Indobufen versus aspirin in patients with acute ischaemic stroke in China (INSURE): a randomised, double-blind, double-dummy, active control, non-inferiority trial

Indobufen versus aspirin in patients with indication for antiplatelet therapy: A systematic review and meta-analysis

INTRODUCTION

Aspirin is commonly recommended for individuals who have experienced stroke or myocardial infarction (MI). Indobufen, a cyclooxygenase-1 inhibitor, has been studied as a potential alternative. We conducted a meta-analysis and trial sequential analysis (TSA) to compare indobufen with aspirin in patients requiring antiplatelet therapy.

METHODS

We searched PubMed, Scopus, and Cochrane Central for studies that compared indobufen and aspirin antiplatelet therapies. We focused on efficacy outcomes, such as composite vascular events, MI, and ischemic stroke, and safety outcomes, such as major bleeding and any bleeding. Heterogeneity was assessed using I2 statistics, and our analysis followed the PRISMA guidelines.

RESULTS

The review included 5 studies with 11,943 patients (indobufen n = 5952, 49.84 %), three involving post-MI and two involving post-stroke patients. No significant differences were found between the groups in composite vascular events at 90 days (RR 0.84; 95 % CI 0.46-1.53; p = 0.560; I2 = 53 %) and 1-year (RR 1.13; 95 % CI 0.99-1.29; p = 0.08; I2 = 0 %). MI (RR 0.73; 95 % CI 0.43-1.22; p = 0.22; I2 = 0 %), ischemic stroke (RR 1.16; 95 % CI 0.99-1.37; p = 0.06; I2 = 0 %), and cardiovascular death (RR 1.35; 95 % CI 0.80-2.26; p = 0.257; I2 = 0 %) at 1-year also showed no significant differences. Major bleeding at 1 year (RR 0.73; 95 % CI 0.41-1.31; p = 0.297; I2 = 64 %) was comparable, but any bleeding at 1 year showed a significant difference (RR 0.65; 95 % CI 0.43-0.98; p = 0.03; I2 = 87 %) favoring indobufen. Subgroup analysis of RCTs showed marginally significant increased risk regarding ischemic stroke with indobufen (RR 1.18; 95 % CI 1.00-1.39; p = 0.05).

CONCLUSION

The efficacy and safety of antiplatelet therapy with indobufen were comparable to those of aspirin alone. Therefore, indobufen can be considered as a suitable alternative for patients who are intolerant or hypersensitive to aspirin. Nevertheless, additional trials involving larger populations are required to establish their clinical applicability.

The efficacy and safety of indobufen in patients with ischemic cardiovascular or cerebrovascular diseases: systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to evaluate the safety and efficacy of indobufen in the treatment of cardiovascular diseases, cerebrovascular diseases, and thromboembolic disorders. The primary focus is on the incidence of major adverse cardiovascular events (MACE), thrombosis, bleeding events, and adverse reactions. The results are intended to provide a reference for the clinical application of indobufen and suggest directions for further large-scale, multi-center, prospective studies.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library databases to identify all relevant studies on indobufen. Twelve trials, all randomized controlled trials (RCTs), met the inclusion criteria. The results were presented as risk ratios (RR) with 95% confidence intervals (CI), and meta-analysis was performed using RevMan 5.3 and Stata 18.0 software.

RESULTS

The meta-analysis included 12 randomized controlled trials. Regarding safety, indobufen showed superior clinical outcomes compared to other antiplatelet agents regarding bleeding events, gastrointestinal adverse reactions, and overall adverse reactions, with these differences being more pronounced in cardiovascular diseases. However, the effects of both treatments on efficacy outcomes, including MACE, myocardial infarction, angina, mortality, and thrombotic events, were similar. For stroke events, particularly in patients with cerebrovascular diseases, the use of indobufen was associated with some risk.

CONCLUSION

Indobufen is associated with a lower risk of adverse reactions and bleeding, making it a viable option for patients at risk of bleeding or adverse effects, particularly in those with cardiovascular diseases. However, compared to anticoagulants such as aspirin and clopidogrel, indobufen has a shorter history of use, and its evidence base is relatively limited, highlighting the need for further research. Currently, indobufen is widely used in secondary cardiovascular and cerebrovascular prevention and provides some guidance for antiplatelet therapy in patients with gastrointestinal discomfort or bleeding risk. However, due to the potential risks in MACE, stroke, and other events, further clinical trials are needed to assess the clinical applicability of indobufen.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/, identifier (CRD42024587938).

Perception and acquaintance of stroke specialists on non-inferiority trials: An international survey

INTRODUCTION

The adoption of non-inferiority trial designs for assessing new interventions in stroke treatment is on the rise. We designed a survey to assess stroke specialists' understanding and familiarity with non-inferiority trials and margins.

METHODS

A brief web-based questionnaire was sent to the members of the World Stroke Organization (WSO). The median acceptable non-inferiority margins in different research settings provided by responders were summarized and reported according to the acquaintance of responders with non-inferiority trials.

RESULTS

A total of 120 WSO members from 42 countries responded to the survey. Thirty-two percent (32 %) of respondents self-identified as being very familiar with non-inferiority trials, while 6 % identified as extremely familiar. When asked about the impact of non-inferiority trials on improving stroke patient care, 42 % rated it as high and 45 % as moderate. 83 % of responders reported that the findings of non-inferiority trials affect their clinical practice. Ease of administration, relative effect of the standard treatment, clinical implications of inappropriately introducing the new treatment, availability, price, ease of storage and shipping were all considered as factors that should influence the size of the non-inferiority margin. The magnitude and variability of acceptable non-inferiority margins were seen to decrease as the acquaintance of responders with non-inferiority trials increased.

CONCLUSION

Although responders acknowledge the importance of non-inferiority trials, most have limited acquaintance with this research design. Educational activities are needed to enhance literacy in non-inferiority trials and the interpretation of non-inferiority margins.

Design, synthesis, and biological evaluation of novel iNOS inhibitors as potent neuroprotective agents for ischemic stroke

Ischemic stroke (IS) is characterized by intricate pathophysiological mechanisms, where single-target treatments have often proven insufficient. Thus, multi-target therapeutic approaches are essential for effective IS management. In this study, we employed a molecular hybridization strategy, merging the structures of the iNOS inhibitor 1400W and the multi-target neuroprotective agent NBP, to develop a series of novel iNOS inhibitors BN-1 ∼ BN-4 with neuroprotective properties. Among these, BN-4 exhibited the most potent cell protective activity in OGD/R-induced SH-SY5Y and BV-2 cells. BN-4 not only reduced ROS levels induced by OGD/R in SH-SY5Y cells but also mitigated necrosis and apoptosis. By binding to iNOS in a manner similar to 1400W, BN-4 significantly inhibited iNOS activity. Furthermore, BN-4 demonstrated high stability, excellent blood-brain barrier permeability, and more than 100-fold increase in aqueous solubility compared to NBP. Additionally, BN-4 notably decreased infarct size and showed neuroprotective effects in tMCAO rats. These findings indicate that BN-4 holds promise as a novel candidate for treatment IS, offering enhanced therapeutic efficacy due to its superior pharmacokinetic and pharmacodynamic properties.

The safety and efficacy of indobufen or aspirin combined with clopidogrel in patients with acute myocardial infarction after percutaneous coronary intervention

Currently, the standard treatment for patients who have undergone percutaneous coronary intervention (PCI) following acute myocardial infarction (MI) involves dual antiplatelet therapy (DAPT) with a combination of aspirin and a potent P2Y12 receptor inhibitor. However, the potential benefits of aspirin were partially constrained by the intolerance of some patients. The safety and efficacy of indobufen, an alternative antiplatelet agents to aspirin, in patients with AMI after PCI are yet to be thoroughly investigated.This retrospective study was conducted at a single center and utilized propensity score matching. The enrollment spanned from January 2019 to June 2022, incorporating patients with AMI after PCI. The participants were categorized into two groups based on discharged prescriptions: the aspirin DAPT group and the indobufen DAPT group. The primary endpoint focused on net adverse clinical event (NACE), defined as a composite outcome, including cardiac death, recurrence of MI, definite or probable stent thrombosis (ST), target lesion revascularization (TLR), ischemic stroke and Bleeding Academic Research Consortium (BARC) criteria type 2, 3, or 5. All the patients underwent a one-year follow-up period.A total of 1451 patients were enrolled in this study, with 258 assigned to the indobufen DAPT group and 1193 to the aspirin DAPT group. Following 1:1 propensity score matching, 224 patients were retained in each group. In the indobufen DAPT group, 58 individuals (25.9%) experienced the primary endpoint within one year, compared to 52 individuals (23.2%) in the aspirin DAPT group (HR 1.128, 95% CI 0.776-1.639, p = .527). Specifically, no significant differences were observed in either the efficacy endpoint (MACCE, 20.1% vs. 14.7%, HR 1.392, 95% CI 0.893-2.170, p = .146) or the safety endpoint (BARC 2,3 or 5, 8.04% vs. 10.30%, HR 0.779, p = .427). These findings remained consistent at 1, 3, or 6 months. Additionally, the incidence of gastrointestinal symptoms were significantly lower in indobufen DAPT group compared to the aspirin DAPT group (7.1% vs. 14.3%, p = .022).Our research reveals that the efficacy and safety of indobufen are comparable to aspirin in Chinese patients with AMI following PCI. Given the potential advantages of indobufen in alleviating gastrointestinal symptoms, we propose it as a viable alternative for individuals intolerant to aspirin.

Metabolomics revealed pharmacodynamic effects of aspirin and indobufen in patients after percutaneous transluminal angioplasty surgery

Introduction

Aspirin and indobufen are commonly used therapeutic drugs for the prevention of vascular restenosis (VR) after percutaneous transluminal angioplasty surgery. They both exhibited antiplatelet effects but molecular mechanisms underlying metabolic changes induced by them remain unclear.

Methods

In this study, we collected plasma samples from patients on aspirin medication (n = 5), patients on indobufen medication, patients with no medication after PTA, and healthy controls (CKs) (n = 5). Our investigation aimed to reveal the metabolic processes in patients during vascular restenosis and its amelioration through drug therapy using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Results

Our data showed significant alterations in amino acid and choline metabolism in patients without medication after PTA. Aspirin and indobufen were able to regulate these metabolic pathways to alleviate VR symptoms. We identified several characteristic amino acids, including pro-leu, L-citrulline, his-glu, and L-glutamate, as important biomarkers for VR assessment in patients without medication after PTA. A total of 17 and 4 metabolites involved in arginine and phenylalanine metabolism were specifically induced by aspirin and indobufen, respectively. Their expression levels were significantly regulated by aspirin or indobufen, nearly reaching normal levels.

Discussion

Taken together, our identification of metabolites involved in metabolic changes affected by aspirin and indobufen medication enhances the understanding of VR pathology after PTA. This may help identify early diagnostic biomarkers and therapeutic targets.

Recent advances in the prevention of secondary ischemic stroke: A narrative review

Stroke remains a significant contributor to global morbidity and mortality, with acute ischemic stroke comprising the majority of cases. Secondary stroke, the recurrent stroke, is often more severe and linked to worse functional outcomes and increased mortality. The secondary prevention of ischemic stroke is crucial for reducing the risk of recurrent events. Significant advancements have been made in secondary prevention strategies in recent years. These include the refinement of antithrombotic regimens, the use of direct oral anticoagulants in managing atrial fibrillation, and the implementation of more aggressive targets for blood pressure, lipid management, and glucose management. Furthermore, emerging therapeutic approaches, such as remote ischemic conditioning and anti-inflammatory agents such as colchicine, have shown promise in reducing stroke recurrence through nontraditional mechanisms. This review summarizes the latest advancements in the secondary prevention of ischemic stroke over the past 5 years, highlighting the key clinical trials and novel interventions. The optimization of traditional risk factor management and the emergence of novel therapeutic methods have provided more options for clinical practice. Future research should focus on identifying the optimal treatment strategies for specific patient subgroups and the clinical translation and application of new therapeutic methods.

The pharmacology of antiplatelet agents for primary, secondary, and tertiary prevention of ischemic stroke

INTRODUCTION

Ischemic etiology accounts for two thirds of all strokes in which platelet activation and aggregation play a major role. A variety of antiplatelet therapies have been tested for primary, secondary, and tertiary prevention, with certain patient subtypes benefiting more than others from a specific regimen.

AREAS COVERED

This review aims at synthetizing current evidence on pharmacology of antiplatelet agents approved for primary, secondary, and tertiary stroke prevention and their application among possible patient subtypes that may benefit more from their administration.

EXPERT OPINION

Management of ischemic stroke has largely evolved over the past decades. A better understanding of stroke pathophysiology has allowed to identify patients who can benefit most from antiplatelet therapies, with varying degrees of benefit depending on whether these agents are being used for primary, secondary, or tertiary prevention. Importantly, the antiplatelet treatment regimens currently available have expanded and no longer limited to aspirin but include other drugs such as P2Y12 and phosphodiesterase inhibitors, also used in combination, as well as precision medicine approaches using genetic testing aiming at optimizing the safety and efficacy in this population.

Chinese expert consensus on anti-thrombotic therapy for pan-vascular diseases (2023 edition)

Pan-vascular disease is a systemic condition characterized by vascular lesions, with atherosclerosis comprising 95% of cases, manifesting as coronary artery disease, cerebrovascular disease, peripheral artery disease, or combinations thereof, known as multivascular disease. In China, the burden of pan-vascular diseases is substantial, necessitating urgent improvements in patient prognosis. Despite being managed by different disciplines, pan-vascular diseases often share common risk factors and pathophysiological mechanisms, underscoring the need for standardized treatment strategies. Anti-thrombotic therapy for pan-vascular diseases primarily involves antiplatelet and anticoagulant therapy. Currently, there is a lack of unified guidance across various disciplines for patients with differing ischemic and bleeding risks and disease stages. Recognizing the pivotal role of standardized anti-thrombotic therapy in pan-vascular disease treatment, the Chinese College of Cardiovascular Physicians organized a consensus working group comprising 33 senior experts from cardiology, vascular surgery, neurology, and endocrinology. The “Chinese expert consensus on anti-thrombotic therapy for pan-vascular diseases (2023 Edition)” was developed based on specific treatment needs in China, incorporating published clinical research evidence, specialized guidelines and consensus, and recommendations from the consensus expert group. The primary aim of this consensus is to standardize the application of anti-thrombotic therapy in pan-vascular diseases, thereby optimizing clinical outcomes, improving patient prognosis, and mitigating the economic and societal burdens associated with pan-vascular disease.

Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction

ABSTRACT

Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.