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Denas G, Santostasi G, Pengo V. The safety of available pharmacotherapy for stroke prevention in atrial fibrillation. Expert Opin Drug Saf 2024:1-10. [PMID: 39344785 DOI: 10.1080/14740338.2024.2409698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/17/2024] [Accepted: 09/18/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION Oral anticoagulant drugs reduce the risk of stroke associated with atrial fibrillation. Vitamin K antagonists, gold standard therapy for decades, have been deposed by the direct oral anticoagulants that exhibit superior safety profiles. However, hemorrhagic complications remain a major concern to anticoagulation. AREAS COVERED We searched available data in the literature to review the current knowledge on the safety profiles of available anticoagulants. EXPERT OPINION Despite a relevant leap forward with the introduction of DOACs, safety concerns persist in some fields of the current pharmacotherapy for stroke prevention in atrial fibrillation. In-depth knowledge of the safety profile of available anticoagulants and dealing with safety issues in patient subgroups is of utmost importance. Bleeding risk scores should not be dichotomously used to decide anticoagulation treatment but rather to promote shared decision, identify and correct modifiable risk factors, and set monitoring frequency. Additional issues that wait to be investigated in order to improve the safety of therapy include circulating levels of direct oral anticoagulants and anticoagulation in patient sub-groups: very elderly, frail, those with advanced kidney or liver disease, and so on. Safety may be improved from the in-depth knowledge of safety concerns and therapeutic options.
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Affiliation(s)
- G Denas
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | | | - V Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
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2
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Milanović Ž, Antonijević M, Avdović E, Simić V, Milošević M, Dolićanin Z, Kojić M, Marković Z. In silico evaluation of pharmacokinetic parameters, delivery, distribution and anticoagulative effects of new 4,7-dihydroxycoumarin derivative. J Biomol Struct Dyn 2024; 42:8343-8358. [PMID: 37545173 DOI: 10.1080/07391102.2023.2245071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
In this study, pharmacological profiling and investigation of the anticoagulant activity of the newly synthesized coumarin derivative: (E)-3-(1-((4-hydroxy-3-methoxyphenyl)amino)ethylidene)-2,4-dioxochroman-7-yl acetate (L) were performed. The obtained results were compared with the parameters obtained for Warfarin (WF), which is a standard good oral anticoagulant. The estimated high binding affinity of L toward plasma proteins (PPS% value is > 90%) justifies the investigation of binding affinity and comparative analysis of L and WF to Human Serum Albumin (HSA) using the spectrofluorimetric method (296, 303 and 310 K) as well as molecular docking and molecular dynamics simulations. Compound L shows a very good binding affinity especially to the active site of WF (the active site I -subdomain IIA), quenching HSA fluorescence by a static process. Also, the finite element smeared model (Kojic Transport Model, KTM), which includes blood vessels and tissue, was implemented to compute the convective-diffusion transport of L and WF within the liver. Finally, compound L shows a high degree of inhibitory activity toward the VKOR receptor comparable to the inhibitory activity of WF. Stabilization and limited flexibility of amino acid residues in the active site of the VKOR after binding of L and WF indicates a very good inhibitory potential of compound L. The high affinity of the L for the VKOR enzyme (Vitamin K antagonist), as well as the structural similarity to commercial anticoagulants (WF), provide a basis for further studies and potential application in the treatment of venous thrombosis, pulmonary embolism and ischemic heart disease.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Žiko Milanović
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
| | - Marko Antonijević
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
| | - Edina Avdović
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
| | - Vladimir Simić
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
| | - Miljan Milošević
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
- Bioengineering Research and Development Center (BioIRC), Kragujevac, Serbia
- Faculty of Information Technology, Belgrade Metropolitan University, Belgrade, Serbia
| | - Zana Dolićanin
- Department of Natural Science and Mathematics, State University of Novi Pazar, Novi Pazar, Serbia
| | - Miloš Kojić
- Bioengineering Research and Development Center (BioIRC), Kragujevac, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
- Houston Methodist Research Institute, Houston, TX, USA
| | - Zoran Marković
- Institute for Information Technologies, University of Kragujevac, Kragujevac, Serbia
- Department of Natural Science and Mathematics, State University of Novi Pazar, Novi Pazar, Serbia
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3
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Roldan V, Badimon JJ. Does One Size Fits All? Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07625-6. [PMID: 39235567 DOI: 10.1007/s10557-024-07625-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/06/2024]
Affiliation(s)
- Vanessa Roldan
- Hematology Unit, Hospital Clinico Universitario Virgen de la Arrixaca, University of Murcia, Murcia, Spain
| | - Juan Jose Badimon
- Atherothrombosis Research Unit, Valentin Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Samaddar A, Singh R, Yang X, Ebersole KC, Forrest ML. Investigating the potential of catheter-assisted pulsed focused ultrasound ablation for atherosclerotic plaques. Med Phys 2024; 51:5181-5189. [PMID: 38873842 PMCID: PMC11409400 DOI: 10.1002/mp.17253] [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: 09/05/2023] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Atherosclerosis is a condition in which an adhesive substance called plaque accumulates over time inside the arteries. Plaque buildup results in the constriction of arteries, causing a shortage of blood supply to tissues and organs. Removing atherosclerotic plaques controls the development of acute ischemic stroke and heart diseases. It remains imperative for positive patient outcomes. PURPOSE This study sought to develop a minimally invasive technique for removing arterial plaques by applying focused ultrasound (FUS) energy on the metal surface of a nitinol catheter wire to induce inertial cavitation. The induced cavitation can deplete plaque mechanically inside the arteries, leading towards improved recanalization of blood vessels. METHODS The enhanced cavitation effect induced by combining FUS with a metal catheter was first verified by exposing agar phantom gels with or without a 0.9-mm diameter nitinol wire to an acoustic field produced by a 0.5-MHz FUS transducer. The phenomenon was further confirmed in pork belly fat samples with or without a 3-mm diameter nitinol catheter wire. Cavitation was monitored by detecting the peaks of emitted ultrasound signals from the samples using a passive cavitation detector (PCD). Cavitation threshold values were determined by observing the jump in the peak amplitude of signals received by the PCD when the applied FUS peak negative pressure (PNP) increased. To simulate arterial plaque removal, FUS with or without a catheter was used to remove tissues from pork belly fat samples and the lipid cores of human atherosclerotic plaque samples using 2500-cycle FUS bursts at 10% duty cycle and a burst repetition rate of 20 Hz. Treatment outcomes were quantified by subtracting the weight of samples before treatment from the weight of samples after treatment. All measurements were repeated 5 times (n = 5) unless otherwise indicated, and paired t-tests were used to compare the means of two groups. A p-value of <0.05 will be considered significant. RESULTS Our results showed that with a nitinol wire, the cavitation threshold in agar phantoms was reduced to 2.6 MPa from 4.3 MPa PNP when there was no nitinol wire in the focal region of FUS. For pork belly fat samples, cavitation threshold values were 1.0 and 2.0 MPa PNP, with and without a catheter wire, respectively. Pork belly fat tissues and lipid cores of atherosclerotic plaques were depleted at the interface between a catheter and the samples at 2 and 4 MPa FUS PNP, respectively. The results showed that with a catheter wire in the focal region of a 3-min FUS treatment session, 24.7 and 25.6 mg of lipid tissues were removed from pork belly fat and human atherosclerotic samples, respectively. In contrast, the FUS-only group showed no reduction in sample weight. The differences between FUS-only and FUS-plus-catheter groups were statistically significant (p < 0.001 for the treatment on pork belly samples, and p < 0.01 for the treatment on human atherosclerotic samples). CONCLUSION This study demonstrated the feasibility of catheter-assisted FUS therapy for removing atherosclerotic plaques.
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Affiliation(s)
- Abhirup Samaddar
- Institute for Bioengineering Research and Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas, USA
| | - Rohit Singh
- Institute for Bioengineering Research and Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas, USA
| | - Xinmai Yang
- Institute for Bioengineering Research and Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas, USA
| | - Koji C Ebersole
- Department of Neurosurgery, the University of Kansas Medical Center, Kansas City, Kansas, USA
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, the University of Kansas, Lawrence, Kansas, USA
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dos Santos A, Francisco Q, Nunes J, Colombo F, Boralli V. ABCG2 polymorphism and rivaroxaban pharmacokinetics in healthy individuals after a single dose. Braz J Med Biol Res 2024; 57:e13257. [PMID: 38958362 PMCID: PMC11221861 DOI: 10.1590/1414-431x2024e13257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/22/2024] [Indexed: 07/04/2024] Open
Abstract
Rivaroxaban is a direct factor Xa inhibitor. Its interindividual variability is large and may be connected to the occurrence of adverse drug reactions or drug inefficacy. Pharmacogenetics studies concentrating on the reasons underlying rivaroxaban's inadequate response could help explain the differences in treatment results and medication safety profiles. Against this background, this study evaluated whether polymorphisms in the gene encoding the ABCG2 transporter modify the pharmacokinetic characteristics of rivaroxaban. A total of 117 healthy volunteers participated in two bioequivalence experiments with a single oral dose of 20 mg rivaroxaban, with one group fasting and the other being fed. Ultra-high-performance liquid chromatography coupled with mass spectrometry was employed to determine the plasma concentrations of rivaroxaban, and the WinNonlin program was used to calculate the pharmacokinetics parameters. In the fasting group, the rivaroxaban pharmacokinetic parameters of Vd (508.27 vs 334.45 vs 275.59 L) and t1/2 (41.04 vs 16.43 vs 15.47 h) were significantly higher in ABCG2 421 A/A genotype carriers than in ABCG2 421 C/C and 421 C/A genotype carriers (P<0.05). The mean values of Cmax (145.81 vs 176.27 vs 190.19 ng/mL), AUC0-t (1193.81 vs 1374.69 vs 1570.77 ng/mL·h), and Cl (11.82 vs 14.50 vs 13.01 mL/h) for these groups were lower, but this difference was not statistically significant (P>0.05). These findings suggested that the ABCG2 421 A/A genotype may impact rivaroxaban parameters after a single dose in healthy subjects. This finding must be validated before it is applied in clinical practice.
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Affiliation(s)
- A.F. dos Santos
- Universidade Federal de Alfenas, Alfenas, MG, Brasil
- Instituto Claudia Marques de Pesquisa e Desenvolvimento, Pouso Alegre, MG, Brasil
| | - Q.A.S Francisco
- Instituto Claudia Marques de Pesquisa e Desenvolvimento, Pouso Alegre, MG, Brasil
| | - J.B. Nunes
- Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - F.A. Colombo
- Universidade Federal de Alfenas, Alfenas, MG, Brasil
| | - V.B. Boralli
- Universidade Federal de Alfenas, Alfenas, MG, Brasil
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Olšerová A, Janský P, Magerová H, Šrámková T, Kešnerová P, Kmetonyová S, Šulc V, Halmová H, Šrámek M, Šarbochová I, Paulasová-Schwabová J, Benešová K, Macek J, Maťoška V, Tomek A. The Effect of ABCB1 and CES1 Polymorphisms on Plasma Levels of Dabigatran and Risk of Hemorrhagic Complications in Ischemic Stroke Patients. Am J Ther 2024; 31:e362-e371. [PMID: 38525959 DOI: 10.1097/mjt.0000000000001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND Dabigatran directly inhibits thrombin and is used in primary and secondary stroke prevention in individuals with nonvalvular atrial fibrillation. The prodrug dabigatran etexilate is absorbed by enteral P-glycoprotein (ABCB1) and then activated by hepatic and intestinal carboxylesterases (CES1) to produce active metabolites. Variations in dabigatran metabolism because of genetics may affect concentration levels and clinical outcomes. STUDY QUESTION We conducted a study to assess how polymorphisms in the CES1 (rs2244613) and ABCB1 (rs4148738) genes affect the through plasma level (c min ) of dabigatran and its correlation to clinical outcomes. STUDY DESIGN Retrospective multicentric study of consecutive patients on dabigatran therapy. Examination of CES1 rs2244613 and ABCB1 rs4148738 polymorphisms, c min 12 hours after administration, clinical follow-up (ischemic stroke, major or clinically relevant hemorrhage, myocardial infarction, other thromboembolism, and death). MEASURES AND OUTCOMES A total of 432 patients received treatment for an average of 19.78 months (SD of 20.165). The sex distribution of the patients was 56.5% male, and the average age was 67.56 years (SD of 14.7). The ABCB1 variant genotype was present in 67.8% of patients, whereas 37.5% carried the CES1 polymorphism. RESULTS Compared with wild-type patients, patients with the CES1 variant had significantly lower dabigatran plasma levels (with a mean difference of 16.986; 95% confidence interval, 5.794-28.178 ng/mL, P = 0.003). We also found a significant risk of major bleeding in patients carrying the ABCB1 rs4148738 allele (hazard ratio = 1.99, confidence interval 95% 1.10 to 3.59, P = 0.024). CONCLUSIONS The CES1 variant genotype rs2244613 is closely linked with reduced c min of dabigatran. Carriers of the ABCB1 rs4148738 polymorphism exhibit a tendency toward higher plasma levels of dabigatran, which leads to a significantly increased risk of bleeding.
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Affiliation(s)
- Anna Olšerová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Petr Janský
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Hana Magerová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Tereza Šrámková
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Petra Kešnerová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Silvia Kmetonyová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Vlastimil Šulc
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Hana Halmová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Martin Šrámek
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
- Department of Neurology, Military University Hospital Prague, Prague, Czech Republic
| | - Ivana Šarbochová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jaroslava Paulasová-Schwabová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Kateřina Benešová
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Macek
- Pharmakl spol. s.r.o, Prague, Czech Republic; and
| | - Václav Maťoška
- Laboratory of Molecular Diagnostics, Hospital Na Homolce, Prague, Czech Republic
| | - Aleš Tomek
- Department of Neurology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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7
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Slišković AM, Palić J, Božina T, Ganoci L, Vrkić Kirhmajer M, Trkulja V, Bulum J, Šimičević L. Common P-glycoprotein ( ABCB1) polymorphisms do not seem to be associated with the risk of rivaroxaban-related bleeding events: Preliminary data. Biochem Med (Zagreb) 2024; 34:020703. [PMID: 38665866 PMCID: PMC11042566 DOI: 10.11613/bm.2024.020703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/16/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction Considering conflicting previous reports, we aimed to evaluate whether the common ABCB1 polymorphisms (rs1128503, rs2032582, rs1045642, rs4148738) affected the risk of bleeding in rivaroxaban-treated patients. Materials and methods We report preliminary data from a larger nested case-control study. Consecutive adults started on rivaroxaban for any indication requiring > 6 months of treatment were followed-up to one year. Patients who experienced major or non-major clinically relevant bleeding during the initial 6 months were considered cases, whereas subjects free of bleeding over > 6 months were controls. The polymorphisms of interest (rs1128503, rs2032582, rs1045642, rs4148738) were in a strong linkage disequilibrium, hence patients were classified regarding the "load" of variant alleles: 0-2, 3-5 or 6-8. The three subsets were balanced regarding a range of demographic, comorbidity, comedication and genetic characteristics. A logistic model was fitted to probability of bleeding. Results There were 60 cases and 220 controls. Raw proportions of cases were similar across the subsets with increasing number of ABCB1 variant alleles (0-2, N = 85; 3-6, N = 133; 6-8, N = 62): 22.4%, 21.8%, and 19.4%, respectively. Fully adjusted probabilities of bleeding were also similar across the subsets: 22.9%, 27.5% and 17.7%, respectively. No trend was observed (linear, t = -0.63, df = 273, P = 0.529; quadratic, t = -1.10, df = 273, P = 0.272). Of the 15 identified haplotypes, the completely variant (c.1236T_c.2677T(A)_c.3435T_c.2482-2236A) (40.7%) and completely wild-type (C_G_C_G) (39.5%) haplotypes prevailed, and had a closely similar prevalence of cases: 21.1% vs. 23.1%, respectively. Conclusions The evaluated common ABCB1 polymorphisms do not seem to affect the risk of early bleeding in patients started on rivaroxaban.
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Affiliation(s)
- Ana Marija Slišković
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jozefina Palić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tamara Božina
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Lana Ganoci
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Majda Vrkić Kirhmajer
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Joško Bulum
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Livija Šimičević
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
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Ingelman-Sundberg M, Lauschke VM. Individualized Pharmacotherapy Utilizing Genetic Biomarkers and Novel In Vitro Systems As Predictive Tools for Optimal Drug Development and Treatment. Drug Metab Dispos 2024; 52:467-475. [PMID: 38575185 DOI: 10.1124/dmd.123.001302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/15/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024] Open
Abstract
In the area of drug development and clinical pharmacotherapy, a profound understanding of the pharmacokinetics and potential adverse reactions associated with the drug under investigation is paramount. Essential to this endeavor is a comprehensive understanding about interindividual variations in absorption, distribution, metabolism, and excretion (ADME) genetics and the predictive capabilities of in vitro systems, shedding light on metabolite formation and the risk of adverse drug reactions (ADRs). Both the domains of pharmacogenomics and the advancement of in vitro systems are experiencing rapid expansion. Here we present an update on these burgeoning fields, providing an overview of their current status and illuminating potential future directions. SIGNIFICANCE STATEMENT: There is very rapid development in the area of pharmacogenomics and in vitro systems for predicting drug pharmacokinetics and risk for adverse drug reactions. We provide an update of the current status of pharmacogenomics and developed in vitro systems on these aspects aimed to achieve a better personalized pharmacotherapy.
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Affiliation(s)
- Magnus Ingelman-Sundberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden (M.I.-S., V.M.L.); Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany (V.M.L.); and University of Tübingen, Tübingen, Germany (V.M.L.)
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden (M.I.-S., V.M.L.); Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany (V.M.L.); and University of Tübingen, Tübingen, Germany (V.M.L.)
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Liu Z, Xie Q, Zhao X, Tan Y, Wang W, Cao Y, Wei X, Mu G, Zhang H, Zhou S, Wang X, Cao Y, Li X, Chen S, Cao D, Cui Y, Xiang Q. The Pharmacogenetic Variability Associated with the Pharmacokinetics and Pharmacodynamics of Rivaroxaban in Healthy Chinese Subjects: A National Multicenter Exploratory Study. Clin Ther 2024; 46:313-321. [PMID: 38553322 DOI: 10.1016/j.clinthera.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/16/2024] [Accepted: 02/23/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study aimed to explore the pharmacogenetic variability associated with the pharmacokinetics (PK) and pharmacodynamics (PD) of rivaroxaban in healthy Chinese subjects. METHODS This was a multicenter study that included 304 healthy adults aged 18 to 45 years with unknown genotypes. All participants were administered a single dose of rivaroxaban at 10 mg, 15 mg, or 20 mg. PK and PD parameters were measured, and exome-wide association analysis was conducted. FINDINGS Sixteen SNPs located on 11 genes influenced the AUC0-t. Among these, the 3 most influential genes were MiR516A2, PARP14, and MIR618. Thirty-six SNPs from 28 genes were associated with the PD of rivaroxaban. The 3 most influential genes were PKNOX2, BRD3, and APOL4 for anti-Xa activity, and GRIP2, PLCE1, and MLX for diluted prothrombin time (dPT). Among them, BRD3 played an important role in both the PK and PD of rivaroxaban. Anti-Xa activity (ng/mL) differed significantly among subjects with BRD3 rs467387: 145.1 ± 55.5 versus 139.9 ± 65.1 versus 164.0 ± 68.6 for GG, GA, and AA carriers, respectively (P = 0.0002). IMPLICATIONS This study found that that the regulation of the BRD3 gene might affect the PK and PD of rivaroxaban, suggesting that it should be studied as a new pharmacologic target. The correlation between this gene locus and clinical outcomes has yet to be verified in patients undergoing clinical treatment.
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Affiliation(s)
- Zhiyan Liu
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China; Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China; Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xia Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yunlong Tan
- Psychiatry Research Center, Beijing HuiLongGuan Hospital, Peking University, Beijing, China
| | - Wenping Wang
- Department of GCP Center, Affiliated Hospital of Liaoning University of TCM, Shenyang City, Liaoning Province, China
| | - Yu Cao
- Office of Drug Clinical Trial Management, Affiliated Hospital of Qingdao University, Qingdao City, Shandong Province, China
| | - Xiaohua Wei
- Clinical Trial Research Center, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang City, Jiangxi Province, China
| | - Guangyan Mu
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Hanxu Zhang
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Ying Cao
- Department of GCP Center, Affiliated Hospital of Liaoning University of TCM, Shenyang City, Liaoning Province, China
| | - Xin Li
- Office of Drug Clinical Trial Management, Affiliated Hospital of Qingdao University, Qingdao City, Shandong Province, China
| | - Song Chen
- Psychiatry Research Center, Beijing HuiLongGuan Hospital, Peking University, Beijing, China
| | - Duanwen Cao
- Clinical Trial Research Center, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang City, Jiangxi Province, China
| | - Yimin Cui
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China.
| | - Qian Xiang
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China.
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10
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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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11
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Ma Y, Song Z, Li X, Jiang D, Zhao R, Yi Z. Toward Genetic Testing of Rivaroxaban? Insights from a Systematic Review on the Role of Genetic Polymorphism in Rivaroxaban Therapy. Clin Pharmacokinet 2024; 63:279-291. [PMID: 38460105 DOI: 10.1007/s40262-024-01358-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Investigations into the rivaroxaban response from the perspective of genetic variation have been relatively recent and wide in scope, whereas there is no consensus on the necessity of genetic testing of rivaroxaban. Thus, this systematic review aims to thoroughly evaluate the relationship between genetic polymorphisms and rivaroxaban outcomes. METHODS The PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese databases were searched to 23 October 2022. We included cohort studies reporting the pharmacogenetic correlation of rivaroxaban. Outcomes measured included efficacy (all-cause mortality, thromboembolic events and coagulation-related tests), safety (major bleeding, clinically relevant non-major bleeding [CRNMB] and any hemorrhage), and pharmacokinetic outcomes. A narrative synthesis was performed to summarize findings from individual studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the reporting guideline for Synthesis Without Meta-Analysis. RESULTS A total of 12 studies published between 2019 and 2022 involving 1364 patients were included. Ten, one, and six studies focused on the ABCB1, ABCG2, and CYP gene polymorphisms, respectively. Pharmacokinetic outcomes accounted for the majority of the outcomes reported (n = 11), followed by efficacy (n = 5) [including prothrombin time (PT) or international normalized ratio (n = 3), platelet inhibition rate (PIR) or platelet reactivity units (PRUs; n = 1), thromboembolic events (n = 1)], and safety (n = 5) [including major bleeding (n = 2), CRNMB (n = 2), any hemorrhage (n = 1)]. For ABCB1 gene polymorphism, the relationship between PT and ABCB1 rs1045642 was inconsistent across studies, however there was no pharmacogenetic relationship with other efficacy outcomes. Safety associations were found in ABCB1 rs4148738 and major bleeding, ABCB1 rs4148738 and CRNMB, ABCB1 rs1045642 and CRNMB, and ABCB1 rs2032582 and hemorrhage. Pharmacokinetic results were inconsistent among studies. For ABCG2 gene polymorphism, no correlation was observed between ABCG2 rs2231142 and dose-adjusted trough concentration (Cmin/D). For CYP gene polymorphisms, PIR or PRUs have a relationship with CYP2C19 rs12248560, however bleeding or pharmacokinetic effects did not show similar results. CONCLUSIONS Currently available data are insufficient to confirm the relationship between clinical or pharmacokinetic outcomes of rivaroxaban and gene polymorphisms. Proactive strategies are advised as a priority in clinical practice rather than detection of SNP genotyping. CLINICAL TRIALS REGISTRATION PROSPERO registration number CRD42022347907.
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Affiliation(s)
- Yi Ma
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China
| | - Zaiwei Song
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China
| | - Xinya Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Dan Jiang
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China.
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China.
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China.
| | - Zhanmiao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China.
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, China.
- Therapeutic Drug Monitoring and Clinical Toxicology Center, Peking University, Beijing, 100191, China.
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12
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Dua P, Seth S, Prasher B, Mukerji M, Maulik SK, Reeta KH. Pharmacogenomic biomarkers in coronary artery disease: a narrative review. Biomark Med 2024; 18:191-202. [PMID: 38456296 DOI: 10.2217/bmm-2023-0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Coronary artery disease (CAD) has a high mortality rate. Despite various therapeutic targets, non-responsiveness to drugs remains a prevalent issue. Pharmacogenomics assesses the way an individual's genetic attributes affect their likely response to drug therapy. Single-nucleotide polymorphisms play a crucial role in determining these outcomes. This review offers an overview of single-nucleotide polymorphisms investigated in clinical studies and their associations with drug response/nonresponse in the treatment of CAD. A total of 104 studies of whole sets of chromosomes and several genes were explored. A total of 161 polymorphisms exhibited associations with drug response/nonresponse in CAD across diverse ethnic populations. This pool can serve as a pharmacogenomic biomarker for predicting response to drug therapy in patients with CAD.
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Affiliation(s)
- Pamila Dua
- All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sandeep Seth
- All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | | | - Mitali Mukerji
- Indian Institute of Technology, Jodhpur, Rajasthan, India
| | | | - K H Reeta
- All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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13
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Daryabari Y, Amreek F, Moghadamnia AA, Tayebi P. An Update on Betrixaban, The Challenging Anticoagulant Agent for Extended Venous Thromboembolism Prophylaxis. J Cardiovasc Pharmacol 2024; 83:134-143. [PMID: 37728553 DOI: 10.1097/fjc.0000000000001485] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/26/2023] [Indexed: 09/21/2023]
Abstract
ABSTRACT Venous thromboembolism (VTE) is a prevalent yet preventable cause of death, particularly among hospitalized patients. Studies have shown that the risk of VTE remains high for up to 6 months after discharge, highlighting the need for extended thromboprophylaxis as a viable treatment approach. Despite the availability of several anticoagulant drugs such as vitamin K antagonists, heparinoids, rivaroxaban, apixaban, edoxaban, and dabigatran, none of them has received approval from the US Food and Drug Administration for long-term thromboprophylaxis. However, an emerging factor Xa inhibitor called betrixaban has shown promising results in Phase II and phase III trials, positioning itself as the first and only US Food and Drug Administration-approved anticoagulant for extended thromboprophylaxis in hospitalized patients after discharge. Betrixaban offers distinct pharmacological characteristics, including a long half-life, low renal excretion, and unique hepatic metabolism, making it an attractive option for various theoretical uses. Numerous articles have been published discussing the safety and efficacy of betrixaban, all of which have emphasized its usefulness and practicality. However, there has been limited discussion regarding its weaknesses and areas of ambiguity. Therefore, this article aimed to explore the challenges faced during the approval process of betrixaban and provide a comprehensive review of the literature on its advantages and disadvantages as a long-term prophylaxis approach for VTE. Furthermore, we aim to identify the ambiguous points that require further investigation in future studies.
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Affiliation(s)
- Yasaman Daryabari
- Department of Vascular and Endovascular Surgery, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Fnu Amreek
- University of Connecticut School of Medicine, Farmington, CT
| | - Ali Akbar Moghadamnia
- Department of Pharmacology and Toxicology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
- Pharmaceutical Sciences Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran; and
| | - Pouya Tayebi
- Vascular Surgery, Department of Vascular and Endovascular Surgery, Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
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Abdrakhmanov A, Shaimerdinova A, Suleimen Z, Abildinova S, Albayev R, Tuyakova G, Rib E, Beysenbayeva A, Kabduyeva G, Bekbossynova M. Gene polymorphism as a cause of hemorrhagic complications in patients with non-valvular atrial fibrillation treated with oral vitamin K-independent anticoagulants. Ther Adv Cardiovasc Dis 2024; 18:17539447241249886. [PMID: 38801157 PMCID: PMC11131409 DOI: 10.1177/17539447241249886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/02/2024] [Indexed: 05/29/2024] Open
Abstract
Atrial fibrillation (AF) accounts for 40% of all cardiac arrhythmias and is associated with a high risk of stroke and systemic thromboembolic complications. Dabigatran, rivaroxaban, apixaban, and edoxaban are direct oral anticoagulants (DOACs) that have been proven to prevent stroke in patients with non-valvular AF. This review summarizes the pharmacokinetics, pharmacodynamics, and drug interactions of DOACs, as well as new data from pharmacogenetic studies of these drugs. This review is aimed at analyzing the scientific literature on the gene polymorphisms involved in the metabolism of DOACs. We searched PubMed, Cochrane, Google Scholar, and CyberLeninka (Russian version) databases with keywords: 'dabigatran', 'apixaban', 'rivaroxaban', 'edoxaban', 'gene polymorphism', 'pharmacogenetics', 'ABCB1', 'CES1', 'SULT1A', 'ABCG2', and 'CYP3A4'. The articles referred for this review include (1) full-text articles; (2) study design with meta-analysis, an observational study in patients taking DOAC; and (3) data on the single-nucleotide polymorphisms and kinetic parameters of DOACs (plasma concentration), or a particular clinical outcome, published in English and Russian languages during the last 10 years. The ages of the patients ranged from 18 to 75 years. Out of 114 reviewed works, 24 were found eligible. As per the available pharmacogenomic data, polymorphisms affecting DOACs are different. This may aid in developing individual approaches to optimize DOAC pharmacotherapy to reduce the risk of hemorrhagic complications. However, large-scale population studies are required to determine the dosage of the new oral anticoagulants based on genotyping. Information on the genetic effects is limited owing to the lack of large-scale studies. Uncovering the mechanisms of the genetic basis of sensitivity to DOACs helps in developing personalized therapy based on patient-specific genetic variants and improves the efficacy and safety of DOACs in the general population.
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Affiliation(s)
- Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Turan Ave 38, Astana 010000, Kazakhstan
- Medical University of Astana, Astana, Kazakhstan
- Hospital of the Medical Center of the Administration of the President of the Republic of Kazakhstan, Astana, Kazakhstan
| | | | | | | | - Rustam Albayev
- Hospital of the Medical Center of the Administration of the President of the Republic of Kazakhstan, Astana, Kazakhstan
| | - Gulnar Tuyakova
- National Research Cardiac Surgery Center, Astana, Kazakhstan
| | - Elena Rib
- Medical University of Astana, Astana, Kazakhstan
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Yamamoto N, Tsuchiya Y, Fukuda M, Niiro H, Hirota T. A Case Report of Drug Interactions Between Nirmatrelvir/Ritonavir and Tacrolimus in a Patient With Systemic Lupus Erythematosus. Cureus 2024; 16:e52506. [PMID: 38371142 PMCID: PMC10874239 DOI: 10.7759/cureus.52506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Nirmatrelvir/ritonavir is a treatment for COVID-19 consisting of nirmatrelvir, which has anti-SARS-CoV-2 activity, and ritonavir, a booster to maintain blood levels. Ritonavir is known to be a potent inhibitor of cytochrome P450 3A (CYP3A), and interactions with CYP3A-metabolized drugs, such as the immunosuppressant tacrolimus, can be problematic. Ritonavir's inhibition of CYP3A is irreversible due to covalent binding, and its inhibitory effects are expected to persist until replaced by new CYP3A. Here, we report a case where the combination of nirmatrelvir/ritonavir and tacrolimus resulted in toxic tacrolimus blood levels. A patient on tacrolimus for systemic lupus erythematosus (SLE) developed COVID-19 and was prescribed nirmatrelvir/ritonavir. After starting the combination of nirmatrelvir/ritonavir and tacrolimus, the patient's tacrolimus blood levels became abnormally high, leading to the discontinuation of these drugs due to symptoms of tacrolimus toxicity. Even after ritonavir blood levels had fallen below the detection limit, the decline in tacrolimus blood levels was delayed. The CYP3A inhibition of ritonavir persists even when its blood concentration decreases, emphasizing the need for careful consideration of concomitant medications before starting nirmatrelvir/ritonavir therapy. Adjustments or discontinuation may be necessary.
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Affiliation(s)
- Nanae Yamamoto
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Yuichi Tsuchiya
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Mio Fukuda
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
| | - Hiroaki Niiro
- Faculty of Medical Sciences, Department of Medical Education, Kyushu University, Fukuoka, JPN
| | - Takeshi Hirota
- Department of Pharmacology and Therapeutics, Kyushu University Hospital, Fukuoka, JPN
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Kasimova A, Labutin D, Gvozdetsky A, Bozhkova S. Association of ABCB1 gene polymorphisms rs1128503, rs2032582, rs4148738 with anemia in patients receiving dabigatran after total knee arthroplasty. Chin J Traumatol 2024; 27:27-33. [PMID: 37423837 PMCID: PMC10859282 DOI: 10.1016/j.cjtee.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/31/2023] [Accepted: 06/15/2023] [Indexed: 07/11/2023] Open
Abstract
PURPOSE Dabigatran is usually prescribed in recommended doses without monitoring of the blood coagulation for the prevention of venous thromboembolism after joint arthroplasty. ABCB1 is a key gene in the metabolism of dabigatran etexilate. Its allele variants are likely to play a pivotal role in the occurrence of hemorrhagic complications. METHODS The prospective study included 127 patients with primary knee osteoarthritis undergoing total knee arthroplasty. Patients with anemia and coagulation disorders, elevated transaminase and creatinine levels as well as already receiving anticoagulant and antiplatelet therapy were excluded from the study. The association of ABCB1 gene polymorphisms rs1128503, rs2032582, rs4148738 with anemia as the outcome of dabigatran therapy was evaluated by single-nucleotide polymorphism analysis with a real-time polymerase chain reaction assay and laboratory blood tests. The beta regression model was used to predict the effect of polymorphisms on the studied laboratory markers. The probability of the type 1 error (p) was less than 0.05 was considered statistically significant. BenjaminiHochberg was used to correct for significance levels in multiple hypothesis tests. All calculations were performed using Rprogramming language v3.6.3. RESULTS For all polymorphisms there was no association with the level of platelets, protein, creatinine, alanine transaminase, prothrombin, international normalized ratio, activated partial thromboplastin time and fibrinogen. Carriers of rs1128503 (TT) had a significant decrease of hematocrit (p = 0.001), red blood count and hemoglobin (p = 0.015) while receiving dabigatran therapy during the postoperative period compared to the CC, CT. Carriers of rs2032582 (TT) had a significant decrease of hematocrit (p = 0.001), red blood count and hemoglobin (p = 0.006) while receiving dabigatran therapy during the postoperative period compared to the GG, GT phenotypes. These differences were not observed in carriers of rs4148738. CONCLUSION It might be necessary to reconsider thromboprophylaxis with dabigatran in carriers of rs1128503 (TT) or rs2032582 (TT) polymorphisms in favor of other new oral anticoagulants. The long-term implication of these findings would be the reduction of bleeding complications after total joint arthroplasty.
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Affiliation(s)
- Alina Kasimova
- Division of Wound Infection Prevention and Treatment, Vreden National Medical Research Center of Traumatology and Orthopaedics, St. Petersburg, Russian Federation; Department of Clinical Pharmacology and Evidence-based Medicine, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russian Federation.
| | - Dmitry Labutin
- Division of Wound Infection Prevention and Treatment, Vreden National Medical Research Center of Traumatology and Orthopaedics, St. Petersburg, Russian Federation
| | - Anton Gvozdetsky
- Department of Psychiatry and Addictology, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russian Federation
| | - Svetlana Bozhkova
- Division of Wound Infection Prevention and Treatment, Vreden National Medical Research Center of Traumatology and Orthopaedics, St. Petersburg, Russian Federation
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Abdrakhmanov A, Zholdybayeva E, Shaimerdinova A, Kulmambetova G, Abildinova S, Albayev R, Tuyakova G, Rib E, Suleimen Z, Abdrakhmanova Z, Bekbossynova M. Genetic variants of ABCB1 and CES1 genes on dabigatran metabolism in the Kazakh population. CASPIAN JOURNAL OF INTERNAL MEDICINE 2024; 15:499-508. [PMID: 39011438 PMCID: PMC11246689 DOI: 10.22088/cjim.15.3.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/22/2023] [Accepted: 10/24/2023] [Indexed: 07/17/2024]
Abstract
Background Allelic variants of genes encoding enzymes of the esterase system (CES1) and P-glycoprotein (ABCB1) can change the metabolism and pharmacokinetics of dabigatran. Therefore, they act as determining factors in the development of side effects, especially bleeding. We analyzed the genotype-phenotype relationship of ABCB1 (rs1045642, rs4148738, rs2032582, and rs1128503) and CES1 (rs8192935, rs71647871, and rs2244613) polymorphisms in patients with atrial fibrillation who had been treated with dabigatran. Methods A total of 150 patients were recruited for this study. TaqMan technology was used for SNP genotyping. Results Patients with the rs2244613 GG genotype had a lower concentration (55.27 ± 34.22 ng/ml) compared to those with the TT genotype (63.33 ± 52.25 ng/ml) (additive model, P = 0.000). Individuals with the rs8192935 AA genotype had a lower concentration (52.72 ± 30.45 ng/ml) compared to those with the GG genotype (79.78 ± 57 ng/ml) (additive model, P = 0.001). The APTT values among the different genotypes of the ABCB1 SNPs, rs4148738 and rs1045642, were significantly different (P = 0.035 and P = 0.024, respectively). Conclusion Our research demonstrates that the CES1 polymorphisms, rs8192935 and rs2244613, are associated with the pharmacodynamics and pharmacokinetics of dabigatran in the Kazakh subpopulation.
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Affiliation(s)
- Ayan Abdrakhmanov
- Department of Arrhythmology, National Research Cardiac Surgery Center, Turan 38, Astana, Kazakhstan
- Hospital of the Medical Center of the Office of the President, E 495, Astana, Kazakhstan
| | - Elena Zholdybayeva
- National Center for Biotechnology, 13/5, Kurgalzhynskoye road, Astana, Kazakhstan
| | | | - Gulmira Kulmambetova
- National Center for Biotechnology, 13/5, Kurgalzhynskoye road, Astana, Kazakhstan
| | - Svetlana Abildinova
- Department of Arrhythmology, National Research Cardiac Surgery Center, Turan 38, Astana, Kazakhstan
| | - Rustam Albayev
- Hospital of the Medical Center of the Office of the President, E 495, Astana, Kazakhstan
| | - Gulnara Tuyakova
- Department of Arrhythmology, National Research Cardiac Surgery Center, Turan 38, Astana, Kazakhstan
| | - Elena Rib
- Medical University Astana, Beibitshilik St 49/A, Astana, Kazakhstan
| | - Zhanasyl Suleimen
- Department of Arrhythmology, National Research Cardiac Surgery Center, Turan 38, Astana, Kazakhstan
| | | | - Makhabbat Bekbossynova
- Department of Arrhythmology, National Research Cardiac Surgery Center, Turan 38, Astana, Kazakhstan
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McCarley SC, Murphy DA, Thompson J, Shovlin CL. Pharmacogenomic Considerations for Anticoagulant Prescription in Patients with Hereditary Haemorrhagic Telangiectasia. J Clin Med 2023; 12:7710. [PMID: 38137783 PMCID: PMC10744266 DOI: 10.3390/jcm12247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia that commonly results in bleeding but with frequent indications for therapeutic anticoagulation. Our aims were to advance the understanding of drug-specific intolerance and evaluate if there was an indication for pharmacogenomic testing. Genes encoding proteins involved in the absorption, distribution, metabolism, and excretion of warfarin, heparin, and direct oral anticoagulants (DOACs) apixaban, rivaroxaban, edoxaban, and dabigatran were identified and examined. Linkage disequilibrium with HHT genes was excluded, before variants within these genes were examined following whole genome sequencing of general and HHT populations. The 44 genes identified included 5/17 actionable pharmacogenes with guidelines. The 76,156 participants in the Genome Aggregation Database v3.1.2 had 28,446 variants, including 9668 missense substitutions and 1076 predicted loss-of-function (frameshift, nonsense, and consensus splice site) variants, i.e., approximately 1 in 7.9 individuals had a missense substitution, and 1 in 71 had a loss-of-function variant. Focusing on the 17 genes relevant to usually preferred DOACs, similar variant profiles were identified in HHT patients. With HHT patients at particular risk of haemorrhage when undergoing anticoagulant treatment, we explore how pre-emptive pharmacogenomic testing, alongside HHT gene testing, may prove beneficial in reducing the risk of bleeding and conclude that HHT patients are well placed to be at the vanguard of personalised prescribing.
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Affiliation(s)
- Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Daniel A. Murphy
- Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| | - Jack Thompson
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
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Hsieh M, Liu C, Lin S, Lin P, Chang Y, Wang C, Chen C, Sung P. Comparing Efficacy and Safety Between Patients With Atrial Fibrillation Taking Direct Oral Anticoagulants or Warfarin After Direct Oral Anticoagulant Failure. J Am Heart Assoc 2023; 12:e029979. [PMID: 38038171 PMCID: PMC10727336 DOI: 10.1161/jaha.123.029979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/19/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND An increased risk of recurrent stroke is noted in patients with atrial fibrillation despite direct oral anticoagulant (DOAC) use. We investigated the efficacy and safety of treatment with each of 4 different DOACs or warfarin after DOAC failure. METHODS AND RESULTS We retrospectively analyzed patients with atrial fibrillation with ischemic stroke despite DOAC treatment between January 2002 and December 2016. The different outcomes of patients with DOAC failure were compared, including recurrent ischemic stroke, major cardiovascular events, intracranial hemorrhage and subarachnoid hemorrhage, mortality, and net composite outcomes according to switching to different DOACs or vitamin K antagonist after index ischemic stroke. We identified 3759 patients with DOAC failure. A total of 84 patients experienced recurrent ischemic stroke after switching to different oral anticoagulants, with a total follow-up time of 14 years. Using the vitamin K antagonist group as a reference, switching to any of the 4 DOACs was associated with a 69% to 77% reduced risk of major cardiovascular events (adjusted hazard ratio [aHR], 0.25 [95% CI, 0.16-0.39] for apixaban, 0.23 [95% CI, 0.14-0.37] for dabigatran, 0.23 [95% CI, 0.09-0.60] for edoxaban, and 0.31 [95% CI, 0.21-0.45] for rivaroxaban), and a 69% to 83% reduced risk of net composite outcomes (aHR, 0.25 [95% CI, 0.18-0.35] for apixaban, 0.17 [95% CI, 0.11-0.25] for dabigatran, 0.31 [95% CI, 0.17-0.56] for edoxaban, and 0.31 [95% CI, 0.23-0.41] for rivaroxaban). CONCLUSIONS In Asian patients with DOAC failure, continuing DOACs after index stroke was associated with fewer undesirable outcomes than switching to a vitamin K antagonist. Alternative pharmacologic and nonpharmacologic strategies warrant investigation.
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Affiliation(s)
- Meng‐Tsang Hsieh
- Stroke Center and Department of NeurologyChi‐Mei Medical CenterTainanTaiwan
- Institute of Clinical Medicine, College of MedicineNational Cheng Kung UniversityTainanTaiwan
| | - Chi‐Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of MedicineChang Gung UniversityTaoyuanTaiwan
- Institute of Health Policy and Management, College of Public HealthNational Taiwan UniversityTaipeiTaiwan
| | - Sheng‐Hsiang Lin
- Institute of Clinical Medicine, College of MedicineNational Cheng Kung UniversityTainanTaiwan
- Department of Public Health, College of MedicineNational Cheng Kung UniversityTainanTaiwan
- Biostatistics Consulting CenterNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Po‐Yu Lin
- Department of NeurologyNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Yu‐Ming Chang
- Department of NeurologyNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Chun‐Min Wang
- Department of NeurologyNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Chih‐Hung Chen
- Department of NeurologyNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
| | - Pi‐Shan Sung
- Department of NeurologyNational Cheng Kung University Hospital, College of Medicine, National Cheng Kung UniversityTainanTaiwan
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20
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Jang EJ, Kim JS, Choi SA, Yee J, Song TJ, Park J, Gwak HS. Construction of a risk scoring system using clinical factors and RYR2 polymorphisms for bleeding complications in patients on direct oral anticoagulants. Front Pharmacol 2023; 14:1290785. [PMID: 38034995 PMCID: PMC10684747 DOI: 10.3389/fphar.2023.1290785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction: Bleeding is one of the most undesirable complications of direct oral anticoagulants (DOACs). While the ryanodine receptor (RYR2) has been related to cardiac diseases, research on bleeding complications is lacking. This study aimed to elucidate the association between RYR2 and bleeding risk to develop the risk scoring system in patients treated with DOACs. Methods: This study was a retrospective analysis of prospectively collected samples. We selected ten SNPs within the RYR2 gene, and two models were constructed (Model I: demographic factors only, Model II: demographic and genetic factors) in multivariable analysis. Independent risk factors for bleeding were used to develop a risk scoring system. Results: A total of 447 patients were included, and 49 experienced either major bleeding or clinically relevant non-major bleeding. In Model I, patients using rivaroxaban and experiencing anemia exhibited an increased bleeding risk after adjusting for covariates. Upon incorporating genetic factors into Model I, a significant association with bleeding was also observed in cases of overdosing on DOACs and in patients with a creatinine clearance (CrCl) < 30 mL/min, in addition to rivaroxaban and anemia (Model II). Among genetic factors, RYR2 rs12594 GG, rs17682073 AA, rs3766871 GG, and rs6678625 T alleles were associated with bleeding complications. The area under the receiver operating characteristic curve (AUROC) of Model I was 0.670, whereas that of Model II increased to 0.803, demonstrating better performance with the inclusion of genetic factors. Using the significant variables in Model II, a risk scoring system was constructed. The predicted bleeding risks for scores of 0, 1-2, 3-4, 5-6, 7-8, and 9-10 points were 0%, 1.2%, 4.6%, 15.7%, 41.7%, and 73.3%, respectively. Conclusion: This study revealed an association between RYR2 and bleeding complications among patients taking DOACs and established a risk scoring system to support individualized DOAC treatment for these patients.
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Affiliation(s)
- Eun Jeong Jang
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jung Sun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Seo A. Choi
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
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21
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Xue S, Na R, Dong J, Wei M, Kong Q, Wang Q, Qiu X, Li F, Song H. Characteristics and Mechanism of Acute Ischemic Stroke in NAVF Patients With Prior Oral Anticoagulant Therapy. Neurologist 2023; 28:379-385. [PMID: 37582631 PMCID: PMC10627545 DOI: 10.1097/nrl.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVES We aimed to analyze the characteristics and mechanisms of acute ischemic stroke (AIS) in patients with nonvalvular atrial fibrillation (NVAF) who received prior anticoagulant therapy. METHODS We retrospectively analyzed the data of patients with NVAF and AIS between January 2016 and December 2021. Patients were divided into non-anticoagulant, adequate anticoagulant, and insufficient anticoagulant groups according to their prior anticoagulant status. Patients with prior anticoagulant therapy were further divided into warfarin and direct oral anticoagulant groups. RESULTS A total of 749 patients (661 without anticoagulants, 33 with adequate anticoagulants, and 55 with insufficient anticoagulants) were included. Patients with adequate anticoagulant had a milder National Institute of Health Stroke Scale at presentation ( P =0.001) and discharge ( P =0.003), a higher proportion of Modified Rankin Scale (mRS) ≤2 at discharge ( P =0.011), and lower rates of massive infarction ( P =0.008) than patients without anticoagulant. Compared with the non-anticoagulant group, the proportion of intravenous thrombolysis was significantly lower in the adequate anticoagulant ( P <0.001) and insufficient anticoagulant ( P =0.009) groups. Patients in the adequate anticoagulant group had higher rates of responsible cerebral atherosclerotic stenosis ( P =0.001 and 0.006, respectively) and competing large artery atherosclerotic mechanisms ( P =0.006 and 0.009, respectively) than those in the other 2 groups. Compared with warfarin, direct oral anticoagulant was associated with higher rates of Modified Rankin Scale ≤2 at discharge ( P =0.003). CONCLUSIONS Adequate anticoagulant therapy may be associated with milder stroke severity and better outcomes at discharge in patients with NVAF. Competing large artery atherosclerotic mechanisms may be associated with anticoagulant failure in patients with NAVF with prior adequate anticoagulant therapy.
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Affiliation(s)
- Sufang Xue
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Risu Na
- Department of Neurology, Tongliao City Hospital, Tongliao, China
| | - Jing Dong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Min Wei
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qi Kong
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qiujia Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xue Qiu
- Department of Neurology, Shuangqiao Hospital, Beijing, China
| | - Fangyu Li
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
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22
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Villapalos-García G, Zubiaur P, Ochoa D, Soria-Chacartegui P, Navares-Gómez M, Matas M, Mejía-Abril G, Casajús-Rey A, Campodónico D, Román M, Martín-Vílchez S, Candau-Ramos C, Aldama-Martín M, Abad-Santos F. NAT2 phenotype alters pharmacokinetics of rivaroxaban in healthy volunteers. Biomed Pharmacother 2023; 165:115058. [PMID: 37385211 DOI: 10.1016/j.biopha.2023.115058] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
Rivaroxaban is a direct inhibitor of factor Xa, a member of direct oral anticoagulant group of drugs (DOACs). Despite being a widely extended alternative to vitamin K antagonists (i.e., acenocoumarol, warfarin) the interindividual variability of DOACs is significant, and may be related to adverse drug reaction occurrence or drug inefficacy, namely hemorrhagic or thromboembolic events. Since there is not a consistent analytic practice to monitor the anticoagulant activity of DOACs, previously reported polymorphisms in genes coding for proteins responsible for the activation, transport, or metabolism of DOACs were studied. The study population comprised 60 healthy volunteers, who completed two randomized, crossover bioequivalence clinical trials between two different rivaroxaban formulations. The effect of food, sex, biogeographical origin and 55 variants (8 phenotypes and 47 single nucleotide polymorphisms) in drug metabolizing enzyme genes (such as CYP2D6, CYP2C9, NAT2) and transporters (namely, ABCB1, ABCG2) on rivaroxaban pharmacokinetics was tested. Individuals dosed under fasting conditions presented lower tmax (2.21 h vs 2.88 h, β = 1.19, R2 =0.342, p = 0.012) compared to fed volunteers. NAT2 slow acetylators presented higher AUC∞ corrected by dose/weight (AUC∞/DW; 8243.90 vs 7698.20 and 7161.25 h*ng*mg /ml*kg, β = 0.154, R2 =0.250, p = 0.044), higher Cmax/DW (1070.99 vs 834.81 and 803.36 ng*mg /ml*kg, β = 0.245, R2 =0.320, p = 0.002), and lower tmax (2.63 vs 3.19 and 4.15 h, β = -0.346, R2 =0.282, p = 0.047) than NAT2 rapid and intermediate acetylators. No other association was statistically significant. Thus, slow NAT2 appear to have altered rivaroxaban pharmacokinetics, increasing AUC∞ and Cmax. Nonetheless, further research should be conducted to verify NAT2 involvement on rivaroxaban pharmacokinetics and to determine its clinical significance.
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Affiliation(s)
- Gonzalo Villapalos-García
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute (CMRI), Kansas City, MO, USA.
| | - Dolores Ochoa
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Paula Soria-Chacartegui
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marcos Navares-Gómez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Miriam Matas
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Gina Mejía-Abril
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana Casajús-Rey
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Diana Campodónico
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Manuel Román
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Samuel Martín-Vílchez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Candau-Ramos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marina Aldama-Martín
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
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23
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Abdrakhmanov A, Akilzhanova A, Shaimerdinova A, Zhalbinova M, Tuyakova G, Abildinova S, Albayev R, Ainabekova B, Chinybayeva A, Suleimen Z, Bekbossynova M. The Distribution of the Genotypes of ABCB1 and CES1 Polymorphisms in Kazakhstani Patients with Atrial Fibrillation Treated with DOAC. Genes (Basel) 2023; 14:1192. [PMID: 37372371 DOI: 10.3390/genes14061192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
Nowadays, direct oral anticoagulants (DOACs) are the first-line anticoagulant strategy in patients with non-valvular atrial fibrillation (NVAF). We aimed to identify the influence of polymorphisms of the genes encoding P-glycoprotein (ABCB1) and carboxylesterase 1 (CES1) on the variability of plasma concentrations of DOACs in Kazakhstani patients with NVAF. We analyzed polymorphisms rs4148738, rs1045642, rs2032582 and rs1128503 in ABCB1 and rs8192935, rs2244613 and rs71647871 CES1 genes and measured the plasma concentrations of dabigatran/apixaban and biochemical parameters in 150 Kazakhstani NVAF patients. Polymorphism rs8192935 in the CES1 gene (p = 0.04), BMI (p = 0.01) and APTT level (p = 0.01) were statistically significant independent factors of trough plasma concentration of dabigatran. In contrast, polymorphisms rs4148738, rs1045642, rs2032582 and rs1128503 in ABCB1 and rs8192935, rs2244613 and rs71647871 CES1 genes did not show significant influence on plasma concentrations of dabigatran/apixaban drugs (p > 0.05). Patients with GG genotype (138.8 ± 100.1 ng/mL) had higher peak plasma concentration of dabigatran than with AA genotype (100.9 ± 59.6 ng/mL) and AG genotype (98.7 ± 72.3 ng/mL) (Kruskal-Wallis test, p = 0.25). Thus, CES1 rs8192935 is significantly associated with plasma concentrations of dabigatran in Kazakhstani NVAF patients (p < 0.05). The level of the plasma concentration shows that biotransformation of the dabigatran processed faster in individual carriers of GG genotype rs8192935 in the CES1 gene than with AA genotype.
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Affiliation(s)
- Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Astana 010000, Kazakhstan
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana 010000, Kazakhstan
| | - Ainur Akilzhanova
- Center for Life Sciences, National Laboratory Astana, Nazarbayev University, Astana 010000, Kazakhstan
| | - Aizhan Shaimerdinova
- Department of Internal Medicine, Medical University Astana, Astana 010000, Kazakhstan
| | - Madina Zhalbinova
- Center for Life Sciences, National Laboratory Astana, Nazarbayev University, Astana 010000, Kazakhstan
| | - Gulnara Tuyakova
- National Research Cardiac Surgery Center, Astana 010000, Kazakhstan
| | | | - Rustam Albayev
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana 010000, Kazakhstan
| | - Bayan Ainabekova
- Department of Internal Medicine, Medical University Astana, Astana 010000, Kazakhstan
| | - Assel Chinybayeva
- Corporate Fund "University Medical Center", Nazarbayev University, Astana 010000, Kazakhstan
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24
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Martin AC, Benamouzig R, Gouin-Thibault I, Schmidt J. Management of Gastrointestinal Bleeding and Resumption of Oral Anticoagulant Therapy in Patients with Atrial Fibrillation: A Multidisciplinary Discussion. Am J Cardiovasc Drugs 2023:10.1007/s40256-023-00582-9. [PMID: 37145342 DOI: 10.1007/s40256-023-00582-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/06/2023]
Abstract
Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.
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Affiliation(s)
- Anne-Céline Martin
- Advanced Heart Failure Unit, AP-HP, Cardiology Department, European Hospital Georges Pompidou, Paris, France.
- INSERM UMRS_1140, Innovative Therapies in Haemostasis, Université Paris Cité, 75006, Paris, France.
| | - Robert Benamouzig
- Service de Gastroentérologie, Hôpital Avicenne, AP-HP, Université Paris-Nord-La Sorbonne, Bobigny, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, IRSET-INSERM UMRS 1085, Rennes University Hospital, Rennes, France
| | - Jeannot Schmidt
- LaPSCo, Physiological and Psychosocial Stress, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
- Emergency Department, CHU Clermont-Ferrand, University Hospital Gabriel Montpied, Clermont-Ferrand, France
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25
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Stöllberger C, Schneider B, Finsterer J. Drug-drug interactions with direct oral anticoagulants for the prevention of ischemic stroke and embolism in atrial fibrillation: a narrative review of adverse events. Expert Rev Clin Pharmacol 2023; 16:313-328. [PMID: 36861431 DOI: 10.1080/17512433.2023.2187376] [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: 03/03/2023]
Abstract
INTRODUCTION In randomized trials, direct oral anticoagulants (DOAC) were non-inferior to the vitamin-K-antagonist (VKA) warfarin in preventing stroke/embolism in patients with atrial fibrillation (AF). DOAC are substrates for P-glycoprotein (P-gp), CYP3A4 and CYP2C9. The activity of these enzymes is modulated by several drugs which might induce pharmacokinetic drug-drug interactions (DDI). Drugs affecting platelet function have the potential for pharmacodynamic DDI of DOAC. AREAS COVERED The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs affecting platelet function, CYP3A4-, CYP2C9- or P-gp-activity. Reports about bleeding and embolic events attributed to DDI with DOAC in AF-patients were found for 43 of 171 drugs with interacting potential (25%), most frequently with antiplatelet and nonsteroidal anti-inflammatory drugs. Whereas a co-medication of platelet-affecting drugs is invariably reported to increase the bleeding risk, the findings regarding P-gp-, CYP3A4- and CYP2C9- activity-affecting drugs are ambiguous. EXPERT OPINION Tests for plasma DOAC-levels and information about DDI of DOAC should be widely available and user-friendly. If advantages and disadvantages of DOAC and VKA can be investigated exhaustively, individualized anticoagulant therapy can be offered to patients, considering co-medication, comorbidities, genetic and geographic factors and the health care system.
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26
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Thompson LE, Davis BH, Narayan R, Goff B, Brown TM, Limdi NA. Personalizing Direct Oral Anticoagulant Therapy for a Diverse Population: Role of Race, Kidney Function, Drug Interactions, and Pharmacogenetics. Clin Pharmacol Ther 2023; 113:585-599. [PMID: 35857814 PMCID: PMC9852362 DOI: 10.1002/cpt.2714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/13/2022] [Indexed: 01/24/2023]
Abstract
Oral anticoagulants (OACs) are commonly used to reduce the risk of venous thromboembolism and the risk of stroke in patients with atrial fibrillation. Endorsed by the American Heart Association, American College of Cardiology, and the European Society of Cardiology, direct oral anticoagulants (DOACs) have displaced warfarin as the OAC of choice for both conditions, due to improved safety profiles, fewer drug-drug and drug-diet interactions, and lack of monitoring requirements. Despite their widespread use and improved safety over warfarin, DOAC-related bleeding remains a major concern for patients. DOACs have stable pharmacokinetics and pharmacodynamics; however, variability in DOAC response is common and may be attributed to numerous factors, including patient-specific factors, concomitant medications, comorbid conditions, and genetics. Although DOAC randomized controlled trials included patients of varying ages and levels of kidney function, they failed to include patients of diverse ancestries. Additionally, current evidence to support DOAC pharmacogenetic associations have primarily been derived from European and Asian individuals. Given differences in genotype frequencies and disease burden among patients of different biogeographic groups, future research must engage diverse populations to assess and quantify the impact of predictors on DOAC response. Current under-representation of patients from diverse racial groups does not allow for proper generalization of the influence of clinical and genetic factors in relation to DOAC variability. Herein, we discuss factors affecting DOAC response, such as age, sex, weight, kidney function, drug interactions, and pharmacogenetics, while offering a new perspective on the need for further research including frequently excluded groups.
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Affiliation(s)
- Lorenzo E. Thompson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Brittney H. Davis
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Renuka Narayan
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Blake Goff
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Todd M Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
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27
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Šimičević L, Slišković AM, Kirhmajer MV, Ganoci L, Holik H, Palić J, Samardžić J, Božina T. Risk Factors for Rivaroxaban-Related Bleeding Events-Possible Role of Pharmacogenetics: Case Series. PHARMACY 2023; 11:29. [PMID: 36827667 PMCID: PMC9966833 DOI: 10.3390/pharmacy11010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants' interindividual trough concentration variability affects efficacy and safety, especially in bleeding events. Rivaroxaban is metabolised via CYP3A4/5-, CYP2J2-, and CYP-independent mechanisms and is a substrate of two transporter proteins: ABCB1 (MDR1, P-glycoprotein) and ABCG2 (BCRP; breast-cancer-resistance protein). The polymorphisms of these genes may possibly affect the pharmacokinetics of rivaroxaban and, consequently, its safety profile. Rivaroxaban variability may be associated with age, liver and kidney function, concomitant illness and therapy, and pharmacogenetic predisposition. This case series is the first, to our knowledge, that presents multiple risk factors for rivaroxaban-related bleeding (RRB) including age, renal function, concomitant diseases, concomitant treatment, and pharmacogenetic data. It presents patients with RRB, along with their complete clinical and pharmacogenetic data, as well as an evaluation of possible risk factors for RRB. Thirteen patients were carriers of ABCB1, ABCG2, CYP2J2, and/or CYP3A4/5 gene polymorphisms. Possible drug-drug interactions with increased bleeding risk were identified in nine patients. Six patients had eGFR <60 mL/min/1.73 m2. Our data suggest a possible role of multiple factors and their interactions in predicting RRB; however, they also indicate the need for further comprehensive multidisciplinary research to enable safer use of this product based on a personalised approach.
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Affiliation(s)
- Livija Šimičević
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Ana Marija Slišković
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Majda Vrkić Kirhmajer
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Lana Ganoci
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Hrvoje Holik
- Department of Internal Medicine, General Hospital Dr Josip Benčević, 35000 Slavonski Brod, Croatia
| | - Jozefina Palić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Jure Samardžić
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Tamara Božina
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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28
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Foulon-Pinto G, Lafuente-Lafuente C, Jourdi G, Guen JL, Tall F, Puymirat E, Delrue M, Rivière L, Ketz F, Gouin-Thibault I, Mullier F, Gaussem P, Pautas E, Lecompte T, Curis E, Siguret V. Assessment of DOAC in GEriatrics (Adage Study): Rivaroxaban/Apixaban Concentrations and Thrombin Generation Profiles in NVAF Very Elderly Patients. Thromb Haemost 2023; 123:402-414. [PMID: 36395818 PMCID: PMC10060059 DOI: 10.1055/a-1981-1763] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although a growing number of very elderly patients with atrial fibrillation (AF), multiple conditions, and polypharmacy receive direct oral anticoagulants (DOACs), few studies specifically investigated both apixaban/rivaroxaban pharmacokinetics and pharmacodynamics in such patients. AIMS To investigate: (1) DOAC concentration-time profiles; (2) thrombin generation (TG); and (3) clinical outcomes 6 months after inclusion in very elderly AF in-patients receiving rivaroxaban or apixaban. METHODS Adage-NCT02464488 was an academic prospective exploratory multicenter study, enrolling AF in-patients aged ≥80 years, receiving DOAC for at least 4 days. Each patient had one to five blood samples at different time points over 20 days. DOAC concentrations were determined using chromogenic assays. TG was investigated using ST-Genesia (STG-ThromboScreen, STG-DrugScreen). RESULTS We included 215 patients (women 71.1%, mean age: 87 ± 4 years), 104 rivaroxaban and 111 apixaban, and 79.5% receiving reduced-dose regimen. We observed important inter-individual variabilities (coefficient of variation) whatever the regimen, at C max [49-46%] and C min [75-61%] in 15 mg rivaroxaban and 2.5 mg apixaban patients, respectively. The dose regimen was associated with C max and C min plasma concentrations in apixaban (p = 0.0058 and p = 0.0222, respectively), but not in rivaroxaban samples (multivariate analysis). Moreover, substantial variability of thrombin peak height (STG-ThromboScreen) was noticed at a given plasma concentration for both xabans, suggesting an impact of the underlying coagulation status on TG in elderly in-patients. After 6-month follow-up, major bleeding/thromboembolic event/death rates were 6.7%/1.0%/17.3% in rivaroxaban and 5.4%/3.6%/18.9% in apixaban patients, respectively. CONCLUSION Our study provides original data in very elderly patients receiving DOAC in a real-life setting, showing great inter-individual variability in plasma concentrations and TG parameters. Further research is needed to understand the potential clinical impact of these findings.
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Affiliation(s)
- Geoffrey Foulon-Pinto
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Carmelo Lafuente-Lafuente
- Service de gériatrie à orientation cardiologique et neurologique, AP-HP, Sorbonne Université, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France.,CEpiA Team (Clinical Epidemiology and Ageing), Université Paris Est Créteil, INSERM, IMRB, Créteil, France
| | - Georges Jourdi
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Research Center, Institut de Cardiologie de Montréal - Université de Montréal, Montréal, QC, Canada
| | - Julien Le Guen
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Fatoumata Tall
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Rothschild, Paris, France
| | - Etienne Puymirat
- Service de Cardiologie, AP-HP. Université de Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Maxime Delrue
- Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Léa Rivière
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Flora Ketz
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Isabelle Gouin-Thibault
- INSERM, CIC 1414 (Centre d'Investigation Clinique de Rennes), Université de Rennes, CHU de Rennes, Rennes, France.,Service d'Hématologie Biologique, CHU de Rennes, Rennes, France
| | - François Mullier
- Department of Laboratory Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, Yvoir, Belgium.,Hematology-Hemostasis Laboratory, CHU UCL Namur, Yvoir, Belgium
| | - Pascale Gaussem
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Eric Pautas
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Thomas Lecompte
- Service d'Hématologie Biologique, CHU de Rennes, Rennes, France.,Université de Lorraine, Faculté de médecine de Nancy, Nancy, France
| | - Emmanuel Curis
- Université de Paris Cité, UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie, Paris, France
| | - Virginie Siguret
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
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Fedina LV, Sychev IN, Rastvorova TD, Strigunkova EV, Kachanova AA, Sozaeva ZA, Bochkov PO, Vardanyan AV, Mirzayev KB, Sychev DA. Effect of ABCB1 Gene Carriage and Drug-Drug Interactions on Apixaban and Rivaroxaban Pharmacokinetics and Clinical Outcomes in Patients with Atrial Fibrillation and Deep Vein Thrombosis. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2022-12-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim. To investigate the effect of ABCB1 gene carriage and interdrug interactions on apixaban pharmacokinetics and clinical outcomes in patients with atrial fibrillation and deep vein thrombosis.Material and methods. Patients hospitalized at Yudin State Clinical Hospital participated in the study. A total of 92 patients (50 patients received apixaban and 42 – rivaroxaban) with non-valvular atrial fibrillation and deep vein thrombosis were included. Genotyping was performed by real-time polymerase chain reaction. Direct oral anticoagulants concentrations were measured using an electrospray ionization mass spectrometer in positive ionization mode.Results. In our study we found that in patients carrying the CT+TT ABCB1 (rs4148738) C>T genotype encoding the carrier protein (P-gp), the plasma concentration of rivaroxaban was statistically significantly higher p= 0.026. In addition, we found that patients taking apixaban together with a CYP3A4/P-gp inhibitor were 3.5 times more likely to have hemorrhagic complications than those without inhibitors p = 0.004.Conclusion. Our study revealed that the plasma concentration of rivaroxaban was higher in patients carrying the ABCB1 (rs4148738) C>T polymorphism T allele. And patients taking apixaban together with CYP3A4/P-gp inhibitor had higher risk of hemorrhagic complications in comparison with patients not taking such drugs. Further studies are needed on the influence of pharmacogenetics and pharmacokinetics on the safety and efficacy profile of apixaban and rivaroxaban, taking into account the trend of systemic approach to optimization of anticoagulant therapy of direct oral anticoagulants based on pharmacokinetic, pharmacogenetic biomarkers.
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Affiliation(s)
- L. V. Fedina
- Russian Medical Academy of Continuous Professional Education
| | - I. N. Sychev
- Russian Medical Academy of Continuous Professional Education
| | | | | | - A. A. Kachanova
- Russian Medical Academy of Continuous Professional Education
| | - Z. A. Sozaeva
- Russian Medical Academy of Continuous Professional Education
| | - P. O. Bochkov
- Russian Medical Academy of Continuous Professional Education
| | - A. V. Vardanyan
- Russian Medical Academy of Continuous Professional Education
| | - K. B. Mirzayev
- Russian Medical Academy of Continuous Professional Education
| | - D. A. Sychev
- Russian Medical Academy of Continuous Professional Education
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Zhang D, Chen W, Qin W, Du W, Wang X, Zuo X, Li P. Population Pharmacokinetics and Hemorrhagic Risk Analysis of Rivaroxaban in Elderly Chinese Patients With Nonvalvular Atrial Fibrillation. J Clin Pharmacol 2023; 63:66-76. [PMID: 36029108 DOI: 10.1002/jcph.2145] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022]
Abstract
Rivaroxaban is a popular direct factor Xa inhibitor used for anticoagulation therapy in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study was to establish a population pharmacokinetic (PPK) model for rivaroxaban in elderly Chinese patients with nonvalvular atrial fibrillation, evaluate precision dosing regimens, and analyze hemorrhagic risk after rivaroxaban treatment. A 1-compartment population PK model with estimated glomerular filtration rate (eGFR), total bilirubin (TBIL), and ABCB1 rs1045642 as major covariates for apparent clearance was developed using the nonlinear mixed-effects model (NONMEM). A Monte Carlo simulation was performed to evaluate various dosing schemes and different levels of covariates for the target range of therapeutic drug-monitoring concentrations (Cmax,ss and Cmin,ss ). The exposure to rivaroxaban was simulated and assessed through hemorrhagic risk evaluation. The results showed that the average probability of target attainment (PTA) for optimal dosing regimens with different covariate levels for the targeted Cmax,ss and Cmin,ss were 29.35% to 31.3% and 64.91% to 65.8%, respectively. A dosage of 10 mg of rivaroxaban in elderly Chinese patients with normal renal and liver function was appropriate. The area under the concentration-time curve estimated over 24 hours with precision dosing at steady state (AUC24,ss ) was statistically significantly associated with an increased risk of bleeding events (OR 1.0006, 95%CI 1.0003 to 1.001, P < .0001), and the bleeding risk increased by 1.82-fold for every 1000 μg*h/L increase in AUC24,ss . A lower dose is recommended for elderly patients with renal impairment to avoid overexposure and bleeding events. The PPK model could inform individualized dosing for elderly Chinese patients with nonvalvular atrial fibrillation receiving rivaroxaban anticoagulation therapy.
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Affiliation(s)
- Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Wei Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xianbo Zuo
- Clinical Trial Research Center, China-Japan Friendship Hospital, Beijing, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
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Kang JH, Lee JE, Jeong SJ, Park CW, Kim DW, Weon KY. Design and Optimization of Rivaroxaban-Cyclodextrin-Polymer Triple Complex Formulation with Improved Solubility. Drug Des Devel Ther 2022; 16:4279-4289. [PMID: 36561308 PMCID: PMC9767707 DOI: 10.2147/dddt.s389884] [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: 09/14/2022] [Accepted: 12/08/2022] [Indexed: 12/16/2022] Open
Abstract
Purpose This study aimed to ensure the convenience of administration and reproducibility of efficacy, regardless of the meal, by improving the solubility of rivaroxaban (RIV). Methods RIV is a non-vitamin K antagonist oral anticoagulants that exhibits a coagulation effect by directly inhibiting coagulation factor Xa. However, RIV has a very low solubility; therefore, it must be administered with a meal at high doses. We used a drug- hydroxypropyl-beta-cyclodextrin (CD)-water-soluble polymer triple complex (R-C-P complex) to solubilize RIV. Using Minitab, we evaluated the effect of each factor on RIV solubility and developed an optimal R-C-P complex formulation. The amount of CD, amount of polymer, and polymer type were set as the independent variables X1, X2, and X3, respectively. RIV solubility (Y1) and dissolution rate for 45 min in pH 4.5 medium (Y2) and pH 1.2 medium (Y3) were set as response variables. Results The most efficient RIV solubilization effect was obtained from the composition using CD and HPMC 2208, and physicochemical properties and dissolution parameters were analyzed. RIV in the R-C-P complex was present in an amorphous form and showed high solubility. Unlike commercial products, it showed a 100% dissolution rate. The R-C-P complex formulation secured high RIV solubility and 100% release regardless of pH. Conclusion The results imply that high-dose RIV can be administered regardless of the meal, reducing the risk of changing the drug effect due to the patient's administration mistake.
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Affiliation(s)
- Ji-Hyun Kang
- College of Pharmacy, Chungbuk National University, Cheongju, Korea
| | - Ji-Eun Lee
- College of Pharmacy, Chungbuk National University, Cheongju, Korea
| | - So-Jeong Jeong
- College of Pharmacy, Chungbuk National University, Cheongju, Korea
| | - Chun-Woong Park
- College of Pharmacy, Chungbuk National University, Cheongju, Korea
| | - Dong-Wook Kim
- College of Pharmacy, Wonkwang University, Iksan, Korea,Correspondence: Dong-Wook Kim, College of Pharmacy, Wonkwang University, Iksan, 54538, Korea, Tel +82-63-229-7130, Fax +82-63-850-7309, Email
| | - Kwon-Yeon Weon
- College of Pharmacy, Daegu Catholic University, Gyeongsan, Korea,Kwon-Yeon Weon, College of Pharmacy, Daegu Catholic University, Gyeongsan, 38430, Korea, Tel +82-53-850-3616, Fax +82-53-850-3602, Email
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Direct oral anticoagulants (DOACs): From the laboratory point of view. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2022; 72:459-482. [PMID: 36651369 DOI: 10.2478/acph-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/20/2023]
Abstract
Direct oral anticoagulants (DOACs) represent a new generation of drugs that have been increasingly used in the prevention and treatment of thromboembolic states. According to the mechanism of anticoagulant action, DOACs are divided into two groups: direct inhibitors of thrombin (dabigatran) and direct inhibitors of activated factor X (FXa) (rivaroxaban, apixaban, edoxaban, betrixaban). Compared to the vitamin K antagonists, DOACs are superior in terms of onset of action, pharmacokinetic and pharmacodynamics properties and fixed daily dose without the need for routine coagulation monitoring. Despite these advantages, there are clinical conditions in which laboratory measurement of DOACs should be performed. Although DOACs have an impact on screening haemostasis assays (prothrombin time, PT; activated partial thromboplastin time, aPTT; and thrombin time, TT), these tests are not appropriate for quantifying drug levels. Therefore, specific quantitative methods (LC-MS/MS as a gold standard method for all DOACs, coagulometric and chromogenic assays for dabigatran, and chromogenic anti-Xa assays with drug-specific calibrators for inhibitors of FXa) should only be used for determination of DOACs concentration. The aim of this review is to present all aspects of laboratory assessment of DOACs, including pre-analytical, analytical and post-analytical factors in the overall testing process with a special accent on the available specific quantitative methods for measurement of DOACs in circulation.
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Xiang Q, Xie Q, Liu Z, Mu G, Zhang H, Zhou S, Wang Z, Wang Z, Zhang Y, Zhao Z, Yuan D, Guo L, Wang N, Xiang J, Song H, Sun J, Jiang J, Cui Y. Genetic variations in relation to bleeding and pharmacodynamics of dabigatran in Chinese patients with nonvalvular atrial fibrillation: A nationwide multicentre prospective cohort study. Clin Transl Med 2022; 12:e1104. [PMID: 36453946 PMCID: PMC9714378 DOI: 10.1002/ctm2.1104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION To identify the potential factors responsible for the individual variability of dabigatran, we investigated the genetic variations associated with clinical outcomes and pharmacodynamics (PD) in Chinese patients with nonvalvular atrial fibrillation (NVAF). MATERIALS AND METHODS Chinese patients with NVAF taking dabigatran etexilate with therapeutic doses were enrolled. The primary (bleeding events) and secondary (thromboembolic and major adverse cardiac events) outcomes for a 2-year follow-up were evaluated. Peak and trough PD parameters (anti-FIIa activity, activated partial thromboplastin time and prothrombin time) were detected. Whole-exome sequencing, genome-wide sequencing and candidate gene association analyses were performed. RESULTS There were 170 patients with NVAF treated with dabigatran (110 mg twice daily) who were finally included. Two single-nucleotide polymorphisms (SNPs) were significantly related with bleeding, which include UBASH3B rs2276408 (odds ratio [OR] = 8.79, 95% confidence interval [CI]: 2.99-25.83, p = 7.77 × 10-5 at sixth month visit) and FBN2 rs3805625 (OR = 8.29, 95% CI: 2.87-23.89, p = 9.08 × 10-5 at 12th month visit), as well as with increased trends at other visits (p < .05). Furthermore, minor allele carriers of 16 new SNPs increased PD levels, and those of one new SNP decreased PD values (p < 1.0 × 10-5 ). Lastly, 33 new SNPs were found to be associated with bleeding and PD among 14 candidate genes. Unfortunately, the low number of secondary outcomes precluded further association analyses. CONCLUSIONS Genetic variations indeed affected bleeding and PD in Chinese patients with NVAF treated with dabigatran. The functions of these suggestive genes and SNPs might further be explored and verified in more in vivo and in vitro investigations.
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Affiliation(s)
- Qian Xiang
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Qiufen Xie
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Zhiyan Liu
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Guangyan Mu
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Hanxu Zhang
- Department of PharmacyPeking University First HospitalBeijingChina
- School of Pharmaceutical SciencesPeking University Health Science CenterBeijingChina
| | - Shuang Zhou
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Zhe Wang
- Department of PharmacyPeking University First HospitalBeijingChina
- School of Pharmaceutical SciencesPeking University Health Science CenterBeijingChina
| | - Zining Wang
- Department of PharmacyPeking University First HospitalBeijingChina
| | - Yatong Zhang
- Department of PharmacyBeijing HospitalBeijingChina
| | - Zinan Zhao
- Department of PharmacyBeijing HospitalBeijingChina
| | - Dongdong Yuan
- Department of PharmacyZhengzhou Seventh People's HospitalZhengzhouChina
| | - Liping Guo
- Department of PharmacyZhengzhou Seventh People's HospitalZhengzhouChina
| | - Na Wang
- Department of PharmacyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Jing Xiang
- Department of PharmacyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hongtao Song
- Department of Pharmacy900 Hospital of the Joint Logistics TeamFuzhouChina
| | - Jianjun Sun
- Department of PharmacyThe Affiliated Hospital of Inner Mongolia Medical UniversityHuhehaoteChina
| | - Jie Jiang
- Department of CardiologyPeking University First HospitalBeijingChina
| | - Yimin Cui
- Department of PharmacyPeking University First HospitalBeijingChina
- School of Pharmaceutical SciencesPeking University Health Science CenterBeijingChina
- Institute of Clinical PharmacologyPeking UniversityBeijingChina
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Zhu Z, Qian C, Su C, Tao H, Mao J, Guo Z, Zhu X, Pan J. The impact of ABCB1 and CES1 polymorphisms on the safety of dabigatran in patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2022; 22:481. [DOI: 10.1186/s12872-022-02910-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
This study aimed to analyze associations between genetic variants and plasma concentrations along with clinical outcomes in dabigatran in patients with non-valvular atrial fibrillation (NVAF).
Methods
We conducted a prospective study and enrolled NVAF patients treated with dabigatran in the real world. A total of 86 patients treated with 110 mg DE twice daily were recruited for this study. Blood samples were obtained from each patient and used for genotyping and determination of plasma dabigatran concentration. All bleeding and thromboembolic complications were recorded during the 1.5 years of follow-up.
Results
Eighty-three patients provided samples at the trough plasma level of dabigatran, and 58 patients provided samples at the peak plasma level of dabigatran. There was a significant association between the CES1 SNP rs8192935 and trough plasma concentrations of dabigatran (P = 0.013). Our results showed that the CES1 SNP rs8192935 significantly influenced dabigatran trough concentrations in the Chinese population, and carriers of the G allele had increased trough plasma concentrations of dabigatran compared to noncarriers. The ABCB1 SNP c.2482-2236G > A (rs4148738) was associated with major bleeding events in the addictive model (P = 0.046, OR = 3.29) and dominant model (P = 0.040, OR = 8.17). Additionally, the ABCB1 SNP c.3435 C > T (rs1045642) was associated with the incidence of major bleeding events in the addictive model (P = 0.043, OR = 3.34) and dominant model (P = 0.046, OR = 7.77). However, no significant associations were found between all the SNPs and the incidence of minor bleeding events.
Conclusion
Our results indicated that the CES1 polymorphism rs8192935 was associated with trough plasma concentrations of dabigatran. Carriers of the G allele had increased trough plasma concentrations of dabigatran compared to noncarriers. The ABCB1 polymorphisms rs4148738 and rs1045642 were associated with an increased risk for major bleeding events for the first time in a Chinese population.
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Yoon HY, Song TJ, Yee J, Park J, Gwak HS. Association between Genetic Polymorphisms and Bleeding in Patients on Direct Oral Anticoagulants. Pharmaceutics 2022; 14:pharmaceutics14091889. [PMID: 36145636 PMCID: PMC9501033 DOI: 10.3390/pharmaceutics14091889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/26/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: The purpose of our study is to investigate the effects of apolipoprotein B (APOB) and APOE gene polymorphisms on bleeding complications in patients receiving direct oral anticoagulants (DOACs). Methods: A total of 16 single nucleotide polymorphisms (SNPs) in 468 patients were genotyped. Six SNPs of ABCB1 (rs3842, rs1045642, rs2032582, rs1128503, rs3213619, and rs3747802), one SNP of CYP3A5 (rs776746), seven SNPs of APOB (rs1042034, rs2163204, rs693, rs679899, rs13306194, rs13306198, and rs1367117), and two SNPs of APOE (rs429358 and rs7412) were analyzed by a TaqMan genotyping assay. Multivariable logistic regression analysis with selected variables was performed for the construction of a risk scoring system. Two risk scoring systems were compared (demographic factors only vs. demographic factors and genetic factors). Results: In the multivariable analyses, two models were constructed; only demographic factors were included in Model I and both demographic factors and genetic factors in Model II. Rivaroxaban and anemia showed significant association with bleeding in both models. Additionally, ABCB1 rs3842 variant homozygote carriers (CC) and APOB rs13306198 variant allele carriers (AG, AA) had a higher risk of bleeding risk compared with that of wild-type allele carriers (TT, TC) and wild-type homozygote carriers (GG), respectively. Whereas the area under the receiver operating characteristic curve (AUROC) value using demographic factors only was 0.65 (95% confidence interval (CI): 0.56–0.74), the AUROC increased to 0.72 by adding genetic factors (95% CI: 0.65–0.80). The predicted bleeding risks of bleeding in patients with 0, 1, 2, 3, 4, 5, 6, 7 and 8 points from the logistic regression curve were 0.8%, 2.0%, 5.4%, 5.2%, 12.5%, 26.9%, 47.0%, 64.3% and 82.3%, respectively. Conclusions: The study results can be used for enhancing individualized treatment strategies in patients taking DOACs, helping clinicians predict the bleeding risk.
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Affiliation(s)
- Ha-Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul 07985, Korea
- Correspondence: (J.P.); (H.-S.G.)
| | - Hye-Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul 03760, Korea
- Correspondence: (J.P.); (H.-S.G.)
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Sychev D, Ostroumova O, Cherniaeva M, Shakhgildian N, Mirzaev K, Abdullaev S, Denisenko N, Sozaeva Z, Kachanova A, Gorbatenkova S, Shastina V. The Influence of ABCB1 (rs1045642 and rs4148738) Gene Polymorphisms on Rivaroxaban Pharmacokinetics in Patients Aged 80 Years and Older with Nonvalvular Atrial Fibrillation. High Blood Press Cardiovasc Prev 2022; 29:469-480. [PMID: 35960493 DOI: 10.1007/s40292-022-00536-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/18/2022] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION ABCB1 gene polymorphisms are associated with rivaroxaban distribution changes and adverse reactions but the data are controversial. AIM To evaluate the influence of ABCB1 (rs1045642 and rs4148738) gene polymorphisms on rivaroxaban pharmacokinetics in patients aged 80 years and older with nonvalvular atrial fibrillation (NAF). METHODS 128 patients aged 80 years and older (median [Me] age 87.5 [83.0-90.0] years) with NAF were included. We performed ABCB1 (rs1045642 and rs4148738) genotyping, measured the trough steady-state plasma concentration (Cmin,ss) of rivaroxaban and prothrombin time (PT) and analyzed prior medical records for clinically relevant non-major bleeding (CRNMB). RESULTS CC genotype carriers had no differences in Cmin,ss (p > 0.05) compared with the CT and TT rs1045642 and rs4148738 genotypes carriers. CC genotype carriers had no differences in PT (p > 0.05) compared with the CT rs1045642 and rs4148738 and TT rs4148738 genotypes carriers. In the TT genotype PT levels were higher than in the CC rs1045642 genotype: Me 14.2 [13.0-16.1] sec vs 13.3 [12.4-14.5] sec (p = 0.049). Incidence of CRNMB was higher in patients with the TT genotype compared with the CC rs1045642 (29.3% vs 4.5%, p = 0.021) and rs4148738 (39.3% vs 8.1%, p = 0.008) and the CT genotype rs4148738 (39.3% vs 14.3%, p = 0.002). CONCLUSION ABCB1 (rs1045642 and rs4148738) polymorphisms didn't influence rivaroxaban pharmacokinetics in patients aged 80 years and older with NAF. TT carriers developed CRNMB more frequently compared with the CC rs1045642 and the CC and CT rs4148738 genotypes. The haplotype TT-TT haplotype was associated with a higher frequency of CRNMB.
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Affiliation(s)
- Dmitry Sychev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation
| | - Olga Ostroumova
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Department of Therapy and Polymorbid Pathology, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation
| | - Marina Cherniaeva
- Department of Internal and Preventive Medicine, Central State Medical Academy of the Presidential Administration of the Russian Federation, Marshal Timoshenko Street, 19, Building 1A, Moscow, 121359, Russian Federation. .,State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradskiy Prospekt, 168, Moscow, 109472, Russian Federation.
| | - Nataliia Shakhgildian
- Lomonosov Moscow State University Medical Research and Educational Center, 27\10, Lomonosovskiy Prospekt, Moscow, 119991, Russian Federation
| | - Karin Mirzaev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Research Center for Medical Genetics, 1 Moskvorechye st., Moscow, 115522, Russian Federation.,Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, 7/2 2nd Bokinskiy Drive, Moscow, 125284, Russian Federation
| | - Sherzod Abdullaev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Department of Molecular Medicine, Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, 7/2 2nd Bokinskiy Drive, Moscow, 125284, Russian Federation
| | - Natalia Denisenko
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, 7/2 2nd Bokinskiy Drive, Moscow, 125284, Russian Federation
| | - Zhannet Sozaeva
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Department of Personalized Medicine, Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, 7/2 2nd Bokinskiy Drive, Moscow, 125284, Russian Federation
| | - Anastasia Kachanova
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, 2/1 Barrikadnaya St., Moscow, 123242, Russian Federation.,Department of Molecular Medicine, Research Institute of Molecular and Personalized Medicine, Russian Medical Academy of Continuous Professional Education, 7/2 2nd Bokinskiy Drive, Moscow, 125284, Russian Federation
| | - Svetlana Gorbatenkova
- State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradskiy Prospekt, 168, Moscow, 109472, Russian Federation
| | - Vera Shastina
- State Budgetary Institution of Health "Hospital for War Veterans No. 2" of the Department of Health of Moscow, Volgogradskiy Prospekt, 168, Moscow, 109472, Russian Federation
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Zhang D, Qin W, Du W, Wang X, Chen W, Li P. Effect of ABCB1 gene variants on rivaroxaban pharmacokinetic and hemorrhage event occurred in patients with non-valvular atrial fibrillation. Biopharm Drug Dispos 2022; 43:163-171. [PMID: 35940587 DOI: 10.1002/bdd.2327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022]
Abstract
Hemorrhage events occurred most frequently in non-valvular atrial fibrillation (NVAF) anticoagulant therapy. Rivaroxaban was widely used for routine anticoagulation care. Genetic polymorphisms are thought to contribute to the wide intraindividual variability seen in rivaroxaban metabolism and anticoagulant response. The aim of this study was to evaluate the effect of drug transport related single-nucleotide polymorphisms (SNPs) on rivaroxaban metabolism and risk of hemorrhage event. A total of 216 Chinese patients with NVAF were enrolled in the study. Rivaroxaban was treated for anticoagulation therapy. Rivaroxaban plasma concentrations were detected using a validated UPLC-MS/MS method. Seven single-nucleotide polymorphisms (SNPs) in four genes were genotyped using the Sanger dideoxy DNA sequencing method. Associations between genotype variants, the incidence of hemorrhage events and time of bleeding were analyzed. ABCB1 2677G (rs2032582) variation was highly associated with dose-adjusted rivaroxaban peak concentration in plasma (Cmax /D) (P = 0.025, FDR = 0.042). The ABCB1 G allele carriers had higher rivaroxaban Cmax /D than non-carriers. Logistic regression showed rivaroxaban Cmax /D and ABCB1 genotype variants were associated with higher incidence of hemorrhage events. No statistically significant difference was found between ABCB1 genotypes and the time of bleeding after anticoagulant therapy in 30 days. These results indicated that ABCB1 2677G (rs2032582) genetic variant affects rivaroxaban Cmax /Dose and the incidence of hemorrhage events significantly. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wei Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
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38
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Li H, Zhang Z, Weng H, Qiu Y, Zubiaur P, Zhang Y, Fan G, Yang P, Vuorinen AL, Zuo X, Zhai Z, Wang C. Association between CES1 rs2244613 and the pharmacokinetics and safety of dabigatran: Meta-analysis and quantitative trait loci analysis. Front Cardiovasc Med 2022; 9:959916. [PMID: 35990949 PMCID: PMC9386138 DOI: 10.3389/fcvm.2022.959916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/29/2022] [Indexed: 12/02/2022] Open
Abstract
Objective To date, the influence of the carboxylesterase 1 (CES1) rs2244613 genotype on the pharmacokinetics (PKs) and safety of dabigatran remains controversial. Hence, a systematic review was performed to study the association between CES1 rs2244613 genotype and the PKs and safety of dabigatran and CES1 relative expression. Methods In addition to the three English databases (Web of Science, PubMed, and Embase), two Chinese databases (CNKI and Wanfang) were thoroughly revised. The mean differences (MD) and corresponding 95% confidence intervals (CI) were applied to evaluate the differences in PKs between the CES1 rs2244613 genotype. Odds ratio (OR) was used to study the risk for bleeding events between the CES1 rs2244613 genotypes. Subsequent expression quantitative trait loci (eQTL) analyses were performed to evaluate genotype-specific expressions in human tissues. Results Ten studies (n = 2,777) were included. CES1 rs2244613 G allele carriers exhibited significantly lower dabigatran trough concentrations compared to T allele carriers (MD: −8.00 ng/mL; 95% CI: −15.08 to −0.92; p = 0.03). The risk for bleeding events was significantly lower in carriers of the G allele compared to T allele carriers (OR: 0.65; 95% CI: 0.44–0.96; p = 0.03). Subsequent eQTL analysis showed significant genome-wide expressions in two human tissues, whole blood (p = 5.1 × 10–10) and liver (p = 6.2 × 10–43). Conclusion Our meta-analysis indicated a definite relation between the CES1 rs2244613 genotype and tolerability variations or pharmacokinetic fluctuations. The carriers of T allele showed higher dabigatran concentrations; therefore, they would benefit from a dose reduction. Systematic review registration [https://inplasy.com/inplasy-2022-6-0027/], identifier [NPLASY202260027].
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Affiliation(s)
- Haobo Li
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Haoyi Weng
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
- WeGene, Shenzhen Zaozhidao Technology Co., Ltd., Shenzhen, China
- Hunan Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
| | - Yuting Qiu
- Graduate School of Capital Medical University, Beijing, China
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria, Universidad Autónoma de Madrid, Madrid, Spain
| | - Yu Zhang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Capital Medical University, Beijing, China
| | - Guohui Fan
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Peiran Yang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | | | - Xianbo Zuo
- Department of Dermatology, China-Japan Friendship Hospital, Beijing, China
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Xianbo Zuo,
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Zhenguo Zhai,
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Adler G, Uzar I, Valjevac A, Kiseljakovic E, Mahmutbegovic E, Salkic NN, Adler MA, Mahmutbegovic N. Genetic Diversity of CYP3A5 and ABCB1 Variants in East-Central and South European Populations. Ann Hum Biol 2022; 49:210-215. [PMID: 35815612 DOI: 10.1080/03014460.2022.2100477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND CYP3A5 enzyme encoded by CYP3A5 is important for drug metabolism in gut and liver, whereas P-glycoprotein by ABCB1, is an ATP-dependent drug efflux pump which exports endo- and exogenous substances outside the cell. Aim: The study was to assess the prevalence of CYP3A5 alleles: *1, *2, *3, *4, *6 and *7, and C and T of ABCB1 in Poles, Belarusians and Bosnians and to compare it with the data reported from other European populations. Subjects and methods: Overall, 511 unrelated healthy subjects from Poland (n = 239), Belarus (n = 104) and Bosnia and Herzegovina (n = 168) were included in this study. Allele frequencies and statistical parameters (AMOVA version 2.9.3) were determined. Results: In Poles, Belarusians and Bosnians the *3 allele of CYP3A5 was the most common, and wild-type allele *1, were: 5.8%, 1.6% and 2.1%, respectively. Allele *2 was very rare, and alleles *4, *6 and *7 were not detected. For the populations mentioned above, the ABCB1 allele C was: 48.1%, 51.4%, 52.4%, respectively. CONCLUSION In compared populations, the distribution of CYP3A5 variants but not ABCB1, differed significantly. Alleles *4, *6 and *7 of CYP3A5 did not occur or occurred rarely.
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Affiliation(s)
- Grazyna Adler
- Department of Studies in Antropogenetics and Biogerontology, Pomeranian Medical University, Szczecin, Poland
| | - Izabela Uzar
- Department of General Pharmacology and Pharmacoeconomics, Pomeranian Medical University, Szczecin, Poland
| | - Amina Valjevac
- Department of Human Physiology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Emina Kiseljakovic
- Department of Medical Biochemistry, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Emir Mahmutbegovic
- Institution of Health Protection of Women and Motherhood Canton Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermin N Salkic
- Department of Gastroenterology and Hepatology, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
| | | | - Nevena Mahmutbegovic
- Neurology Clinic, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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40
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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Drug-Drug Interactions of Direct Oral Anticoagulants (DOACs): From Pharmacological to Clinical Practice. Pharmaceutics 2022; 14:pharmaceutics14061120. [PMID: 35745692 PMCID: PMC9229376 DOI: 10.3390/pharmaceutics14061120] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/24/2022] Open
Abstract
The direct oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban, and edoxaban, are becoming the most commonly prescribed drugs for preventing ischemic stroke in patients with non-valvular atrial fibrillation (NVAF) and for the treatment and prevention of venous thromboembolism (VTE). Rivaroxaban was also recently approved for the treatment of patients with a recent acute coronary syndrome (ACS). Their use demonstrated to have a favorable risk-benefit profile, with significant reductions in stroke, intracranial hemorrhage, and mortality compared to warfarin, but with increased gastrointestinal bleeding. Nevertheless, their safety profile is compromised in multimorbidity patients requiring contemporary administration of several drugs. Comorbidity and polypharmacy have a high prevalence in elderly patients, who are also more susceptible to bleeding events. The combination of multiple treatments can cause relevant drug–drug interactions (DDIs) by affecting the exposure or the pharmacological activities of DOACs. Although important differences of the pharmacokinetic (PK) properties can be observed between DOACs, all of them are substrate of P-glycoprotein (P-gp) and thus may interact with strong inducers or inhibitors of this drug transporter. On the contrary, rivaroxaban and, to a lower extent, apixaban, are also susceptible to drugs altering the cytochrome P450 isoenzyme (CYP) activities. In the present review, we summarize the potential DDI of DOACs with several classes of drugs that have been reported or have characteristics that may predict clinically significant DDIs when administered together with DOACs. Possible strategies, including dosage reduction, avoiding concomitant administration, or different time of treatment, will be also discussed to reduce the incidence of DDI with DOACs. Considering the available data from specific clinical trials or registries analysis, the use of DOACs is associated with fewer clinically relevant DDIs than warfarin, and their use represents an acceptable clinical choice. Nevertheless, DDIs can be significant in certain patient conditions so a careful evaluation should be made before prescribing a specific DOAC.
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42
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Xie Q, Li Y, Liu Z, Mu G, Zhang H, Zhou S, Wang Z, Wang Z, Jiang J, Li X, Xiang Q, Cui Y. SLC4A4, FRAS1, and SULT1A1 Genetic Variations Associated With Dabigatran Metabolism in a Healthy Chinese Population. Front Genet 2022; 13:873031. [PMID: 35646073 PMCID: PMC9136018 DOI: 10.3389/fgene.2022.873031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 12/21/2022] Open
Abstract
Background: The purpose of this study was to identify genetic variations associated with the metabolism of dabigatran in healthy Chinese subjects, with particular focus given to pharmacokinetics (PK) and pharmacodynamics (PD).Methods: Healthy Chinese adults aged 18–65 years with unknown genotypes from a bioequivalence trial were included according to the protocol registered at ClinicalTrial.org (NCT03161496). All subjects received a single dose (150 mg) of dabigatran etexilate. PK (main outcomes: area under the concentration-time, AUC0-t, of total and free dabigatran) and PD (main outcomes: anti-FIIa activity, APTT, and PT) parameters were evaluated. Whole-exome sequencing and genome-wide association analyses were performed. Additionally, candidate gene association analyses related to dabigatran were conducted.Results: A total of 118 healthy Chinese subjects were enrolled in this study. According to the p-value suggestive threshold (1.0 × 10−4), the following three SNPs were found to be associated with the AUC0–t of total dabigatran: SLC4A4 SNP rs138389345 (p = 5.99 × 10−5), FRAS1 SNP rs6835769 (p = 6.88 × 10−5), and SULT1A1 SNP rs9282862 (p = 7.44 × 10−5). Furthermore, these SNPs were also found to have significant influences on the AUC0–t of free dabigatran, maximum plasma concentration, and anti-FIIa activity (p < 0.05). Moreover, we identified 30 new potential SNPs of 13 reported candidate genes (ABCB1, ABCC2, ABCG2, CYP2B6, CYP1A2, CYP2C19, CYP3A5, CES1, SLCO1B1, SLC22A1, UGT1A1, UGT1A9, and UGT2B7) that were associated with drug metabolism.Conclusion: Genetic variations were indeed found to impact dabigatran metabolism in a population of healthy Chinese subjects. Further research is needed to explore the more detailed functions of these SNPs. Additionally, our results should be verified in studies that use larger sample sizes and investigate other ethnicities.
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Affiliation(s)
- Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yuan Li
- Department of Pharmacy, The Third Hospital of Changsha, Changsha, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xin Li
- Department of Pharmacy, The Third Hospital of Changsha, Changsha, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
- Institute of Clinical Pharmacology, Peking University, Beijing, China
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Asiimwe IG, Pirmohamed M. Ethnic Diversity and Warfarin Pharmacogenomics. Front Pharmacol 2022; 13:866058. [PMID: 35444556 PMCID: PMC9014219 DOI: 10.3389/fphar.2022.866058] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/14/2022] [Indexed: 12/23/2022] Open
Abstract
Warfarin has remained the most commonly prescribed vitamin K oral anticoagulant worldwide since its approval in 1954. Dosing challenges including having a narrow therapeutic window and a wide interpatient variability in dosing requirements have contributed to making it the most studied drug in terms of genotype-phenotype relationships. However, most of these studies have been conducted in Whites or Asians which means the current pharmacogenomics evidence-base does not reflect ethnic diversity. Due to differences in minor allele frequencies of key genetic variants, studies conducted in Whites/Asians may not be applicable to underrepresented populations such as Blacks, Hispanics/Latinos, American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. This may exacerbate health inequalities when Whites/Asians have better anticoagulation profiles due to the existence of validated pharmacogenomic dosing algorithms which fail to perform similarly in the underrepresented populations. To examine the extent to which individual races/ethnicities are represented in the existing body of pharmacogenomic evidence, we review evidence pertaining to published pharmacogenomic dosing algorithms, including clinical utility studies, cost-effectiveness studies and clinical implementation guidelines that have been published in the warfarin field.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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Lenoir C, Terrier J, Gloor Y, Gosselin P, Daali Y, Combescure C, Desmeules JA, Samer CF, Reny JL, Rollason V. Impact of the Genotype and Phenotype of CYP3A and P-gp on the Apixaban and Rivaroxaban Exposure in a Real-World Setting. J Pers Med 2022; 12:jpm12040526. [PMID: 35455642 PMCID: PMC9028714 DOI: 10.3390/jpm12040526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/04/2023] Open
Abstract
Apixaban and rivaroxaban are the two most prescribed direct factor Xa inhibitors. With the increased use of DOACs in real-world settings, safety and efficacy concerns have emerged, particularly regarding their concomitant use with other drugs. Increasing evidence highlights drug−drug interactions with CYP3A/P-gp modulators leading to adverse events. However, current recommendations for dose adjustment do not consider CYP3A/P-gp genotype and phenotype. We aimed to determine their impact on apixaban and rivaroxaban blood exposure. Three-hundred hospitalized patients were included. CYP3A and P-gp phenotypic activities were assessed by the metabolic ratio of midazolam and AUC0−6h of fexofenadine, respectively. Relevant CYP3A and ABCB1 genetic polymorphisms were also tested. Capillary blood samples collected at four time-points after apixaban or rivaroxaban administration allowed the calculation of pharmacokinetic parameters. According to the developed multivariable linear regression models, P-gp activity (p < 0.001) and creatinine clearance (CrCl) (p = 0.01) significantly affected apixaban AUC0−6h. P-gp activity (p < 0.001) also significantly impacted rivaroxaban AUC0−6h. The phenotypic switch (from normal to poor metabolizer) of P-gp led to an increase of apixaban and rivaroxaban AUC0−6h by 16% and 25%, respectively, equivalent to a decrease of 38 mL/min in CrCl according to the apixaban model. CYP3A phenotype and tested SNPs of CYP3A/P-gp had no significant impact. In conclusion, P-gp phenotypic activity, rather than known CYP3A/P-gp polymorphisms, could be relevant for dose adjustment.
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Affiliation(s)
- Camille Lenoir
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, 1206 Geneva, Switzerland
| | - Jean Terrier
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Department of Medicine, Division of General Internal Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.G.); (J.-L.R.)
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
| | - Yvonne Gloor
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
| | - Pauline Gosselin
- Department of Medicine, Division of General Internal Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.G.); (J.-L.R.)
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
| | - Youssef Daali
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, 1206 Geneva, Switzerland
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Christophe Combescure
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Department of Health and Community Medicine, Division of Clinical Epidemiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Jules Alexandre Desmeules
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, 1206 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Caroline Flora Samer
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Jean-Luc Reny
- Department of Medicine, Division of General Internal Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.G.); (J.-L.R.)
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
| | - Victoria Rollason
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.L.); (J.T.); (Y.G.); (Y.D.); (J.A.D.); (C.F.S.)
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Correspondence:
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Disease-Specific Health Disparities: A Targeted Review Focusing on Race and Ethnicity. Healthcare (Basel) 2022; 10:healthcare10040603. [PMID: 35455781 PMCID: PMC9025451 DOI: 10.3390/healthcare10040603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022] Open
Abstract
Background: Wide disparities in health status exist in the United States across race and ethnicity, broadly driven by social determinants of health—most notably race and ethnic group differences in income, education, and occupational status. However, disparities in disease frequency or severity remain underappreciated for many individual diseases whose distribution in the population varies. Such information is not readily accessible, nor emphasized in treatment guidelines or reviews used by practitioners. Specifically, a summary on disease-specific evidence of disparities from population-based studies is lacking. Our goal was to summarize the published evidence for specific disease disparities in the United States so that this knowledge becomes more widely available “at the bedside”. We hope this summary stimulates health equity research at the disease level so that these disparities can be addressed effectively. Methods: A targeted literature review of disorders in Pfizer’s current pipeline was conducted. The 38 diseases included metabolic disorders, cancers, inflammatory conditions, dermatologic disorders, rare diseases, and infectious targets of vaccines under development. Online searches in Ovid and Google were performed to identify sources focused on differences in disease rates and severity between non-Hispanic Whites and Black/African Americans, and between non-Hispanic Whites and Hispanics. As a model for how this might be accomplished for all disorders, disparities in disease rates and disease severity were scored to make the results of our review most readily accessible. After primary review of each condition by one author, another undertook an independent review. Differences between reviewers were resolved through discussion. Results: For Black/African Americans, 29 of the 38 disorders revealed a robust excess in incidence, prevalence, or severity. After sickle cell anemia, the largest excesses in frequency were identified for multiple myeloma and hidradenitis suppurativa. For Hispanics, there was evidence of disparity in 19 diseases. Most notable were metabolic disorders, including non-alcoholic steatohepatitis (NASH). Conclusions: This review summarized recent disease-specific evidence of disparities based on race and ethnicity across multiple diseases, to inform clinicians and health equity research. Our findings may be well known to researchers and specialists in their respective fields but may not be common knowledge to health care providers or public health and policy institutions. Our hope is that this effort spurs research into the causes of the many disease disparities that exist in the United States.
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Zhang X, Zhang X, Tong F, Cai Y, Zhang Y, Song H, Tian X, Yan C, Han Y. Gut microbiota induces high platelet response in patients with ST segment elevation myocardial infarction after ticagrelor treatment. eLife 2022; 11:70240. [PMID: 35258452 PMCID: PMC8903831 DOI: 10.7554/elife.70240] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 02/23/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Ticagrelor is a first-line drug for the treatment of acute ST elevation myocardial infarction (STEMI). However, approximately 20% STEMI patients taking ticagrelor exhibited a delayed response and the mechanism was still unclear. Methods: To explore the mechanism of the poor response of ticagrelor in post-percutaneous coronary intervention (PCI) patients, we enrolled 65 high platelet reactivity (HPR) patients and 90 controls (normal platelet reactivity [NPR]). Pharmacokinetic assessment result showed that the plasma concentrations of ticagrelor and its metabolism production, AR-C124910XX, were lower in HPR patients than controls. Further single nucloetide polymorphism (SNP) analysis identified that there is no difference in ATP binding cassette subfamily B member 1 (ABCB1) gene expression between the NPR group and the HPR group. Metagenomic and metabolomic analyses of fecal samples showed that HPR patients had higher microbial richness and diversity. Transplantation of the gut microbiota from HPR donors to microbiota-depleted mice obviously decreased plasma concentration of ticagrelor. Results: Our findings highlight that gut microbiota dysbiosis may be an important mechanism for the ticagrelor of HPR in patients with STEMI and support that modify gut microbiota is a potential therapeutic option for STEMI. Conclusions: Our findings highlight that gut microbiota dysbiosis may be an important mechanism for the ticagrelor of HPR in patients with ST elevation myocardial infarction (STEMI) and support that modify gut microbiota is a potential therapeutic option for STEMI Funding: NSFC 82170297 and 82070300 from the National Natural Science Foundation of China.
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Affiliation(s)
- Xi Zhang
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaolin Zhang
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Fangnian Tong
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Cai
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zhang
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Haixu Song
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaoxiang Tian
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Chenghui Yan
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology and Cardiovascular Research Institute of PLA, General Hospital of Northern Theater Command, Shenyang, China.,Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
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47
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Pharmacogenetics to Avoid Adverse Drug Reactions. J Pers Med 2022; 12:jpm12020159. [PMID: 35207648 PMCID: PMC8879652 DOI: 10.3390/jpm12020159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 01/27/2023] Open
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48
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Babayeva M, Azzi B, Loewy ZG. Pharmacogenomics Informs Cardiovascular Pharmacotherapy. Methods Mol Biol 2022; 2547:201-240. [PMID: 36068466 DOI: 10.1007/978-1-0716-2573-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Precision medicine exemplifies the emergence of personalized treatment options which may benefit specific patient populations based upon their genetic makeup. Application of pharmacogenomics requires an understanding of how genetic variations impact pharmacokinetic and pharmacodynamic properties. This particular approach in pharmacotherapy is helpful because it can assist in and improve clinical decisions. Application of pharmacogenomics to cardiovascular pharmacotherapy provides for the ability of the medical provider to gain critical knowledge on a patient's response to various treatment options and risk of side effects.
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Affiliation(s)
| | | | - Zvi G Loewy
- Touro College of Pharmacy, New York, NY, USA.
- School of Medicine, New York Medical College, Valhalla, NY, USA.
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49
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Palmirotta R. Direct Oral Anticoagulants (DOAC): Are We Ready for a Pharmacogenetic Approach? J Pers Med 2021; 12:jpm12010017. [PMID: 35055332 PMCID: PMC8777772 DOI: 10.3390/jpm12010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Raffaele Palmirotta
- Interdisciplinary Department of Medicine, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy
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50
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Hirata TDC, Dagli-Hernandez C, Genvigir FDV, Lauschke VM, Zhou Y, Hirata MH, Hirata RDC. Cardiovascular Pharmacogenomics: An Update on Clinical Studies of Antithrombotic Drugs in Brazilian Patients. Mol Diagn Ther 2021; 25:735-755. [PMID: 34357562 DOI: 10.1007/s40291-021-00549-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Anticoagulant and antiplatelet drugs effectively prevent thrombotic events in patients with cardiovascular diseases, ischemic stroke, peripheral vascular diseases, and other thromboembolic diseases. However, genetic and non-genetic factors affect the response to antithrombotic therapy and can increase the risk of adverse events. This narrative review discusses pharmacogenomic studies on antithrombotic drugs commonly prescribed in Brazil. Multiple Brazilian studies assessed the impact of pharmacokinetic (PK) and pharmacodynamic (PD) gene variants on warfarin response. The reduced function alleles CYP2C9*2 and CYP2C9*3, and VKORC1 rs9923231 (c.-1639G>A) are associated with increased sensitivity to warfarin and a low dose requirement to prevent bleeding episodes, whereas CYP4F2 rs2108622 (p.Val433Met) carriers have higher dose requirements (warfarin resistance). These deleterious variants and non-genetic factors (age, gender, body weight, co-administered drugs, food interactions, and others) account for up to 63% of the warfarin dose variability. Few pharmacogenomics studies have explored antiplatelet drugs in Brazilian cohorts, finding associations between CYP2C19*2, PON1 rs662 and ABCC3 rs757421 genotypes and platelet responsiveness or clopidogrel PK in subjects with coronary artery disease (CAD) or acute coronary syndrome (ACS), whereas ITGB3 contributes to aspirin PK but not platelet responsiveness in diabetic patients. Brazilian guidelines on anticoagulants and antiplatelets recommend the use of a platelet aggregation test or genotyping only in selected cases of ACS subjects without ST-segment elevation taking clopidogrel, and also suggest CYP2C9 and VKORC1 genotyping before starting warfarin therapy to assess the risk of bleeding episodes or warfarin resistance.
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Affiliation(s)
- Thiago Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Carolina Dagli-Hernandez
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Fabiana Dalla Vecchia Genvigir
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Volker Martin Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Solna, Sweden.,Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, 70376, Germany
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Solna, Sweden
| | - Mario Hiroyuki Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil
| | - Rosario Dominguez Crespo Hirata
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, Av. Prof. Lineu Prestes 580, Sao Paulo, 05508-000, Brazil.
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