1
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Lewis JP, Backman JD, Reny JL, Bergmeijer TO, Mitchell BD, Ritchie MD, Déry JP, Pakyz RE, Gong L, Ryan K, Kim EY, Aradi D, Fernandez-Cadenas I, Lee MTM, Whaley RM, Montaner J, Gensini GF, Cleator JH, Chang K, Holmvang L, Hochholzer W, Roden DM, Winter S, Altman RB, Alexopoulos D, Kim HS, Gawaz M, Bliden KP, Valgimigli M, Marcucci R, Campo G, Schaeffeler E, Dridi NP, Wen MS, Shin JG, Fontana P, Giusti B, Geisler T, Kubo M, Trenk D, Siller-Matula JM, Ten Berg JM, Gurbel PA, Schwab M, Klein TE, Shuldiner AR. Pharmacogenomic polygenic response score predicts ischaemic events and cardiovascular mortality in clopidogrel-treated patients. Eur Heart J Cardiovasc Pharmacother 2020; 6:203-210. [PMID: 31504375 DOI: 10.1093/ehjcvp/pvz045] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/15/2019] [Accepted: 08/29/2019] [Indexed: 01/23/2023]
Abstract
AIMS Clopidogrel is prescribed for the prevention of atherothrombotic events. While investigations have identified genetic determinants of inter-individual variability in on-treatment platelet inhibition (e.g. CYP2C19*2), evidence that these variants have clinical utility to predict major adverse cardiovascular events (CVEs) remains controversial. METHODS AND RESULTS We assessed the impact of 31 candidate gene polymorphisms on adenosine diphosphate (ADP)-stimulated platelet reactivity in 3391 clopidogrel-treated coronary artery disease patients of the International Clopidogrel Pharmacogenomics Consortium (ICPC). The influence of these polymorphisms on CVEs was tested in 2134 ICPC patients (N = 129 events) in whom clinical event data were available. Several variants were associated with on-treatment ADP-stimulated platelet reactivity (CYP2C19*2, P = 8.8 × 10-54; CES1 G143E, P = 1.3 × 10-16; CYP2C19*17, P = 9.5 × 10-10; CYP2B6 1294 + 53 C > T, P = 3.0 × 10-4; CYP2B6 516 G > T, P = 1.0 × 10-3; CYP2C9*2, P = 1.2 × 10-3; and CYP2C9*3, P = 1.5 × 10-3). While no individual variant was associated with CVEs, generation of a pharmacogenomic polygenic response score (PgxRS) revealed that patients who carried a greater number of alleles that associated with increased on-treatment platelet reactivity were more likely to experience CVEs (β = 0.17, SE 0.06, P = 0.01) and cardiovascular-related death (β = 0.43, SE 0.16, P = 0.007). Patients who carried eight or more risk alleles were significantly more likely to experience CVEs [odds ratio (OR) = 1.78, 95% confidence interval (CI) 1.14-2.76, P = 0.01] and cardiovascular death (OR = 4.39, 95% CI 1.35-14.27, P = 0.01) compared to patients who carried six or fewer of these alleles. CONCLUSION Several polymorphisms impact clopidogrel response and PgxRS is a predictor of cardiovascular outcomes. Additional investigations that identify novel determinants of clopidogrel response and validating polygenic models may facilitate future precision medicine strategies.
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Affiliation(s)
- Joshua P Lewis
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA
| | - Joshua D Backman
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA
| | - Jean-Luc Reny
- Department of Internal Medicine, Béziers Hospital, 2 Rue Valentin Hau, BP 740, Béziers 34525, France.,Department of Medicine, Geneva Platelet Group, University of Geneva School of Medicine, University Hospitals of Geneva, 24 rue du Général-Dufour, Genève 4 CH-1211, Switzerland
| | - Thomas O Bergmeijer
- Department of Cardiology, Antonius Center for Platelet Function Research, St Antonius Hospital, P O Box 2500, Nieuwegein 3432 EM, The Netherlands
| | - Braxton D Mitchell
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA.,Geriatrics Research and Education Clinical Center, Baltimore Veterans Administration Medical Center, 10 N. Greene St., Baltimore, MD 21201, USA
| | - Marylyn D Ritchie
- Center for Translational Bioinformatics, Institute for Biomedical Informatics, University of Pennsylvania, A301 Richards Building, 3700 Hamilton Walk, Philadelphia, PA 19104, USA
| | - Jean-Pierre Déry
- Quebec Heart and Lung Institute, University Laval, 2725 chemin Sainte-Foy, Quebec City G1V 4G5, Canada
| | - Ruth E Pakyz
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, 443 Via Ortega, Room 213, Stanford, CA 94305, USA
| | - Kathleen Ryan
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA
| | - Eun-Young Kim
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Bokji-ro 75, Busangjin-gu, Busan 614-735, South Korea
| | - Daniel Aradi
- Department of Cardiology, Heart Center Balatonfüred, 2 Gyogy Ter, Balatonfured 8230, Hungary
| | - Israel Fernandez-Cadenas
- Stroke Pharmacogenomics and Genetic Group, Fundació Docencia i Recerca Mutuaterrassa, 508221 Terrassa, Barcelona 8041, Spain.,Department of Neurology, Vall d'Hebron Institute of Research, Passeig Vall d'Hebron, Barcelona 8035, Spain
| | - Ming Ta Michael Lee
- Genomic Medicine Institute, Geisinger Health System, 100 N. Academy Ave., Danville, PA 17822, USA
| | - Ryan M Whaley
- Department of Biomedical Data Science, Stanford University, 443 Via Ortega, Room 213, Stanford, CA 94305, USA
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Passeig Vall d'Hebron 119-129, Barcelona 8035, Spain
| | - Gian Franco Gensini
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, Florence 50055, Italy
| | - John H Cleator
- Division of Cardiology, Vanderbilt University Medical Center, 2215B Garland Avenue, Nashville, TN 37232, USA.,Department of Pharmacology, Vanderbilt University Medical Center, 2215B Garland Avenue, Nashville, TN 37232, USA
| | - Kiyuk Chang
- Department of Internal Medicine, Cardiology Division, Seoul St. Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul 6591, South Korea
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7 - 2142, Copenhagen 2100, Denmark
| | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg, Suedring 15, Bad Krozingen 79189, Germany
| | - Dan M Roden
- Department of Pharmacology, Vanderbilt University Medical Center, 2215B Garland Avenue, Nashville, TN 37232, USA.,Department of Medicine, Vanderbilt University Medical Center, 2215B Garland Avenue, Nashville, TN 37232, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, 2215B Garland Avenue, Nashville, TN 37232, USA
| | - Stefan Winter
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, Stuttgart, 70376 Germany
| | - Russ B Altman
- Department of Bioengineering, Genetics, and Medicine, Stanford University, 443 Via Ortega Drive, Shriram Room 209, Stanford, CA 94305, USA
| | | | - Ho-Sook Kim
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Gaegum2-dong 622-165, Busanjin-Gu, Busan 614-735, South Korea
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, University of Tübingen, Otfired-Müller-Straße 10, Tübingen 72076, Germany
| | - Kevin P Bliden
- Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, 3300 Gallows Rd, Falls Church, VA 22042, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 8, Bern 3010, Switzerland
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, Florence 50055, Italy.,Atherothrombotic Diseases Center, Careggi University Hospital, Largo G. Alessandro Brambilla, Florence 50134, Italy
| | - Gianluca Campo
- Department of Cardiology, University Hospital of Ferrara, Via Aldo Moro 8, Cona (FE), Ferrara 44123, Italy.,GVM Care & Research, Maria Cecilia Hospital, Via Madonna di Genova, 1, Cotignola 48033, Italy
| | - Elke Schaeffeler
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, Stuttgart, 70376 Germany
| | - Nadia P Dridi
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Inge Lehmannsvej 7 - 2142, Copenhagen 2100, Denmark
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and School of Medicine, Chang Gung University, No. 5, Fuxing St, Guishan Dist., Taoyuan City 333, Taiwan
| | - Jae Gook Shin
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Gaegum2-dong 622-165, Busanjin-Gu, Busan 614-735, South Korea
| | - Pierre Fontana
- Department of Medicine, Geneva Platelet Group, University of Geneva School of Medicine, University Hospitals of Geneva, 24 rue du Général-Dufour, Genève 4 CH-1211, Switzerland.,Division of Angiology and Haemostasis, University Hospitals of Geneva, 24 Rue Gabrielle-Perret-Gentil, Geneva 1205, Switzerland
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, Florence 50055, Italy.,Atherothrombotic Diseases Center, Careggi University Hospital, Largo G. Alessandro Brambilla, Florence 50134, Italy
| | - Tobias Geisler
- Department of Cardiology and Angiology, University of Tübingen, Otfired-Müller-Straße 10, Tübingen 72076, Germany
| | - Michiaki Kubo
- Laboratory for Genotyping Development, RIKEN Center for Integrative Medical Sciences, 1-7-22, Suehiro-cho, Tsurumi, Yokohama 230-0045, Japan
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, Clinical Pharmacology, University Heart Centre Freiburg, Suedring 15, Bad Krozingen D-79189, Germany
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria
| | - Jurriën M Ten Berg
- Department of Cardiology, Antonius Center for Platelet Function Research, St Antonius Hospital, P O Box 2500, Nieuwegein 3432 EM, The Netherlands
| | - Paul A Gurbel
- Department of Cardiology and Angiology, University of Tübingen, Otfired-Müller-Straße 10, Tübingen 72076, Germany
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Auerbachstrasse 112, Stuttgart, 70376 Germany.,Department of Clinical Pharmacology, University of Tuebingen, Otfried-Mueller-Strasse 10, Tuebingen 72076, Germany.,Department of Pharmacy and Biochemistry, University of Tuebingen, Otfried-Mueller-Strasse 10, Tuebingen 72076, Germany
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, 443 Via Ortega, Room 213, Stanford, CA 94305, USA.,Department of Bioengineering, Genetics, and Medicine, Stanford University, 443 Via Ortega Drive, Shriram Room 209, Stanford, CA 94305, USA
| | - Alan R Shuldiner
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, 670 W. Baltimore St., Baltimore, MD 21201, USA
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2
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Verma SS, Bergmeijer TO, Gong L, Reny JL, Lewis JP, Mitchell BD, Alexopoulos D, Aradi D, Altman RB, Bliden K, Bradford Y, Campo G, Chang K, Cleator JH, Déry JP, Dridi NP, Fernandez-Cadenas I, Fontana P, Gawaz M, Geisler T, Gensini GF, Giusti B, Gurbel PA, Hochholzer W, Holmvang L, Kim EY, Kim HS, Marcucci R, Montaner J, Backman JD, Pakyz RE, Roden DM, Schaeffeler E, Schwab M, Shin JG, Siller-Matula JM, Ten Berg JM, Trenk D, Valgimigli M, Wallace J, Wen MS, Kubo M, Lee MTM, Whaley R, Winter S, Klein TE, Shuldiner AR, Ritchie MD. Genomewide Association Study of Platelet Reactivity and Cardiovascular Response in Patients Treated With Clopidogrel: A Study by the International Clopidogrel Pharmacogenomics Consortium. Clin Pharmacol Ther 2020; 108:1067-1077. [PMID: 32472697 PMCID: PMC7689744 DOI: 10.1002/cpt.1911] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/08/2020] [Indexed: 01/07/2023]
Abstract
Antiplatelet response to clopidogrel shows wide variation, and poor response is correlated with adverse clinical outcomes. CYP2C19 loss‐of‐function alleles play an important role in this response, but account for only a small proportion of variability in response to clopidogrel. An aim of the International Clopidogrel Pharmacogenomics Consortium (ICPC) is to identify other genetic determinants of clopidogrel pharmacodynamics and clinical response. A genomewide association study (GWAS) was performed using DNA from 2,750 European ancestry individuals, using adenosine diphosphate‐induced platelet reactivity and major cardiovascular and cerebrovascular events as outcome parameters. GWAS for platelet reactivity revealed a strong signal for CYP2C19*2 (P value = 1.67e−33). After correction for CYP2C19*2 no other single‐nucleotide polymorphism reached genomewide significance. GWAS for a combined clinical end point of cardiovascular death, myocardial infarction, or stroke (5.0% event rate), or a combined end point of cardiovascular death or myocardial infarction (4.7% event rate) showed no significant results, although in coronary artery disease, percutaneous coronary intervention, and acute coronary syndrome subgroups, mutations in SCOS5P1, CDC42BPA, and CTRAC1 showed genomewide significance (lowest P values: 1.07e−09, 4.53e−08, and 2.60e−10, respectively). CYP2C19*2 is the strongest genetic determinant of on‐clopidogrel platelet reactivity. We identified three novel associations in clinical outcome subgroups, suggestive for each of these outcomes.
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Affiliation(s)
- Shefali Setia Verma
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas O Bergmeijer
- Department of Cardiology, St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Jean-Luc Reny
- Internal Medicine, Béziers Hospital, Béziers, France.,Geneva Platelet Group, School of Medicine, University of Geneva, Geneva, Switzerland.,Department of Internal Medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva Platelet Group and Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Joshua P Lewis
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Braxton D Mitchell
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, Maryland, USA.,Geriatrics Research and Education Clinical Center, Baltimore Veterans Administration Medical Center, Baltimore, Maryland, USA
| | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Daniel Aradi
- Department of Cardiology, Heart Center Balatonfüred, Balatonfüred, Hungary
| | - Russ B Altman
- Department of Bioengineering, Genetics and Medicine, Stanford University, Stanford, California, USA
| | - Kevin Bliden
- Sinai Center for Thrombosis Research and Drug Development, Baltimore, Maryland, USA
| | - Yuki Bradford
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara and Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Kiyuk Chang
- Department of Internal Medicine, Cardiology Division, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - John H Cleator
- Division of Cardiology and Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean-Pierre Déry
- Quebec Heart and Lung Institute, University Laval, Quebec City, QC, Canada
| | - Nadia P Dridi
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Israel Fernandez-Cadenas
- Neurology, Stroke Pharmacogenomics and Genetics Group, Sant Pau Institute of Research, Barcelona, Spain
| | - Pierre Fontana
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA.,Geneva Platelet Group and Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, Medizinische Klinik III, University Hospital Tübingen, Tübingen, Germany
| | - Gian Franco Gensini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Baltimore, Maryland, USA
| | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eun-Young Kim
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Busan, South Korea
| | - Ho-Sook Kim
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Busan, South Korea
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Joshua D Backman
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Ruth E Pakyz
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Dan M Roden
- Medicine, Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tübingen, Tübingen, Germany.,Department of Clinical Pharmacology, and Pharmacy and Biochemistry, University of Tübingen, Tübingen, Germany
| | - Jae Gook Shin
- Department of Clinical Pharmacology, Inje University, Busan Paik Hospital, Busan, South Korea.,Department of Pharmacology and Pharmacogenomics Research Center, Inje University, Busan Paik Hospital, Busan, South Korea
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany.,Department of Clinical Pharmacology, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - John Wallace
- Department of Biochemistry and Molecular Biology, Penn State University, University Park, Pennsylvania, USA
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Michiaki Kubo
- Center for Integrative Medical Sciences, RIKEN, Yokohama, Japan
| | | | - Ryan Whaley
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Stefan Winter
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tübingen, Tübingen, Germany
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA
| | - Alan R Shuldiner
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Marylyn D Ritchie
- Department of Genetics and Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Bergmeijer TO, Reny JL, Pakyz RE, Gong L, Lewis JP, Kim EY, Aradi D, Fernandez-Cadenas I, Horenstein RB, Lee MTM, Whaley RM, Montaner J, Gensini GF, Cleator JH, Chang K, Holmvang L, Hochholzer W, Roden DM, Winter S, Altman RB, Alexopoulos D, Kim HS, Déry JP, Gawaz M, Bliden K, Valgimigli M, Marcucci R, Campo G, Schaeffeler E, Dridi NP, Wen MS, Shin JG, Simon T, Fontana P, Giusti B, Geisler T, Kubo M, Trenk D, Siller-Matula JM, Ten Berg JM, Gurbel PA, Hulot JS, Mitchell BD, Schwab M, Ritchie MD, Klein TE, Shuldiner AR. Genome-wide and candidate gene approaches of clopidogrel efficacy using pharmacodynamic and clinical end points-Rationale and design of the International Clopidogrel Pharmacogenomics Consortium (ICPC). Am Heart J 2018; 198:152-159. [PMID: 29653637 PMCID: PMC5903579 DOI: 10.1016/j.ahj.2017.12.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/10/2017] [Indexed: 02/07/2023]
Abstract
RATIONALE The P2Y12 receptor inhibitor clopidogrel is widely used in patients with acute coronary syndrome, percutaneous coronary intervention, or ischemic stroke. Platelet inhibition by clopidogrel shows wide interpatient variability, and high on-treatment platelet reactivity is a risk factor for atherothrombotic events, particularly in high-risk populations. CYP2C19 polymorphism plays an important role in this variability, but heritability estimates suggest that additional genetic variants remain unidentified. The aim of the International Clopidogrel Pharmacogenomics Consortium (ICPC) is to identify genetic determinants of clopidogrel pharmacodynamics and clinical response. STUDY DESIGN Based on the data published on www.clinicaltrials.gov, clopidogrel intervention studies containing genetic and platelet function data were identified for participation. Lead investigators were invited to share DNA samples, platelet function test results, patient characteristics, and cardiovascular outcomes to perform candidate gene and genome-wide studies. RESULTS In total, 17 study sites from 13 countries participate in the ICPC, contributing individual patient data from 8,829 patients. Available adenosine diphosphate-stimulated platelet function tests included vasodilator-stimulated phosphoprotein assay, light transmittance aggregometry, and the VerifyNow P2Y12 assay. A proof-of-principle analysis based on genotype data provided by each group showed a strong and consistent association between CYP2C19*2 and platelet reactivity (P value=5.1 × 10-40). CONCLUSION The ICPC aims to identify new loci influencing clopidogrel efficacy by using state-of-the-art genetic approaches in a large cohort of clopidogrel-treated patients to better understand the genetic basis of on-treatment response variability.
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Affiliation(s)
- Thomas O Bergmeijer
- St Antonius Center for Platelet Function Research, Department of Cardiology, St Antonius Hospital Nieuwegein, the Netherlands
| | - Jean-Luc Reny
- Internal Medicine, Béziers Hospital, France, Geneva Platelet Group, University of Geneva School of Medicine, Department of Internal Medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Ruth E Pakyz
- Department of Medicine, Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Joshua P Lewis
- Department of Medicine, Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eun-Young Kim
- Department of Clinical Pharmacology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Daniel Aradi
- Heart Center Balatonfüred and Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Israel Fernandez-Cadenas
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Neurovascular Research Laboratory, Valle d'Hebron Hebron Institute of Research, Barcelona, Spain
| | - Richard B Horenstein
- Department of Medicine, Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Ryan M Whaley
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Gian Franco Gensini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - John H Cleator
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Kiyuk Chang
- Cardiovascular Center and Cardiology Division, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Lene Holmvang
- Department of Cardiology and Cardiac Catheterization Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Willibald Hochholzer
- University Heart Center Freiburg, Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany
| | - Dan M Roden
- Departments of Medicine, Pharmacology, and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Stefan Winter
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart and University of Tübingen, Tübingen, Germany
| | - Russ B Altman
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA; Departments of Bioengineering and Genetics, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Ho-Sook Kim
- Department of Pharmacology and Pharmacogenomics Research Center, College of Medicine, Inje University, Busan, South Korea
| | | | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Kevin Bliden
- Inova Center for Thrombosis Research and Drug Development. Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Atherothrombotic Diseases Center, Careggi Hospital, Florence, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitria di Ferrara, Cona (FE) and Maria Cecilia Hospital, GVM Care and Research, Cotignola, (RA), Italy
| | - Elke Schaeffeler
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart and University of Tübingen, Tübingen, Germany
| | - Nadia P Dridi
- Department of Cardiology and Cardiac Catheterization Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Jae Gook Shin
- Department of Pharmacology and Pharmacogenomics Research Center, College of Medicine, Inje University, Busan, South Korea
| | | | - Pierre Fontana
- Geneva Platelet Group, University of Geneva School of Medicine, Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Atherothrombotic Diseases Center, Careggi Hospital, Florence, Italy
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Michiaki Kubo
- Laboratory for Genotyping Development, RIKEN Center for Integrative Medical Sciences, Tokyo, Japan
| | - Dietmar Trenk
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Tübingen, Germany
| | | | - Jurriën M Ten Berg
- St Antonius Center for Platelet Function Research, Department of Cardiology, St Antonius Hospital Nieuwegein, the Netherlands
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development. Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Jean-Sebastien Hulot
- Sorbonne Universités, UPMC Univ Paris 06, Institute of Cardiometabolism and Nutrition (ICAN), Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Braxton D Mitchell
- Department of Medicine, University of Maryland, Baltimore, MD, USA; Geriatric Research, Education and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart and University of Tübingen, Tübingen, Germany; Department of Clinical Pharmacology, University Hospital, Tübingen, Germany
| | - Marylyn DeRiggi Ritchie
- Department of Biomedical and Translational Informatics, Geisinger Health System, Danville, PA, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Alan R Shuldiner
- Department of Medicine, Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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4
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Cavallari LH, Lee CR, Beitelshees AL, Cooper-DeHoff RM, Duarte JD, Voora D, Kimmel SE, McDonough CW, Gong Y, Dave CV, Pratt VM, Alestock TD, Anderson RD, Alsip J, Ardati AK, Brott BC, Brown L, Chumnumwat S, Clare-Salzler MJ, Coons JC, Denny JC, Dillon C, Elsey AR, Hamadeh IS, Harada S, Hillegass WB, Hines L, Horenstein RB, Howell LA, Jeng LJB, Kelemen MD, Lee YM, Magvanjav O, Montasser M, Nelson DR, Nutescu EA, Nwaba DC, Pakyz RE, Palmer K, Peterson JF, Pollin TI, Quinn AH, Robinson SW, Schub J, Skaar TC, Smith DM, Sriramoju VB, Starostik P, Stys TP, Stevenson JM, Varunok N, Vesely MR, Wake DT, Weck KE, Weitzel KW, Wilke RA, Willig J, Zhao RY, Kreutz RP, Stouffer GA, Empey PE, Limdi NA, Shuldiner AR, Winterstein AG, Johnson JA. Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 11:181-191. [PMID: 29102571 DOI: 10.1016/j.jcin.2017.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI). BACKGROUND CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. METHODS After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. RESULTS Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). CONCLUSIONS These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Deepak Voora
- Department of Medicine, Center for Applied Genomics & Precision Medicine, Duke University, Durham, North Carolina
| | - Stephen E Kimmel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - R David Anderson
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Jorge Alsip
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amer K Ardati
- Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Brigitta C Brott
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lawrence Brown
- Veterans Administration Medical Center, Baltimore, Maryland
| | - Supatat Chumnumwat
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michael J Clare-Salzler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Shuko Harada
- Department of Pathology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William B Hillegass
- Heart South Cardiovascular Group, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Hines
- Department of Neuropsychology, University of North Dakota, Fargo, North Dakota
| | | | - Lucius A Howell
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda J B Jeng
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark D Kelemen
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Yee Ming Lee
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Oyunbileg Magvanjav
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - May Montasser
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - David R Nelson
- College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois; Department of Pharmacy Systems, Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Devon C Nwaba
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Ruth E Pakyz
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Kathleen Palmer
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni I Pollin
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Alison H Quinn
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Shawn W Robinson
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Jamie Schub
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Todd C Skaar
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Vindhya B Sriramoju
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Tomasz P Stys
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James M Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nicholas Varunok
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark R Vesely
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Russell A Wilke
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James Willig
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Y Zhao
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan R Shuldiner
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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5
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Luzum JA, Pakyz RE, Elsey AR, Haidar CE, Peterson JF, Whirl-Carrillo M, Handelman SK, Palmer K, Pulley JM, Beller M, Schildcrout JS, Field JR, Weitzel KW, Cooper-DeHoff RM, Cavallari LH, O’Donnell PH, Altman RB, Pereira N, Ratain MJ, Roden DM, Embi PJ, Sadee W, Klein TE, Johnson JA, Relling MV, Wang L, Weinshilboum RM, Shuldiner AR, Freimuth RR. The Pharmacogenomics Research Network Translational Pharmacogenetics Program: Outcomes and Metrics of Pharmacogenetic Implementations Across Diverse Healthcare Systems. Clin Pharmacol Ther 2017; 102:502-510. [PMID: 28090649 PMCID: PMC5511786 DOI: 10.1002/cpt.630] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/11/2017] [Indexed: 12/23/2022]
Abstract
Numerous pharmacogenetic clinical guidelines and recommendations have been published, but barriers have hindered the clinical implementation of pharmacogenetics. The Translational Pharmacogenetics Program (TPP) of the National Institutes of Health (NIH) Pharmacogenomics Research Network was established in 2011 to catalog and contribute to the development of pharmacogenetic implementations at eight US healthcare systems, with the goal to disseminate real-world solutions for the barriers to clinical pharmacogenetic implementation. The TPP collected and normalized pharmacogenetic implementation metrics through June 2015, including gene-drug pairs implemented, interpretations of alleles and diplotypes, numbers of tests performed and actionable results, and workflow diagrams. TPP participant institutions developed diverse solutions to overcome many barriers, but the use of Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines provided some consistency among the institutions. The TPP also collected some pharmacogenetic implementation outcomes (scientific, educational, financial, and informatics), which may inform healthcare systems seeking to implement their own pharmacogenetic testing programs.
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Affiliation(s)
- Jasmine A. Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
- Center for Pharmacogenomics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Ruth E. Pakyz
- Program for Personalized and Genomic Medicine, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Amanda R. Elsey
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Cyrine E. Haidar
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Josh F. Peterson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Samuel K. Handelman
- Center for Pharmacogenomics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Kathleen Palmer
- Program for Personalized and Genomic Medicine, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jill M. Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Marc Beller
- Office of Research Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jonathan S. Schildcrout
- Department of Statistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Julie R. Field
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kristin W. Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Rhonda M. Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Russ B. Altman
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Naveen Pereira
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Mark J. Ratain
- Center for Personalized Therapeutics, University of Chicago, Chicago, IL, USA
| | - Dan M. Roden
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter J. Embi
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Wolfgang Sadee
- Center for Pharmacogenomics, College of Medicine, Ohio State University, Columbus, OH, USA
- Department of Cancer Biology and Genetics, College of Medicine, Ohio State University, Columbus, OH, USA
| | - Teri E. Klein
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Liewei Wang
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Richard M. Weinshilboum
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Alan R. Shuldiner
- Program for Personalized and Genomic Medicine, School of Medicine, University of Maryland, Baltimore, MD, USA
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6
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Shuldiner AR, Palmer K, Pakyz RE, Alestock TD, Maloney KA, O'Neill C, Bhatty S, Schub J, Overby CL, Horenstein RB, Pollin TI, Kelemen MD, Beitelshees AL, Robinson SW, Blitzer MG, McArdle PF, Brown L, Jeng LJB, Zhao RY, Ambulos N, Vesely MR. Implementation of pharmacogenetics: the University of Maryland Personalized Anti-platelet Pharmacogenetics Program. Am J Med Genet C Semin Med Genet 2014; 166C:76-84. [PMID: 24616408 DOI: 10.1002/ajmg.c.31396] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite a substantial evidence base, implementation of pharmacogenetics into routine patient care has been slow due to a number of non-trivial practical barriers. We implemented a Personalized Anti-platelet Pharmacogenetics Program (PAP3) for cardiac catheterization patients at the University of Maryland Medical Center and the Baltimore Veterans Administration Medical Center Patients' are offered CYP2C19 genetic testing, which is performed in our Clinical Laboratory Improvement Amendment (CLIA)-certified Translational Genomics Laboratory. Results are returned within 5 hr along with clinical decision support that includes interpretation of results and prescribing recommendations for anti-platelet therapy based on the Clinical Pharmacogenetics Implementation Consortium guidelines. Now with a working template for PAP3, implementation of other drug-gene pairs is in process. Lessons learned as described in this article may prove useful to other medical centers as they implement pharmacogenetics into patient care, a critical step in the pathway to personalized and genomic medicine.
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7
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Shuldiner AR, Relling MV, Peterson JF, Hicks JK, Freimuth RR, Sadee W, Pereira NL, Roden DM, Johnson JA, Klein TE, Shuldiner AR, Vesely M, Robinson SW, Ambulos N, Stass SA, Kelemen MD, Brown LA, Pollin TI, Beitelshees AL, Zhao RY, Pakyz RE, Palmer K, Alestock T, O'Neill C, Maloney K, Branham A, Sewell D, Relling MV, Crews K, Hoffman J, Cross S, Haidar C, Baker D, Hicks JK, Bell G, Greeson F, Gaur A, Reiss U, Huettel A, Cheng C, Gajjar A, Pappo A, Howard S, Hudson M, Pui CH, Jeha S, Evans WE, Broeckel U, Altman RB, Gong L, Whirl-Carrillo M, Klein TE, Sadee W, Manickam K, Sweet KM, Embi PJ, Roden D, Peterson J, Denny J, Schildcrout J, Bowton E, Pulley J, Beller M, Mitchell J, Danciu I, Price L, Pereira NL, Weinshilboum R, Wang L, Johnson JA, Nelson D, Clare-Salzler M, Elsey A, Burkley B, Langaee T, Liu F, Nessl D, Dong HJ, Lesko L, Freimuth RR, Chute CG. The Pharmacogenomics Research Network Translational Pharmacogenetics Program: overcoming challenges of real-world implementation. Clin Pharmacol Ther 2013; 94:207-10. [PMID: 23588301 DOI: 10.1038/clpt.2013.59] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/14/2013] [Indexed: 11/09/2022]
Affiliation(s)
- A R Shuldiner
- Program in Personalized and Genomic Medicine and Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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8
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Gurbel PA, Shuldiner AR, Bliden KP, Ryan K, Pakyz RE, Tantry US. The relation between CYP2C19 genotype and phenotype in stented patients on maintenance dual antiplatelet therapy. Am Heart J 2011; 161:598-604. [PMID: 21392617 DOI: 10.1016/j.ahj.2010.12.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 12/06/2010] [Indexed: 11/19/2022]
Abstract
Both high platelet reactivity (HPR) and CYP2C19 genotyping have been proposed to stratify cardiovascular event risk and to personalize maintenance dual antiplatelet therapy (DAPT) in stented patients. However, how well CYP2C19 genotype correlates with HPR in patients on maintenance DAPT is less clear. We determined the association of CYP2C19 loss-of-function (*2) and gain-of-function (*17) allele status with platelet reactivity in 118 stented patients on DAPT ≥2 weeks and in 143 patients with stable coronary artery disease on aspirin therapy alone. Thirty-three percent and 39% carried at least 1 copy of *2 and *17 alleles, respectively. Neither allele was associated with platelet reactivity in patients on aspirin therapy alone. On DAPT, platelet aggregation was higher in those with *2 allele than noncarriers (P ≤ .01) but did not differ between those with the *17 allele and noncarriers. The prevalence of HPR using the 20 μM adenosine diphosphate-induced aggregation cutpoint was 34% in the total population: 26% in *1/*1 homozygotes, 49% in those with the *2 allele, and 20% in those with the *17 allele (P = .006). Determination of diplotype status enhanced identification of HPR. However, platelet function on DAPT is highly variable within diplotype groups. Therefore, CYP2C19 genotype and HPR are imperfect correlates of each other. Because both predict cardiovascular events with similar risk ratios, CYP2C19 genotyping and HPR may provide complementary information to stratify risk and personalized DAPT in stented patients than either alone.
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Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, MD 21215, USA.
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9
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Gurbel PA, Bliden KP, Antonino MJ, Stephens G, Gretler DD, Jurek MM, Pakyz RE, Shuldiner AR, Conley PB, Tantry US. The effect of elinogrel on high platelet reactivity during dual antiplatelet therapy and the relation to CYP2C19*2 genotype: first experience in patients. J Thromb Haemost 2010; 8:43-53. [PMID: 19817997 DOI: 10.1111/j.1538-7836.2009.03648.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
UNLABELLED To study the effect of a new direct acting reversible P2Y(12) inhibitor, elinogrel (PRT060128), and the relation to cytochrome P450 (CYP) polymorphisms in patients with high platelet reactivity (HPR) on standard dual antiplatelet therapy. METHODS AND RESULTS We studied the pharmacodynamic and pharmacokinetic effects of a single 60-mg oral dose of elinogrel in 20 of 45 previously stented stable patients with HPR. We also genotyped for CYP2C19*2,3,5,17 and CYP3A5*3. Platelet reactivity fell within 4 h of dosing, the earliest time point evaluated as measured by the following assays: maximum 5 and 10 microM ADP LTA (P < 0.001 for both vs. predosing); maximum 20 microM ADP LTA (P < 0.05); VerifyNow (P < 0.001); thrombelastography (P < 0.05); VASP phosphorylation (P < 0.01); and perfusion chamber assay (P < 0.05); this was reversible within 24 h in these same assays (P = ns vs. predosing for all assays). CYP2C19*2 was present in 44% of all patients but was more frequent in HPR patients (77% vs. 16%, P = 0.0004). CONCLUSIONS HPR is reversibly overcome by a single 60-mg oral dose of elinogrel, a drug now being investigated in a phase 2 trial. CYP2C19*2 was associated with HPR during conventional dual antiplatelet therapy.
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Affiliation(s)
- P A Gurbel
- Sinai Center for Thrombosis Research, Cardiac Catheterization Laboratory, Baltimore, MD 21215, USA.
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10
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Mitchell BD, McArdle PF, Shen H, Rampersaud E, Pollin TI, Bielak LF, Jaquish C, Douglas JA, Roy-Gagnon MH, Sack P, Naglieri R, Hines S, Horenstein RB, Chang YPC, Post W, Ryan KA, Brereton NH, Pakyz RE, Sorkin J, Damcott CM, O'Connell JR, Mangano C, Corretti M, Vogel R, Herzog W, Weir MR, Peyser PA, Shuldiner AR. The genetic response to short-term interventions affecting cardiovascular function: rationale and design of the Heredity and Phenotype Intervention (HAPI) Heart Study. Am Heart J 2008; 155:823-8. [PMID: 18440328 PMCID: PMC2443415 DOI: 10.1016/j.ahj.2008.01.019] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 01/08/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND The etiology of cardiovascular disease (CVD) is multifactorial. Efforts to identify genes influencing CVD risk have met with limited success to date, likely because of the small effect sizes of common CVD risk alleles and the presence of gene by gene and gene by environment interactions. METHODS The HAPI Heart Study was initiated in 2002 to measure the cardiovascular response to 4 short-term interventions affecting cardiovascular risk factors and to identify the genetic and environmental determinants of these responses. The measurements included blood pressure responses to the cold pressor stress test and to a high salt diet, triglyceride excursion in response to a high-fat challenge, and response in platelet aggregation to aspirin therapy. RESULTS The interventions were carried out in 868 relatively healthy Amish adults from large families. The heritabilities of selected response traits for each intervention ranged from 8% to 38%, suggesting that some of the variation associated with response to each intervention can be attributed to the additive effects of genes. CONCLUSIONS Identifying these response genes may identify new mechanisms influencing CVD and may lead to individualized preventive strategies and improved early detection of high-risk individuals.
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Affiliation(s)
- Braxton D Mitchell
- Division of Endocrinology, Department of Medicine, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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11
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Malik NS, Matlin SA, Fried J, Pakyz RE, Consentino MJ. The contraceptive effects of etoprine on male mice and rats. J Androl 1995; 16:169-74. [PMID: 7559148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We had previously found that 2,4-diaminopyrimidines affected spermatogenesis, possibly through the inhibition of testicular dihydrofolate reductase (DHFR). The current study examined the effects of etoprine, a highly lipophilic 2,4-diaminopyrimidine that is also a potent DHFR inhibitor, on the fertility of male mice at various dosages (0.1-50 mg/kg/day) for 55 days and male rats at 5 mg/kg/day for 65 days. Two other substituted diaminopyrimidines were tested at dosages of 50 mg/kg/day for 55 days. Results of breeding trials along with assessment of various parameters indicative of male fertility were noted. We found that of the compounds tested, etoprine is a potent antifertility agent that causes complete infertility at doses of > or = 5 mg/kg/day in mice with a threshold of effectiveness occurring between 1 and 5 mg/kg/day. The antifertility action of etoprine may be related to its capacity to inhibit testicular DHFR and its high degree of lipophilicity.
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Affiliation(s)
- N S Malik
- Department of Biology, Millersville University, Pennsylvania 17551, USA
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Heckman WR, Kane BR, Pakyz RE, Cosentino MJ. The effect of ketoconazole on endocrine and reproductive parameters in male mice and rats. J Androl 1992; 13:191-8. [PMID: 1601740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ketoconazole has been shown to reduce steroidogenesis by inhibiting the cytochrome P-450 enzymes in these pathways. This finding, along with the observation that the compound reduces sperm motility, led us to study the effectiveness of ketoconazole as a male contraceptive agent administered in acute and chronic studies of both rats and mice. Four hours after a single administration, male rats showed significant reductions in both serum testosterone and corticosterone levels that completely recovered (testosterone) or nearly recovered (corticosterone) 24 hours after administration. Chronic administration of ketoconazole to male rats and mice resulted in steroid levels comparable with those of control animals. Epididymal sperm motility was only slightly reduced in male mice 4 hours after administration of the drug. No effect on sperm motility was noted after chronic administration in either species studied. In vitro exposure of epididymal sperm to ketoconazole resulted in a significant reduction of sperm motility. Breeding trials after ketoconazole administration resulted in normal fertility and fecundity even at the highest dosage studied. The lack of correlation between steroid levels and sperm immobilization, along with rapid in vivo and in vitro effects on sperm motility, suggests that the reduction in sperm motility is not related to a decrease in steroid levels. From these data, the authors conclude that ketoconazole is probably not a viable approach to the development of a male contraceptive.
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Affiliation(s)
- W R Heckman
- Department of Biology, Millersville University, Pennsylvania 17551
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Heindel RM, Pakyz RE, Cosentino MJ. Spermatic cord torsion. Contralateral testicular degeneration at various ages in the rat. J Androl 1990; 11:506-13. [PMID: 2086577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Unilateral spermatic cord torsion causes damage to the contralateral testis in humans and animals models. It is now known, however, at what age an animal's reproductive capacity is most susceptible to this type of trauma. To determine if the animal's age is a factor in its susceptibility to reproductive damage, rats at 30 to 70 days of age were subjected to unilateral spermatic cord torsion. Rats of the same ages underwent sham surgery and served as controls. The animals were allowed to recover from the surgery and to attain puberty before a period of fertility testing. Fertility, serum testosterone, organ weight, and testicular histologic data were obtained after the breeding period. Our data indicate that animals undergoing torsion at the youngest (30 days) and oldest (70 days) ages exhibited no change in the parameters studied. Animals between the ages of 35 and 50 days are highly susceptible to reproductive damage due to unilateral spermatic cord torsion, and the 35-day-old animals exhibit the most susceptibility. The stages of testicular development occurring during this period are such that damage to one testicle will result in degeneration of both organs. However, once the animal is older than 50 days, its reproductive capacity is not affected by spermatic cord torsion. The specific period of susceptibility in the development of human testes is yet to be defined.
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Affiliation(s)
- R M Heindel
- Department of Biology, Millersville University, Pennsylvania 17551
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Pakyz RE, Heindel RM, Kallish M, Cosentino MJ. Spermatic cord torsion: effects of cyclosporine and prednisone on fertility and the contralateral testis in the rat. J Androl 1990; 11:401-8. [PMID: 2254174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Unilateral spermatic cord torsion results in contralateral degeneration and reduced fertility in the prepubertal male rat. This study was conducted to investigate the use of immunosuppression with cyclosporine and prednisone to prevent these untoward effects. Thirty-five-day-old male rats were subjected to 720 degrees unilateral spermatic cord torsion of 9 hours duration. At the time of detorsion, animals were given a subcutaneous injection of i) cyclosporine, ii) prednisone, or iii) cyclosporine combined with prednisone. Control groups included: i) animals undergoing orchiectomy of the ipsilateral testis following the torsion period, ii) hemicastration in the absence of torsion and iii) sham surgery. Orchiectomy at the end of the torsion period prevented the torsion induced reduction of fertility, contralateral seminiferous tubule diameter and testis weight. Treatment with cyclosporine combined with prednisone significantly increased these parameters above detorsion alone. These data indicate that short term immunosuppression with cyclosporine alone or in combination with prednisone limits the adverse effects of unilateral spermatic cord torsion as does removal of the damaged organ at the end of the torsion period.
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Affiliation(s)
- R E Pakyz
- Department of Biology, Millersville University, Millersville, Pennsylvania 17551
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Abstract
Unilateral spermatic cord torsion has been shown to cause damage to the contralateral testis in humans and animal models. In an attempt to explain conflicts among various laboratories concerning the extent of this contralateral effect and to determine the importance of the extent of torsion, prepubertal rats (35 to 40 days) were subjected to unilateral spermatic cord torsion of various degrees (zero to 1440 degrees). Sham surgeries were performed and served as controls (0 degrees of torsion). The animals were allowed to recover from the surgeries and to attain puberty before a period of fertility testing. Fertility, fecundity, organ weight and testicular histological data were obtained after the breeding period. Our data indicate that animals undergoing 360 degrees of torsion exhibited no changes in the parameters studied. However, if 720 degrees, 1080 degrees or 1440 degrees of torsion was induced, a significantly lower percentage of fertile males and pregnant females resulted for each of these experimental groups when compared to those values for the 0 degrees controls. These data indicate that the extent of contralateral testicular degeneration is dependent upon the degree of spermatic cord torsion to which the ipsilateral testis is subjected. The induction of unilateral spermatic cord torsion at 720 degrees or more causes a significant reduction of subsequent fertility while torsion of a lesser degree has little or no effect in the development of this phenomenon.
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Affiliation(s)
- R M Heindel
- Department of Biology, Millersville University, Pennsylvania 17551
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Abstract
With the human population of the world currently more than 5.2 billion and growing at an explosive rate, the need for additional forms of readily available contraception appears paramount. To date, contraception techniques in the male have been very limited. The present study demonstrates the ability of pyrimethamine (PYR) to cause spermatogenic arrest and male infertility in mice in a dose-dependent manner. Furthermore, upon cessation of drug administration all animals returned to normal fertility status. It is also suggested that the action of PYR is due to its antifolate action. Thus, PYR represents another approach toward development of a male contraceptive.
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Affiliation(s)
- M J Cosentino
- Department of Biology, Millersville University, PA 17551
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