19*2 (rs4244285) polymorphisms as well as mRNA expression were evaluated. A positive correlation was found between CAM concentrations and ABCC3 mRNA expression (r = 0.494, p < 0.0001). Patients carrying genotype AA (rs757421 variant) had higher CAM concentrations and ABCC3 mRNA expression as compared to those of GG + GA carriers (p = 0.017). A multiple linear regression analysis revealed that ABCC3 mRNA expression (p = 0.017), rs757421 AA genotype (p = 0.001), blood collection time (p = 0.018) and clopidogrel dose (p = 0.001) contributed to the concentration of CAM. No associations were observed for the CYP2C19*2 polymorphism. These results suggest that up-regulation of ABCC3 mRNA expression leads to increased plasma CAM levels through MRP3-mediated cell efflux. The ABCC3 rs757421 polymorphism may contribute to gene expression. Therefore, ABCC3 may be a potential biomarker for the response to clopidogrel.
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Affiliation(s)
- André Ducati Luchessi
- School of Pharmaceutical Science, University of Sao Paulo, Sao Paulo, Brazil.,Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Marta Concheiro
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Vivian Nogueira Silbiger
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Raul Hernandes Bortolin
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Angelines Cruz
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Oscar Quintela
- Department of Madrid, National Institute of Toxicology and Forensic Science, Madrid, Spain
| | - Maria Brion
- Genetics of Cardiovascular and Ophthalmological Diseases, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Genomic Medicine, University of Santiago de Compostela, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Angel Carracedo
- Genomic Medicine, University of Santiago de Compostela, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Andres Iñiguez
- Cardiology Service, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Marisol Bravo
- Cardiology Service, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Manuel López-Rivadulla
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
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15
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Rosa GM, Bianco D, Valbusa A, Massobrio L, Chiarella F, Brunelli C. Pharmacokinetics and pharmacodynamics of ticagrelor in the treatment of cardiac ischemia. Expert Opin Drug Metab Toxicol 2016; 12:1491-1502. [PMID: 27715344 DOI: 10.1080/17425255.2016.1244524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Gian Marco Rosa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Daniele Bianco
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Alberto Valbusa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Laura Massobrio
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Francesco Chiarella
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
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16
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Kubica A, Obońska K, Fabiszak T, Kubica J. Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials. Curr Med Res Opin 2016; 32:1441-51. [PMID: 27112628 DOI: 10.1080/03007995.2016.1182901] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions. Non-adherence to medication after ACS may lead to increased morbidity, mortality, and costs to the healthcare system due to elevated risk of stent thrombosis, myocardial infarction or death. Medication adherence is an issue of growing concern regarding the improvement of health system performance. Promoting medication adherence offers a rare opportunity to simultaneously improve health outcomes while reducing costs of treatment in patients with coronary artery disease (CAD). The aim of this systematic review was to critically discuss adherence to antiplatelet treatment with P2Y12 receptor inhibitors in CAD patients. After a systematic investigation of the literature in databases including PubMed, CENTRAL and Google Scholar, using appropriate keywords, and considering clinical randomized, prospective observational and retrospective studies, reporting on adherence to treatment with inhibitors of P2Y12 platelet receptors or educational interventions aimed to improve medication adherence in patients with CAD, seven articles were considered eligible for inclusion in this systematic review. Reported adherence to clopidogrel, despite catastrophic consequences of its premature discontinuation, is low. We identified several determinants of low adherence and early discontinuation of clopidogrel. We also present data on the usefulness, utilization and credibility of different methods of medication adherence assessment, and suggest and critically discuss available interventions aimed at improvement of adherence to clopidogrel, still showing the need for innovative approaches to achieve enhanced medication adherence and improve health outcomes after acute myocardial infarction.
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Affiliation(s)
- Aldona Kubica
- a Department of Health Promotion, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Karolina Obońska
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Tomasz Fabiszak
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Jacek Kubica
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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17
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Management of Patients With NSTE-ACS. J Am Coll Cardiol 2016; 68:313-321. [DOI: 10.1016/j.jacc.2016.03.599] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/25/2016] [Accepted: 03/01/2016] [Indexed: 11/24/2022]
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18
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Homocysteine Levels Influence Platelet Reactivity in Coronary Artery Disease Patients Treated With Acetylsalicylic Acid. J Cardiovasc Pharmacol 2016; 66:35-40. [PMID: 25714593 DOI: 10.1097/fjc.0000000000000240] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Suboptimal platelet inhibition with antiplatelet treatments is associated with a severe prognosis in patients with coronary artery disease (CAD), and the identification of its determinants is still challenging. Homocysteine elevation has emerged as a prothrombotic factor, influencing coagulative status and endothelial function and potentially modulating platelet aggregation. We therefore aimed to evaluate the effects of homocysteine (Hcy) levels on platelet reactivity in patients receiving acetylsalicylic acid (ASA) with or without ADP antagonists. METHODS Patients undergoing coronary angiography and receiving ASA (100-160 mg daily) for >7 days, with or without ADP antagonists, were included. Aggregation tests were performed by multiple electrode aggregometry. Suboptimal platelet inhibition was defined as on-treatment aggregation above the lower limit of normality. RESULTS Our population is represented by 508 ASA-treated patients, 406 (80.1%) of whom on dual antiplatelet therapy (ASA and ADP antagonists). Hcy levels above the median (15.1 nmol/mL) were associated with male gender (P = 0.04), hypertension (P = 0.004), hypercholesterolemia (P = 0.03), aging, renal failure (P < 0.001, respectively), previous coronary bypass grafting (P = 0.04), therapy with calcium antagonists (P = 0.04) and diuretics (P = 0.001), and multivessel CAD (P = 0.03). Higher Hcy is directly related with serum creatinine and uric acid (P < 0.001). Suboptimal platelet inhibition was found in 16 patients (3.2%) for ASA and for ADP antagonists in 80 patients (19.7%). Hcy levels significantly affected suboptimal response to ASA, but not to ADP-mediated aggregation. In fact, a linear relationship was found between homocysteine and platelet reactivity after stimulation with arachidonic acid (r = 0.14, P = 0.004) and collagen (r = 0.12, P = 0.02), but not with ADP (r = 0.02, P = 0.77). Moreover, after correction for baseline differences, Hcy above the median was confirmed as an independent predictor of impaired ASA response [adjusted odds ratio (95% confidence interval) = 3.7 (1.08-12.4), P = 0.04]. CONCLUSIONS Among patients with CAD, elevated homocysteine is an independent predictor of suboptimal response to ASA, but not to ADP antagonists.
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19
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Mărginean A, Bănescu C, Scridon A, Dobreanu M. Anti-platelet Therapy Resistance - Concept, Mechanisms and Platelet Function Tests in Intensive Care Facilities. J Crit Care Med (Targu Mures) 2016; 2:6-15. [PMID: 29967831 PMCID: PMC5939137 DOI: 10.1515/jccm-2015-0021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 07/10/2015] [Indexed: 01/22/2023] Open
Abstract
It is well known that critically ill patients require special attention and additional consideration during their treatment and management. The multiple systems and organ dysfunctions, typical of the critical patient, often results in different patterns of enteral absorption in these patients. Anti-platelet drugs are the cornerstone in treating patients with coronary and cerebrovascular disease. Dual anti-platelet therapy with aspirin and clopidogrel is the treatment of choice in patients undergoing elective percutaneous coronary interventions and is still widely used in patients with acute coronary syndromes. However, despite the use of dual anti-platelet therapy, some patients continue to experience cardiovascular ischemic events. Recurrence of ischemic events is partly attributed to the fact that some patients have poor inhibition of platelet reactivity despite treatment. These patients are considered low- or non-responders to therapy. The underlying mechanisms leading to resistance are not yet fully elucidated and are probably multifactorial, cellular, genetic and clinical factors being implicated. Several methods have been developed to asses platelet function and can be used to identify patients with persistent platelet reactivity, which have an increased risk of thrombosis. In this paper, the concept of anti-platelet therapy resistance, the underlying mechanisms and the methods used to identify patients with low responsiveness to anti-platelet therapy will be highlighted with a focus on aspirin and clopidogrel therapy and addressing especially critically ill patients.
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Affiliation(s)
- Alina Mărginean
- University of Medicine and Pharmacy of Tîrgu Mures, Tîrgu Mures, Romania
- Emergency Military Hospital “Dr. Constantin Papilian”, Cluj-Napoca, Romania
| | - Claudia Bănescu
- University of Medicine and Pharmacy of Tîrgu Mures, Tîrgu Mures, Romania
| | - Alina Scridon
- University of Medicine and Pharmacy of Tîrgu Mures, Tîrgu Mures, Romania
| | - Minodora Dobreanu
- University of Medicine and Pharmacy of Tîrgu Mures, Tîrgu Mures, Romania
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20
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Lundström A, Wallén H, von Arbin M, Jörneskog G, Gigante B, Höeg Dembrower K, Laurencikas E, Laska AC. Clopidogrel Resistance after Minor Ischemic Stroke or Transient Ischemic Attack is Associated with Radiological Cerebral Small-Vessel Disease. J Stroke Cerebrovasc Dis 2015; 24:2348-57. [PMID: 26303791 DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/20/2015] [Accepted: 06/15/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The objective of this study was to compare nonresponders (NR) and responders (R) to clopidogrel with respect to presence of microvascular and macrovascular pathology in a cohort of patients with recent minor ischemic stroke (IS) or transient ischemic attack (TIA). METHODS Seventy-two patients treated with clopidogrel after IS or TIA were evaluated 1 month after onset. Platelet aggregation was measured by multiple electrode aggregometry (Multiplate). Nonresponse was defined according to recent consensus. The degree of cerebral small-vessel disease (cSVD) was evaluated on computed tomography scans of the brain using Fazekas scale for white matter changes. Carotid atherosclerosis was evaluated by ultrasound or computed tomography/magnetic resonance angiography. RESULTS Twenty-two percent of patients were NR. Moderate to extensive cSVD was more common for NR than R, 56% versus 25%, odds ratio 3.9 (1.2-12), P = .03. Correspondingly, 39% of patients with cSVD were NR versus 14% of patients with no or mild cSVD. No differences were found between NR and R in prevalence or severity of carotid atherosclerosis. NR had higher platelet aggregation response than R after stimulation with arachidonic acid or thrombin receptor-activating peptide, indicating a general platelet hyperreactivity. In a univariate analysis, hypertension, previous IS, glucose intolerance, pulse pressure above median, and presence of moderate to extensive cSVD were associated with the NR phenotype. CONCLUSIONS Nonresponsiveness to clopidogrel after minor IS or TIA is associated with radiological cSVD but not with carotid atherosclerosis. PRACTICE/IMPLICATIONS Measurement of platelet function is warranted in patients with cSVD. Larger studies on alternative or tailored antiplatelet treatment for these patients should be initiated.
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Affiliation(s)
- Annika Lundström
- Division of Internal Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Håkan Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus von Arbin
- Division of Internal Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Gun Jörneskog
- Division of Internal Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Institute of Environmental Medicine, Unit of Cardiovascular Epidemiology, and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karin Höeg Dembrower
- Division of Radiology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Evaldas Laurencikas
- Division of Radiology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ann Charlotte Laska
- Division of Internal Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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21
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Arya V, Mahajan P, Saraf A, Mohanty A, Sawhney JPS, Bhargava M. Association of CYP2C19, CYP3A5 and GPIIb/IIIa gene polymorphisms with Aspirin and Clopidogrel Resistance in a cohort of Indian patients with Coronary Artery Disease. Int J Lab Hematol 2015; 37:809-18. [PMID: 26264906 DOI: 10.1111/ijlh.12416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 07/13/2015] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy with clopidogrel and aspirin is the current standard of care in the management of patients with coronary artery disease (CAD) and acute coronary syndrome (ACS). The variability in response to these antiplatelet agents may be due to the underlying genetic diversity. This study was designed to determine the resistance to aspirin and clopidogrel in Indian patients and to look for correlation, if any, with selected polymorphisms. METHODS Platelet function testing by light transmission aggregometry was performed on 72 patients with CAD/ACS who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 150 mg OD) along with 72 controls. Aspirin resistance was considered as mean platelet aggregation ≥ 70% with 10 μm ADP and ≥ 20% with 0.75 mm arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 μm and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19*2, *3, CYP3A5*3 and PLA1/A2 were genotyped. RESULTS We found 51.4% patients with inadequate response to clopidogrel (1.4% resistant and 50% semi-responders) and 5.5% patients semi-responders to aspirin, none being completely resistant. The genotype and allele frequencies of CYP2C19*2 and PLA1/A2 gene polymorphisms were significantly different between clopidogrel semi-responders and responders. Carriers of CYP2C19*2 and CYP3A5*3 showed diminished inhibition of platelet aggregation. No significant correlation was found between coronary events, type of coronary intervention with clopidogrel nonresponsiveness. CONCLUSION Unlike aspirin, a high proportion of partial responders to clopidogrel were identified. In an interim analysis on 72 Indian patients, a significant association was found between CYP2C19*2 and PLA1/A2 in clopidogrel semi-responders.
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Affiliation(s)
- V Arya
- Department of Haematology, Sir Ganga Ram Hospital, New Delhi, India
| | - P Mahajan
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - A Saraf
- Department of Haematology, Sir Ganga Ram Hospital, New Delhi, India
| | - A Mohanty
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - J P S Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - M Bhargava
- Department of Haematology, Sir Ganga Ram Hospital, New Delhi, India
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Cayla G, Silvain J, Collet JP, Montalescot G. Updates and current recommendations for the management of patients with non-ST-elevation acute coronary syndromes: what it means for clinical practice. Am J Cardiol 2015; 115:10A-22A. [PMID: 25728969 DOI: 10.1016/j.amjcard.2015.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The American Heart Association (AHA) and the American College of Cardiology (ACC) have recently updated their joint guidelines for the management of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS, including unstable angina [UA] and non-ST-elevation myocardial infarction [NSTEMI]). These guidelines replace the 2007 guidelines and the focused updates from 2011 and 2012 and now combine UA and NSTEMI into a new classification, NSTE-ACS, and updating the terminology around noninvasive management to ischemia-guided strategy. The latest guidelines include updated recommendations for the use of the oral antiplatelet agents (P2Y12 inhibitors) prasugrel and ticagrelor as part of dual-antiplatelet therapy-the cornerstone of treatment for these patients. This report provides a comprehensive overview of the new and modified recommendations for the management of patients with NSTE-ACS and the evidence supporting them. Also, where appropriate, similarities and differences between the current recommendations of the AHA/ACC and those of the European Society of Cardiology (ESC) are highlighted. For example, the AHA/ACC recommends the P2Y12 inhibitor ticagrelor over clopidogrel in all patients with NSTE-ACS and clopidogrel, prasugrel, or ticagrelor for patients in whom percutaneous coronary intervention is planned, whereas the ESC guidelines specifically recommend individual P2Y12 inhibitors for particular patient subgroups.
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Affiliation(s)
- Guillaume Cayla
- Service de Cardiologie, Centre Hospitalier Universitaire Nîmes (ACTION group, Université Montpellier 1), INSERM 937, Nîmes, France; Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (ACTION group, AP-HP, Université Paris 6), INSERM 937, Paris, France
| | - Johanne Silvain
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (ACTION group, AP-HP, Université Paris 6), INSERM 937, Paris, France
| | - Jean-Philippe Collet
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (ACTION group, AP-HP, Université Paris 6), INSERM 937, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (ACTION group, AP-HP, Université Paris 6), INSERM 937, Paris, France.
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Karaźniewicz-Łada M, Danielak D, Burchardt P, Kruszyna L, Komosa A, Lesiak M, Główka F. Clinical pharmacokinetics of clopidogrel and its metabolites in patients with cardiovascular diseases. Clin Pharmacokinet 2014; 53:155-64. [PMID: 24127209 PMCID: PMC3899497 DOI: 10.1007/s40262-013-0105-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Objective Approximately 5–40 % of patients treated with clopidogrel do not display an adequate antiplatelet response. Clopidogrel resistance may be caused by insufficient drug absorption or impaired metabolic activation of the drug. The aim of this study was to evaluate the pharmacokinetics of clopidogrel and its metabolites in plasma samples from patients treated with high and low doses of clopidogrel, to obtain a possible explanation for antiplatelet resistance. Methods The study included patients receiving either a single 300 mg loading dose of clopidogrel (n = 17) or a 75 mg dose (n = 45) for at least 7 days before sample collection. The concentrations of clopidogrel and its metabolites—the inactive H3 and the pharmacologically active H4 isomers of the thiol metabolite and the inactive carboxylic acid metabolite—in plasma samples (stabilized with 2-bromo-3′-methoxyacetophenone) from three patients after 300 mg and from 41 patients after 75 mg of the drug were determined using a validated high-performance liquid chromatography method with tandem mass spectrometry. The non-stabilized samples from the remaining patients were analysed using a validated capillary electrophoresis method. The calculated concentrations were used to determine the pharmacokinetic parameters of the analytes. The pharmacodynamic response to clopidogrel treatment, expressed as adenosine diphosphate-induced platelet aggregation, was measured using a Multiplate analyser. Results The pharmacokinetic parameter values for the H3 and H4 isomers determined in the studied group of patients treated with clopidogrel 75 mg (maximum plasma concentration [Cmax] 5.29 ± 5.54 and 7.13 ± 6.32 ng/mL for H3 and H4, respectively; area under the plasma concentration-time curve from time zero to time t [AUCt] 7.37 ± 6.71 and 11.30 ± 9.58 ng·h/mL for H3 and H4, respectively) were lower than those reported in healthy volunteers, according to the literature data. Platelet aggregation measured with a Multiplate analyser ranged between 37 and 747 AU·min. A significant correlation was found between the Cmax of the active H4 isomer and platelet aggregation (p = 0.025). Conclusion The Cmax of the active H4 isomer and platelet aggregation measured by the Multiplate analyser may serve as markers of the patient response to clopidogrel therapy.
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Affiliation(s)
- Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781, Poznan, Poland,
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Kubica A, Kasprzak M, Siller-Matula J, Koziński M, Pio Navarese E, Obońska K, Andruszkiewicz A, Sztuba B, Fabiszak T, Swiątkiewicz I, Paciorek P, Kubica J. Time-related changes in determinants of antiplatelet effect of clopidogrel in patients after myocardial infarction. Eur J Pharmacol 2014; 742:47-54. [PMID: 25199965 DOI: 10.1016/j.ejphar.2014.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 08/14/2014] [Accepted: 08/18/2014] [Indexed: 01/20/2023]
Abstract
Substantial variability of antiplatelet action is an important limitation of clopidogrel. The aim of this study was to evaluate time-related changes in determinants of clopidogrel responsiveness in patients after myocardial infarction. The study population comprised 191 consecutive patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Follow-up visits were scheduled at 3, 6 and 9 months after discharge. ADP-induced platelet aggregation was tested with Multiplate Analyzer. Patients with ADP-PA>46.8U were defined as clopidogrel non-responders. The prevalence of clopidogrel non-responsiveness was highest during hospitalization and at 9 month follow-up visit, while it was lowest at 3 and 6 months after myocardial infarction (P=0.004). According to multivariate analysis, platelet count, mean platelet volume, concentration of hsCRP and leukocyte count influenced ADP-induced platelet aggregation in multiple assessment points. BMI, concentrations of hemoglobin, glycated hemoglobin, and BNP, hematocrit, adherence to medication, and patient׳s age were found to be independent predictors of high on-treatment ADP-induced platelet aggregation only at a single follow-up visit. Determinants of clopidogrel responsiveness in patients after myocardial infarction change within the long-term therapy. During hospitalization and early after discharge only biological factors affect ADP-induced platelet aggregation, while non-adherence to antiplatelet therapy may be a significant factor in determining clopidogrel non-responsiveness during late follow-up visits.
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Affiliation(s)
- Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, 3 Techników Street, 85-801 Bydgoszcz, Poland.
| | - Michał Kasprzak
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland; Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Jolanta Siller-Matula
- Department of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Marek Koziński
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Karolina Obońska
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland; Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland.
| | - Anna Andruszkiewicz
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, 3 Techników Street, 85-801 Bydgoszcz, Poland
| | - Beata Sztuba
- National Health Fund, 4A/30 Chołoniewskiego Street, 85-127 Bydgoszcz, Poland
| | - Tomasz Fabiszak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Iwona Swiątkiewicz
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Przemysław Paciorek
- Department of Emergency Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
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Dobesh PP, Oestreich JH. Ticagrelor: pharmacokinetics, pharmacodynamics, clinical efficacy, and safety. Pharmacotherapy 2014; 34:1077-90. [PMID: 25164528 PMCID: PMC4282310 DOI: 10.1002/phar.1477] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dual antiplatelet therapy, composed of aspirin plus a P2Y12-receptor antagonist, is the cornerstone of treatment for patients with acute coronary syndrome (ACS). A number of U.S. Food and Drug Administration–approved P2Y12-receptor antagonists are available for treating patients with ACS, including the thienopyridine compounds clopidogrel and prasugrel. Ticagrelor, the first of a new class of antiplatelet agents, is a noncompetitive, direct-acting P2Y12-receptor antagonist. Unlike the thienopyridine compounds, ticagrelor does not require metabolism for activity. Also, whereas clopidogrel and prasugrel are irreversible inhibitors of the P2Y12 receptor, ticagrelor binds reversibly to inhibit receptor signaling and subsequent platelet activation. In pharmacodynamic studies, ticagrelor demonstrated faster onset and more potent inhibition of platelet aggregation than clopidogrel. These properties of ticagrelor may contribute to reduced rates of thrombotic outcomes compared with clopidogrel, as demonstrated in a phase III clinical trial. However, in addition to bleeding, distinctive adverse effects of this new chemical entity have not been reported with the thienopyridine P2Y12-receptor inhibitors. Although ticagrelor represents an advancement in P2Y12-receptor inhibition therapy, a thorough understanding of this compound as an antiplatelet therapy remains to be elucidated.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
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Karaźniewicz-Łada M, Danielak D, Rubiś B, Burchardt P, Oszkinis G, Główka F. The influence of genetic polymorphism of Cyp2c19 isoenzyme on the pharmacokinetics of clopidogrel and its metabolites in patients with cardiovascular diseases. J Clin Pharmacol 2014; 54:874-80. [DOI: 10.1002/jcph.323] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/28/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics; Poznan University of Medical Sciences; 6 Święcickiego Street Poznań Poland
| | - Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics; Poznan University of Medical Sciences; 6 Święcickiego Street Poznań Poland
| | - Błażej Rubiś
- Department of Clinical Chemistry and Molecular Diagnostics; Poznan University of Medical Sciences; 49 Przybyszewskiego Street Poznań Poland
| | - Paweł Burchardt
- Division of Cardiology-Intensive Therapy, Department of Internal Medicine; Poznan University of Medical Sciences; 49 Przybyszewskiego Street Poznań Poland
| | - Grzegorz Oszkinis
- Department of General and Vascular Surgery; Poznan University of Medical Sciences; 1/2 Długa Street Poznań Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics; Poznan University of Medical Sciences; 6 Święcickiego Street Poznań Poland
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Association of P2Y12 gene promoter DNA methylation with the risk of clopidogrel resistance in coronary artery disease patients. BIOMED RESEARCH INTERNATIONAL 2014; 2014:450814. [PMID: 24745016 PMCID: PMC3976931 DOI: 10.1155/2014/450814] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 02/06/2023]
Abstract
Background. Clopidogrel inhibits the ADP receptor P2Y12 to keep down the platelet aggregation. The goal of our study is to investigate the contribution of P2Y12 promoter DNA methylation to the risk of clopidogrel resistance (CR). Methods. The platelet functions were measured by the VerifyNow P2Y12 assay. Applying the bisulfite pyrosequencing technology, DNA methylation levels of two CpG dinucleotides on P2Y12 promoter were tested among 49 CR cases and 57 non-CR controls. We also investigated the association among P2Y12 DNA methylation, various biochemical characteristics, and CR. Result. Lower methylation of two CpGs indicated the poorer clopidogrel response (CpG1, P = 0.009; CpG2, P = 0.022) in alcohol abusing status. Meanwhile CpG1 methylation was inversely correlated with CR in smoking patients (P = 0.026) and in subgroup of Albumin < 35 (P = 0.002). We observed that the level of DNA methylation might be affected by some clinical markers, such as TBIL, LEVF, Albumin, AST. The results also showed that the quantity of stent, fasting blood-glucose, and lower HbAC1 were the predictors of CR. Conclusions. The evidence from our study indicates that P2Y12 methylation may bring new hints to elaborate the pathogenesis of CR.
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Ambient hemolysis and activation of coagulation is different between HeartMate II and HeartWare left ventricular assist devices. J Heart Lung Transplant 2013; 33:80-7. [PMID: 24418734 DOI: 10.1016/j.healun.2013.11.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 11/13/2013] [Accepted: 11/26/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Thromboembolic and bleeding events in patients with a left ventricular assist device (LVAD) are still a major cause of complications. Therefore, the balance between anti-coagulant and pro-coagulant factors needs to be tightly controlled. The principle hypothesis of this study is that different pump designs may have an effect on hemolysis and activation of the coagulation system. Referring to this, the HeartMate II (HMII; Thoratec Corp, Pleasanton, CA) and the HeartWare HVAD (HeartWare International Inc, Framingham, MA) were investigated. METHODS For 20 patients with LVAD support (n = 10 each), plasma coagulation, full blood count, and clinical chemistry parameters were measured. Platelet function was monitored using platelet aggregometry, platelet function analyzer-100 system ( Siemens, Marburg, Germany), vasodilator-stimulated phosphoprotein phosphorylation assay, immature platelet fraction, platelet-derived microparticles, and von Willebrand diagnostic. RESULTS Acquired von Willebrand syndrome could be detected in all patients. Signs of hemolysis, as measured by lactate dehydrogenase levels (mean, 470 U/liter HMII, 250 U/liter HVAD; p < 0.001), were more pronounced in the HMII patients. In contrast, D-dimer analysis indicated a significantly higher activation of the coagulation system in HVAD patients (mean, 0.94 mg/liter HMII, 2.01 mg/liter HVAD; p < 0.01). The efficacy of anti-platelet therapy using clopidogrel was not sufficient in more than 50% of the patients. CONCLUSIONS Our results support the finding that all patients with rotary blood pumps suffered from von Willebrand syndrome. In addition, a distinct footprint of effects on hemolysis and the coagulation system can be attributed to different devices. As a consequence, the individual status of the coagulation system needs to be controlled in long-term patients.
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Abstract
INTRODUCTION Prasugrel (CS-747, LY640315) is a third-generation thienopyridine, which gained approval by the FDA in 2009 for its use in patients with acute coronary syndrome undergoing percutaneous coronary intervention. AREAS COVERED This article focuses on the preclinical profile of prasugrel. Using published preclinical and clinical studies, the authors summarize the pharmacokinetics, pharmacodynamics, and pharmacogenomics of prasugrel and their distinguishing features in efficacy and safety. EXPERT OPINION Prasugrel has a more rapid, more potent antiplatelet effect with less interindividual response variability when compared to clopidogrel. Those therapeutic advantages are attributed to features of its chemical structure that favor the metabolic conversion of prasugrel to its active metabolite. However, the increased risk of bleeding has been associated with a greater antiplatelet effect and dosing profile; this is especially the case in those patients who are at a higher risk of bleeding complications. It is therefore important for an optimal dosing strategy of prasugrel to be identified to provide a formulation that has the best balance for efficacy and safety.
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Affiliation(s)
- Jiaqi Shan
- China Pharmaceutical University, Center of Drug Discovery, College of Pharmacy, State Key Laboratory of Natural Medicines, 24 Tongjia Xiang, Nanjing 210009, China
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Lundström A, Laska AC, Von Arbin M, Jörneskog G, Wallén H. Glucose intolerance and insulin resistance as predictors of low platelet response to clopidogrel in patients with minor ischemic stroke or TIA. Platelets 2013; 25:102-10. [PMID: 23527528 DOI: 10.3109/09537104.2013.777951] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relation between high on-treatment platelet reactivity (HPR), and the level of glucose intolerance and insulin resistance (IR) was studied in clopidogrel-treated patients with minor ischemic stroke or TIA. The cohort consisted of 66 patients, 11 of which had known type 2 diabetes mellitus (DM). Platelet aggregation in whole blood (Multiplate™) and metabolic variables were measured 1 month after acute onset of neurological symptoms. Glucose tolerance was measured by Oral Glucose Tolerance Test (OGTT). IR was estimated by homeostasis model assessment HOMA-IR. Patients were categorized as "responders" (R) or "non-responders" (NR) to clopidogrel according to an established cut-off in platelet aggregation induced by adenosine diphosphate (ADP). In total, 14/66 (21%) patients were NR. Impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or DM was seen in 13/14 NR (93%), while for R this was the case in 25/52 (48%), p = 0.001. The percentage of NR was 33% in patients with DM and 35% in patients with IGT or IFG. In the group with normal glucose tolerance (NGT) the percentage of NR was low, 4% (1/28). Fasting plasma glucose (f-PG) was higher for NR than for R, 6.0 (5.5-6.7) mM vs. 5.3 (5.0-6.0) mM, p = 0.023. Glycated hemoglobin (HbA1c) did not differ between NR and R. NR also had higher arachidonic acid-induced platelet aggregation than R, and a tendency towards higher aggregation induced by thrombin receptor agonist peptide (TRAP), indicating that HPR reflects a global platelet hyper-reactivity. HOMA-IR was calculated for 52 of the patients above without known diabetes, 9 of which were NR (17%). NR were significantly more insulin resistant than R, with median HOMA-IR 4.5 (3.0-7.4) compared to 2.1 (1.5-3.2) for R, p = 0.001. HOMA-IR and fasting plasma insulin were the only metabolic variables with significant relationships to ADP-induced platelet aggregation. The results suggest that HPR develops in the pre-diabetic phase. A metabolic disturbance with glucose intolerance and/or high level of IR was a pre-requisite for HPR in the tested cohort. Conversely, normal glucose tolerance combined with normal or mildly elevated HOMA-IR excluded HPR. NR are likely to constitute a high-risk group among patients with ischemic cerebrovascular disease. Measurement of f-PG or HbA1c is insufficient to identify NR, while OGTT and HOMA-IR are more predictive.
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Affiliation(s)
- Annika Lundström
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine , Stockholm , Sweden
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P2Y12 Receptor Inhibitors in Acute Coronary Syndromes: What Is New on the Horizon? Cardiol Res Pract 2013; 2013:195456. [PMID: 23533940 PMCID: PMC3590496 DOI: 10.1155/2013/195456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 12/21/2012] [Indexed: 01/31/2023] Open
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor represents the cornerstone therapy for patients with acute coronary syndromes or undergoing percutaneous interventions, leading to a reduction of subsequent ischemic events. Variable response to clopidogrel has received close attention, and pharmacokinetic, pharmacodynamic, and pharmacogenomic factors have been identified as culprits. This led to the introduction of newer, potentially safer, and more effective antiplatelet agents (prasugrel and ticagrelor). Additionally, several point-of-care assays of platelet function have been developed in recent years to rapidly screen individuals on antiplatelet therapy. While the routine use of platelet function testing is uncertain and not currently recommended, it may be useful in instances when the degree of platelet inhibition may be uncertain such as high-risk patients undergoing percutaneous coronary intervention or when there may be a suspected pharmacodynamic interaction with other drugs. The current paper focuses on the P2Y12 receptor inhibitors and their pharmacogenetics and indications in patients with acute coronary syndromes or receiving percutaneous coronary interventions as well as the applicability of platelet function testing in this clinical context.
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Zhu HJ, Wang X, Gawronski BE, Brinda BJ, Angiolillo DJ, Markowitz JS. Carboxylesterase 1 as a Determinant of Clopidogrel Metabolism and Activation. J Pharmacol Exp Ther 2012; 344:665-72. [DOI: 10.1124/jpet.112.201640] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Karaźniewicz-Łada M, Danielak D, Teżyk A, Żaba C, Tuffal G, Główka F. HPLC–MS/MS method for the simultaneous determination of clopidogrel, its carboxylic acid metabolite and derivatized isomers of thiol metabolite in clinical samples. J Chromatogr B Analyt Technol Biomed Life Sci 2012; 911:105-12. [DOI: 10.1016/j.jchromb.2012.11.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 10/30/2012] [Accepted: 11/01/2012] [Indexed: 11/27/2022]
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