1
|
Ton MD, Phuong DV, Tho PQ, Dung NT, Tuan TA, Thien NT. Management of ruptured aneurysmal subarachnoid hemorrhage with multiple basilar trunk aneurysms using a flow-diverter stent: A case report. Radiol Case Rep 2024; 19:2629-2632. [PMID: 38645949 PMCID: PMC11026529 DOI: 10.1016/j.radcr.2024.03.038] [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] [Received: 01/18/2024] [Revised: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Ruptured aneurysmal subarachnoid hemorrhage associated with multiple basilar trunk aneurysms represents a rare clinical condition. Endovascular intervention stands as the preferred therapeutic approach. We present the case of a 35-year-old patient with subarachnoid hemorrhage and three consecutive basilar trunk aneurysms. Utilizing a flow-diverter stent, we achieved simultaneous occlusion of all 3 aneurysms, performed 2 hours post dual antiplatelet therapy (comprising salicylic acid 300 mg and ticagrelor 180 mg). Sustained resistance to clopidogrel necessitated the subsequent 3 months, followed by single antiplatelet therapy. At the 1-month follow-up, the patient demonstrated a favorable clinical course, devoid of cerebral infarction, and evidenced unobstructed stent patency upon brain magnetic resonance imaging.
Collapse
Affiliation(s)
- Mai D. Ton
- Stroke Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
- Hanoi Medical University, No 1, Ton That Tung Street, Dong Da District, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy; 144 Xuan Thuy Street, Cau Giay District, Hanoi, Vietnam
| | - Dao V. Phuong
- Stroke Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
- Hanoi Medical University, No 1, Ton That Tung Street, Dong Da District, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy; 144 Xuan Thuy Street, Cau Giay District, Hanoi, Vietnam
| | - Pham Q. Tho
- Stroke Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
| | - Nguyen T. Dung
- Stroke Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
- Hanoi Medical University, No 1, Ton That Tung Street, Dong Da District, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy; 144 Xuan Thuy Street, Cau Giay District, Hanoi, Vietnam
| | - Tran A. Tuan
- Stroke Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy; 144 Xuan Thuy Street, Cau Giay District, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
| | - Nguyen T. Thien
- Radiology Center, Bach Mai Hospital, 78 Giai Phong Street, Dong Da District, Hanoi, Vietnam
| |
Collapse
|
2
|
Omidiran O, Patel A, Usman S, Mhatre I, Abdelhalim H, DeGroat W, Narayanan R, Singh K, Mendhe D, Ahmed Z. GWAS advancements to investigate disease associations and biological mechanisms. CLINICAL AND TRANSLATIONAL DISCOVERY 2024; 4:e296. [PMID: 38737752 PMCID: PMC11086745 DOI: 10.1002/ctd2.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
Genome-wide association studies (GWAS) have been instrumental in elucidating the genetic architecture of various traits and diseases. Despite the success of GWAS, inherent limitations such as identifying rare and ultra-rare variants, the potential for spurious associations, and in pinpointing causative agents can undermine diagnostic capabilities. This review provides an overview of GWAS and highlights recent advances in genetics that employ a range of methodologies, including Whole Genome Sequencing (WGS), Mendelian Randomization (MR), the Pangenome's high-quality T2T-CHM13 panel, and the Human BioMolecular Atlas Program (HuBMAP), as potential enablers of current and future GWAS research. State of the literature demonstrate the capabilities of these techniques in enhancing the statistical power of GWAS. WGS, with its comprehensive approach, captures the entire genome, surpassing the capabilities of the traditional GWAS technique focused on predefined Single Nucleotide Polymorphism (SNP) sites. The Pangenome's T2T-CHM13 panel, with its holistic approach, aids in the analysis of regions with high sequence identity, such as segmental duplications (SDs). Mendelian Randomization has advanced causative inference, improving clinical diagnostics and facilitating definitive conclusions. Furthermore, spatial biology techniques like HuBMAP, enable 3D molecular mapping of tissues at single-cell resolution, offering insights into pathology of complex traits. This study aims to elucidate and advocate for the increased application of these technologies, highlighting their potential to shape the future of GWAS research.
Collapse
Affiliation(s)
- Oluwaferanmi Omidiran
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Aashna Patel
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Sarah Usman
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Ishani Mhatre
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Habiba Abdelhalim
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - William DeGroat
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Rishabh Narayanan
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Kritika Singh
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Dinesh Mendhe
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
| | - Zeeshan Ahmed
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, USA
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, 125 Paterson St, New Brunswick, NJ, USA
| |
Collapse
|
3
|
Wu Y, Shen H, Cai B, Chen C, Yin Q, Zhao Y, Zhou G. Factors associated with clopidogrel resistance and clinical outcomes in ischemic cerebrovascular disease: A retrospective study. J Stroke Cerebrovasc Dis 2024; 33:107684. [PMID: 38518890 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107684] [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: 12/13/2023] [Revised: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVE Clopidogrel resistance may lead to the recurrence of cerebrovascular diseases. We aimed to identify potential factors associated with clopidogrel resistance and evaluate the clinical outcomes of the patients. MATERIALS AND METHODS In this retrospective study, patients with ischemic cerebrovascular disease treated with clopidogrel were included and classified into 2 groups according to the adenosine diphosphate (ADP)-induced platelet aggregation. Patients with the ADP inhibition rate of <30 % were included in clopidogrel resistance group, otherwise were included in clopidogrel sensitive group. CYP2C19 genotype and other clinical data were analyzed to identify factors and clinical features in the multivariate analysis. The outcomes were vascular events in 6 months. RESULTS In total, 139 patients were enrolled with 81 (58.27 %) in clopidogrel sensitive group and 58 (41.73 %) in clopidogrel resistance group. Female and CYP2C19 *2*3 carrying were risk factors for clopidogrel resistance, and female was an independent risk factor (OR 2.481, 95 % CI 1.066-5.771, P=0.035). The clopidogrel resistance group showed a higher use rate of argatroban (P=0.030) and a lower arachidonic acid-induced inhibition of platelet aggregation (P=0.036). Clopidogrel resistance was related to the progressing stroke (HR 3.521, 95 % CI 1.352-9.170, P=0.010), but had no influence on the bleeding events (P>0.05). CONCLUSIONS The risk of clopidogrel resistance increased significantly in female patients. Patients with clopidogrel resistance may have an increased incidence of stroke progression in the acute phase.
Collapse
Affiliation(s)
- Yanzi Wu
- Department of Clinical Pharmacy, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No 305 Zhongshan East Road, Xuanwu District, Nanjing 210002, China
| | - Huachao Shen
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Biyang Cai
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chen Chen
- Department of Clinical Pharmacy, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No 305 Zhongshan East Road, Xuanwu District, Nanjing 210002, China
| | - Qiong Yin
- Department of Clinical Pharmacy, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No 305 Zhongshan East Road, Xuanwu District, Nanjing 210002, China
| | - Yulei Zhao
- Department of Clinical Pharmacy, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No 305 Zhongshan East Road, Xuanwu District, Nanjing 210002, China
| | - Guohua Zhou
- Department of Clinical Pharmacy, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No 305 Zhongshan East Road, Xuanwu District, Nanjing 210002, China.
| |
Collapse
|
4
|
Fakhri YA, Al-Ani AW. Superoxide Dismutase and Clopidogrel: A Potential Role in Peripheral Arterial Disease Treatment. DOKL BIOCHEM BIOPHYS 2024; 516:83-92. [PMID: 38700818 DOI: 10.1134/s1607672924600088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/10/2024] [Accepted: 04/14/2024] [Indexed: 05/26/2024]
Abstract
Oxidative stress plays a crucial role in the pathogenesis of peripheral artery disease (PAD). This study aimed to investigate the effect of clopidogrel on oxidative stress in PAD patients. Seventy subjects were divided into three groups: PAD patients before treatment (B-PAD), PAD patients after treatment with clopidogrel (A-PAD), and healthy controls. Serum levels of superoxide dismutase (SOD), copper (Cu), zinc (Zn), manganese (Mn), and oxidized protein were measured. SOD activities were also determined. The results showed that SOD activities, and SOD specific activities were significantly decreased in PAD patients compared to healthy individuals. After treatment with clopidogrel, SOD activities, and SOD specific activities were continuously decrease in PAD patients. The SOD and oxidized protein concentrations were significantly increased in PAD patients compared to healthy individuals. After treatment with clopidogrel, the oxidized protein concentration was significantly decreased, while SOD concentration was significantly increased in PAD patients. These findings suggest that the treatment by clopidogrel stimulated the production of the enzyme but the ratio of active enzyme remained low. The decrease in oxidized protein can be explained by the treatment having antioxidant efficacy that may have compensated for the deficiency in enzyme activity and led to a decrease in oxidized protein. Additionally, the results of this study provide promising evidence that oxidative stress biomarkers including SOD concentration, T-SOD activity, Mn-SOD activity, and oxidized protein levels have potential utility in the diagnosis and management of PAD.
Collapse
Affiliation(s)
- Yasameen Ali Fakhri
- Department of Chemistry, College of Science, University of Baghdad, 10071, Baghdad, Iraq.
| | - Ali W Al-Ani
- Department of Chemistry, College of Science, University of Baghdad, 10071, Baghdad, Iraq
| |
Collapse
|
5
|
Kim JH, Lee SJ, Cha JJ, Park JH, Hong SJ, Ahn TH, Kim BK, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Jeong YH, Kim HS, Kim MH, Shin ES, Lim DS. Prognostic Impact of CYP2C19 Genotypes on Long-Term Clinical Outcomes in Older Patients After Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e032248. [PMID: 38761068 DOI: 10.1161/jaha.123.032248] [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: 01/03/2024] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Carriers of CYP2C19 loss-of-function alleles have increased adverse events after percutaneous coronary intervention, but limited data are available for older patients. We aimed to evaluate the prognostic impact of CYP2C19 genotypes on clinical outcomes in older patients after percutaneous coronary intervention. METHODS AND RESULTS The study included 1201 older patients (aged ≥75 years) who underwent percutaneous coronary intervention and received clopidogrel-based dual antiplatelet therapy in South Korea. Patients were grouped on the basis of CYP2C19 genotypes. The primary outcome was 3-year major adverse cardiac events, defined as a composite of cardiac death, myocardial infarction, and stent thrombosis. Older patients were grouped into 3 groups: normal metabolizer (36.6%), intermediate metabolizer (48.1%), and poor metabolizer (15.2%). The occurrence of the primary outcome was significantly different among the groups (3.1, 7.0, and 6.2% in the normal metabolizer, intermediate metabolizer, and poor metabolizer groups, respectively; P=0.02). The incidence rate of all-cause death at 3 years was greater in the intermediate metabolizer and poor metabolizer groups (8.1% and 9.2%, respectively) compared with that in the normal metabolizer group (3.5%, P=0.03) without significant differences in major bleeding. In the multivariable analysis, the intermediate metabolizer and poor metabolizer groups were independent predictors of 3-year clinical outcomes. CONCLUSIONS In older patients, the presence of any CYP2C19 loss-of-function allele was found to be predictive of a higher incidence of major adverse cardiac events within 3 years following percutaneous coronary intervention. This finding suggests a need for further investigation into an optimal antiplatelet strategy for older patients. REGISTRATION URL: https://clinicaltrials.gov. Identifier: NCT04734028.
Collapse
Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | | | - Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Tae Hoon Ahn
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | | | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine College of Medicine, Catholic University of Korea Seoul South Korea
| | - Yongwhi Park
- Department of Internal Medicine Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital Changwon South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Sung Gyun Ahn
- Department of Cardiology Yonsei University Wonju Severance Christian Hospital Wonju South Korea
| | - Jung-Won Suh
- Department of Cardiology, Department of Internal Medicine Seoul National University Bundang Hospital, Seoul National University College of Medicine Seoul South Korea
| | - Sang Yeub Lee
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital Hallym University College of Medicine Seoul South Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine Kangwon National University School of Medicine Chuncheon South Korea
| | - Young-Hoon Jeong
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Moo Hyun Kim
- Department of Cardiology Dong-A University Hospital Busan South Korea
| | - Eun-Seok Shin
- Division of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| |
Collapse
|
6
|
Teng JM, Qin S, Lu D, Gu Y, Tang SJ, Yan Q, Yao J, Zhang C. Evaluation of CYP2C19 Genetic Variant and Its Lack of Association with Valproic Acid Plasma Concentrations Among Zhuang and Han Schizophrenia Patients in Guangxi. Pharmgenomics Pers Med 2024; 17:225-236. [PMID: 38765788 PMCID: PMC11102100 DOI: 10.2147/pgpm.s457805] [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: 01/04/2024] [Accepted: 04/27/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose To investigate the CYP2C19 genotype distribution and allelic frequency among the Zhuang and Han schizophrenic populations in Guangxi, examine the correlation between CYP2C19 genetic variants and standardized blood levels of Valproic Acid (VPA) in schizophrenic patients, and evaluate the effects of age, gender, and Body Mass Index (BMI) on standardized VPA blood concentrations. Patients and Methods Between February and December 2022, 192 Zhuang and Han schizophrenia patients treated with VPA were studied. Steady-state VPA concentrations were determined using homogeneous enzyme immunoassays, and CYP2C19 *1, *2, and *3 loci via q-PCR. CYP2C19 genotype distributions between Zhuang and Han groups in Nanning were compared using chi-square tests and contrasted with other ethnicities. Non-parametric tests analyzed VPA variations, identifying critical factors through multivariate stepwise regression. Results The study identified five CYP2C19 genotypes at the *2 and *3 loci, with the *3/*3 genotype absent in both cohorts. The CYP2C19 distribution in Guangxi Zhuang and Han mirrors, yet diverges significantly from Hui and Kazakh groups. Among 192 subjects, VPA blood levels remained consistent across metabolic types and ages 18-60 but varied significantly by gender. Multivariate analysis revealed gender and BMI as significant factors, overshadowing CYP2C19 genotype and age. Conclusion In Guangxi, CYP2C19 genetic variants in Zhuang and Han schizophrenia patients demonstrate statistically indistinguishable allelic and metabolic distributions. Gender and BMI can influence standardized VPA blood concentrations in schizophrenia patients. However, in our study cohort, the CYP2C19 genotype and age are not the primary determinants of standardized VPA blood levels.
Collapse
Affiliation(s)
- Jun Mei Teng
- Laboratory Department, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Shuiqing Qin
- Department of Science and Education, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Danyu Lu
- Laboratory Department, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Yefa Gu
- Department of Psychiatry, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Shi Jie Tang
- Department of Psychiatry, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Qiong Yan
- Laboratory Department, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Jiawei Yao
- Laboratory Department, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| | - Chao Zhang
- Laboratory Department, The Fifth People’s Hospital of Nanning, Nanning, Guangxi Zhuang Autonomous Region, People’s Republic of China
| |
Collapse
|
7
|
Ganoci L, Palić J, Trkulja V, Starčević K, Šimičević L, Božina N, Lovrić-Benčić M, Poljaković Z, Božina T. Is CYP2C Haplotype Relevant for Efficacy and Bleeding Risk in Clopidogrel-Treated Patients? Genes (Basel) 2024; 15:607. [PMID: 38790236 PMCID: PMC11121599 DOI: 10.3390/genes15050607] [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: 04/14/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
A recently discovered haplotype-CYP2C:TG-determines the ultrarapid metabolism of several CYP2C19 substrates. The platelet inhibitor clopidogrel requires CYP2C19-mediated activation: the risk of ischemic events is increased in patients with a poor (PM) or intermediate (IM) CYP2C19 metabolizer phenotype (vs. normal, NM; rapid, RM; or ultrarapid, UM). We investigated whether the CYP2C:TG haplotype affected efficacy/bleeding risk in clopidogrel-treated patients. Adults (n = 283) treated with clopidogrel over 3-6 months were classified by CYP2C19 phenotype based on the CYP2C19*2*17 genotype, and based on the CYP2C19/CYP2C cluster genotype, and regarding carriage of the CYP2:TG haplotype, and were balanced on a number of covariates across the levels of phenotypes/haplotype carriage. Overall, 45 (15.9%) patients experienced ischemic events, and 49 (17.3%) experienced bleedings. By either classification, the incidence of ischemic events was similarly numerically higher in PM/IM patients (21.6%, 21.8%, respectively) than in mutually similar NM, RM, and UM patients (13.2-14.8%), whereas the incidence of bleeding events was numerically lower (13.1% vs. 16.6-20.5%). The incidence of ischemic events was similar in CYP2C:TG carries and non-carries (14.1% vs. 16.1%), whereas the incidence of bleedings appeared mildly lower in the former (14.9% vs. 20.1%). We observed no signal to suggest a major effect of the CYP2C19/CYP2C cluster genotype or CYP2C:TG haplotype on the clinical efficacy/safety of clopidogrel.
Collapse
Affiliation(s)
- Lana Ganoci
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (L.G.)
- Department of Pharmacology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (V.T.); (N.B.)
| | - Jozefina Palić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Vladimir Trkulja
- Department of Pharmacology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (V.T.); (N.B.)
| | - Katarina Starčević
- Department of Neurology, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (K.S.); (Z.P.)
| | - Livija Šimičević
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (L.G.)
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Nada Božina
- Department of Pharmacology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; (V.T.); (N.B.)
| | - Martina Lovrić-Benčić
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Zdravka Poljaković
- Department of Neurology, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (K.S.); (Z.P.)
- 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;
| |
Collapse
|
8
|
Birocchi S, Rocchetti M, Minardi A, Podda GM, Squizzato A, Cattaneo M. Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design. Thromb Haemost 2024; 124:482-496. [PMID: 37549688 DOI: 10.1055/a-2149-4344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled trials (RCTs) with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided therapy. Some meta-analysis also included RCTs that did not explore GT, but included the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed three distinct systematic reviews/meta-analyses, each exploring only RCTs with homogeneous design. METHODS MEDLINE, Embase, and Central databases were searched for RCTs testing genotype-GT, PFT-GT, or HTPR-Therapy in PCI-treated patients, through October 1, 2022. Two reviewers extracted the data. Risk ratios (RRs) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MBs) and major adverse cardiovascular events (MACE). RESULTS In seven genotype-GT RCTs, RRs were: MB, 1.06 (0.73-1.54; p = 0.76); MACE, 0.65 (0.47-0.91; p = 0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; p < 0.0001) and not elsewhere (0.75, 0.48-1.18; p = 0.21). In six PFT-GT RCTs, RRs were: MB, 0.91 (0.64-1.28, p = 0.58); MACE, 0.82 (0.56-1.19; p = 0.30): 0.62 (0.42-0.93; p = 0.02) in China, 1.08 (0.82-1.41; p = 0.53) elsewhere. In eight HTPR-Therapy RCTs, RRs were: MB, 0.71 (0.41-1.23; p = 0.22); MACE, 0.57 (0.44-0.75; p < 0.0001): 0.56 (0.43-0.74, p < 0.0001) in China, 0.58 (0.27-1.23, p = 0.16) elsewhere. CONCLUSION No GT strategy affected MB. Overall, genotype-GT but not PFT-GT reduced MACE. However, genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT performed poorly compared to HTPR-Therapy, likely due to inaccurate identification of HTPR patients by PFT.
Collapse
Affiliation(s)
- Simone Birocchi
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Matteo Rocchetti
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Minardi
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Gian Marco Podda
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Marco Cattaneo
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| |
Collapse
|
9
|
Govaere O, Cockell SJ, Zatorska M, Wonders K, Tiniakos D, Frey AM, Palmowksi P, Walker R, Porter A, Trost M, Anstee QM, Daly AK. Pharmacogene expression during progression of metabolic dysfunction-associated steatotic liver disease: Studies on mRNA and protein levels and their relevance to drug treatment. Biochem Pharmacol 2024:116249. [PMID: 38697308 DOI: 10.1016/j.bcp.2024.116249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/04/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) is common worldwide. Genes and proteins contributing to drug disposition may show altered expression as MASLD progresses. To assess this further, we undertook transcriptomic and proteomic analysis of 137 pharmacogenes in liver biopsies from a large MASLD cohort. We performed sequencing on RNA from 216 liver biopsies (206 MASLD and 10 controls). Untargeted mass spectrometry proteomics was performed on a 103 biopsy subgroup. Selected RNA sequencing signals were replicated with an additional 187 biopsies. Comparison of advanced MASLD (fibrosis score 3/4) with milder disease (fibrosis score 0-2) by RNA sequencing showed significant alterations in expression of certain phase I, phase II and ABC transporters. For cytochromes P450, CYP2C19 showed the most significant decreased expression (30 % of that in mild disease) but significant decreased expression of other CYPs (including CYP2C8 and CYP2E1) also occurred. CYP2C19 also showed a significant decrease comparing the inflammatory form of MASLD (MASH) with non-MASH biopsies. Findings for CYP2C19 were confirmed in the replication cohort. Proteomics on the original discovery cohort confirmed decreased levels of several CYPs as MASLD advanced but this decrease was greatest for CYP2C19 where levels fell to 40 % control. This decrease may result in decreased CYP2C19 activity that could be problematic for prescription of drugs activated or metabolized by CYP2C19 as MASLD advances. More limited decreases for other P450s suggest fewer issues with non-CYP2C19 drug substrates. Negative correlations at RNA level between CYP2C19 and several cytokine genes provided initial insights into the mechanism underlying decreased expression.
Collapse
Affiliation(s)
- Olivier Govaere
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Department of Imaging and Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Simon J Cockell
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Michalina Zatorska
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Kristy Wonders
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Dina Tiniakos
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Department of Pathology, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andrew M Frey
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Pawel Palmowksi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Ruth Walker
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Andrew Porter
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Matthias Trost
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Ann K Daly
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
10
|
Peng P, Xiao Y, Peng X, Chen J, Chen N. Genetic variability in stroke patients: CYP2C19 polymorphisms unraveled. BMC Med Genomics 2024; 17:109. [PMID: 38671468 PMCID: PMC11055221 DOI: 10.1186/s12920-024-01886-8] [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: 08/05/2023] [Accepted: 04/22/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVE To study the distribution characteristics of CYP2C19 polymorphisms in patients suffering from stroke in Han Chinese patients. METHOD PCR and DNA microarray chip technology were used to detect the CYP2C19 genotype of 549 patients with stroke, and the genotype, allele frequency and metabolic type of patients with different sexes, ages and types of infarctions and the independent risk factors for clopidogrel resistance were analyzed. RESULTS Six genotypes were detected in these 549 patients. A total of 233 (42.44%) patients had the heterozygous allele *1/*2, which was the most prevalent, followed by the homozygous wild-type allele *1/*1 (191, 34.79%). A total of 30 (5.46%) patients possessed the heterozygous allele *1/*3, and 65 (11.84%) patients had the homozygous mutant allele *2/*2. Twenty-nine (5.28%) patients had the compound heterozygous mutant allele *2/*3, and only 1 patient had the homozygous mutant allele *3/*3. The distribution of genotypes, alleles, and metabolic types did not change significantly (P > 0.05) by sex, age, or type of stroke. In addition, no independent risk factors for clopidogrel resistance were found in this analysis. CONCLUSION The distribution of CYP2C19 genotypes, allele frequencies, and metabolic types in patients with stroke in Han Chinese patients were not correlated with sex, age, or infarction type. The possibilities of hyperglycemia, hypercholesterolemia, hypertriglyceridemia, hypo-HDL-cholesterolemia, hyper-LDL-cholesterolemia and high blood pressure were not statistically associated with CYP2C19 genotypes. CYP2C19 gene polymorphism detection is recommended for patients who are available, and during treatment, the CYP2C19 genotype can be used to guide personalized precise medication use in patients with stroke.
Collapse
Affiliation(s)
- Peiyi Peng
- Shantou University Medical College, Shantou, Guangdong, China
| | - Yingxiu Xiao
- Department of Neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xuehong Peng
- Department of Thoracic Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jianqiang Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Nuan Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China.
| |
Collapse
|
11
|
Ike JI, Smith IT, Mosley D, Madden C, Grossarth S, Halle BR, Lewis A, Mentch F, Hakonarson H, Bastarache L, Wheless L. Voriconazole Metabolism is Associated with the Number of Skin Cancers Per Patient. RESEARCH SQUARE 2024:rs.3.rs-4152279. [PMID: 38699337 PMCID: PMC11065087 DOI: 10.21203/rs.3.rs-4152279/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Voriconazole exposure is associated with skin cancer, but it is unknown how the full spectrum of its metabolizer phenotypes impacts this association. We conducted a retrospective cohort study to determine how variation in metabolism of voriconazole as measured by metabolizer status of CYP2C19 is associated with the total number of skin cancers a patient develops and the rate of development of the first skin cancer after treatment. There were 1,739 organ transplant recipients with data on CYP2C19 phenotype. Of these, 134 were exposed to voriconazole. There was a significant difference in the number of skin cancers after transplant based on exposure to voriconazole, metabolizer phenotype, and the interaction of these two (p < 0.01 for all three). This increase was driven primarily by number of squamous cell carcinomas among rapid metabolizes with voriconazole exposure (p < 0.01 for both). Patients exposed to voriconazole developed skin cancers more rapidly than those without exposure (Fine-Grey hazard ratio 1.78, 95% confidence interval 1.19-2.66). This association was similarly driven by development of SCC (Fine-Grey hazard ratio 1.83, 95% confidence interval 1.14-2.94). Differences in voriconazoles metabolism are associated with an increase in the number of skin cancers developed after transplant, particularly SCC.
Collapse
Affiliation(s)
| | | | | | | | - Sarah Grossarth
- Quillen College of Medicine, East Tennessee State University
| | - Briana R Halle
- University of California, Irvine, Department of Dermatology
| | - Adam Lewis
- Vanderbilt University Medical Center, Department of Biomedical Informatics
| | - Frank Mentch
- Children's Hospital of Philadelphia Center for Applied Genomics
| | | | - Lisa Bastarache
- Vanderbilt University Medical Center, Department of Biomedical Informatics
| | - Lee Wheless
- Tennessee Valley Healthcare System VA Medical Center
| |
Collapse
|
12
|
Thomas CD, Franchi F, Rossi JS, Keeley EC, Anderson RD, Beitelshees AL, Duarte JD, Ortega-Paz L, Gong Y, Kerensky RA, Kulick N, McDonough CW, Nguyen AB, Wang Y, Winget M, Yang WE, Johnson JA, Winterstein AG, Stouffer GA, Angiolillo DJ, Lee CR, Cavallari LH. Effectiveness of Clopidogrel vs Alternative P2Y 12 Inhibitors Based on the ABCD-GENE Score. J Am Coll Cardiol 2024; 83:1370-1381. [PMID: 38599713 PMCID: PMC11074948 DOI: 10.1016/j.jacc.2024.02.015] [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: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND An ABCD-GENE (age, body mass index, chronic kidney disease, diabetes, and CYP2C19 genetic variants) score ≥10 predicts reduced clopidogrel effectiveness, but its association with response to alternative therapy remains unclear. OBJECTIVES The aim of this study was to evaluate the association between ABCD-GENE score and the effectiveness of clopidogrel vs alternative P2Y12 inhibitor (prasugrel or ticagrelor) therapy after percutaneous coronary intervention (PCI). METHODS A total of 4,335 patients who underwent PCI, CYP2C19 genotyping, and P2Y12 inhibitor treatment were included. The primary outcome was major atherothrombotic events (MAE) within 1 year after PCI. Cox regression was performed to assess event risk in clopidogrel-treated (reference) vs alternatively treated patients, with stabilized inverse probability weights derived from exposure propensity scores after stratifying by ABCD-GENE score and further by CYP2C19 loss-of-function (LOF) genotype. RESULTS Among patients with scores <10 (n = 3,200), MAE was not different with alternative therapy vs clopidogrel (weighted HR: 0.89; 95% CI: 0.65-1.22; P = 0.475). The risk for MAE also did not significantly differ by treatment among patients with scores ≥10 (n = 1,135; weighted HR: 0.75; 95% CI: 0.51-1.11; P = 0.155). Among CYP2C19 LOF allele carriers, MAE risk appeared lower with alternative therapy in both the group with scores <10 (weighted HR: 0.50; 95% CI: 0.25-1.01; P = 0.052) and the group with scores ≥10 (weighted HR: 0.48; 95% CI: 0.29-0.80; P = 0.004), while there was no difference in the group with scores <10 and no LOF alleles (weighted HR: 1.03; 95% CI: 0.70-1.51; P = 0.885). CONCLUSIONS These data support the use of alternative therapy over clopidogrel in CYP2C19 LOF allele carriers after PCI, regardless of ABCD-GENE score, while clopidogrel is as effective as alternative therapy in non-LOF patients with scores <10.
Collapse
Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - R David Anderson
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Richard A Kerensky
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Natasha Kulick
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Anh B Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yehua Wang
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Marshall Winget
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William E Yang
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA; Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.
| |
Collapse
|
13
|
Biswas M, Hossain MS, Ahmed Rupok T, Hossain MS, Sukasem C. The association of CYP2C19 LoF alleles with adverse clinical outcomes in stroke patients taking clopidogrel: An updated meta-analysis. Clin Transl Sci 2024; 17:e13792. [PMID: 38581109 PMCID: PMC10997845 DOI: 10.1111/cts.13792] [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: 12/07/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 04/08/2024] Open
Abstract
The aggregated risk of recurrent stroke in stroke/transient ischemic attack (TIA) patients carrying CYP2C19 LoF alleles who take clopidogrel has not been investigated recently, and the available research is limited. This study aimed to perform an updated meta-analysis to assess the association between CYP2C19 LoF alleles and the risk of recurrent stroke in patients taking clopidogrel. Databases were searched for the literature on eligible studies. The end points were recurrent stroke, composite vascular events, and bleeding events. Odds ratios (ORs) were calculated using RevMan software, where p < 0.05 was considered statistically significant. Patients carrying CYP2C19 LoF alleles who were treated with clopidogrel had a significantly increased risk of recurrent ischemic stroke compared with non-carriers (OR 2.18, 96% CI 1.80-2.63; p < 0.00001). The risk of recurrent stroke was only significantly different in Asian patients (OR 2.29, 96% CI 1.88-2.80; p < 0.00001) but not in patients of other ethnicities; however, there were a limited number of studies in other ethnic groups. Both observational studies (OR 2.83, 96% CI 2.20-3.65; p < 0.00001) and RCTs (OR 1.48, 96% CI 1.10-1.98; p = 0.009) found associations with a significantly increased risk of recurrent ischemic stroke. Asian stroke patients or TIA patients carrying CYP2C19 LoF alleles and taking clopidogrel were at a significantly higher risk of recurrent ischemic stroke than non-carriers. Significantly increased risk of recurrent ischemic stroke was found in both observational studies and RCTs.
Collapse
Affiliation(s)
- Mohitosh Biswas
- Department of PharmacyUniversity of RajshahiRajshahiBangladesh
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | | | | | | | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
- Pharmacogenomics and Precision Medicine, The Preventive Genomics & Family Check‐up Services Center, Bumrungrad International HospitalBangkokThailand
- Faculty of Pharmaceutical SciencesBurapha UniversitySaensuk, MueangChonburiThailand
| |
Collapse
|
14
|
Alkhatib O, Miles T, Jones RP, Mair R, Palmer R, Winter H, McDermott FD. Current and future genomic applications for surgeons. Ann R Coll Surg Engl 2024; 106:321-328. [PMID: 38555869 PMCID: PMC10981988 DOI: 10.1308/rcsann.2024.0031] [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] [Accepted: 03/04/2024] [Indexed: 04/02/2024] Open
Abstract
Genomics is a crucial part of managing surgical disease. This review focuses on some of the genomic advances that are available now and looks to the future of their application in surgical practice. Whole-genome sequencing enables unbiased coverage across the entire human genome of approximately three billion base pairs. Newer technologies, such as those that permit long-read sequence analysis, provide additional information in longer phased fragment and base pair epigenomic (methylomic) data. Whole-genome sequencing is currently available in England for cancers in children, teenagers and young adults, central nervous system tumours, sarcoma and haematological malignancies. Circulating tumour DNA (ctDNA), immunotherapy and pharmacogenomics have emerged as groundbreaking approaches in the field of cancer treatment. These are now revolutionising the way oncologists and surgeons approach curative cancer surgery. Cancer vaccines offer an innovative approach to reducing recurrence after surgery by priming the immune system to trigger an immune response. The Cancer Vaccine Launch Pad project facilitates cancer vaccine studies in England. The BNT122-01 trial is recruiting patients with ctDNA-positive high-risk colorectal cancer after surgery to assess the impact of cancer vaccines. The evolving landscape of cancer treatment demands a dynamic and integrated approach from the surgical multidisciplinary team. Immunotherapy, ctDNA, pharmacogenomics, vaccines, mainstreaming and whole-genome sequencing are just some of the innovations that have the potential to redefine the standards of care. The continued exploration of these innovative diagnostics and therapies, the genomic pathway evolution and their application in diverse cancer types highlights the transformative impact of precision medicine in surgery.
Collapse
Affiliation(s)
- O Alkhatib
- Liverpool University Teaching Hospitals NHS Foundation Trust, UK
| | - T Miles
- Southwest Genomics Medicine Service Alliance, UK
| | | | | | | | - H Winter
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | | |
Collapse
|
15
|
Bedair KF, Smith B, Palmer CNA, Doney ASF, Pearson ER. Pharmacogenetics at scale in real-world bioresources: CYP2C19 and clopidogrel outcomes in UK Biobank. Pharmacogenet Genomics 2024; 34:73-82. [PMID: 38179710 DOI: 10.1097/fpc.0000000000000519] [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: 01/06/2024]
Abstract
OBJECTIVE The impact of CYP2C19 genotype on clopidogrel outcomes is one of the most well established pharmacogenetic interactions, supported by robust evidence and recommended by the Food and Drug Administration and clinical pharmacogenetics implementation consortium. However, there is a scarcity of large-scale real-world data on the extent of this pharmacogenetic effect, and clinical testing for the CYP2C19 genotype remains infrequent. This study utilizes the UK Biobank dataset, including 10 365 patients treated with clopidogrel, to offer the largest observational analysis of these pharmacogenetic effects to date. METHODS Incorporating time-varying drug exposure and repeated clinical outcome, we adopted semiparametric frailty models to detect and quantify exposure-based effects of CYP2C19 (*2,*17) variants and nongenetic factors on the incidence risks of composite outcomes of death or recurrent hospitalizations due to major adverse cardiovascular events (MACE) or hemorrhage in the entire cohort of clopidogrel-treated patients. RESULTS Out of the 10 365 clopidogrel-treated patients, 40% (4115) experienced 10 625 MACE events during an average follow-up of 9.23 years. Individuals who received clopidogrel (coverage >25%) with a CYP2C19*2 loss-of-function allele had a 9.4% higher incidence of MACE [incidence rate ratios (IRR), 1.094; 1.044-1.146], but a 15% lower incidence of hemorrhage (IRR, 0.849; 0.712-0.996). These effects were stronger with high clopidogrel exposure. Conversely, the gain-of-function CYP2C19*17 variant was associated with a 5.3% lower incidence of MACE (IRR, 0.947; 0.903-0.983). Notably, there was no evidence of *2 or *17 effects when clopidogrel exposure was low, confirming the presence of a drug-gene interaction. CONCLUSION The impact of CYP2C19 on clinical outcomes in clopidogrel-treated patients is substantial, highlighting the importance of incorporating genotype-based prescribing into clinical practice, regardless of the reason for clopidogrel use or the duration of treatment. Moreover, the methodology introduced in this study can be applied to further real-world investigations of known drug-gene and drug-drug interactions and the discovery of novel interactions.
Collapse
Affiliation(s)
- Khaled F Bedair
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
- Department of Statistics & Mathematics, Tanta University, Tanta, Egypt
| | - Blair Smith
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Colin N A Palmer
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Alex S F Doney
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan R Pearson
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| |
Collapse
|
16
|
Zhang Y, Ran Q, Yin K, Wang Y, Liu J, Zong Y, Wang Y, Cao Y. The effects of CYP2C19 genotype polymorphism and clopidogrel resistance on ischemic event occurrence in patients with peripheral arterial disease undergoing revascularization: A prospective cohort study. Thromb Res 2024; 236:37-50. [PMID: 38387302 DOI: 10.1016/j.thromres.2024.02.010] [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: 10/23/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Peripheral arterial disease (PAD) affects approximately 236 million people worldwide. Therefore, this study aimed to investigate the relationship between CYP2C19 genotype polymorphisms and clopidogrel resistance (CR) following revascularization in patients with PAD. MATERIALS AND METHODS In total, 345 patients who underwent PAD revascularization were monitored for five years and risk factors for ischemic events were identified. Platelet reactivity and CYP2C19 genotypes were measured, and patients were classified as normal, intermediate, or poor metabolizers based on their genotypes. The study endpoint was defined as an ischemic event, that encompassed major adverse cardiovascular or limb events, or all-cause death. RESULTS In this study, ischemic events following PAD revascularization were associated with patient age, prior minor amputation, the Rutherford category before revascularization, indications for revascularization, index ankle-branchial index before revascularization, CYP2C19 phenotypes, and CR. Intermediate and poor metabolism, the Rutherford category before revascularization, and CR were independent risk factors for ischemic events in patients after PAD revascularization. Similarly, intermediate and poor metabolism, the Rutherford category before revascularization, and CR were independent risk factors for ischemic events in patients with PAD after revascularization within five years. Intermediate and poor metabolizers had a higher platelet reactivity and risk of CR than normal metabolizers. However, poor metabolizers had a higher platelet reactivity and risk of CR than intermediate metabolizers. Furthermore, the hazard ratio for ischemic events increased with platelet reactivity. This effect was more prevalent in intermediate and poor metabolizers than in normal metabolizers. CONCLUSIONS Ischemic events in patients after PAD revascularization were affected by independent risk factors. Decreased clopidogrel metabolism increased the platelet reactivity and CR in patients after PAD revascularization. Furthermore, high platelet reactivity was associated with an increased risk of ischemic events in patients with intermediate and poor metabolism.
Collapse
Affiliation(s)
- Yongkang Zhang
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qingzhi Ran
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kangli Yin
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yinkai Wang
- Rehabilitation Treatment Center, The First Rehabilitation Hospital of Shanghai, Shanghai, China
| | - Jiarui Liu
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuan Zong
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuzhen Wang
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yemin Cao
- Diagnosis and Treatment Center of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| |
Collapse
|
17
|
Gurbel PA, Bliden K, Sherwood M, Taheri H, Tehrani B, Akbari M, Yazdani S, Asgar JA, Chaudhary R, Tantry US. Development of a routine bedside CYP2C19 genotype assessment program for antiplatelet therapy guidance in a community hospital catheterization laboratory. J Thromb Thrombolysis 2024; 57:566-575. [PMID: 38480590 PMCID: PMC11031274 DOI: 10.1007/s11239-024-02953-8] [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] [Accepted: 01/19/2024] [Indexed: 04/19/2024]
Abstract
Genotype based personalized antiplatelet therapy in the setting of percutaneous coronary intervention (PCI) has been studied in clinical trials. Despite the demonstrated risk associated with CYP2C19 loss-of-function (LoF) carriage in clopidogrel-treated PCI patients, real-world implementation of genotyping for PCI has been low. The goal of the current study was to provide CYP2C19 genotype information to the interventionalist prior to the completion of the catheterization to facilitate immediate personalized antiplatelet therapy. Routine personalization of P2Y12 inhibitor therapy for PCI in a community hospital cardiac catheterization laboratory by POC genotyping with the SpartanRx system was first offered in February 2017. A best practice advisory (BPA) based on the Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 genotype and clopidogrel therapy was placed in the electronic health record prescription medication ordering system. By December 2019, 1,052 patients had CYP2C19 genotype testing, 429 patients underwent PCI with genotype guided antiplatelet therapy, and 250 patients underwent PCI without genotype testing and received antiplatelet therapy at the discretion of the treating physician. BPA compliance was 93. 87% of LoF allele carriers were prescribed ticagrelor or prasugrel whereas 96% of non-LoF allele carriers were prescribed clopidogrel. The genotyping results were available within 1 h and made immediately available for decision making by the interventional cardiologist. POC CYP2C19 genotyping is feasible in a community hospital catheterization laboratory and is associated with high rate of best practice compliance.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03040622.
Collapse
Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA.
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA.
| | - Kevin Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Matthew Sherwood
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Hamid Taheri
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Behnam Tehrani
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Marjaneh Akbari
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Shahram Yazdani
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Juzer Ali Asgar
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA
| | - Rahul Chaudhary
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Artificial Intelligence for Holistic Evaluation and Advancement of Cardiovascular Thrombosis (AI-HEART) Lab, Pittsburgh, PA, USA
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| |
Collapse
|
18
|
Gui J, Zhu Y, Chen X, Gong T, Zhang Z, Yu R, Fu Y. Systemic platelet inhibition with localized chemotherapy by an injectable ROS-scavenging gel against postsurgical breast cancer recurrence and metastasis. Acta Biomater 2024; 177:388-399. [PMID: 38307476 DOI: 10.1016/j.actbio.2024.01.037] [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: 11/24/2023] [Revised: 01/13/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Early solid tumors benefit from surgical resection, but residual stubborn microtumors, pro-inflammatory microenvironment and activated platelets at the postoperative wound site are prone to recurrence and metastasis, resulting in poor prognosis. Here, we developed a dual-pronged strategy consisting of (i) in-situ forming ROS-scavenging gels loaded with anticancer drugs at the postoperative wound site to improve the tumor microenvironment and inhibit the recurrence of residual microtumors after orthotopic surgery, and (ii) systemic administration of clopidegrol via albumin nanoparticles for inhibiting activated platelets in the circulation thus inhibiting tumor remote migration. In a mouse model of postoperative recurrence and metastasis of orthotopic 4T1 breast cancer, the dual-pronged strategy greatly inhibited postoperative orthotopic tumor recurrence and reduced lung metastasis. This work provides an effective strategy for the postoperative intervention and treatment of solid tumors to inhibit postoperative tumor recurrence and metastasis, which has the potential to improve the prognosis and survival of patients with postoperative solid tumors. STATEMENT OF SIGNIFICANCE: Early-stage solid tumors benefit from surgical resection. However, the presence of residual microtumors, pro-inflammatory tumor microenvironment, and activated platelets at the postoperative wound site lead to recurrence and metastasis, ultimately resulting in poor prognosis. Here, we have devised a dual-pronged approach that includes (i) in-situ forming ROS-scavenging gels loaded with anticancer drugs (TM@Gel) at the wound site after surgery to enhance the tumor microenvironment (TME) and hinder the reappearance of residual microtumors, and (ii) systemic administration of clopidegrol through albumin nanoparticles (HHP) for inhibiting activated platelets in the circulation thus impeding tumor distant migration. This work provides a viable option for postoperative intervention and treatment of solid tumors to suppress postoperative tumor recurrence and metastasis.
Collapse
Affiliation(s)
- Jiajia Gui
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Yueting Zhu
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Xue Chen
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Tao Gong
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Zhirong Zhang
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China
| | - Ruilian Yu
- Department of Oncology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China.
| | - Yao Fu
- Key Laboratory of Drug- Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu 610041, China.
| |
Collapse
|
19
|
Lim KK, Koleva‐Kolarova R, Kamaruzaman HF, Kamil AA, Chowienczyk P, Wolfe CDA, Fox‐Rushby J. Genetic-Guided Pharmacotherapy for Coronary Artery Disease: A Systematic and Critical Review of Economic Evaluations. J Am Heart Assoc 2024; 13:e030058. [PMID: 38390792 PMCID: PMC10944053 DOI: 10.1161/jaha.123.030058] [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: 07/24/2023] [Accepted: 12/15/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Genetic-guided pharmacotherapy (PGx) is not recommended in clinical guidelines for coronary artery disease (CAD). We aimed to examine the extent and quality of evidence from economic evaluations of PGx in CAD and to identify variables influential in changing conclusions on cost-effectiveness. METHODS AND RESULTS From systematic searches across 6 databases, 2 independent reviewers screened, included, and rated the methodological quality of economic evaluations of PGx testing to guide pharmacotherapy for patients with CAD. Of 35 economic evaluations included, most were model-based cost-utility analyses alone, or alongside cost-effectiveness analyses of PGx testing to stratify patients into antiplatelets (25/35), statins (2/35), pain killers (1/35), or angiotensin-converting enzyme inhibitors (1/35) to predict CAD risk (8/35) or to determine the coumadin doses (1/35). To stratify patients into antiplatelets (96/151 comparisons with complete findings of PGx versus non-PGx), PGx was more effective and more costly than non-PGx clopidogrel (28/43) but less costly than non-PGx prasugrel (10/15) and less costly and less effective than non-PGx ticagrelor (22/25). To predict CAD risk (51/151 comparisons), PGx using genetic risk scores was more effective and less costly than clinical risk score (13/17) but more costly than no risk score (16/19) or no treatment (9/9). The remaining comparisons were too few to observe any trend. Mortality risk was the most common variable (47/294) changing conclusions. CONCLUSIONS Economic evaluations to date found PGx to stratify patients with CAD into antiplatelets or to predict CAD risk to be cost-effective, but findings varied based on the non-PGx comparators, underscoring the importance of considering local practice in deciding whether to adopt PGx.
Collapse
Affiliation(s)
- Ka Keat Lim
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| | - Rositsa Koleva‐Kolarova
- Health Economics Research Centre, Nuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
| | - Hanin Farhana Kamaruzaman
- Health Economics and Health Technology Assessment (HEHTA), School of Health and WellbeingUniversity of GlasgowGlasgowUnited Kingdom
- Malaysian Health Technology Assessment Section (MaHTAS), Medical Development Division, Ministry of HealthPutrajayaMalaysia
| | - Ahmad Amir Kamil
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| | - Phil Chowienczyk
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
- King’s College London British Heart Foundation CentreSt. Thomas’ Hospital, Westminster BridgeLondonUnited Kingdom
| | - Charles D. A. Wolfe
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC), South LondonLondonUnited Kingdom
| | - Julia Fox‐Rushby
- School of Life Course & Population SciencesFaculty of Life Sciences & Medicine, King’s College LondonLondonUnited Kingdom
| |
Collapse
|
20
|
Jones D, Persad-Ramdeensingh S, Abrahim SC, Seecheran N, Haraksingh RR. Prevalence of CYP2C19*2 and CYP2C19*3 Allelic Variants and Clopidogrel Use in Patients with Cardiovascular Disease in Trinidad & Tobago. Cardiol Ther 2024; 13:191-203. [PMID: 38285330 PMCID: PMC10899551 DOI: 10.1007/s40119-024-00348-7] [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: 08/09/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Trinidad & Tobago has the highest prevalence of cardiovascular disease (CVD) in the Caribbean and clopidogrel is a ubiquitously used treatment. Yet, the extent of genetically mediated clopidogrel resistance is unknown. To determine this, we investigated whether the association between CYP2C19*2 and CYP2C19*3 genetic variants and clopidogrel resistance holds, and calculated the frequencies of these in the Trinidadian CVD population. METHODS Demographic data, clinical data, and a saliva sample were collected under informed consent from 22 patients with CVD on dual anti-platelet therapy whose biochemical resistance to clopidogrel is known, and a further 162 patients accessing the main public CVD clinic in Trinidad and who are either currently being treated or are likely to be treated with clopidogrel. A polymerase chain reaction (PCR) and restriction enzyme digestion procedure was used to genotype each patient for the CYP2C19*2 and CYP2C19*3 allelic variants. Genotype was compared to known clopidogrel resistance in the 22 patients, and to disease status and clopidogrel usage in the larger cohort. RESULTS CYP2C19*2 genotype was concordant with clopidogrel resistance. CYP2C19*2 was detected in 61.1% (99/162) of patients and CYP2C19*3 was undetected. Clopidogrel was the most prescribed antiplatelet therapy (42%). A total of 120 people presented with coronary artery disease (CAD) and 52.5% of these (n = 63/120) are currently prescribed clopidogrel. 63.5% (40/63) of patients with CAD who are prescribed clopidogrel carry the CYP2C19*2 allele; ten homozygous and 30 heterozygous. Indian patients comprised 65% of the cohort and were four times more likely to carry the CYP2C19*2 allele than African patients. CONCLUSIONS A large proportion of Trinidadian patients with CVD who are prescribed or may be prescribed clopidogrel carry genetic variants associated with clopidogrel resistance. These results emphasize the clinical need for further investigation into whether CYP2C19*2 genotype should guide clopidogrel use for the cardiovascular disease population in Trinidad & Tobago. A slide deck is available for this article.
Collapse
Affiliation(s)
- Daniele Jones
- Department of Life Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | | | | | - Naveen Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Rajini Rani Haraksingh
- Department of Life Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
| |
Collapse
|
21
|
Huh KY, Hwang S, Na JY, Yu K, Jang I, Chung J, Yoon S. Estimation of the benefit from pre-emptive genotyping based on the nationwide cohort data in South Korea. Clin Transl Sci 2024; 17:e13772. [PMID: 38501281 PMCID: PMC10949179 DOI: 10.1111/cts.13772] [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] [Received: 11/12/2023] [Revised: 01/29/2024] [Accepted: 02/28/2024] [Indexed: 03/20/2024] Open
Abstract
Genetic variants affect drug responses, making pre-emptive genotyping crucial for averting serious adverse events (SAEs) and treatment failure. However, assessing the benefits of pre-emptive genotyping based on genetic distribution, drug exposure, and demographics is challenging. This study aimed to estimate the population-level benefits of pre-emptive genotyping in the Korean population using nationwide cohort data. We reviewed actionable gene-drug combinations recommended by both the Clinical Pharmacogenomics Implementation Consortium (CPIC) and the Dutch Pharmacogenetics Working Group (DPWG) as of February 2022, identifying high-risk phenotypes. We collected reported risk reduction from genotyping and standardized it into population attributable risks. Healthcare reimbursement costs for SAEs and treatment failures were obtained from the Health Insurance Review and Assessment Service Statistics in 2021. The benefits of pre-emptive genotyping for a specific group were determined by multiplying drug exposure from nationwide cohort data by individual genotyping benefits. We identified 31 gene-drug-event pairs, with CYP2D6 and CYP2C19 demonstrating the greatest benefits for both male and female patients. Individuals aged 65-70 years had the highest individual benefit from pre-emptive genotyping, with $84.40 for men and $100.90 for women. Pre-emptive genotyping, particularly for CYP2D6 and CYP2C19, can provide substantial benefits.
Collapse
Affiliation(s)
- Ki Young Huh
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulSouth Korea
| | - Sejung Hwang
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulSouth Korea
| | - Joo Young Na
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulSouth Korea
| | - Kyung‐Sang Yu
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulSouth Korea
| | - In‐Jin Jang
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University HospitalSeoulSouth Korea
| | - Jae‐Yong Chung
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University Bundang HospitalGyeonggi‐doSouth Korea
| | - Seonghae Yoon
- Department of Clinical Pharmacology and TherapeuticsSeoul National University College of MedicineSeoulSouth Korea
- Department of Clinical Pharmacology and TherapeuticsSeoul National University Bundang HospitalGyeonggi‐doSouth Korea
| |
Collapse
|
22
|
Massmann A, Christensen KD, Van Heukelom J, Schultz A, Shaukat MHS, Hajek C, Weaver M, Green RC, Wu AC, Hickingbotham MR, Zoltick ES, Stys A, Stys TP. Clinical impact of preemptive pharmacogenomic testing on antiplatelet therapy in a real-world setting. Eur J Hum Genet 2024:10.1038/s41431-024-01567-1. [PMID: 38424298 DOI: 10.1038/s41431-024-01567-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
CYP2C19 genotyping to guide antiplatelet therapy after patients develop acute coronary syndromes (ACS) or require percutaneous coronary interventions (PCIs) reduces the likelihood of major adverse cardiovascular events (MACE). Evidence about the impact of preemptive testing, where genotyping occurs while patients are healthy, is lacking. In patients initiating antiplatelet therapy for ACS or PCI, we compared medical records data from 67 patients who received CYP2C19 genotyping preemptively (results >7 days before need), against medical records data from 67 propensity score-matched patients who received early genotyping (results within 7 days of need). We also examined data from 140 patients who received late genotyping (results >7 days after need). We compared the impact of genotyping approaches on medication selections, specialty visits, MACE and bleeding events over 1 year. Patients with CYP2C19 loss-of-function alleles were less likely to be initiated on clopidogrel if they received preemptive rather than early or late genotyping (18.2%, 66.7%, and 73.2% respectively, p = 0.001). No differences were observed by genotyping approach in the number of specialty visits or likelihood of MACE or bleeding events (all p > 0.21). Preemptive genotyping had a strong impact on initial antiplatelet selection and a comparable impact on patient outcomes and healthcare utilization, compared to genotyping ordered after a need for antiplatelet therapy had been identified.
Collapse
Affiliation(s)
- Amanda Massmann
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA.
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA.
| | - Kurt D Christensen
- Broad Institute of Harvard and MIT, Cambridge, MA, 02141, USA
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, 02215, USA
| | - Joel Van Heukelom
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
| | - April Schultz
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
| | - Muhammad Hamza Saad Shaukat
- Minneapolis Heart Institute/Abbott Northwestern Hospital Institute, Minneapolis, MN, 55407, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
| | - Catherine Hajek
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
- Helix OpCo, LLC, San Mateo, CA, 94401, USA
| | - Max Weaver
- Sanford Imagenetics, Sioux Falls, SD, 57105, USA
| | - Robert C Green
- Broad Institute of Harvard and MIT, Cambridge, MA, 02141, USA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Ariadne Labs, Boston, MA, 02215, USA
| | - Ann Chen Wu
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
- Department of Population Medicine, Harvard Medical School, Boston, MA, 02215, USA
| | - Madison R Hickingbotham
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
| | - Emilie S Zoltick
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, 02215, USA
| | - Adam Stys
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
| | - Tomasz P Stys
- Department of Internal Medicine, University of South Dakota School of Medicine, Vermillion, SD, 57069, USA
- Sanford Cardiovascular Institute, Sioux Falls, SD, 57105, USA
| |
Collapse
|
23
|
Kennedy A, Ma G, Manshaei R, Jobling RK, Kim RH, Lewis T, Cohn I. A call for increased inclusivity and global representation in pharmacogenetic testing. NPJ Genom Med 2024; 9:13. [PMID: 38388691 PMCID: PMC10883987 DOI: 10.1038/s41525-024-00403-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Commercial pharmacogenetic testing panels capture a fraction of the genetic variation underlying medication metabolism and predisposition to adverse reactions. In this study we compared variation in six pharmacogenes detected by whole genome sequencing (WGS) to a targeted commercial panel in a cohort of 308 individuals with family history of pediatric heart disease. In 1% of the cohort, WGS identified rare variants that altered the interpretation of metabolizer status and would thus prevent potential errors in gene-based dosing.
Collapse
Affiliation(s)
- April Kennedy
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabriel Ma
- University of Toronto, Toronto, ON, Canada
| | - Roozbeh Manshaei
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rebekah K Jobling
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Genome Diagnostics, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Raymond H Kim
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tamorah Lewis
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada.
- Cardiac Genome Clinic, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, Toronto, ON, Canada.
| |
Collapse
|
24
|
Tatarūnas V, Čiapienė I, Giedraitienė A. Precise Therapy Using the Selective Endogenous Encapsidation for Cellular Delivery Vector System. Pharmaceutics 2024; 16:292. [PMID: 38399346 PMCID: PMC10893373 DOI: 10.3390/pharmaceutics16020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
Interindividual variability in drug response is a major problem in the prescription of pharmacological treatments. The therapeutic effect of drugs can be influenced by human genes. Pharmacogenomic guidelines for individualization of treatment have been validated and used for conventional dosage forms. However, drugs can often target non-specific areas and produce both desired and undesired pharmacological effects. The use of nanoparticles, liposomes, or other available forms for drug formulation could help to overcome the latter problem. Virus-like particles based on retroviruses could be a potential envelope for safe and efficient drug formulations. Human endogenous retroviruses would make it possible to overcome the host immune response and deliver drugs to the desired target. PEG10 is a promising candidate that can bind to mRNA because it is secreted like an enveloped virus-like extracellular vesicle. PEG10 is a retrotransposon-derived gene that has been domesticated. Therefore, formulations with PEG10 may have a lower immunogenicity. The use of existing knowledge can lead to the development of suitable drug formulations for the precise treatment of individual diseases.
Collapse
Affiliation(s)
- Vacis Tatarūnas
- Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu 15, LT 50103 Kaunas, Lithuania; (V.T.); (I.Č.)
| | - Ieva Čiapienė
- Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu 15, LT 50103 Kaunas, Lithuania; (V.T.); (I.Č.)
| | - Agnė Giedraitienė
- Institute of Microbiology and Virology, Lithuanian University of Health Sciences, Eiveniu 4, LT 50161 Kaunas, Lithuania
| |
Collapse
|
25
|
Shubbar Q, Alchakee A, Issa KW, Adi AJ, Shorbagi AI, Saber-Ayad M. From genes to drugs: CYP2C19 and pharmacogenetics in clinical practice. Front Pharmacol 2024; 15:1326776. [PMID: 38420192 PMCID: PMC10899532 DOI: 10.3389/fphar.2024.1326776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
The CYP2C19 gene is frequently included in different pharmacogenomic panels tested in clinical practice, due to its involvement in the metabolism of a myriad of frequently prescribed medications. Accordingly, CYP2C19 genotyping can promote precise therapeutic decisions and avoid the occurrence of significant drug-drug-gene interactions in the clinical setting. A comprehensive examination of the role of the CYP2C19 gene in real-world medical settings is presented in this review. This review summarizes the most recent information on how genetic variants in CYP2C19 affect drug metabolism and therapeutic outcomes. It goes into the wide range of CYP2C19 phenotypes, with different degrees of metabolizing activity, and their implications for customized medication response through a review of the literature. The review also analyzes the clinical significance of CYP2C19 in several medical specialties, including cardiology, psychiatry, and gastro-enterology clinics, and illuminates how it affects pharmacological efficacy, safety, and adverse effects. Finally, CYP2C19-supported clinical decision-making is outlined, highlighting the possibility of improving therapeutic outcomes and achieving more affordable treatment options, a step towards optimizing healthcare provision through precision medicine.
Collapse
Affiliation(s)
- Qamar Shubbar
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Aminah Alchakee
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Khaled Walid Issa
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Abdul Jabbar Adi
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Maha Saber-Ayad
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| |
Collapse
|
26
|
Pelter MN, Druz RS. Precision medicine: Hype or hope? Trends Cardiovasc Med 2024; 34:120-125. [PMID: 36375778 DOI: 10.1016/j.tcm.2022.11.001] [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: 09/06/2022] [Revised: 11/05/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
In recent years, precision medicine has steadily risen to the forefront of many aspects of medicine, including cardiology [1]. While this field has exponentially expanded and advanced in the last few years, a lot of questions remain regarding exact definition, usage, and clinical applications [2,3]. This review will provide a brief synopsis of the current state of precision medicine, its limitations, future directions, as well as analyze emerging clinical applications in cardiology.
Collapse
|
27
|
HU CY, WANG YL, FAN ZX, SUN XP, WANG S, LIU Z. Effect of cytochrome P450 2C19 (CYP2C19) gene polymorphism and clopidogrel reactivity on long term prognosis of patients with coronary heart disease after PCI. J Geriatr Cardiol 2024; 21:90-103. [PMID: 38440340 PMCID: PMC10908579 DOI: 10.26599/1671-5411.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Objective To investigate the impact of CYP2C19 gene polymorphism on clopidogrel reactivity and its association with long-term clinical outcome in patients with coronary heart disease (CHD) undergoing percutaneous coronary intervention (PCI). Methods In total, 675 patients were enrolled. Based on the platelet inhibition rate, patients were categorized into two groups: clopidogrel low responsiveness (CLR) and normal clopidogrel responsiveness (NCR). The CLR group was divided into ticagrelor and clopidogrel group based on the antiplatelet drugs used in the follow-up treatment. Patients were classified into three groups (normal metabolizer, intermediate metabolizer, and poor metabolizer) based on the CYP2C19 genotype. We aimed to evaluate the impact of CYP2C19 gene polymorphism on clopidogrel reactivity. The cumulative rates of 12-month all-cause deaths, major adverse cardiovascular events (MACCEs), and bleeding events were calculated. Results CLR was observed in 44.4% of the overall population. Significant differences were observed in the platelet inhibition rate of clopidogrel among the three metabolic genotypes (P < 0.05). At the 12-month follow-up, 13 patients (1.9%) died and 96 patients (14.2%) experienced MACCEs. Patients with CLR (9.6% vs. 11.7% vs. 22.1%, P < 0.05) or poor metabolizer (10.7% vs. 16.4% vs. 22.6%, P = 0.026) experienced a higher rate of MACCEs. A MACCEs risk score between zero and two was calculated. The highest incidence of MACCEs significantly increased with the 2-positive results, and the area under the curve (AUC) was 0.712 (95% CI: 0.650-0.774, P < 0.05). There was no significant difference between the group with a score of one and the occurrence of MACCEs (P > 0.05). Conclusions Low response to clopidogrel in CHD patients is correlated with CYP2C19 gene polymorphism. CYP2C19 genotyping combined with platelet reactivity is an independent predictor of 12-months MACCEs in patients with clopidogrel treatment after PCI, which is better than either test alone.
Collapse
Affiliation(s)
- Cheng-Yan HU
- Department of Geriatrics, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Yan-Ling WANG
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Zhen-Xing FAN
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xi-Peng SUN
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Shuai WANG
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
- Emergency Department of Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhi LIU
- Emergency Department of Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
28
|
Akkaif MA, Daud NAA, Noor DAM, Sha'aban A, Kader MASA, Ibrahim B. The Impact of CYP2C19 Genotype on the Platelet Reactivity Index (PRI) among Chronic Coronary Syndromes (CCS) Patients Undergoing Percutaneous Coronary Intervention (PCI): Affectability of Rapid Genetic Testing. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07544-6. [PMID: 38224415 DOI: 10.1007/s10557-024-07544-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND In the Asian population, the presence of the CYP2C19 loss-of-function (LOF) allele is a known genetic variation. This allele is associated with a reduced capacity to metabolize clopidogrel into its active forms through the CYP2C19 enzyme, resulting in diminished platelet inhibition and an elevated risk of recurrent cardiovascular events. Regulatory authorities have recommended an alternative P2Y12 inhibitor, ticagrelor, for individuals carrying the LOF allele. Consequently, this study seeks to assess the impact of the CYP2C19 genotype on the Platelet reactivity index (PRI) using a rapid genetic testing approach in Asian patients with chronic coronary syndromes (CCS) who undergo percutaneous coronary intervention (PCI). METHODS This prospective study employed a parallel design, single-center design, and randomized approach. Genotyping for the CYP2C19*2 and *3 polymorphisms was conducted using the Nested Allele-Specific Multiplex PCR (NASM-PCR) technique. Patients meeting the inclusion criteria underwent genotyping for CYP2C19 polymorphisms. Following PCI, patients were randomly assigned to receive either ticagrelor or clopidogrel. PRI assessments were performed four hours after loading dose administration. The trial was registered with ClinicalTrials.gov under the identifier NCT05516784. RESULTS Among the 94 patients recruited for the study, 40 (42.55%) were identified as carriers of the LOF allele for CYP2C19*2 and *3 (*1/*2, *2/*2, *1/*3). Out of the 84 patients evaluated for PRI (44 receiving clopidogrel and 40 receiving ticagrelor), 21 (47.7%) of the clopidogrel group and 39 (97.5%) of the ticagrelor group exhibited a favorable response to antiplatelet therapy (PRI < 50). Patients treated with ticagrelor demonstrated superior antiplatelet responses compared to those receiving clopidogrel, regardless of LOF carrier status (P = 0.005 and < 0.001 for non-LOF and LOF carriers, respectively). CONCLUSION NASM-PCR as a rapid genetic test holds promise for personalizing antiplatelet therapy in Asian CCS patients.
Collapse
Affiliation(s)
- Mohammed Ahmed Akkaif
- Department of Cardiology, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201700, People's Republic of China.
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, 11800, Malaysia.
| | | | | | - Abubakar Sha'aban
- School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK
| | | | - Baharudin Ibrahim
- Faculty of Pharmacy, University of Malaya, Federal Territory Malaysia, Kuala Lumpur, 50603, Malaysia.
| |
Collapse
|
29
|
Khasawneh LQ, Alsafar H, Alblooshi H, Allam M, Patrinos GP, Ali BR. The diversity and clinical implications of genetic variants influencing clopidogrel bioactivation and response in the Emirati population. Hum Genomics 2024; 18:2. [PMID: 38173046 PMCID: PMC10765826 DOI: 10.1186/s40246-023-00568-3] [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: 10/31/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Clopidogrel is a widely prescribed prodrug that requires activation via specific pharmacogenes to exert its anti-platelet function. Genetic variations in the genes encoding its transporter, metabolizing enzymes, and target receptor lead to variability in its activation and platelet inhibition and, consequently, its efficacy. This variability increases the risk of secondary cardiovascular events, and therefore, some variations have been utilized as genetic biomarkers when prescribing clopidogrel. METHODS Our study examined clopidogrel-related genes (CYP2C19, ABCB1, PON1, and P2Y12R) in a cohort of 298 healthy Emiratis individuals. The study used whole exome sequencing (WES) data to comprehensively analyze pertinent variations of these genes, including their minor allele frequencies, haplotype distribution, and their resulting phenotypes. RESULTS Our data shows that approximately 37% (n = 119) of the cohort are likely to benefit from the use of alternative anti-platelet drugs due to their classification as intermediate or poor CYP2C19 metabolizers. Additionally, more than 50% of the studied cohort exhibited variants in ABCB1, PON1, and P2YR12 genes, potentially influencing clopidogrel's transport, enzymatic clearance, and receptor performance. CONCLUSIONS Recognizing these alleles and genotype frequencies may explain the clinical differences in medication response across different ethnicities and predict adverse events. Our findings underscore the need to consider genetic variations in prescribing clopidogrel, with potential implications for implementing personalized anti-platelet therapy among Emiratis based on their genetic profiles.
Collapse
Affiliation(s)
- Lubna Q Khasawneh
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
| | - Habiba Alsafar
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- ASPIRE Precision Medicine Research Institute Abu Dhabi, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Hiba Alblooshi
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
| | - Mushal Allam
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
| | - George P Patrinos
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates
- ASPIRE Precision Medicine Research Institute Abu Dhabi, United Arab Emirates University, Al Ain, United Arab Emirates
- School of Health Sciences, Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras, Patras, Greece
- Zayed Centre for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box: 15551, Al-Ain, United Arab Emirates.
- ASPIRE Precision Medicine Research Institute Abu Dhabi, United Arab Emirates University, Al Ain, United Arab Emirates.
| |
Collapse
|
30
|
Post RAJ, Petkovic M, van den Heuvel IL, van den Heuvel ER. Flexible Machine Learning Estimation of Conditional Average Treatment Effects: A Blessing and a Curse. Epidemiology 2024; 35:32-40. [PMID: 37889951 DOI: 10.1097/ede.0000000000001684] [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: 10/29/2023]
Abstract
Causal inference from observational data requires untestable identification assumptions. If these assumptions apply, machine learning methods can be used to study complex forms of causal effect heterogeneity. Recently, several machine learning methods were developed to estimate the conditional average treatment effect (ATE). If the features at hand cannot explain all heterogeneity, the individual treatment effects can seriously deviate from the conditional ATE. In this work, we demonstrate how the distributions of the individual treatment effect and the conditional ATE can differ when a causal random forest is applied. We extend the causal random forest to estimate the difference in conditional variance between treated and controls. If the distribution of the individual treatment effect equals that of the conditional ATE, this estimated difference in variance should be small. If they differ, an additional causal assumption is necessary to quantify the heterogeneity not captured by the distribution of the conditional ATE. The conditional variance of the individual treatment effect can be identified when the individual effect is independent of the outcome under no treatment given the measured features. Then, in the cases where the individual treatment effect and conditional ATE distributions differ, the extended causal random forest can appropriately estimate the variance of the individual treatment effect distribution, whereas the causal random forest fails to do so.
Collapse
Affiliation(s)
- Richard A J Post
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Marko Petkovic
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Isabel L van den Heuvel
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
| | - Edwin R van den Heuvel
- From the Department of Mathematics and Computer Science, Eindhoven University of Technology, the Netherlands
- Department of Preventive Medicine and Epidemiology, School of Medicine, Boston University, Boston, MA
| |
Collapse
|
31
|
Casajús A, Zubiaur P, Alday E, Soria‐Chacartegui P, Saiz‐Rodríguez M, Gutierrez L, Aragonés C, Campodónico D, Gómez‐Fernández A, Navares‐Gómez M, Villapalos‐García G, Mejía‐Abril G, Ochoa D, Abad‐Santos F. Impact of CYP2D6 and CYP2B6 phenotypes on the response to tramadol in patients with acute post-surgical pain. Clin Transl Sci 2024; 17:e13698. [PMID: 38140786 PMCID: PMC10787143 DOI: 10.1111/cts.13698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 11/17/2023] [Accepted: 11/25/2023] [Indexed: 12/24/2023] Open
Abstract
Tramadol is an important minor opioid prescribed for pain management. In this study, we analyzed the well-known impact of CYP2D6 genetic variation and 60 additional variants in eight candidate genes (i.e., ABCG2, SLCO1B1, CYP2D6, CYP2B6, CYP2C19, CYP2C9, CYP3A5, and CYP3A4) on tramadol efficacy and safety. Some 108 patients with pain after surgery admitted to a post-anesthesia care unit (PACU) and prescribed tramadol were recruited. They were genotyped, and tramadol M1/M2 metabolite concentrations were determined by a newly validated HPLC-MS/MS method. CYP2D6 intermediate (IM) and poor (PM) metabolizers showed lower M1 concentrations adjusted for dose/weight at 30 and 120 min compared to ultrarapid (UM) and normal (NM) metabolizers (univariate p < 0.001 and 0.020, multivariate p < 0.001 and 0.001, unstandardized β coefficients = 0.386 and 0.346, R2 = 0.146 and 0.120, respectively). CYP2B6 PMs (n = 10) were significantly related to a higher reduction in pain 30 min after tramadol intake (univariate p = 0.038, multivariate p = 0.016, unstandardized β coefficient = 0.224, R2 = 0.178), to lower PACU admission time (p = 0.007), and to lower incidence of adverse drug reactions (p = 0.038) compared to the other phenotypes. CYP3A4 IMs and PMs showed a higher prevalence of drowsiness and dizziness (p = 0.028 and 0.005, respectively). Our results suggest that the interaction of CYP2B6 and CYP2D6 phenotypes may be clinically relevant, pending validation of these results in large, independent cohorts. Additional research is required to clarify the impact of CYP3A4 genetic variation on tramadol response.
Collapse
Affiliation(s)
- Ana Casajús
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Pablo Zubiaur
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Enrique Alday
- Anesthesia and Surgical Critical Care DepartmentHospital Universitario de la PrincesaMadridSpain
| | - Paula Soria‐Chacartegui
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Miriam Saiz‐Rodríguez
- Research Unit, Fundación Burgos por la Investigación de la Salud (FBIS)Hospital Universitario de BurgosBurgosSpain
- Department of Health SciencesUniversity of BurgosBurgosSpain
| | - Lara Gutierrez
- Anesthesia and Surgical Critical Care DepartmentHospital Universitario de MóstolesMadridSpain
| | - Catalina Aragonés
- Anesthesia and Surgical Critical Care DepartmentHospital Universitario de la PrincesaMadridSpain
| | - Diana Campodónico
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Antía Gómez‐Fernández
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Marcos Navares‐Gómez
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Gonzalo Villapalos‐García
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Gina Mejía‐Abril
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Dolores Ochoa
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
| | - Francisco Abad‐Santos
- Clinical Pharmacology DepartmentHospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria La Princesa (IP)MadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Instituto de Salud Carlos IIIMadridSpain
| |
Collapse
|
32
|
Lehtisalo M, Tarkiainen EK, Neuvonen M, Holmberg M, Kiiski JI, Lapatto-Reiniluoto O, Filppula AM, Kurkela M, Backman JT, Niemi M. Ticagrelor Increases Exposure to the Breast Cancer Resistance Protein Substrate Rosuvastatin. Clin Pharmacol Ther 2024; 115:71-79. [PMID: 37786998 DOI: 10.1002/cpt.3067] [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] [Received: 08/04/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
Ticagrelor and rosuvastatin are often used concomitantly after atherothrombotic events. Several cases of rhabdomyolysis during concomitant ticagrelor and rosuvastatin have been reported, suggesting a drug-drug interaction. We showed recently that ticagrelor inhibits breast cancer resistance protein (BCRP) and organic anion transporting polypeptide (OATP) 1B1, 1B3, and 2B1-mediated rosuvastatin transport in vitro. The aim of this study was to investigate the effects of ticagrelor on rosuvastatin pharmacokinetics in humans. In a randomized, crossover study, 9 healthy volunteers ingested a single dose of 90 mg ticagrelor or placebo, followed by a single 10 mg dose of rosuvastatin 1 hour later. Ticagrelor 90 mg or placebo were additionally administered 12, 24, and 36 hours after their first dose. Ticagrelor increased rosuvastatin area under the plasma concentration-time curve (AUC) and peak plasma concentration 2.6-fold (90% confidence intervals: 1.8-3.8 and 1.7-4.0, P = 0.001 and P = 0.003), and prolonged its half-life from 3.1 to 6.6 hours (P = 0.009). Ticagrelor also decreased the renal clearance of rosuvastatin by 11% (3%-19%, P = 0.032). The N-desmethylrosuvastatin:rosuvastatin AUC0-10h ratio remained unaffected by ticagrelor. Ticagrelor had no effect on the plasma concentrations of the endogenous OATP1B substrates glycodeoxycholate 3-O-glucuronide, glycochenodeoxycholate 3-O-glucuronide, glycodeoxycholate 3-O-sulfate, and glycochenodeoxycholate 3-O-sulfate, or the sodium-taurocholate cotransporting polypeptide substrate taurocholic acid. These data indicate that ticagrelor increases rosuvastatin concentrations more than twofold in humans, probably mainly by inhibiting intestinal BCRP. Because the risk for rosuvastatin-induced myotoxicity increases along with rosuvastatin plasma concentrations, using ticagrelor concomitantly with high doses of rosuvastatin should be avoided.
Collapse
Affiliation(s)
- Minna Lehtisalo
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - E Katriina Tarkiainen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Neuvonen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Mikko Holmberg
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Johanna I Kiiski
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Outi Lapatto-Reiniluoto
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Anne M Filppula
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Pharmaceutical Sciences Laboratory, Faculty of Science and Engineering, Åbo Akademi University, Turku, Finland
| | - Mika Kurkela
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
33
|
Voicu V, Diehm N, Moarof I, Parejo S, Badiqué F, Burden A, Niedrig D, Béchir M, Russmann S. Antiplatelet therapy guided by CYP2C19 point-of-care pharmacogenetics plus multidimensional treatment decisions. Pharmacogenomics 2024; 25:5-19. [PMID: 38230622 DOI: 10.2217/pgs-2023-0200] [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: 01/18/2024] Open
Abstract
Aim: Implementation of CYP2C19 point-of-care (POC) pharmacogenetic (PGx) testing with personalized treatment recommendations. Methods: POC CYP2C19 genotyping plus expert evaluation of risk factors for ischemic and bleeding events. Results: 167 patients underwent PGx testing, 54 (32.3%) were CYP2C19 loss of function carriers, and POC versus standard PGx analysis results for *2 and *3 variants matched in 100%. Antiplatelet therapy was adjusted in 44 patients (26.3%), but always required consideration of patient-specific factors. Conclusion: CYP2C19 POC-PGx is reliable and offers clinically relevant advantages for immediate evidence-based adaptations of antiplatelet therapy, whereas in less acute cases conventional PGx testing can also have advantages. Antiplatelet therapy has become more complex, and implementation of PGx-based personalized antiplatelet therapy requires complementary expert knowledge.
Collapse
Affiliation(s)
- Victor Voicu
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
| | - Nicolas Diehm
- Center for Vascular Medicine, 5000, Aarau, Switzerland
| | - Igal Moarof
- Cardiology Center Mittelland, 5001, Aarau, Switzerland
| | - Sarah Parejo
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Florent Badiqué
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Andrea Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - David Niedrig
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032, Zurich, Switzerland
| | - Markus Béchir
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
| | - Stefan Russmann
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
- University of Nicosia Medical School, 2408, Nicosia-Egkomi, Cyprus
| |
Collapse
|
34
|
Takahashi K, Iwamura T, Hiratsuka Y, Sasaki D, Yamamura N, Ueda M, Yoshino M, Enomoto D, Morioka H, Uemura S, Okura T, Sakaue T, Ikeda S. Iatrogenic intramuscular hematoma of the oblique muscles as a complication of technetium-99m-labeled pyrophosphate imaging-based computed tomography-guided core-needle biopsy in a patient with wild-type transthyretin cardiac amyloidosis. Radiol Case Rep 2024; 19:330-340. [PMID: 38028290 PMCID: PMC10661599 DOI: 10.1016/j.radcr.2023.09.107] [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: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 12/01/2023] Open
Abstract
Technetium-99m-labeled pyrophosphate imaging-based computed tomography-guided core-needle biopsy of the internal oblique muscle with tracer uptake is a safe and sensitive extracardiac screening biopsy. It can provide histopathological confirmation of the deposition of amyloid transthyretin in patients with wild-type transthyretin cardiac amyloidosis. This case report presents the case of a 73-year-old man receiving triple anti-thrombotic therapy for atrial flutter and coronary stenting who underwent this biopsy to confirm the diagnosis of transthyretin cardiac amyloidosis. The biopsy needle reached the internal oblique muscle via the external oblique muscle between the skin and the target. A type 1 intramuscular hematoma involving these muscles developed subsequently; however, manual compression hemostasis prevented further increase in size. Since this biopsy often targets elderly patients receiving anti-thrombotic therapy who are at high risk of bleeding owing to multimorbidity and polypharmacy, efforts should be made to reduce the frequency of complications, particularly bleeding, which can lead to the development of intramuscular hematoma.
Collapse
Affiliation(s)
- Koji Takahashi
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Takaaki Iwamura
- Department of Radiology, Yawatahama City General Hospital, Ehime, Japan
| | | | - Daisuke Sasaki
- Department of Radiology, Yawatahama City General Hospital, Ehime, Japan
| | - Nobuhisa Yamamura
- Department of Clinical Pathology, Yawatahama City General Hospital, Ehime, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mako Yoshino
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Daijiro Enomoto
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Hiroe Morioka
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Shigeki Uemura
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Takafumi Okura
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Tomoki Sakaue
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| | - Shuntaro Ikeda
- Department of Community Emergency Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
- Department of Cardiology, Yawatahama City General Hospital, 1-638, Ohira, Yawatahama, Ehime 796-8502, Japan
| |
Collapse
|
35
|
Jung YS, Jin BH, Park MS, Kim CO, Chae D. Population pharmacokinetic-pharmacodynamic modeling of clopidogrel for dose regimen optimization based on CYP2C19 phenotypes: A proof of concept study. CPT Pharmacometrics Syst Pharmacol 2024; 13:29-40. [PMID: 37775990 PMCID: PMC10787215 DOI: 10.1002/psp4.13053] [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] [Received: 08/03/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 10/01/2023] Open
Abstract
Clopidogrel is an antiplatelet drug used to reduce the risk of acute coronary syndrome and stroke. It is converted by CYP2C19 to its active metabolite; therefore, poor metabolizers (PMs) of CYP2C19 exhibit diminished antiplatelet effects. Herein, we conducted a proof-of-concept study for using population pharmacokinetic-pharmacodynamic (PK-PD) modeling to recommend a personalized clopidogrel dosing regimen for individuals with varying CYP2C19 phenotypes and baseline P2Y12 reaction unit (PRU) levels. Data from a prospective phase I clinical trial involving 36 healthy male participants were used to develop the population PK-PD model predicting the concentrations of clopidogrel, clopidogrel H4, and clopidogrel carboxylic acid, and linking clopidogrel H4 concentrations to changes in PRU levels. A two-compartment model effectively described the PKs of both clopidogrel and clopidogrel carboxylic acid, and a one-compartment model of those of clopidogrel H4. The CYP2C19 phenotype was identified as a significant covariate influencing the metabolic conversion of the parent drug to its metabolites. A PD submodel of clopidogrel H4 that stimulated the fractional turnover rate of PRU levels showed the best performance. Monte Carlo simulations suggested that PMs require three to four times higher doses than extensive metabolizers to reach the target PRU level. Individuals within the top 20th percentile of baseline PRU levels were shown to require 2.5-3 times higher doses than those in the bottom 20th percentile. We successfully developed a population PK-PD model for clopidogrel considering the impact of CYP2C19 phenotypes and baseline PRU levels. Further studies are necessary to confirm actual dosing recommendations for clopidogrel.
Collapse
Affiliation(s)
- Yun Seob Jung
- Department of Convergence MedicineYonsei University Wonju College of MedicineWonjuKorea
| | - Byung Hak Jin
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
| | - Min Soo Park
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
- Department of PediatricsYonsei University College of MedicineSeoulKorea
| | - Choon Ok Kim
- Department of Clinical PharmacologySeverance Hospital, Yonsei University Health SystemSeoulKorea
| | - Dongwoo Chae
- Department of PharmacologyYonsei University College of MedicineSeoulKorea
| |
Collapse
|
36
|
Yang G, Alarcon C, Chanfreau C, Lee NH, Friedman P, Nutescu E, Tuck M, O'Brien T, Gong L, Klein TE, Chang KM, Tsao PS, Meltzer DO, Tuteja S, Perera MA. Investigation of genomic and transcriptomic risk factors in clopidogrel response in African Americans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299140. [PMID: 38106031 PMCID: PMC10723512 DOI: 10.1101/2023.12.05.23299140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Clopidogrel, an anti-platelet drug, used to prevent thrombosis after percutaneous coronary intervention. Clopidogrel resistance results in recurring ischemic episodes, with African Americans suffering disproportionately. The aim of this study was to identify biomarkers of clopidogrel resistance in African American patients. We conducted a genome-wide association study, including local ancestry adjustment, in 141 African Americans on clopidogrel to identify associations with high on-treatment platelet reactivity (HTPR). We validated genome-wide and suggestive hits in an independent cohort of African American clopidogrel patients (N = 823) from the Million Veteran's Program (MVP) along with in vitro functional follow up. We performed differential gene expression (DGE) analysis in whole blood with functional follow-up in MEG-01 cells. We identified rs7807369, within thrombospondin 7A (THSD7A), as significantly associated with increasing risk of HTPR (p = 4.56 × 10-9). Higher THSD7A expression was associated with HTPR in an independent gene expression cohort of clopidogrel treated patients (p = 0.004) and supported by increased gene expression on THSD7A in primary human endothelial cells carrying the risk haplotype. Two SNPs (rs1149515 and rs191786) were validated in the MVP cohort. DGE analysis identified an association with decreased LAIR1 expression to HTPR. LAIR1 knockdown in a MEG-01 cells resulted in increased expression of SYK and AKT1, suggesting an inhibitory role of LAIR1 in the Glycoprotein VI pathway. Notably, the CYP2C19 variants showed no association with clopidogrel response in the discovery or MVP cohorts. In summary, these finding suggest that other variants outside of CYP2C19 star alleles play an important role in clopidogrel response in African Americans.
Collapse
Affiliation(s)
- Guang Yang
- Department of Pharmacology, Center for Pharmacogenomics, Fienberg School of Medicine, Northwestern University, Chicago IL
| | - Cristina Alarcon
- Department of Pharmacology, Center for Pharmacogenomics, Fienberg School of Medicine, Northwestern University, Chicago IL
| | | | - Norman H Lee
- Department of Pharmacology and Physiology, George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Paula Friedman
- Department of Pharmacology, Center for Pharmacogenomics, Fienberg School of Medicine, Northwestern University, Chicago IL
| | - Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, College of Pharmacy, Chicago, IL
| | - Matthew Tuck
- Washington DC VA Medical Center, Washington, DC and The George Washington University, Washington, DC
| | - Travis O'Brien
- Department of Pharmacology and Physiology, George Washington University, 2300 I Street NW, Washington, DC, 20037, USA
| | - Li Gong
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Teri E Klein
- Department of Biomedical Data Science and Department of Medicine, Stanford University, Stanford, CA
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Philip S Tsao
- VA Palo Alto Healthcare System and Stanford University, Palo Alto, CA
| | - David O Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Sony Tuteja
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Minoli A Perera
- Department of Pharmacology, Center for Pharmacogenomics, Fienberg School of Medicine, Northwestern University, Chicago IL
| |
Collapse
|
37
|
Masimirembwa C, Ramsay M, Botha J, Ellis E, Etheredge H, Hurrell T, Kanji CR, Kapungu NN, Maher H, Mthembu B, Naidoo J, Scholefield J, Rambarran S, van der Schyff F, Smyth N, Strobele B, Thelingwani RS, Loveland J, Fabian J. The African Liver Tissue Biorepository Consortium: Capacitating Population-Appropriate Drug Metabolism, Pharmacokinetics, and Pharmacogenetics Research in Drug Discovery and Development. Drug Metab Dispos 2023; 51:1551-1560. [PMID: 37751997 DOI: 10.1124/dmd.123.001400] [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: 05/24/2023] [Revised: 08/21/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Pharmaceutical companies subject all new molecular entities to a series of in vitro metabolic characterizations that guide the selection and/or design of compounds predicted to have favorable pharmacokinetic properties in humans. Current drug metabolism research is based on liver tissue predominantly obtained from people of European origin, with limited access to tissue from people of African origin. Given the interindividual and interpopulation genomic variability in genes encoding drug-metabolizing enzymes, efficacy and safety of some drugs are poorly predicted for African populations. To address this gap, we have established the first comprehensive liver tissue biorepository inclusive of people of African origin. The African Liver Tissue Biorepository Consortium currently includes three institutions in South Africa and one in Zimbabwe, with plans to expand to other African countries. The program has collected 67 liver samples as of July 2023. DNA from the donors was genotyped for 120 variants in 46 pharmacogenes and revealed variants that are uniquely found in African populations, including the low-activity, African-specific CYP2C9*5 and *8 variants relevant to the metabolism of diclofenac. Larger liver tissue samples were used to isolate primary human hepatocytes. Viability of the hepatocytes and microsomal fractions was demonstrated by the activity of selected cytochrome P450s. This resource will be used to ensure the safety and efficacy of existing and new drugs in African populations. This will be done by characterizing compounds for properties such as drug clearance, metabolite and enzyme identification, and drug-drug and drug-gene interactions. SIGNIFICANCE STATEMENT: Standard optimization of the drug metabolism of new molecular entities in the pharmaceutical industry uses subcellular fractions such as microsomes and isolated primary hepatocytes, being done mainly with tissue from donors of European origin. Pharmacogenetics research has shown that variants in genes coding for drug-metabolizing enzymes have interindividual and interpopulation differences. We established an African liver tissue biorepository that will be useful in ensuring drug discovery and development research takes into account drug responses in people of African origin.
Collapse
Affiliation(s)
- Collen Masimirembwa
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Michele Ramsay
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jean Botha
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Ewa Ellis
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Harriet Etheredge
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Tracey Hurrell
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Comfort Ropafadzo Kanji
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Nyasha Nicole Kapungu
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Heather Maher
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Busisiwe Mthembu
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jerolen Naidoo
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Janine Scholefield
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Sharan Rambarran
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Francisca van der Schyff
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Natalie Smyth
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Bernd Strobele
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Roslyn Stella Thelingwani
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jerome Loveland
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - June Fabian
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| |
Collapse
|
38
|
Lemke LK, Cicali EJ, Williams R, Nguyen KA, Cavallari LH, Wiisanen K. Clinician Response to Pharmacogenetic Clinical Decision Support Alerts. Clin Pharmacol Ther 2023; 114:1350-1357. [PMID: 37716912 PMCID: PMC10726431 DOI: 10.1002/cpt.3051] [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: 05/09/2023] [Accepted: 08/09/2023] [Indexed: 09/18/2023]
Abstract
The objective of this study was to characterize clinician response following standardization of pharmacogenetic (PGx) clinical decision support alerts at University of Florida (UF) Health. A retrospective analysis of all PGx alerts that fired at a tertiary academic medical center from August 2020 through May 2022 was performed. Alert acceptance rate was calculated and compared across six gene-drug pairs, patient care setting, and clinician specialty. The disposition of the triggering medication was compared with the alert response and evaluated for congruence. There were a total of 818 alerts included for analysis of alert response, 557 alerts included in acceptance rate calculations, and 392 alerts with sufficient information to assess clinical response. The overall acceptance rate was 63%. The alert response and clinical response were congruent for 47% of alerts. Alert response was influenced by the triggering gene-drug pair, clinician specialty, patient care setting, and specialty of the provider who initially ordered the PGx test. Clinical response was mostly incongruent with alert response. Alert acceptance is influenced by the triggering gene-drug pair, clinician specialty, and care setting. Alert response is not a reliable surrogate marker for clinical action. Any future research into the impact of clinical decision support (CDS) alerts should focus on clinical response rather than alert response. Given the reliance on CDS alerts to enhance uptake of PGx, it is worthwhile to further investigate their impact on prescribing and patient outcomes.
Collapse
Affiliation(s)
- Lauren K Lemke
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Emily J Cicali
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Roy Williams
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Khoa A Nguyen
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Larisa H Cavallari
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Kristin Wiisanen
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| |
Collapse
|
39
|
Hiraya D, Watabe H, Hoshi T, Ieda M. Instant subacute stent thrombosis after maximum-load cardiopulmonary exercise test in a clopidogrel poor metabolizer with acute coronary syndrome. J Cardiol Cases 2023; 28:265-268. [PMID: 38126046 PMCID: PMC10730278 DOI: 10.1016/j.jccase.2023.08.011] [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: 05/19/2023] [Revised: 07/18/2023] [Accepted: 08/14/2023] [Indexed: 12/23/2023] Open
Abstract
A 63-year-old man with a hobby of full marathon and triathlon fainted while commuting on a 25-km one-way bicycle trip and was admitted to the hospital after return of spontaneous circulation. The patient was diagnosed with acute coronary syndrome, and contrast-enhanced computed tomography for trauma diagnosis indicated suspicion of liver injury. Although coronary angiography revealed a severe stenotic lesion in the left anterior descending artery, percutaneous coronary intervention (PCI) was deferred because of thrombolysis in myocardial infarction grade 3 flow. Following neurological recovery, the patient was started on dual antiplatelet therapy (aspirin and clopidogrel). On day 11, a 3.0/34-mm Resolute Onyx stent (Medtronic, Dublin, Ireland) was deployed following rotablation. As a pre-discharge evaluation, a maximum-load cardiopulmonary exercise test was performed 8 days after PCI. However, the patient developed stent thrombosis after 2 h. Subsequently, the patient was diagnosed as a clopidogrel poor metabolizer using a blood test. Learning objective Existing guidelines recommend a cardiopulmonary exercise test (CPET) before or immediately after the discharge of patients with acute coronary syndrome (ACS). However, the safety of the maximum-load CPET has not been established, especially in clopidogrel poor metabolizers with ACS. Acute maximal exercise induces platelet aggregation; therefore, further discussion is needed regarding the timing of CPET, exercise load level, and patient observation post-CPET in ACS patients after stent placement.
Collapse
Affiliation(s)
- Daigo Hiraya
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroaki Watabe
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoya Hoshi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| |
Collapse
|
40
|
Gao H, Yang N, Yang L, Wang H, Zhang G, Ma X, Deng N. Advances and Perspectives in methods for identifying high platelet reactivity. Heliyon 2023; 9:e22214. [PMID: 38107326 PMCID: PMC10724541 DOI: 10.1016/j.heliyon.2023.e22214] [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: 05/08/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy is the foundational treatment for the prevention and treatment of coronary and cerebrovascular ischemic events in patients with coronary heart disease, ischemic stroke, and transient ischemic attack (TIA). However, with more and more studies reporting an increased risk of thrombosis in some patients due to poor response to therapeutic agents, the selection of appropriate P2Y12 inhibitors has become a major challenge that needs to be addressed urgently. Currently, commonly used oral P2Y12 inhibitors include clopidogrel, ticagrelor, and prasugrel. Assessing patients' risk factors before the development of treatment regimens by effectively predicting the risk of high platelet reactivity with specific P2Y12 inhibitors in advance to avert the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) is the key point to the problem. Up to now, methods available for predicting platelet reactivity include genetic testing, platelet function testing, and risk scores. This review provides a summarization of the existent available identification methods and analyzes the advantages and drawbacks of different methods in specific clinical settings, intending to guide the rational clinical application of P2Y12 receptor inhibitors.
Collapse
Affiliation(s)
- Hua Gao
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Nan Yang
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Libo Yang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Hui Wang
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Guoshan Zhang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xueping Ma
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Ning Deng
- Office of Drug Clinical Trial Organization, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| |
Collapse
|
41
|
Stanger L, Yamaguchi A, Holinstat M. Antiplatelet strategies: past, present, and future. J Thromb Haemost 2023; 21:3317-3328. [PMID: 38000851 PMCID: PMC10683860 DOI: 10.1016/j.jtha.2023.09.013] [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: 09/01/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 11/26/2023]
Abstract
Antiplatelet therapy plays a critical role in the prevention and treatment of major cardiovascular diseases triggered by thrombosis. Since the 1900s, significant progress in reducing morbidity and death caused by cardiovascular diseases has been made. However, despite the development and approval of drugs that specifically target the platelet, including inhibitors for cycloxygenase-1, P2Y12 receptor, integrin αIIbβ3, phosphodiesterases, and protease-activated receptor 1, the risk of recurrent thrombotic events remains high, and the increased risk of bleeding is a major concern. Scientific advances in our understanding of the role of platelets in haemostasis and thrombosis have revealed novel targets, such as protease-activated receptor 4 (PAR4), glycoprotein Ib (GPIb)-V-IX complex, glycoprotein VI, and 12-lipoxygenase. The antithrombotic effects and safety of the pharmacologic inhibition of these targets are currently under investigation in clinical studies. This review provides an overview of drugs in early development to target the platelet and those in current use in clinical practice. Furthermore, it describes the emerging drug targets being developed and studied to reduce platelet activity and outlines potential novel therapeutic targets in the platelet.
Collapse
Affiliation(s)
- Livia Stanger
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Adriana Yamaguchi
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Surgery, Division of Vascular Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| |
Collapse
|
42
|
Hoang Ngo T, Tran Khuong Nguyen N, Thi Ngoc Pham N, Tran BLT, Tuan Huynh A, Duy Nguyen K, Duy Nguyen K, Tran AV. The combination of CYP2C19 polymorphism and inflammatory cell ratios in prognosis cardiac adverse events after acute coronary syndrome. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 19:200222. [PMID: 37920809 PMCID: PMC10618803 DOI: 10.1016/j.ijcrp.2023.200222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Background CYP2C19 gene polymorphism combination with inflammatory cell ratios was significant in the prognosis of coronary heart disease. Materials and methods A cross-sectional analysis study, with 6 months follow-up on 142 patients with acute coronary syndrome. Patients were analyzed for CYP2C19 gene polymorphisms by real-time polymerase chain reaction (PCR) and complete blood count to determine inflammatory cell ratios and recorded cardiovascular events (CEs) after following up to 6 months. Results For 90-day CEs, CYP2C19 gene polymorphism (Hazard Ratio (HR): 1.965, 95 % Confidence Interval (CI): 1.012-3.814), the combination of a neutrophil and lymphocyte ratio (NLR) ≥ 2.982 (HR: 13.001, 95 % CI: 1.37-97.304) or a platelet to lymphocyte ratio (PLR) ≥ 162.42 (HR: 2.878, 95 % CI: 1.212-6.835) was independent predictors of CEs. For 180-day CEs, CYP2C19 gene polymorphism combination with NLR ≥3.02 (HR: 13.946, 95 % CI: 1.833-106.121) or PLR ≥160.38 (HR: 5.349, 95 % CI: 1.379-20.745) or monocyte to lymphocyte ratio (MLR) ≥ 0.3 (HR: 4.699, 95 % CI: 1.032-31.393) were independent predictors of CEs. Conclusion NLR, PLR or MLR combined with CYP2C19 gene polymorphism were stronger independent predictors of cardiovascular events in patients with acute coronary syndromes compared to CYP2C19 gene polymorphism and inflammatory cell ratios separately. CYP2C19 polymorphism and high NLR was the strongest predictor of both CEs at 90 days and 180 days.
Collapse
Affiliation(s)
- Toan Hoang Ngo
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - Nha Tran Khuong Nguyen
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - Nga Thi Ngoc Pham
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - Bao Lam Thai Tran
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - An Tuan Huynh
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - Khue Duy Nguyen
- Department of Interventional Cardiovascular and Neurology, Can Tho University of Medicine and Pharmacy Hospital, Can Tho City, 90000, Viet Nam
| | - Khuong Duy Nguyen
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| | - An Viet Tran
- Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City, 90000, Viet Nam
| |
Collapse
|
43
|
Leung JG. Ethnopsychopharmacology: Clinical and scientific writing pearls. Ment Health Clin 2023; 13:276-288. [PMID: 38058595 PMCID: PMC10696167 DOI: 10.9740/mhc.2023.12.276] [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: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 12/08/2023] Open
Abstract
The concept of ethnopsychopharmacology aims to predict or explain the pharmacologic response to psychiatric medications based on the influence of biologic and nonbiologic factors. Interactions involving these factors are complex and influence patient outcomes in health care. Pharmacists and other clinicians working in patient care environments, research, or medical education should engage in lifelong learning to enhance ethnopsychopharmacologic knowledge gaps, which ultimately may improve and individualize care across diverse populations. Through two cases, this paper provides pearls on how biogeographical ancestry and cytochrome P450 status may influence pharmacotherapy selection, dosing, or response. A third scenario highlights a publication, like many other published works, with deficiencies in how data on ancestry, race, and ethnicity are collected or reported. Current recommendations on the use of inclusive language in scientific writing are reviewed, with attention to specific examples.
Collapse
|
44
|
Cargnin S, Ferrari F, Terrazzino S. Impact of CYP2C19 Genotype on Efficacy and Safety of Clopidogrel-based Antiplatelet Therapy in Stroke or Transient Ischemic Attack Patients: An Updated Systematic Review and Meta-analysis of Non-East Asian Studies. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07534-0. [PMID: 38038819 DOI: 10.1007/s10557-023-07534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE Inconclusive and limited results have been reported on the clinical utility of CYP2C19 genotyping in stroke/TIA patients of non-East Asian ancestries. We herein performed an updated systematic review and meta-analysis to quantitatively estimate the association of CYP2C19 loss-of function (LOF) status with efficacy and safety of clopidogrel-based antiplatelet therapy in non-East Asian patients affected by stroke or TIA. METHODS A comprehensive search was performed up to July 2023 using PubMed, Web of Knowledge, and Cochrane Library databases. The clinical outcomes investigated were stroke, composite vascular events and bleeding. Pooled estimates were calculated as risk ratios (RR) with 95% CI using the Mantel- Haenszel random-effects model. The quality of evidence was assessed using the GRADEpro tool. RESULTS A total number of 1673 stroke/TIA patients from 8 non-East Asian studies, published between 2014 and 2022, were included in the systematic review. Clopidogrel-treated carriers of CYP2C19 LOF alleles were found at increased risk of stroke compared to non-carriers (RR: 1.68, 95%CI: 1.04-2.71, P = 0.03). However, no significant association was observed with the risk of composite vascular events (RR: 1.15, 95%CI: 0.58-2.28, P = 0.69) or bleeding (RR: 0.84, 95%CI: 0.38-1.86, P = 0.67). Similarly, European ancestry patients carrying CYP2C19 LOF alleles displayed a higher risk of stroke (RR: 2.69 (1.11-6.51, P = 0.03), but not of composite vascular events or bleeding. CONCLUSION The present updated meta-analysis provides moderate quality evidence of association between CYP2C19 LOF alleles and an increased risk of stroke in non-East Asian patients with stroke/TIA after receiving clopidogrel therapy. Further large pharmacogenetic studies are still warranted to corroborate these findings.
Collapse
Affiliation(s)
- Sarah Cargnin
- Department of Health Sciences, Università del Piemonte Orientale (UPO), Novara, Italy
| | - Federica Ferrari
- Dept of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Department of Emergency Neurology and Stroke Unit, IRCCS Mondino Foundation, Pavia, 27100, Italy
| | - Salvatore Terrazzino
- Department of Pharmaceutical Sciences, University of Piemonte Orientale A. Avogadro. Largo, Donegani 2, Novara, 28100, Italy.
| |
Collapse
|
45
|
Olson AW, Brown JT. How Pharmacogenomics Informs and Influences the Medication Experience. Innov Pharm 2023; 14:10.24926/iip.v14i4.5796. [PMID: 38495361 PMCID: PMC10939485 DOI: 10.24926/iip.v14i4.5796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Both pharmacogenomics (PGx) and the medication experience (MedXp) share a common purpose for their use, which is to optimally tailor medications to each unique individual. The former pursues this aim by using an individual's genetic makeup, while the latter considers the subjective experience of medication-taking in one's life. The different ways by which these fields of study pursue their shared aim have resulted in relatively little understanding of their relationship when utilized in care processes to produce health outcomes. This commentary explores this gap and identifies implications for future research that can help close it to improve person-centered care.
Collapse
Affiliation(s)
- Anthony W. Olson
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Duluth, Minnesota
- Essentia Institute of Rural Health, Duluth, Minnesota
| | - Jacob T. Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Duluth, Minnesota
| |
Collapse
|
46
|
Mauriello A, Ascrizzi A, Molinari R, Falco L, Caturano A, D’Andrea A, Russo V. Pharmacogenomics of Cardiovascular Drugs for Atherothrombotic, Thromboembolic and Atherosclerotic Risk. Genes (Basel) 2023; 14:2057. [PMID: 38003001 PMCID: PMC10671139 DOI: 10.3390/genes14112057] [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: 09/30/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
PURPOSE OF REVIEW Advances in pharmacogenomics have paved the way for personalized medicine. Cardiovascular diseases still represent the leading cause of mortality in the world. The aim of this review is to summarize the background, rationale, and evidence of pharmacogenomics in cardiovascular medicine, in particular, the use of antiplatelet drugs, anticoagulants, and drugs used for the treatment of dyslipidemia. RECENT FINDINGS Randomized clinical trials have supported the role of a genotype-guided approach for antiplatelet therapy in patients with coronary heart disease undergoing percutaneous coronary interventions. Numerous studies demonstrate how the risk of ineffectiveness of new oral anticoagulants and vitamin K anticoagulants is linked to various genetic polymorphisms. Furthermore, there is growing evidence to support the association of some genetic variants and poor adherence to statin therapy, for example, due to the appearance of muscular symptoms. There is evidence for resistance to some drugs for the treatment of dyslipidemia, such as anti-PCSK9. SUMMARY Pharmacogenomics has the potential to improve patient care by providing the right drug to the right patient and could guide the identification of new drug therapies for cardiovascular disease. This is very important in cardiovascular diseases, which have high morbidity and mortality. The improvement in therapy could be reflected in the reduction of healthcare costs and patient mortality.
Collapse
Affiliation(s)
- Alfredo Mauriello
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
| | - Antonia Ascrizzi
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
| | - Riccardo Molinari
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
| | - Luigi Falco
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
| | - Alfredo Caturano
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, 80100 Naples, Italy;
| | - Antonello D’Andrea
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
- Unit of Cardiology, “Umberto I” Hospital, Nocera Inferiore, 84014 Salerno, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Campania”—Monaldi Hospital, 80126 Naples, Italy; (A.M.); (A.A.); (R.M.); (L.F.); (A.D.)
| |
Collapse
|
47
|
Xie J, Pan T, Luo W, Zhang S, Fang Y, Xu Z. CYP2C19 *2/*2 Genotype is a Risk Factor for Multi-Site Arteriosclerosis: A Hospital-Based Cohort Study. Int J Gen Med 2023; 16:5139-5146. [PMID: 37954650 PMCID: PMC10637229 DOI: 10.2147/ijgm.s437251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023] Open
Abstract
Background Vascular diseases such as atherosclerosis usually affect multiple organs. Genetic factors have a certain proportion in the risk factors of atherosclerosis. The purpose was to investigate the relationship of cytochrome P450 2C19 (CYP2C19) polymorphisms with multi-site atherosclerosis. Methods The study included 410 patients with single-site atherosclerosis and 529 patients with multi-site atherosclerosis. The relationship between CYP2C19 rs4244285 and rs4986893 polymorphisms and single-site atherosclerosis and multi-site atherosclerosis was analyzed. Results The proportion of CYP2C19 rs4244285 A allele (35.9% vs 29.9%, P=0.007) and rs4986893 G allele (97.7% vs 94.8%, P=0.001) in multi-site atherosclerosis group was significantly higher than that in single-site atherosclerosis group. The distribution of CYP2C19 genotypes was significantly different between the two groups (P=0.002). The results of univariate logistic regression indicated that CYP2C19 *1/*3 genotype (*1/*3 vs *1/*1: odds ratio (OR) 0.456, 95% confidence interval (CI): 0.231-0.902, P=0.024) may decrease risk of multi-site atherosclerosis, while *2/*2 genotype (*2/*2 vs *1/*1: OR 1.780, 95% CI: 1.100-2.880, P=0.019) may increase risk of multi-site atherosclerosis. Multivariate logistic regression (adjusted for gender, age, smoking, drinking, hypertension, and diabetes) indicated that CYP2C19 *1/*3 genotype (*1/*3 vs *1/*1: OR 0.459, 95% CI: 0.231-0.909, P=0.026) may be an independent protective factor for multi-site atherosclerosis, while *2/*2 genotype (*2/*2 vs *1/*1: OR 1.767, 95% CI: 1.091-2.864, P=0.021) may be an independent risk factor for multi-site atherosclerosis. Conclusion CYP2C19 *1/*3 genotype may be an independent protective factor for multi-site atherosclerosis, while *2/*2 genotype may be an independent risk factor for multi-site atherosclerosis.
Collapse
Affiliation(s)
- Jieyao Xie
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Tingjun Pan
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Weiwen Luo
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Songsheng Zhang
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Yuquan Fang
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Zhou Xu
- Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| |
Collapse
|
48
|
Kim SE, Jeon HS, Go TH, Lee JH, Lee JW, Youn YJ, Kim BK, Joo HJ, Lim DS, Chang K, Park Y, Song YB, Suh JW, Lee SY, Cho JR, Her AY, Kim HS, Kim MH, Shin ES, Gorog DA, Tantry US, Gurbel PA, Jeong YH, Ahn SG. High Platelet Reactivity Combined with CYP2C19 Genotype in Predicting Outcomes in East Asian Patients Undergoing Percutaneous Coronary Intervention. Clin Pharmacol Ther 2023; 114:1104-1115. [PMID: 37597219 DOI: 10.1002/cpt.3026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Loss-of-function (LoF) alleles of cytochrome P450 2C19 (CYP2C19), which are prevalent in East Asians, are linked to high platelet reactivity (HPR) phenotype and poor prognosis. We aimed to investigate the incremental predictive value of HPR combined with CYP2C19 genotype in predicting outcomes after drug-eluting stent (DES) implantation. The patients treated with platelet function and genotype-related long-term prognosis in drug-eluting stent (PTRG-DES) consortium enrolled a total of 13,160 Korean patients treated with DES who had platelet function test (PFT) or CYP2C19 genotype, of which, 6,717 patients with PFT and genotype together were categorized. HPR was defined as VerifyNow ≥ 252 P2Y12 reaction unit. The primary outcome was the incidence of major adverse cardiac and cerebrovascular event (MACCE) 5 years after treatment. The patients with both HPR and CYP2C19 LoF/LoF had the highest MACCE rates (6.2%) and increased MACCE risk (adjusted hazard ratio: 1.89, 95% confidence interval: 1.20-2.91, P = 0.006) compared with those without both HPR and CYP2C19 LoF/LoF. There was no effect of interaction between HPR and CYP2C19 genotype on the primary outcome (P = 0.424). Adding combined HPR and CYP2C19 genotype to the conventional model had an incremental influence in predicting MACCE and stent thrombosis. Compared to the model including HPR or CYP2C19 genotype alone, a combination model significantly improved the risk stratification for stent thrombosis but not MACCE. In DES-treated East Asian patients, the combined evaluation of PFT results and CYP2C19 genotyping might improve risk prediction of ischemic events during clopidogrel treatment.
Collapse
Affiliation(s)
- Se-Eun Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ho-Sung Jeon
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Tae-Hwa Go
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sang Yeob Lee
- Division of Cardiology, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Young-Hoon Jeong
- Division of Cardiology, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| |
Collapse
|
49
|
Zubiaur P, Soria-Chacartegui P, Boone EC, Prasad B, Dinh J, Wang WY, Zugbi S, Rodríguez-Lopez A, González-Iglesias E, Leeder JS, Abad-Santos F, Gaedigk A. Impact of CYP2C:TG Haplotype on CYP2C19 Substrates Clearance In Vivo, Protein Content, and In Vitro Activity. Clin Pharmacol Ther 2023; 114:1033-1042. [PMID: 37528442 PMCID: PMC10592245 DOI: 10.1002/cpt.3012] [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: 05/03/2023] [Accepted: 07/26/2023] [Indexed: 08/03/2023]
Abstract
A novel haplotype composed of two non-coding variants, CYP2C18 NM_000772.3:c.*31T (rs2860840) and NM_000772.2:c.819+2182G (rs11188059), referred to as "CYP2C:TG," was recently associated with ultrarapid metabolism of various CYP2C19 substrates. As the underlying mechanism and clinical relevance of this effect remain uncertain, we analyzed existing in vivo and in vitro data to determine the magnitude of the CYP2C:TG haplotype effect. We assessed variability in pharmacokinetics of CYP2C19 substrates, including citalopram, sertraline, voriconazole, omeprazole, pantoprazole, and rabeprazole in 222 healthy volunteers receiving one of these six drugs. We also determined its impact on CYP2C8, CYP2C9, CYP2C18, and CYP2C19 protein abundance in 135 human liver tissue samples, and on CYP2C18/CYP2C19 activity in vitro using N-desmethyl atomoxetine formation. No effects were observed according to CYP2C:TG haplotype or to CYP2C19*1+TG alleles (i.e., CYP2C19 alleles containing the CYP2C:TG haplotype). In contrast, CYP2C19 intermediate (e.g., CYP2C19*1/*2) and poor metabolizers (e.g., CYP2C19*2/*2) showed significantly higher exposure in vivo, lower CYP2C19 protein abundance in human liver microsomes, and lower activity in vitro compared with normal, rapid (i.e., CYP2C19*1/*17), and ultrarapid metabolizers (i.e., CYP2C19*17/*17). Moreover, a tendency toward lower exposure was observed in ultrarapid metabolizers compared with rapid metabolizers and normal metabolizers. Furthermore, when the CYP2C19*17 allele was present, CYP2C18 protein abundance was increased suggesting that genetic variation in CYP2C19 may be relevant to the overall metabolism of certain drugs by regulating not only its expression levels, but also those of CYP2C18. Considering all available data, we conclude that there is insufficient evidence supporting clinical CYP2C:TG testing to inform drug therapy.
Collapse
Affiliation(s)
- Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), 28006 Madrid, Spain
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
| | - Paula Soria-Chacartegui
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), 28006 Madrid, Spain
| | - Erin C Boone
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, United States
| | - Jean Dinh
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
| | - Wendy Y Wang
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
| | - Santiago Zugbi
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Andrea Rodríguez-Lopez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), 28006 Madrid, Spain
| | - Eva González-Iglesias
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), 28006 Madrid, Spain
| | - J. Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28006 Madrid, Spain
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Research Institute (CMRI), Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| |
Collapse
|
50
|
Lopez J, Mark J, Duarte GJ, Shaban M, Sosa F, Mishra R, Jain S, Tran A, Khizar A, Karpel D, Acosta G, Rodriguez-Guerra M. Role of genetic polymorphisms in clopidogrel response variability: a systematic review. Open Heart 2023; 10:e002436. [PMID: 37963685 PMCID: PMC10649851 DOI: 10.1136/openhrt-2023-002436] [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: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Clopidogrel is a P2Y12 inhibitor that has become a mainstay treatment following percutaneous intervention with drug-eluting stent placement to decrease restenosis and its potential complications, including sudden cardiac death and ischaemic strokes in patients with significant vascular disease. AREAS COVERED As a prodrug, the metabolism and efficacy of clopidogrel are contingent on the presence of wild-type CYP450 (CYP2C19) alleles. Genetic polymorphisms and variants are well known to impair its ability to prevent major adverse cardiovascular events in these patients, with inadequate response rates as high as 30% in previous publications. Patterns of allelic frequencies are expected to exhibit similarities between individuals of the same ancestry, ethnic group or geographic region. Accordingly, we seek to further elucidate worldwide prevalence rates for genetic polymorphisms in the CYP2C19-dependent metabolism of clopidogrel and review the potential of personalised CYP2C19 genotyping in clinical practice to mitigate this high treatment resistance and its associated burden on patients. EXPERTS' COMMENTARY Our findings support the consideration of genotyping before initiation of therapy to guide adequate dosage or substitutions of other P2Y12 inhibitors to promote personalised, precision medicine and to prevent adverse events when these therapies may inevitably fail in patients with variants of the CYP450 (CYP2C19) system.
Collapse
Affiliation(s)
- Jose Lopez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, Lantana, Florida, USA
| | - Justin Mark
- Department of Internal Medicine, University of Miami Miller School of Medicine, Fort Lauderdale, Florida, USA
| | - Gustavo J Duarte
- Division of Cardiology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mohammed Shaban
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Franklin Sosa
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rishabh Mishra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Swati Jain
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - An Tran
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Asma Khizar
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Karpel
- Department of Internal Medicine, HCA Florida Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Giancarlo Acosta
- Division of Cardiology, Georgia Heart Institute, Gainesville, Florida, USA
| | - Miguel Rodriguez-Guerra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|