Ticagrelor

The effect of gene polymorphism on ticagrelor metabolism: an in vitro study of 22 CYP3A4 variants in Chinese Han population

Background

Ticagrelor is a novel oral antiplatelet agent which can selectively inhibit P2Y12 receptor. Bleeding and dyspnea are common adverse reactions of ticagrelor in clinic. The side effects of ticagrelor are correlated with the plasma concentration of ticagrelor.

Objective

This study aimed to evaluate the catalytic characteristics of 22 CYP3A4 alleles identified in the Chinese Han population on the metabolism of ticagrelor in vitro, focusing on the effect of CYP3A4 polymorphism on ticagrelor metabolism.

Methods

In this study, insect cells were used to express 22 CYP3A4 variants, which were then incubated with 1-50 µM ticagrelor at 37 °C for 30 minutes to obtain the metabolite (AR-C124910XX). AR-C124910XX was detected by UHPLC-MS/MS to calculate the kinetic parameters, including Km, Vmax and CLint.

Results

Compared to the wild-type, most CYP3A4 alleles exhibited significant differences in intrinsic clearance. The intrinsic clearance of CYP3A4*11, *18 and *33 was much higher than that of wild-type; four variants exhibited similar intrinsic clearance values as the wild-type enzyme; The remaining 14 variants showed significantly reduced intrinsic clearance values, ranging from 1.48% to 75.11% of the wild-type; CYP3A4*30 displayed weak or no activity.

Conclusion

This study conducted a comprehensive assessment of the effect of CYP3A4 variants on ticagrelor's metabolism. The results suggested that there is allele-specific activity towards ticagrelor in vitro. These findings can provide some insights and predictions for treatment strategies and risk assessments associated with ticagrelor in clinical practice.

The U.S. FDA approved cardiovascular drugs from 2011 to 2023: A medicinal chemistry perspective

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. A total of 28 new molecular entities (NMEs) were approved by the U.S. Food and Drug Administration (FDA) for the treatment of cardiovascular diseases from 2011 to 2023. Approximately 25 % of the medications were sanctioned for the management of diverse vascular disorders. The other major therapeutic areas of focus included antilipemic agents (15 %), blood pressure disease (11 %), heart failure, hyperkalemia, and cardiomyopathy (7-8% each). Among all the approved drugs, there are a total of 22 new chemical entities (NCEs), including inhibitors, agonists, polymers, and inorganic compounds. In addition to NCEs, 6 biological agents (BLAs), including monoclonal antibodies, small interfering RNAs (siRNAs), and antisense oligonucleotides, have also obtained approval for the treatment of cardiovascular diseases. From this perspective, approved NCEs are itemized and discussed based on their disease, targets, chemical classes, major drug metabolites, and biochemical and pharmacological properties. Systematic analysis has been conducted to examine the binding modes of these approved drugs with their targets using cocrystal structure information or docking studies to provide valuable insights for designing next-generation agents. Furthermore, the synthetic approaches employed in the creation of these drug molecules have been emphasized, aiming to inspire the development of novel, efficient, and applicable synthetic methodologies. Generally, the primary objective of this review is to provide a comprehensive examination of the clinical applications, pharmacology, binding modes, and synthetic methodologies employed in small-molecule drugs approved for treating CVD. This will facilitate the development of more potent and innovative therapeutics for effectively managing cardiovascular diseases.

Antiplatelet drug ticagrelor suppresses triple negative breast cancer metastasis by targeting PI3K

Metastatic recurrence is still a major challenge in breast cancer treatment. Patients with triple negative breast cancer (TNBC) develop early recurrence and relapse more frequently. Due to the lack of specific therapeutic targets, new targeted therapies for TNBC are urgently needed. Phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt)/mammalian target of rapamycin (mTOR) pathway is one of the active pathways involved in chemoresistance and survival of TNBC, being considered as a potential target for TNBC treatment. Our present study identified ticagrelor, an anti-platelet drug, as a pan-PI3K inhibitor with potent inhibitory activity against four isoforms of class I PI3K. At doses normally used in clinic, ticagrelor showed weak cytotoxicity against a panel of breast cancer cells, but significantly inhibited the migration, invasion and the actin cytoskeleton organization of human TNBC MDA-MB-231 and SUM-159PT cells. Mechanistically, ticagrelor effectively inhibited PI3K downstream mTOR complex 1 (mTORC1) and mTORC2 signaling by targeting PI3K and decreased the protein expression of epithelial-mesenchymal transition (EMT) markers. In vivo, ticagrelor significantly suppressed tumor cells lung metastasis in 4T1 tumor bearing BALB/c mice model and experimental lung metastasis model which was established by tail vein injection of GFP-labeled MDA-MB-231 cells. The above data demonstrated that ticagrelor can inhibit the migration and invasion of TNBC both in vitro and in vivo by targeting PI3K, suggesting that ticagrelor, a pan-PI3K inhibitor, might represent a promising therapeutic agent for the treatment of metastatic TNBC.

Preparation and Evaluation of a Self-Emulsifying Drug Delivery System for Improving the Solubility and Permeability of Ticagrelor

Ticagrelor (TCG) is a BCS class IV antiplatelet drug used to prevent platelet aggregation in patients with acute coronary syndrome, having poor solubility and permeability. The goal of this study was to develop a self-nanoemulsifying drug delivery system (SNEDDS) of TCG to improve its solubility and permeability. The excipients were selected based on the maximum solubility of TCG and observed by UV spectrophotometer. Different combinations of oil, surfactant, and co-surfactant (1:1, 2:1, and 3:1) were used to prepare TCG-SNEDDS formulations, and pseudo-ternary phase diagrams were plotted. The nanoemulsion region was observed. Clove oil (10-20%), Tween-80 (45-70%), and PEG-400 (20-45%) were used as an oil, surfactant, and co-surfactant, respectively. The selected formulations (F1, F2, F3, F4, F5, and F6) were analyzed for ζ potential, polydispersity index (PDI), ζ size, self-emulsification test, cloud point determination, thermodynamic studies, entrapment efficiency, Fourier transform infrared (FTIR) spectroscopy, X-ray diffraction (XRD), differential scanning calorimetry (DSC), thermogravimetric analysis (TGA), scanning electron microscopy (SEM), in vitro dissolution, ex vivo permeation, and pharmacodynamic study. The TCG-SNEDDS formulations exhibited ζ potential from -9.92 to -6.23 mV, a ζ average of 11.85-260.4 nm, and good PDI. The in vitro drug release in phosphate buffer pH 6.8 from selected TCG-SNEDDS F4 was about 98.45%, and F6 was about 97.86%, displaying improved dissolution of TCG in 0.1 N HCl and phosphate buffer pH 6.8, in comparison to 28.05% of pure TCG suspension after 12 h. While the in vitro drug release in 0.1 N HCl from F4 was about 62.03%, F6 was about 73.57%, which is higher than 10.35% of the pure TCG suspension. In ex vivo permeability studies, F4 also exhibited an improved apparent permeability of 2.7 × 10-6versus 0.6708 × 10-6 cm2/s of pure drug suspension. The pharmacodynamic study in rabbits demonstrated enhanced antiplatelet activity from TCG-SNEDDS F4 compared to that from pure TCG suspension. These outcomes imply that the TCG-SNEDDS may serve as an effective means of enhancing TCG's antiplatelet activity by improving the solubility and permeability of TCG.

Rosuvastatin plus ticagrelor decreases the risk of major adverse cardiovascular events and elevates cardiac function compared with ticagrelor alone in patients undergoing percutaneous coronary intervention: A meta‑analysis

Several previous studies have reported that rosuvastatin plus ticagrelor is superior to ticagrelor monotherapy in patients receiving percutaneous coronary intervention (PCI); several others, however, dispute this. The present meta-analysis summarized relevant studies, aiming to comprehensively explore the efficacy of rosuvastatin plus ticagrelor vs. ticagrelor monotherapy in patients receiving PCI. Published studies comparing the efficacy between rosuvastatin plus ticagrelor and ticagrelor alone among patients receiving PCI were searched in the CNKI, Wanfang, CQVIP, EMBASE, Cochrane and PubMed databases until January 2023. The present meta-analysis included 3 cohort studies and 4 randomized controlled trials with 426 patients receiving rosuvastatin plus ticagrelor and 424 patients receiving ticagrelor monotherapy. Rosuvastatin plus ticagrelor decreased the occurrence of major adverse cardiovascular events (MACE) compared with ticagrelor [relative risk (RR), 0.29; 95% confidence interval (CI), 0.18-0.47]. Subgroup analysis revealed similar findings in studies with a follow-up of <6 months (RR, 0.24; 95% CI, 0.13-0.47) and ≥6 months (RR, 0.36; 95% CI, 0.18-0.70), as well as in studies using 10 mg rosuvastatin (RR, 0.27; 95% CI, 0.15-0.50) and 20 mg rosuvastatin (RR, 0.33; 95% CI, 0.16-0.69). In addition, rosuvastatin plus ticagrelor decreased the left ventricular (LV) end-systolic diameter [mean difference (MD), -0.71; 95% CI, -(1.36-0.07)], LV end-diastolic diameter [MD, -1.17; 95% CI, -(1.91-0.43)] and N-terminal pro-B-type natriuretic peptide [MD, -2.97; 95% CI, -(4.55-1.38)], and increased the LV ejection fraction (MD, 0.99; 95% CI, 0.74-1.25). In conclusion, rosuvastatin plus ticagrelor was shown to decrease the risk of MACE and elevate cardiac function compared with ticagrelor monotherapy in patients receiving PCI.

Ticagrelor and primidone interaction masquerading as dual antiplatelet therapy noncompliance

Ticagrelor and aspirin is a common dual antiplatelet therapy regimen for patients who undergo percutaneous coronary intervention. Despite its ability to significantly reduce cardiovascular complications, ticagrelor response may be altered by other medications causing subtherapeutic effects. Traditionally, ticagrelor is thought to have fewer drug-drug interactions compared to other thienopyridine antiplatelet medications such as clopidogrel. Primidone, metabolized into phenobarbital, is a strong CYP-3A inducer that can reduce serum concentrations of ticagrelor resulting in ineffective antiplatelet therapy. We present a 67-year-old male who suffered in-stent thrombosis after percutaneous intervention possibly due to the interaction between primidone and ticagrelor.