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Hou Q, Chen Y, Zhang Y, Pang C. Comparative Muscle Tolerability of Different Types and Intensities of Statins: A Network Meta-Analysis of Double-Blind Randomized Controlled Trials. Cardiovasc Drugs Ther 2024; 38:459-469. [PMID: 36447018 DOI: 10.1007/s10557-022-07405-0] [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: 11/04/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE The benefits of statins for ischemic cardio-cerebrovascular diseases are well known. However, concerns around muscle adverse events still exist. We therefore aimed to compare the muscle safety of individual statins in adults. METHODS PubMed, Embase, Cochrane Central Register of Controlled Trials and Web of Science were searched to include double-blind randomized controlled trials (RCTs) comparing one statin with another or with control treatment. Pairwise meta-analyses and network meta-analyses were undertaken with Stata 14.0 software. Relative risk (RR) with 95% confidence intervals (CIs) was adopted for each outcome. RESULTS A total of 83 RCTs were included. In the pairwise meta-analysis, statins were significantly associated with only a slight increase in muscle symptoms compared with control (RR=1.05; 95% CI=1.01-1.09). In the drug-level network meta-analyses, no statistically significant difference was found between individual statins in the incidence of muscle symptoms, myalgia, myopathy, rhabdomyolysis, creatine kinase (CK) >10 times the upper limit of normal (ULN) or discontinuation due to muscle adverse events. In the dose-level network meta-analyses, there were no statistically significant dose-dependent effects on any outcomes except that moderate-intensity statins had a higher incidence of muscle symptoms than control (RR=1.13; 95% CI=1.01-1.27). Moderate simvastatin (RR=6.57; 95% CI=1.26-34.41) and moderate pravastatin (RR=5.96; 95% CI=1.00-35.44) had a statistically significantly higher incidence of CK >10×ULN compared with moderate atorvastatin. Lipophilic statins and statins metabolized by liver cytochrome P450 3A4 were not associated with an increased risk of muscle adverse events. CONCLUSION Statins may be generally safe on muscle. Moderate atorvastatin may be superior to equivalent simvastatin and pravastatin in muscle tolerability.
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Affiliation(s)
- Qingtao Hou
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, 1# Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Yuqin Chen
- Neuroscience Research Center, College of Basic Medicine, Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Yingxiao Zhang
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, 1# Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Caishuang Pang
- Chongqing Medical University, Chongqing, 400016, People's Republic of China
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Mykkänen AJH, Tarkiainen EK, Taskinen S, Neuvonen M, Paile-Hyvärinen M, Lilius TO, Tapaninen T, Klein K, Schwab M, Backman JT, Tornio A, Niemi M. Genome-Wide Association Study of Atorvastatin Pharmacokinetics: Associations With SLCO1B1, UGT1A3, and LPP. Clin Pharmacol Ther 2024; 115:1428-1440. [PMID: 38493369 DOI: 10.1002/cpt.3236] [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: 11/18/2023] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
In a genome-wide association study of atorvastatin pharmacokinetics in 158 healthy volunteers, the SLCO1B1 c.521T>C (rs4149056) variant associated with increased area under the plasma concentration-time curve from time zero to infinity (AUC0-∞) of atorvastatin (P = 1.2 × 10-10), 2-hydroxy atorvastatin (P = 4.0 × 10-8), and 4-hydroxy atorvastatin (P = 2.9 × 10-8). An intronic LPP variant, rs1975991, associated with reduced atorvastatin lactone AUC0-∞ (P = 3.8 × 10-8). Three UGT1A variants linked with UGT1A3*2 associated with increased 2-hydroxy atorvastatin lactone AUC0-∞ (P = 3.9 × 10-8). Furthermore, a candidate gene analysis including 243 participants suggested that increased function SLCO1B1 variants and decreased activity CYP3A4 variants affect atorvastatin pharmacokinetics. Compared with individuals with normal function SLCO1B1 genotype, atorvastatin AUC0-∞ was 145% (90% confidence interval: 98-203%; P = 5.6 × 10-11) larger in individuals with poor function, 24% (9-41%; P = 0.0053) larger in those with decreased function, and 41% (16-59%; P = 0.016) smaller in those with highly increased function SLCO1B1 genotype. Individuals with intermediate metabolizer CYP3A4 genotype (CYP3A4*2 or CYP3A4*22 heterozygotes) had 33% (14-55%; P = 0.022) larger atorvastatin AUC0-∞ than those with normal metabolizer genotype. UGT1A3*2 heterozygotes had 16% (5-25%; P = 0.017) smaller and LPP rs1975991 homozygotes had 34% (22-44%; P = 4.8 × 10-5) smaller atorvastatin AUC0-∞ than noncarriers. These data demonstrate that genetic variation in SLCO1B1, UGT1A3, LPP, and CYP3A4 affects atorvastatin pharmacokinetics. This is the first study to suggest that LPP rs1975991 may reduce atorvastatin exposure. [Correction added on 6 April, after first online publication: An incomplete sentence ("= 0.017) smaller in heterozygotes for UGT1A3*2 and 34% (22%, 44%; P × 10-5) smaller in homozygotes for LPP noncarriers.") has been corrected in this version.].
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Affiliation(s)
- Anssi J H Mykkänen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - E Katriina Tarkiainen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Suvi Taskinen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Mikko Neuvonen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Maria Paile-Hyvärinen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Tuomas O Lilius
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Tuija Tapaninen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Kathrin Klein
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
- Department of Clinical Pharmacology, University of Tübingen, Tübingen, Germany
- Department of Biochemistry and Pharmacy, University of Tübingen, Tübingen, Germany
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Aleksi Tornio
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
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Park YA, Chang Y, Lee DH, Kim JS, Park M, Choi SA, Song TJ, Gwak HS. Association between coenzyme Q 10-related genetic polymorphisms and statin-associated myotoxicity in Korean stroke patients. Front Pharmacol 2024; 15:1358567. [PMID: 38774208 PMCID: PMC11106472 DOI: 10.3389/fphar.2024.1358567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/17/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction The purpose of this study is to identify the relationship between coenzyme Q 10 (CoQ10)-related gene polymorphisms and statin-related myotoxicity (SRM). Methods We retrospectively analyzed prospectively collected samples from February to May 2021. To investigate the association between CoQ10-related genetic factors and SRM, we selected 37 single nucleotide polymorphisms from five genes (COQ2, COQ3, COQ5, COQ6, and COQ7). The odds ratio (OR) and adjusted OR with 95% confidence intervals (CI) were calculated for univariate and multivariable logistic regression analyses, respectively. Results A total of 688 stroke patients were included in the analysis, including 56 SRM cases. In the multivariable analysis, two models were constructed using demographic factors only in model I, and demographic and genetic factors in model II. Compared to other statins, atorvastatin decreased the SRM risk whereas ezetimibe use increased the SRM risk in model I and model II. Patients with COQ2 rs4693075 G allele, COQ3 rs11548336 TT genotype, and COQ5 rs10849757 A allele had a 2.9-fold (95% CI: 1.6-5.3), 1.9-fold (95% CI: 1.1-3.5), and 3.3-fold (95% CI: 1.5-8.3) higher risk of SRM, respectively. Conclusion This study could be utilized to develop a personalized medicine strategy in patients treated with statins.
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Affiliation(s)
- Yoon-A Park
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Da Hoon Lee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jung Sun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Minju Park
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Seo-A Choi
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
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Ingelman-Sundberg M, Pirmohamed M. Precision medicine in cardiovascular therapeutics: Evaluating the role of pharmacogenetic analysis prior to drug treatment. J Intern Med 2024; 295:583-598. [PMID: 38343077 DOI: 10.1111/joim.13772] [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] [Indexed: 04/09/2024]
Abstract
Pharmacogenomics is the examination of how genetic variation influences drug metabolism and response, in terms of both efficacy and safety. In cardiovascular disease, patient-specific diplotypes determine phenotypes, thereby influencing the efficacy and safety of drug treatments, including statins, antiarrhythmics, anticoagulants and antiplatelets. Notably, polymorphisms in key genes, such as CYP2C9, CYP2C19, VKORC1 and SLCO1B1, significantly impact the outcomes of treatment with clopidogrel, warfarin and simvastatin. Furthermore, the CYP2C19 polymorphism influences the pharmacokinetics and safety of the novel hypertrophic cardiomyopathy inhibitor, mavacamten. In this review, we critically assess the clinical application of pharmacogenomics in cardiovascular disease and delineate present and future utilization of pharmacogenomics. This includes insights into identifying missing heritability, the integration of whole genome sequencing and the application of polygenic risk scores to enhance the precision of personalized drug therapy. Our discussion encompasses health economic analyses that underscore the cost benefits associated with pre-emptive genotyping for warfarin and clopidogrel treatments, albeit acknowledging the need for further research in this area. In summary, we contend that cardiovascular pharmacogenomic analyses are underpinned by a wealth of evidence, and implementation is already occurring for some of these gene-drug pairs, but as with any area of medicine, we need to continually gather more information to optimize the use of pharmacogenomics in clinical practice.
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Affiliation(s)
- Magnus Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, Stockholm, Sweden
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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Ohyama K, Iida M, Akiyama S, Yamazaki H, Hori Y. Time-to-onset Analysis of Rhabdomyolysis due to Different Proton Pump Inhibitors Using a Pharmacovigilance Database. In Vivo 2024; 38:1285-1291. [PMID: 38688634 PMCID: PMC11059858 DOI: 10.21873/invivo.13567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND/AIM Recent research has increasingly demonstrated an association between proton pump inhibitors (PPIs) and serious adverse events. This study aimed to evaluate the association between PPI and rhabdomyolysis (RM), examining its time-to-onset profiles using the Japanese Adverse Drug Event Report (JADER) database. PATIENTS AND METHODS Data spanning from April 2004 to March 2022 were used. The association between PPIs and RM was evaluated using the reporting odds ratio (ROR), adjusted for sex and age. Subsequent analyses were conducted after excluding cases involving concomitant use of statins or fibrates. Furthermore, the onset time of RM and Weibull distribution parameters were calculated to evaluate the expression profile of RM, and the outcomes were examined. RESULTS RM was associated with the use of esomeprazole, omeprazole, and rabeprazole, even in the absence of concomitant statin or fibrate use. The median time to RM onset varied among PPIs, ranging from 6.5 to 127 d. The Weibull distribution parameters indicated that the hazard types of nearly all orally administered PPIs were classified as early failure or close to random failure. Regarding outcomes, cases of death were reported for all PPIs except vonoprazan. CONCLUSION The findings suggest the need for vigilant monitoring of RM during PPI administration, particularly in the early stages, considering the varying onset times.
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Affiliation(s)
- Katsuhiro Ohyama
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan;
| | - Megumi Iida
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Shota Akiyama
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Hiroshi Yamazaki
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, Tokyo, Japan
| | - Yusuke Hori
- Center for Experiential Pharmacy Practice, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
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Miernik S, Matusiewicz A, Olesińska M. Drug-Induced Myopathies: A Comprehensive Review and Update. Biomedicines 2024; 12:987. [PMID: 38790948 PMCID: PMC11117896 DOI: 10.3390/biomedicines12050987] [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: 03/09/2024] [Revised: 04/19/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
Drug-induced myopathies are a common cause of muscle pain, and the range of drugs that can cause muscle side effects is constantly expanding. In this article, the authors comprehensively discuss the diagnostic and therapeutic process in patients with myalgia, and present the spectrum of drug-induced myopathies. The review provides a detailed analysis of the literature on the incidence of myopathy during treatment with hypolipemic drugs, beta-blockers, amiodarone, colchicine, glucocorticosteroids, antimalarials, cyclosporine, zidovudine, and checkpoint inhibitors, a group of drugs increasingly used in the treatment of malignancies. The article considers the clinical course of the different types of myopathies, their pathogenesis, histopathological features, and treatment methods of these disorders. The aim of this paper is to gather from the latest available literature up-to-date information on the course, pathophysiology, and therapeutic options of drug-induced myopathies, to systematize the knowledge of drug-induced myopathies and to draw the attention of internists to the fact that these clinical issues are an important therapeutic problem.
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Affiliation(s)
| | - Agata Matusiewicz
- Department of Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland; (S.M.); (M.O.)
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Alla SSM, Shah DJ, Ratheesh V, Alla D, Tummala T, Khetan MS, Shah RJ, Bayeh RG, Fatima M, Ahmed SK, Sabıroğlu M. Effectiveness of statins in people living with HIV: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Clin Pharmacol 2024:1-9. [PMID: 38629133 DOI: 10.1080/17512433.2024.2344672] [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: 12/04/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION People living with HIV (PLWH) receiving statin therapy have shown improved lipid profiles. However, they are not free from side effects, thereby requiring strict monitoring of the therapy. The meta-analysis aims to analyze the effect of statins in PLWH and critically appraise the effectiveness of statin therapy in PLWH. METHODS PubMed, Scopus, and Web of Science servers were used to conduct a systematic search in compliance with the PRISMA guidelines. The meta-analysis of pooled effect estimates is produced using Revman software. RESULTS A total of 12 RCTs with 8716 participants were included in the analysis. Analysis of the overall effect estimates found that statins resulted in a mean reduction of 41.15 mg/dl (MD = -41.15; 95% CI: -44.19, -38.11; p < 0.00001), 34.99 mg/dl (MD = -34.99; 95% CI: -34.99; 95% CI: -41.16, -28.82; p < 0.00001), and 7.36 mg/dl (MD = -7.36; 95% CI = -48.35, -33.62; p < 0.00001) in total cholesterol, low-density lipoprotein, and triglyceride levels, respectively. It is revealed that statins are associated with a significant increase in the discontinuation rate of treatment compared to placebo treatment (RR: 1.90; 95% CI: 1.36-2.65; p = 0.0002). CONCLUSION When considered collectively, statin therapy's advantages appear to exceed its occasional predictable side effects like liver or muscle toxicity. REGISTRATION PROSPERO registration ID: CRD42023469521.
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Affiliation(s)
| | - Dhruv J Shah
- Department of Public Health, Massachusetts College of Pharmacy and Health Sciences, Boston, USA
| | - Vysakh Ratheesh
- Department of General Medicine, Medical University Pleven, Pleven, Bulgaria
| | - Deekshitha Alla
- Department of General Medicine, Andhra Medical College, Visakhapatnam, India
| | - Thanmayee Tummala
- Department of General Medicine, Bhaskar Medical College and Bhaskar General Hospital, Hyderabad, India
| | - Moksh S Khetan
- Department of General Medicine, Vedantaa Institute of Medical Sciences, Dahanu, India
| | - Ritika J Shah
- Department of General Medicine, Vedantaa Institute of Medical Sciences, Dahanu, India
| | - Ruth G Bayeh
- Department of General Medicine, Adama General Hospital and Medical College, Adama, Ethiopia
| | - Mahek Fatima
- Department of General Medicine, Osmania Medical College, Hyderabad, India
| | - Sanah K Ahmed
- Department of General Medicine, MVJ Medical College and Research Hospital, Bangalore, India
| | - Mert Sabıroğlu
- Department of Medicine, Koc University School of Medicine, Istanbul, Türkiye
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Park S, Lee JW, Nam DR, Jung SY. Exploring signals of myopathy associated with statin and contraindicated comedications in the realworld. Fundam Clin Pharmacol 2024; 38:380-388. [PMID: 37818695 DOI: 10.1111/fcp.12959] [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: 08/11/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Using statins in combination with other drugs was reported to increase the risk of myopathy. However, there was a sparse number of studies on the incidence of adverse events (AEs) associated with the concomitant use of statin and contraindicated drugs in the real world. OBJECTIVES This study aimed to identify the risk of concomitant use of statins with contraindicated drugs by exploring signals related to statin-drug interactions. METHODS We performed a disproportionality analysis for drugs and AEs by applying the case/non-case study using the KIDS-KAERS database (KIDS-KD), 2016-2020. A case was defined as an individual case safety reports (ICSRs) including "rhabdomyolysis/myopathy." A non-case was defined as an ICSR, including all other AEs. We applied Ω shrinkage measure model, chi-square statics model, additive model, multiplicative model, and combination risk ratio model to detect signals of myopathy due to statin with concomitant drugs including antiviral agents, immunosuppressants, and antifungals. RESULTS Among 1 011 234 ICSRs, 2708 were cases, with 861 cases of statin monotherapy and 1248 of concomitant uses of statin. The adjusted reporting odds ratios were 3.27 (95% confidence interval [CI]: 3.11-3.43), 8.70 (95% CI: 8.04-9.40), and 1.83 (95% CI: 1.73-1.94), respectively. Several combinations of signals were detected through an additive model or multiplicative model. CONCLUSION Signals of an increased risk of myopathy associated with the use of statins with concomitant drugs, including contraindicated drugs, were confirmed in a real-world setting.
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Affiliation(s)
- Sewon Park
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Ju Won Lee
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Dal Ri Nam
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
- Department of Global Innovative Drugs, The Graduate School of Chung-Ang University, Seoul, Republic of Korea
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Lauritzen T, Munkhaugen J, Bergan S, Peersen K, Svarstad AC, Andersen AM, Pahnke J, Husebye E, Vethe NT. The atorvastatin metabolite pattern in muscle tissue and blood plasma is associated with statin muscle side effects in patients with coronary heart disease; An exploratory case-control study. ATHEROSCLEROSIS PLUS 2024; 55:31-38. [PMID: 38293288 PMCID: PMC10825484 DOI: 10.1016/j.athplu.2024.01.001] [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: 12/27/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
Background and aims Statin-associated muscle symptoms (SAMS) is a prevalent cause of statin discontinuation. It is challenging and time-consuming for clinicians to assess whether symptoms are caused by the statin or not, and diagnostic biomarkers are requested. Atorvastatin metabolites have been associated with SAMS. We aimed to compare atorvastatin pharmacokinetics between coronary heart disease (CHD) patients with and without clinically statin intolerance and statin-dependent histopathological alterations in muscle tissue. Secondarily we aimed to assess genetic variants relevant for the observed pharmacokinetic variables. Methods Twenty-eight patients with CHD and subjective SAMS were included in the exploratory MUSE biomarker study in 2020. Participants received atorvastatin 40 mg/day for seven weeks followed by no statins for eight weeks. Muscle biopsies and blood were collected at the end of each period. Four patients were categorized as clinically intolerant to ≥3 statins prior to study start whereas four patients had signs of muscle cell damage during treatment. Results We found significantly lower levels of atorvastatin acids, and higher lactone/acid ratios in the statin intolerant, both in muscle and plasma. With optimal cut-off, the combination of 2-OH-atorvastatin acid and the 2-OH-atorvastatin lactone/acid ratio provided sensitivity, specificity, and predictive values of 100 %. Patients with variants in UGT1A1 and UGT1A3 had higher lactone metabolite levels than those with wild type, both in muscle and plasma. Conclusion Atorvastatin metabolites appear promising as biomarkers for the identification of clinical statin intolerance in patients with self-perceived SAMS, but the findings have to be confirmed in larger studies.
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Affiliation(s)
- Trine Lauritzen
- Department of Medicine, Vestre Viken Trust, Drammen Hospital, Drammen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Laboratory Medicine, Vestre Viken Trust, Drammen Hospital, Drammen, Norway
| | - John Munkhaugen
- Department of Medicine, Vestre Viken Trust, Drammen Hospital, Drammen, Norway
- Department of Behavioural Medicine, Institute of Basic Medical Sciences, University of Oslo, Norway
| | - Stein Bergan
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Kari Peersen
- Department of Cardiology, Vestfold Hospital Trust, Tønsberg, Norway
| | | | | | - Jens Pahnke
- Section of Neuropathology Research1, Departments of Clinical Medicine and Pathology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Einar Husebye
- Department of Medicine, Vestre Viken Trust, Drammen Hospital, Drammen, Norway
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
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Hoste E, Haufroid V, Deldicque L, Balligand JL, Elens L. Atorvastatin-associated myotoxicity: A toxicokinetic review of pharmacogenetic associations to evaluate the feasibility of precision pharmacotherapy. Clin Biochem 2024; 124:110707. [PMID: 38182100 DOI: 10.1016/j.clinbiochem.2024.110707] [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: 10/11/2023] [Revised: 01/02/2024] [Accepted: 01/02/2024] [Indexed: 01/07/2024]
Abstract
Atorvastatin (ATV) and other statins are highly effective in reducing cholesterol levels. However, in some patients, the development of drug-associated muscle side effects remains an issue as it compromises the adherence to treatment. Since the toxicity is dose-dependent, exploring factors modulating pharmacokinetics (PK) appears fundamental. The purpose of this review aims at reporting the current state of knowledge about the singular genetic susceptibilities influencing the risk of developing ATV muscle adverse events through PK modulations. Multiple single nucleotide polymorphisms (SNP) in efflux (ABCB1, ABCC1, ABCC2, ABCC4 and ABCG2) and influx (SLCO1B1, SLCO1B3 and SLCO2B1) transporters have been explored for their association with ATV PK modulation or with statin-related myotoxicities (SRM) development. The most convincing pharmacogenetic association with ATV remains the influence of the rs4149056 (c.521 T > C) in SLCO1B1 on ATV PK and pharmacodynamics. This SNP has been robustly associated with increased ATV systemic exposure and consequently, an increased risk of SRM. Additionally, the SNP rs2231142 (c.421C > A) in ABCG2 has also been associated with increased drug exposure and higher risk of SRM occurrence. SLCO1B1 and ABCG2 pharmacogenetic associations highlight that modulation of ATV systemic exposure is important to explain the risk of developing SRM. However, some novel observations credit the hypothesis that additional genes (e.g. SLCO2B1 or ABCC1) might be important for explaining local PK modulations within the muscle tissue, indicating that studying the local PK directly at the skeletal muscle level might pave the way for additional understanding.
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Affiliation(s)
- Emilia Hoste
- Integrated PharmacoMetrics, pharmacoGenomics and Pharmacokinetics, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels 1200, Belgium; Louvain Center for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Center for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium; Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Louise Deldicque
- Institute of Neuroscience (IoNS), Université Catholique de Louvain (UCLouvain), Louvain-la-Neuve 1348, Belgium
| | - Jean-Luc Balligand
- Pole of Pharmacology and Therapeutics (FATH), Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Laure Elens
- Integrated PharmacoMetrics, pharmacoGenomics and Pharmacokinetics, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels 1200, Belgium; Louvain Center for Toxicology and Applied Pharmacology, Institut de recherche expérimentale et clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium.
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11
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Chowdhury FH, Mahneva O, Maharaj M, Marciales W. Unveiling the Rare Complication: Statin-Induced Immune-Mediated Necrotizing Myopathy. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941387. [PMID: 38087774 PMCID: PMC10731803 DOI: 10.12659/ajcr.941387] [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: 06/07/2023] [Revised: 11/06/2023] [Accepted: 10/02/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Statin-induced necrotizing autoimmune myopathy is an exceptionally rare yet severe complication of statin therapy that may develop in individuals at any time during their exposure to statins. The development of proximal muscle weakness, muscle pain, and elevated creatine kinase (CK) levels in patients while taking statins should prompt clinical consideration of statin-induced myopathy. The pathophysiology arises from the production of auto-antibodies, which target the 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA reductase) enzyme, leading to the aggressive breakdown of myofibrils. CASE REPORT Here, we present a case of a 59-year-old woman with a medical history of dyslipidemia who developed anti-HMG-CoA reductase antibodies after taking atorvastatin. She came to the emergency department with complaints of severe proximal muscle weakness. The laboratory workup showed an elevated CK level up to 12 000 IU/L. Despite discontinuing atorvastatin, the patient's elevated CK levels persisted. The patient underwent a muscle biopsy, demonstrating myofibril necrosis. Serological analysis showed anti-HMG-CoA reductase antibodies in the patient's serum, which led to the diagnosis of immune-mediated necrotizing myopathy due to statins. The patient's statin therapy was promptly discontinued, and she was treated with a high dose of IV corticosteroids. After the patient's discharge, brief discontinuation of the corticosteroids resulted in CK elevation and a return of symptoms. This led to the second re-admission and restarting of corticosteroids until stabilization and discharge. CONCLUSIONS This case represents an important reminder for clinicians to recognize the possibility of statin-induced immune-mediated necrotizing myopathy in patients presenting with proximal muscle weakness while taking a statin, notwithstanding the rarity of this condition.
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Affiliation(s)
| | - Olena Mahneva
- Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - Maniekha Maharaj
- Department of Internal Medicine, Manatee Memorial Hospital, Bradenton, FL, USA
| | - Werther Marciales
- Department of Internal Medicine, Manatee Memorial Hospital, Bradenton, FL, USA
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12
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Khoo T, Chinoy H. Anti-HMGCR immune-mediated necrotising myopathy: Addressing the remaining issues. Autoimmun Rev 2023; 22:103468. [PMID: 37884200 DOI: 10.1016/j.autrev.2023.103468] [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: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
The discovery of autoantibodies directed against the 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) enzyme has defined a sub-set of immune-mediated necrotising myopathy (IMNM) which is strongly associated with exposure to statin medications. Although understanding of anti-HMGCR IMNM has grown considerably with the reporting of multiple cohorts in North America, Europe, Asia and Oceania, there remain many unanswered questions. The true incidence of anti-HMGCR IMNM is not known and heterogeneity of phenotype and treatment response within this autoantibody sub-group is being increasingly recognised. Statin-naïve adults and juvenile patients with anti-HMGCR potentially share characteristics distinct from statin-exposed patients, alluding to unique pathogenesis. Conflicting data exists on whether malignancies are associated with anti-HMGCR and further clarification is required to determine the degree of cancer screening required. Treatment approaches to anti-HMGCR IMNM are heterogeneous but generally highlight the efficacy of intravenous immunoglobulin. Even with multimodal immunosuppression, patients with anti-HMGCR remain prone to relapse, with younger patients generally manifesting more refractory disease. In this Review, we aim to summarise the current literature on anti-HMGCR and discuss the remaining issues.
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Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, South Australia, Australia; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom.
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, United Kingdom
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13
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Khoo T, Lilleker JB, Thong BYH, Leclair V, Lamb JA, Chinoy H. Epidemiology of the idiopathic inflammatory myopathies. Nat Rev Rheumatol 2023; 19:695-712. [PMID: 37803078 DOI: 10.1038/s41584-023-01033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of systemic autoimmune diseases that affect the skeletal muscles and can also involve the skin, joints, lungs and heart. The epidemiology of IIM is obscured by changing classification criteria and the inherent shortcomings of case identification using healthcare record diagnostic coding. The incidence of IIM is estimated to range from 0.2 to 2 per 100,000 person-years, with prevalence from 2 to 25 per 100,000 people. Although the effects of age and gender on incidence are known, there is only sparse understanding of ethnic differences, particularly in indigenous populations. The incidence of IIM has reportedly increased in the twenty-first century, but whether this is a genuine increase is not yet known. Understanding of the genetic risk factors for different IIM subtypes has advanced considerably. Infections, medications, malignancy and geography are also commonly identified risk factors. Potentially, the COVID-19 pandemic has altered IIM incidence, although evidence of this occurrence is limited to case reports and small case series. Consideration of the current understanding of the epidemiology of IIM can highlight important areas of interest for future research into these rare diseases.
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Affiliation(s)
- Thomas Khoo
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - James B Lilleker
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neuroscience, Manchester Academic Health Science Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valérie Leclair
- Department of Medicine, Division of Rheumatology, McGill University, Montreal, Canada
| | - Janine A Lamb
- Epidemiology and Public Health Group, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Hector Chinoy
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
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14
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Lönnberg KI, Tornio A, Hirvensalo P, Keskitalo J, Mustaniemi AL, Kiiski JI, Filppula AM, Niemi M. Real-world pharmacogenetics of statin intolerance: effects of SLCO1B1, ABCG2 , and CYP2C9 variants. Pharmacogenet Genomics 2023; 33:153-160. [PMID: 37490620 PMCID: PMC10399933 DOI: 10.1097/fpc.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE The association of SLCO1B1 c.521T>C with simvastatin-induced muscle toxicity is well characterized. However, different statins are subject to metabolism and transport also by other proteins exhibiting clinically meaningful genetic variation. Our aim was to investigate associations of SLCO1B1 c.521T>C with intolerance to atorvastatin, fluvastatin, pravastatin, rosuvastatin, or simvastatin, those of ABCG2 c.421C>A with intolerance to atorvastatin, fluvastatin, or rosuvastatin, and that of CYP2C9*2 and *3 alleles with intolerance to fluvastatin. METHODS We studied the associations of these variants with statin intolerance in 2042 patients initiating statin therapy by combining genetic data from samples from the Helsinki Biobank to clinical chemistry and statin purchase data. RESULTS We confirmed the association of SLCO1B1 c.521C/C genotype with simvastatin intolerance both by using phenotype of switching initial statin to another as a marker of statin intolerance [hazard ratio (HR) 1.88, 95% confidence interval (CI) 1.08-3.25, P = 0.025] and statin switching along with creatine kinase measurement (HR 5.44, 95% CI 1.49-19.9, P = 0.011). No significant association was observed with atorvastatin and rosuvastatin. The sample sizes for fluvastatin and pravastatin were relatively small, but SLCO1B1 c.521T>C carriers had an increased risk of pravastatin intolerance defined by statin switching when compared to homozygous reference T/T genotype (HR 2.11, 95% CI 1.01-4.39, P = 0.047). CONCLUSION The current results can inform pharmacogenetic statin prescribing guidelines and show feasibility for the methodology to be used in larger future studies.
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Affiliation(s)
- K. Ivar Lönnberg
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
| | - Aleksi Tornio
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku
- Unit of Clinical Pharmacology, Turku University Hospital, Turku
| | - Päivi Hirvensalo
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
| | - Jenni Keskitalo
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki
| | - Anna-Liina Mustaniemi
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
| | - Johanna I. Kiiski
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
| | - Anne M. Filppula
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
- Pharmaceutical Science Laboratory Åbo Akademi University, Turku, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki
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15
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McEvoy L, Cliff J, Carr DF, Jorgensen A, Lord R, Pirmohamed M. CYP3A genetic variation and taxane-induced peripheral neuropathy: a systematic review, meta-analysis, and candidate gene study. Front Pharmacol 2023; 14:1178421. [PMID: 37469869 PMCID: PMC10352989 DOI: 10.3389/fphar.2023.1178421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
Background: Taxane-induced peripheral neuropathy (TIPN) is an important cause of premature treatment cessation and dose-limitation in cancer therapy. It also reduces quality of life and survivorship in affected patients. Genetic polymorphisms in the CYP3A family have been investigated but the findings have been inconsistent and contradictory. Methods: A systematic review identified 12 pharmacogenetic studies investigating genetic variation in CYP3A4*22 and CYP3A5*3 and TIPN. In our candidate gene study, 288 eligible participants (211 taxane participants receiving docetaxel or paclitaxel, and 77 control participants receiving oxaliplatin) were successfully genotyped for CYP3A4*22 and CYP3A5*3. Genotyping data was transformed into a combined CYP3A metaboliser phenotype: Poor metabolisers, intermediate metabolisers and extensive metabolisers. Individual genotypes and combined CYP3A metaboliser phenotypes were assessed in relation to neurotoxicity, including by meta-analysis where possible. Results: In the systematic review, no significant association was found between CYP3A5*3 and TIPN in seven studies, with one study reporting a protective association. For CYP3A4*22, one study has reported an association with TIPN, while four other studies failed to show an association. Evaluation of our patient cohort showed that paclitaxel was found to be more neurotoxic than docetaxel (p < 0.001). Diabetes was also significantly associated with the development of TIPN. The candidate gene analysis showed no significant association between either SNP (CYP3A5*3 and CYP3A4*22) and the development of TIPN overall, or severe TIPN. Meta-analysis showed no association between these two variants and TIPN. Transformed into combined CYP3A metaboliser phenotypes, 30 taxane recipients were poor metabolisers, 159 were intermediate metabolisers, and 22 were extensive metabolisers. No significant association was observed between metaboliser status and case-control status. Summary: We have shown that the risk of peripheral neuropathy during taxane chemotherapy is greater in patients who have diabetes. CYP3A genotype or phenotype was not identified as a risk factor in either the candidate gene analysis or the systematic review/meta-analysis, although we cannot exclude the possibility of a minor contribution, which would require a larger sample size.
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Affiliation(s)
- Laurence McEvoy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Joanne Cliff
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - Daniel F Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Andrea Jorgensen
- Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Rosemary Lord
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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16
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Padmanabhan S, du Toit C, Dominiczak AF. Cardiovascular precision medicine - A pharmacogenomic perspective. CAMBRIDGE PRISMS. PRECISION MEDICINE 2023; 1:e28. [PMID: 38550953 PMCID: PMC10953758 DOI: 10.1017/pcm.2023.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 05/16/2024]
Abstract
Precision medicine envisages the integration of an individual's clinical and biological features obtained from laboratory tests, imaging, high-throughput omics and health records, to drive a personalised approach to diagnosis and treatment with a higher chance of success. As only up to half of patients respond to medication prescribed following the current one-size-fits-all treatment strategy, the need for a more personalised approach is evident. One of the routes to transforming healthcare through precision medicine is pharmacogenomics (PGx). Around 95% of the population is estimated to carry one or more actionable pharmacogenetic variants and over 75% of adults over 50 years old are on a prescription with a known PGx association. Whilst there are compelling examples of pharmacogenomic implementation in clinical practice, the case for cardiovascular PGx is still evolving. In this review, we shall summarise the current status of PGx in cardiovascular diseases and look at the key enablers and barriers to PGx implementation in clinical practice.
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Affiliation(s)
- Sandosh Padmanabhan
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Clea du Toit
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Anna F. Dominiczak
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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17
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Anim-Koranteng C, Akpoigbe O, Miller M, Averbukh Y. From Studio to Rehab: A Debilitating Form of Anti-HMGCR Myopathy. Cureus 2023; 15:e40825. [PMID: 37489210 PMCID: PMC10363017 DOI: 10.7759/cureus.40825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 07/26/2023] Open
Abstract
Immune-mediated necrotizing myopathy is a subtype of immune-mediated myopathy associated with or without statin use. Statins, or HMG-CoA reductase inhibitors, are the most prescribed medications for dyslipidemia. The statin-associated myopathic syndromes range from asymptomatic elevations in creatine kinase to severe debilitating muscle weakness with associated rhabdomyolysis and elevated liver enzymes. Clinical improvement occurs upon discontinuation of statins, but some patients do not recover completely. Diagnostic tests include electromyography, muscle biopsy, myositis autoantibody panel, and antibodies against the HMGCR. Here, we present a case of anti-HMGCR-related myopathy associated with atorvastatin.
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Affiliation(s)
| | | | - Michael Miller
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, USA
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18
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Roule V, Alexandre J, Lemaitre A, Chrétien B, Sassier M, Fedrizzi S, Beygui F, Dolladille C. Rhabdomyolysis with Co-Administration of Statins and Antiplatelet Therapies-Analysis of the WHO Pharmacovigilance Database. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07459-8. [PMID: 37115431 DOI: 10.1007/s10557-023-07459-8] [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: 04/21/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE While statins and antiplatelet therapies are largely prescribed together worldwide, limited information is available on the safety of their association regarding rhabdomyolysis occurrence. We aimed to assess the reporting of rhabdomyolysis in patients treated with a combination of statin and antiplatelet therapy, compared to statin alone. METHODS We used the World Health Organization pharmacovigilance database (VigiBase®) to compare the rhabdomyolysis reporting between statin (atorvastatin, fluvastatin, pravastatin, rosuvastatin, and simvastatin) plus antiplatelet therapy (acetylsalicylic acid, clopidogrel, prasugrel and ticagrelor) groups versus statin alone groups, for each statin and antiplatelet therapy. Study setting was restricted to patients aged 45 or older, including reports up until 1st September, 2021. We computed reporting Odds-Ratio (ROR) and their 95% confidence interval (CI) to quantify the disproportionality between groups, adjusted on age and sex. RESULTS Among the 11,431,708 reports of adverse reactions, we extracted 9,489 cases of rhabdomyolysis in patients treated with statins, of whom 2,464 (26%) were also treated with antiplatelet therapy. The reporting of rhabdomyolysis was increased when ticagrelor was associated with atorvastatin (ROR 1.30 [1.02-1.65]) or rosuvastatin (ROR 1.90 [1.42-2.54]) compared to the respective statin alone but did not change when aspirin, clopidogrel or prasugrel were considered. CONCLUSION Rhabdomyolysis reporting was increased when ticagrelor -but not other antiplatelet agents- was notified with the most prescribed statins in practice. This finding needs to be considered by physicians especially in high-risk patients.
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Affiliation(s)
- Vincent Roule
- Service de Cardiologie, CHU de Caen Normandie, 14000, Caen, France.
- UMRS 1237, INSERM, GIP Cyceron, 14000, Caen, France.
- Cardiology department, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
| | - Joachim Alexandre
- Service de Pharmacologie, CHU de Caen Normandie, PICARO Cardio-Oncology Program, 14000, Caen, France
| | - Adrien Lemaitre
- Service de Cardiologie, CHU de Caen Normandie, 14000, Caen, France
| | - Basile Chrétien
- Service de Pharmacologie, CHU de Caen Normandie, PICARO Cardio-Oncology Program, 14000, Caen, France
| | - Marion Sassier
- Service de Pharmacologie, CHU de Caen Normandie, PICARO Cardio-Oncology Program, 14000, Caen, France
| | - Sophie Fedrizzi
- Service de Pharmacologie, CHU de Caen Normandie, PICARO Cardio-Oncology Program, 14000, Caen, France
| | - Farzin Beygui
- Service de Cardiologie, CHU de Caen Normandie, 14000, Caen, France
- UMRS 1237, INSERM, GIP Cyceron, 14000, Caen, France
- ACTION Study Group, Pitié-Salpêtrière University Hospital, Cardiology Department, Paris, France
| | - Charles Dolladille
- Service de Pharmacologie, CHU de Caen Normandie, PICARO Cardio-Oncology Program, 14000, Caen, France
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19
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Oni-Orisan A, Lu M, Peng JA, Krauss RM, Iribarren C, Medina MW. Development and application of an algorithm for statin-induced myopathy based on electronic health record-derived structured elements. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23289059. [PMID: 37162948 PMCID: PMC10168492 DOI: 10.1101/2023.04.24.23289059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Objective Considering the non-specific nature of muscle symptoms, studies of statin-induced myopathy (SIM) in electronic health records require accurate algortihms that can reliably identify true statin-related cases. However, prior algorithms have been constructed in study populations that preclude broad applicability. Here we developed and validated an algorithm that accurately defines SIM from electronic health records using structured data elements and conducted a study of determinants of SIM after applying the algorithm. Materials and Methods We used electronic records from an integrated health care delivery system (including comprehensive pharmacy dispensing records) and defined SIM as elevated creatine kinase (CK) ≥4 x upper limit of normal. A diverse cohort of participants receiving a variety of statin regimens met the criteria for study inclusion. Results We identified multiple conditions strongly associated with elevated CK independent of statin use. A 2-step algorithm was developed using these all-cause conditions as secondary causes (step 1) along with evidence of a statin regimen change (step 2). We identified 1,262 algorithm-derived statin-induced elevated CK cases. Gold standard SIM cases determined from manual chart reviews on a random subset of the all-cause elevated CK cases were used to validate the algorithm, which had a 76% sensitivity and 77% specificity for detecting the most certain cases. Pravastatin use was associated with a 2.18 odds (95% confidence interval 1.39-3.40, P=0.0007) for statin-induced CK elevation compared to lovastatin use after adjusting for dose and other factors. Conclusions We have produced an efficient, easy-to-apply methodological tool that can improve the quality of future research on statin-induced myopathy.
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Affiliation(s)
- Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, Institute for Human Genetics, University of California San Francisco, San Francisco CA 94143, USA
| | - Meng Lu
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Jonathan A. Peng
- Department of Cardiology, Kaiser Permanente, Santa Rosa, CA 95403, USA
| | - Ronald M. Krauss
- Department of Medicine, Department of Pediatrics, University of California San Francisco, Oakland CA 94609, USA
| | - Carlos Iribarren
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Marisa W. Medina
- Department of Pediatrics, University of California San Francisco, Oakland CA 94609, USA
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20
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Tornio A, Bigossi M, Siddiqui MK, Kennedy G, Melhem A, Chourasia MK, Maroteau C, Pola R, Chasman DI, Doney ASF, Palmer CNA. The cholesterol-lowering effect of statins is modified by LILRB5 intolerance genotype: Results from a recruit-by-genotype clinical trial. Front Pharmacol 2023; 14:1090010. [PMID: 36998609 PMCID: PMC10043296 DOI: 10.3389/fphar.2023.1090010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/23/2023] [Indexed: 03/17/2023] Open
Abstract
Background/Aims: Statin intolerance leads to poor adherence to statin therapy, resulting in a failure to achieve desired cholesterol reduction and adverse outcomes. The LILRB5 Asp247Gly genotype has been identified as being associated with statin intolerance and statin-induced myalgia. We conducted a randomized clinical trial to examine its role in immune response through T regulatory cell aggregation and in achieving cholesterol reduction targets.Methods: A double-blind, cross-over, recruit-by-genotype trial was undertaken. A total of 18 participants who had either the Asp247Asp (T/T) genotype or the Gly247Gly (C/C) genotype were recruited to the study. Participants were randomised to receive placebo or atorvastatin 80 mg daily for 28 days. Following a washout period of 3 weeks, they were then switched to the opposite treatment. Biochemical and immunological measurements as well as interviews were performed prior to and after both treatment periods. Within genotype group comparisons were performed using repeated measures Wilcoxon tests. Two-way repeated measures ANOVA with genotype and treatment as factors were used to compare changes in biochemical parameters between groups during placebo and atorvastatin periods.Results: Individuals with the Asp247Asp genotype had a greater increase in creatine kinase (CK) compared to those with Gly247Gly genotype in response to atorvastatin (p = 0.03). Those with Gly247Gly genotype had a mean non-HDL cholesterol reduction of 2.44 (95% CI:1.59 – 3.29) mmol/L while in Asp247Asp genotype group the mean reduction was 1.28 (95%CI: 0.48 – 2.07) mmol/L. The interaction between the genotype and atorvastatin treatment for total cholesterol (p = 0.007) and non-HDL cholesterol response was significant (p = 0.025). Immunological assessment showed no significant changes in aggregation of T regulatory cells by genotype.Conclusion: The Asp247Gly variant in LILRB5, previously associated with statin intolerance, was associated with differential increases in creatine kinase and total cholesterol and non-HDL cholesterol-lowering response to atorvastatin. Taken together, these results suggest that this variant could have utility in precision cardiovascular therapy.
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Affiliation(s)
- Aleksi Tornio
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Margherita Bigossi
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
- Section of Internal Medicine and Thromboembolic Diseases, Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Moneeza K. Siddiqui
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
- *Correspondence: Moneeza K. Siddiqui,
| | - Gwen Kennedy
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Ala’a Melhem
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Mehul K. Chourasia
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Cyrielle Maroteau
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel I. Chasman
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Alexander S. F. Doney
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Colin N. A. Palmer
- Pat Macpherson Centre for Pharmacogenomics and Pharmacogenetics, Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
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21
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Lehtisalo M, Taskinen S, Tarkiainen EK, Neuvonen M, Viinamäki J, Paile-Hyvärinen M, Lilius TO, Tapaninen T, Backman JT, Tornio A, Niemi M. A comprehensive pharmacogenomic study indicates roles for SLCO1B1, ABCG2 and SLCO2B1 in rosuvastatin pharmacokinetics. Br J Clin Pharmacol 2023; 89:242-252. [PMID: 35942816 PMCID: PMC10087178 DOI: 10.1111/bcp.15485] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim was to comprehensively investigate the effects of genetic variability on the pharmacokinetics of rosuvastatin. METHODS We conducted a genome-wide association study and candidate gene analyses of single dose rosuvastatin pharmacokinetics in a prospective study (n = 159) and a cohort of previously published studies (n = 88). RESULTS In a genome-wide association meta-analysis of the prospective study and the cohort of previously published studies, the SLCO1B1 c.521 T > C (rs4149056) single nucleotide variation (SNV) associated with increased area under the plasma concentration-time curve (AUC) and peak plasma concentration of rosuvastatin (P = 1.8 × 10-12 and P = 3.2 × 10-15 ). The candidate gene analysis suggested that the ABCG2 c.421C > A (rs2231142) SNV associates with increased rosuvastatin AUC (P = .0079), while the SLCO1B1 c.388A > G (rs2306283) and SLCO2B1 c.1457C > T (rs2306168) SNVs associate with decreased rosuvastatin AUC (P = .0041 and P = .0076). Based on SLCO1B1 genotypes, we stratified the participants into poor, decreased, normal, increased and highly increased organic anion transporting polypeptide (OATP) 1B1 function groups. The OATP1B1 poor function phenotype associated with 2.1-fold (90% confidence interval 1.6-2.8, P = 4.69 × 10-5 ) increased AUC of rosuvastatin, whereas the OATP1B1 highly increased function phenotype associated with a 44% (16-62%; P = .019) decreased rosuvastatin AUC. The ABCG2 c.421A/A genotype associated with 2.2-fold (1.5-3.0; P = 2.6 × 10-4 ) increased AUC of rosuvastatin. The SLCO2B1 c.1457C/T genotype associated with 28% decreased rosuvastatin AUC (11-42%; P = .01). CONCLUSION These data suggest roles for SLCO1B1, ABCG2 and SLCO2B1 in rosuvastatin pharmacokinetics. Poor SLCO1B1 or ABCG2 function genotypes may increase the risk of rosuvastatin-induced myotoxicity. Reduced doses of rosuvastatin are advisable for patients with these genotypes.
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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
| | - Suvi Taskinen
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland.,Individualized Drug Therapy Research Program, University of Helsinki, 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
| | - Jenni Viinamäki
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland.,Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Maria Paile-Hyvärinen
- 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
| | - Tuomas O Lilius
- 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
| | - Tuija Tapaninen
- 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
| | - 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
| | - Aleksi Tornio
- 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
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22
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Martins A, Nadais G, Pinto M, Taipa R, Costa L, Pimenta S. Progressive proximal muscle weakness with subacute onset in an elderly patient: a case report. Rev Neurol 2023; 76:31-34. [PMID: 36544374 PMCID: PMC10364021 DOI: 10.33588/rn.7601.2021276] [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: 07/15/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Statins are some of the most widely prescribed medications. Although statins are generally well tolerated, they can lead to musculoskeletal side effects. Statin-induced necrotizing autoimmune myositis (SINAM) is a rare condition and the prevalence is only 1 per 100,000 people. This disorder is characterized by progressive and severe symmetric muscle weakness, marked elevation of creatine kinase and persistent symptoms despite statin discontinuation. Electromyography commonly shows a nonspecific irritable myopathy pattern indistinguishable from other inflammatory myopathies. Muscle biopsy shows the presence of necrotic fibers, regenerating fibers without significant inflammatory cells and diffuse or focal upregulation of major histocompatibility complex class I expression. The anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibodies represent a characteristic serological feature of SINAM. CASE REPORT We present a patient who developed progressive muscle weakness after taking simvastatin for the last seven years. At initial presentation, her creatine kinase level was 2,954 U/L and anti-HMGCR antibodies were positive. The biopsy showed a profound myopathic features with numerous necrotic fibers, some regenerating fibers and perimysial inflammatory cell infiltrate, combined with a diffuse overexpression of major histocompatibility complex class I products. She was diagnosed with SINAM, statin was suspended and a high dose of systemic corticosteroids, intravenous immunoglobulin therapy and methotrexate was started. At three-month follow-up, she had significant improvement in muscle strength and creatine kinase level returned to normal. CONCLUSION In this case, exclusion of inflammatory myopathies, metabolic muscle disorders and other neurological diseases is necessary for establishing a reliable diagnosis. In SINAM, simply discontinuing statin is often insufficient and aggressive immunosuppression or immunomodulation therapy is needed to achieve disease remission. This case aims to demonstrate that statins can induce serious muscular diseases that require aggressive immunosuppression.
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Affiliation(s)
- Ana Martins
- Department of RheumatologyDepartment of RheumatologyDepartment of RheumatologyPortoPortugal
- Faculty of Medicine. Universidade do Porto. Porto, PortugalFaculty of MedicineUniversidade do PortoPortoPortugal
| | - Goreti Nadais
- Department of Neurology. Centro Hospitalar Universitário de São JoãoDepartment of NeurologyCentro Hospitalar Universitário de São JoãoPortoPortugal
| | - Miguel Pinto
- Neuropathology Unit. Department of Neurosciences. Centro Hospitalar e Universitário do PortoNeuropathology Unit. Department of NeurosciencesCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Ricardo Taipa
- Neuropathology Unit. Department of Neurosciences. Centro Hospitalar e Universitário do PortoNeuropathology Unit. Department of NeurosciencesCentro Hospitalar e Universitário do PortoPortoPortugal
| | - Lúcia Costa
- Department of RheumatologyDepartment of RheumatologyDepartment of RheumatologyPortoPortugal
| | - Sofia Pimenta
- Department of RheumatologyDepartment of RheumatologyDepartment of RheumatologyPortoPortugal
- Faculty of Medicine. Universidade do Porto. Porto, PortugalFaculty of MedicineUniversidade do PortoPortoPortugal
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23
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Cornelis L, Duyck J, Dedeurwaerdere F, De Schoenmakere G, Malfait T. Statin-induced necrotizing autoimmune myopathy (SINAM): case report and review of the literature. Acta Clin Belg 2022:1-6. [DOI: 10.1080/17843286.2022.2156701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Julien Duyck
- Department of Nephrology, AZ Delta, Roeselare, Belgium
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24
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Andronie-Cioară FL, Jurcău A, Jurcău MC, Nistor-Cseppentö DC, Simion A. Cholesterol Management in Neurology: Time for Revised Strategies? J Pers Med 2022; 12:jpm12121981. [PMID: 36556202 PMCID: PMC9784893 DOI: 10.3390/jpm12121981] [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: 10/31/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022] Open
Abstract
Statin therapy has been extensively evaluated and shown to reduce the incidence of new or recurrent vascular events, ischemic stroke included. As a consequence, each published guideline pushes for lower low-density cholesterol levels in the population at large, recommending increased statin doses and/or adding new cholesterol-lowering molecules. Neurologists find it sometimes difficult to apply these guidelines, having to confront situations such as (1) ischemic strokes, mainly cardioembolic ones, in patients with already low LDL-cholesterol levels; (2) myasthenic patients, whose lifespan has been extended by available treatment, and whose age and cholesterol levels put them at risk for ischemic stroke; (3) patients with myotonic dystrophy, whose disease often associates diabetes mellitus and heart conduction defects, and in whom blood cholesterol management is also not settled. As such, further trials are needed to address these issues.
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Affiliation(s)
- Felicia Liana Andronie-Cioară
- Department of Psycho-Neuroscience and Rehabilitation, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Anamaria Jurcău
- Department of Psycho-Neuroscience and Rehabilitation, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Maria Carolina Jurcău
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
- Correspondence: (M.C.J.); (D.C.N.-C.); Tel.: +40-744-600-833 (M.C.J.)
| | - Delia Carmen Nistor-Cseppentö
- Department of Psycho-Neuroscience and Rehabilitation, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
- Correspondence: (M.C.J.); (D.C.N.-C.); Tel.: +40-744-600-833 (M.C.J.)
| | - Aurel Simion
- Department of Psycho-Neuroscience and Rehabilitation, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
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25
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Kytö V, Rautava P, Tornio A. Initial statin dose after myocardial infarction and long-term cardiovascular outcomes. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:156-164. [PMID: 36385668 PMCID: PMC9892868 DOI: 10.1093/ehjcvp/pvac064] [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: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
AIMS Effective statin therapy is a cornerstone of secondary prevention after myocardial infarction (MI). Real-life statin dosing is nevertheless suboptimal and largely determined early after MI. We studied long-term outcome impact of initial statin dose after MI. METHODS AND RESULTS Consecutive MI patients treated in Finland who used statins early after index event were retrospectively studied (N = 72 401; 67% men; mean age 68 years) using national registries. High-dose statin therapy was used by 26.3%, moderate dose by 69.2%, and low dose by 4.5%. Differences in baseline features, comorbidities, revascularisation, and usage of other evidence-based medications were adjusted for with multivariable regression. The primary outcome was major adverse cardiovascular or cerebrovascular event (MACCE) within 10 years. Median follow-up was 4.9 years. MACCE was less frequent in high-dose group compared with moderate dose [adjusted hazard ratio (HR) 0.92; P < 0.0001; number needed to treat (NNT) 34.1] and to low dose [adj.HR 0.81; P < 0.001; NNT 13.4] as well as in moderate-dose group compared with low dose (adj.HR 0.88; P < 0.0001; NNT 23.4). Death (adj.HR 0.87; P < 0.0001; NNT 23.6), recurrent MI (adj.sHR 0.91; P = 0.0001), and stroke (adj.sHR 0.86; P < 0.0001) were less frequent with a high- vs. moderate-dose statin. Higher initial statin dose after MI was associated with better long-term outcomes in subgroups by age, sex, atrial fibrillation, dementia, diabetes, heart failure, revascularisation, prior statin usage, or usage of other evidence-based medications. CONCLUSION Higher initial statin dose after MI is dose-dependently associated with better long-term cardiovascular outcomes. These results underline the importance of using a high statin dose early after MI.
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Affiliation(s)
- Ville Kytö
- Corresponding author. Tel: +358 2 3130000,
| | - Päivi Rautava
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland,Department of Public Health, University of Turku, Turku, Finland
| | - Aleksi Tornio
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland,Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
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26
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Infection-Induced Rhabdomyolysis in an Elderly Patient on Stable Rosuvastatin Therapy: A Case Report and Review of the Literature. Am J Ther 2022; 29:e657-e661. [PMID: 33443867 DOI: 10.1097/mjt.0000000000001325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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27
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Jeeyavudeen MS, Pappachan JM, Arunagirinathan G. Statin-related Muscle Toxicity: An Evidence-based Review. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 18:89-95. [PMID: 36694885 PMCID: PMC9835810 DOI: 10.17925/ee.2022.18.2.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022]
Abstract
The efficacy of statins in the primary and secondary prevention of cardiovascular disease has been proven beyond doubt. The number needed to treat to prevent one cardiovascular event is 1 in 30 over 10 years, and the number needed to treat for secondary prevention is much lower. However, a recent study demonstrated that only 68% of eligible patients are on statin therapy. Moreover, there seems to be a reluctance to escalate statin doses due to the fear of adverse effects. The adverse effects that worries patients and their physicians most frequently are those related to muscular symptoms. N-of-1 trial evidence suggests that muscular symptoms attributed to statins are often caused by the nocebo effect. This article aims to provide a structured, evidence-based approach to suspected statin-related muscle toxicity.
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Affiliation(s)
| | - Joseph M Pappachan
- Lancashire Teaching Hospitals NHS Trust, Lancashire, UK,Manchester Metropolitan University, Manchester, UK
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28
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Barrons R. Statin-Associated Autoimmune Myopathy: Review of the Literature. J Pharm Pract 2022; 36:383-393. [PMID: 35707933 DOI: 10.1177/08971900211040291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Statin-associated autoimmune myopathy (SAAM) is a rare adverse event characterized by progressive muscle symptoms despite discontinuation, requiring immunosuppressive therapy for remission. The objective of this review was to characterize SAAM, for timely detection, while examining the literature for effective treatment considerations. METHODS PubMed search was conducted from 2010 to 2020 was for relevant case series and studies of at least 8 patients displaying muscle discomfort or weakness, anti-HMGCR antibodies, exposure to statins, and biopsies consistent with SAAM. RESULTS Three case series and 3 case cohort studies identified 199 patients with SAAM. Exhibiting a mean age of 63.74 years, patients were more likely Caucasian (81%) and female (1.2X), and required a mean duration of 4.75 years before symptomatic. The presentation involved proximal muscle weakness (94%), myalgias (37%) and dysphagia (23%), accompanied by a mean creatinine kinase of 6383 IU/L. Most patients (57%) required 2 or more immunosuppressive (IMS) agents to achieve 62% remission. After 2 years of treatment, 15% of patients without remission reported symptomatic improvement, while another 12% were refractory to treatment. CONCLUSION Delayed onset of SAAM greater than 4 years from statin initiation may create a low index of suspicion. However, progression of symptoms beyond 2 months from statin discontinuation and positive anti-HMGCR antibodies requires immunosuppressive agents. Data and expert opinion support use of at least two IMS medications upon diagnosis for a minimum of 2 years. Therapy success depends on timely recognition and initiation of IMS combinations to achieve earlier remission and symptomatic improvement.
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Affiliation(s)
- Robert Barrons
- School of Pharmacy, 15543Wingate University, Wingate, NC, USA
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29
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Murphy WA, Lin N, Damask A, Schwartz GG, Steg PG, Szarek M, Banerjee P, Fazio S, Manvelian G, Pordy R, Shuldiner AR, Paulding C. Pharmacogenomic Study of Statin-Associated Muscle Symptoms in the ODYSSEY OUTCOMES Trial. Circ Genom Precis Med 2022; 15:e003503. [PMID: 35543701 PMCID: PMC9213083 DOI: 10.1161/circgen.121.003503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Statin-associated muscle symptoms (SAMS) are the most frequently reported adverse events for statin therapies. Previous studies have reported an association between the p.Val174Ala missense variant in SLCO1B1 and SAMS in simvastatin-treated subjects; however, evidence for genetic predictors of SAMS in atorvastatin- or rosuvastatin-treated subjects is currently lacking.
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Affiliation(s)
- William A. Murphy
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill‚ Chapel Hill‚ NC (W.A.M.)
| | - Nan Lin
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Amy Damask
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill‚ Chapel Hill‚ NC (W.A.M.)
| | | | - P. Gabriel Steg
- Université de Paris, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris‚ INSERM U1148, France (P.G.S.)
| | - Michael Szarek
- University of Colorado School of Medicine, Aurora‚ CO (G.G.S., M.S.)
- Department of Biostatistics and Epidemiology, SUNY Downstate School of Public Health, Brooklyn, NY (M.S.)
- CPC Clinical Research, Aurora, CO (M.S.)
| | - Poulabi Banerjee
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Sergio Fazio
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Garen Manvelian
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Robert Pordy
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Alan R. Shuldiner
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
| | - Charles Paulding
- Regeneron Genetics Center, Regeneron Pharmaceuticals Inc, Tarrytown, NY (N.L., A.D., P.B., S.F., G.M., R.P., A.R.S., C.P.)
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30
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Early statin use and cardiovascular outcomes after myocardial infarction: A population-based case-control study. Atherosclerosis 2022; 354:8-14. [DOI: 10.1016/j.atherosclerosis.2022.06.1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/21/2022]
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31
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Ramudo-Cela L, Santana-Martínez S, García-Ramos M, Bergamino M, García-Giustiniani D, Vélez-Vieitez P, Hernández-Hernández JL, García-Ibarbia C, González-Bustos P, Ruíz-Martín P, González-Lozano J, Santomé-Collazo L, Grana-Fernandez A, Cabaleiro-Cerviño P, Ortíz M, Monserrat-Iglesias L. Combining familial hypercholesterolemia and statin genetic studies as a strategy for the implementation of pharmacogenomics. A multidisciplinary approach. THE PHARMACOGENOMICS JOURNAL 2022; 22:180-187. [PMID: 35361995 DOI: 10.1038/s41397-022-00274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 02/27/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
The diagnostic process of familial hypercholesterolemia frequently involves the use of genetic studies. Patients are treated with lipid-lowering drugs, frequently statins. Although pharmacogenomic clinical practice guidelines focusing on genotype-based statin prescription have been published, their use in routine clinical practice remains very modest.We have implemented a new NGS strategy that combines a panel of genes related to familial hypercholesterolemia with genomic regions related to the pharmacogenomics of lipid-lowering drugs described in clinical practice guidelines and in EMA and FDA drug labels. A multidisciplinary team of doctors, biologists, and pharmacists creates a clinical report that provides diagnostic and therapeutic findings using a knowledge management and clinical decision support system, as well as an algorithm for treatment selection.For 12 months, a total of 483 genetic diagnostic studies for familial hypercholesterolemia were carried out, of which 221 (45.8%) requested a complementary pharmacogenomic test. Of these 221 patients, 66.5% were carriers of actionable variants in any of the studied pharmacogenomic pathways: 46.6% of patients in one pathway, 19.0% in two pathways, and 0.9% in three pathways. 45.7% of patients could have a response to atorvastatin different from that of the reference population, 45.7% for simvastatin and lovastatin, 29.0% for fluvastatin, and 6.7% patients for pitavastatin.This implementation approach facilitates the incorporation of pharmacogenomic studies in clinical care practice, it does not add complexity nor additional steps to laboratory processes, and improves the pharmacotherapeutic process of patients.
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Affiliation(s)
- Luis Ramudo-Cela
- Health in Code S.L., Scientific Department, A Coruña, Spain.
- Complexo Hospitalario Universitario A Coruña, A Coruña, Spain.
- Universidade da Coruña, A Coruña, Spain.
| | | | | | | | | | | | - Jose Luis Hernández-Hernández
- Department of Internal Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Carmen García-Ibarbia
- Department of Internal Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | | | - Patricia Ruíz-Martín
- Department of Cardiology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | - Martín Ortíz
- Health in Code S.L., Scientific Department, A Coruña, Spain
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Kuruvilla R, Scott K, Pirmohamed SM. Pharmacogenomics of Drug Hypersensitivity. Immunol Allergy Clin North Am 2022; 42:335-355. [DOI: 10.1016/j.iac.2022.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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33
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Cooper‐DeHoff RM, Niemi M, Ramsey LB, Luzum JA, Tarkiainen EK, Straka RJ, Gong L, Tuteja S, Wilke RA, Wadelius M, Larson EA, Roden DM, Klein TE, Yee SW, Krauss RM, Turner RM, Palaniappan L, Gaedigk A, Giacomini KM, Caudle KE, Voora D. The Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for
SLCO1B1, ABCG2
, and
CYP2C9
and statin‐associated musculoskeletal symptoms. Clin Pharmacol Ther 2022; 111:1007-1021. [PMID: 35152405 PMCID: PMC9035072 DOI: 10.1002/cpt.2557] [Citation(s) in RCA: 98] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/02/2022] [Indexed: 11/09/2022]
Abstract
Statins reduce cholesterol, prevent cardiovascular disease, and are among the most commonly prescribed medications in the world. Statin-associated musculoskeletal symptoms (SAMS) impact statin adherence and ultimately can impede the long-term effectiveness of statin therapy. There are several identified pharmacogenetic variants that impact statin disposition and adverse events during statin therapy. SLCO1B1 encodes a transporter (SLCO1B1; alternative names include OATP1B1 or OATP-C) that facilitates the hepatic uptake of all statins. ABCG2 encodes an efflux transporter (BCRP) that modulates the absorption and disposition of rosuvastatin. CYP2C9 encodes a phase I drug metabolizing enzyme responsible for the oxidation of some statins. Genetic variation in each of these genes alters systemic exposure to statins (i.e., simvastatin, rosuvastatin, pravastatin, pitavastatin, atorvastatin, fluvastatin, lovastatin), which can increase the risk for SAMS. We summarize the literature supporting these associations and provide therapeutic recommendations for statins based on SLCO1B1, ABCG2, and CYP2C9 genotype with the goal of improving the overall safety, adherence, and effectiveness of statin therapy. This document replaces the 2012 and 2014 Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for SLCO1B1 and simvastatin-induced myopathy.
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Affiliation(s)
- Rhonda M. Cooper‐DeHoff
- 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 Department of Medicine College of Medicine University of Florida Gainesville Florida USA
| | - Mikko Niemi
- Department of Clinical Pharmacology Individualized Drug Therapy Research Program University of Helsinki Helsinki Finland
- HUS Diagnostic Center Helsinki University Hospital Helsinki Finland
- Individualized Drug Therapy Research Program University of Helsinki Helsinki Finland
| | - Laura B. Ramsey
- Divisions of Clinical Pharmacology & Research in Patient Services Cincinnati Children’s Hospital Medical Center Cincinnati OH USA
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor
| | - E. Katriina Tarkiainen
- Department of Clinical Pharmacology Individualized Drug Therapy Research Program University of Helsinki Helsinki Finland
- HUS Diagnostic Center Helsinki University Hospital Helsinki Finland
- Individualized Drug Therapy Research Program University of Helsinki Helsinki Finland
| | - Robert J. Straka
- Department of Experimental and Clinical Pharmacology University of Minnesota College of Pharmacy Minneapolis Minnesota USA
| | - Li Gong
- Department of Biomedical Data Science School of Medicine Stanford University Stanford California USA
| | - Sony Tuteja
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
| | - Russell A. Wilke
- Department of Internal Medicine University of South Dakota Sanford School of Medicine Sioux Falls South Dakota USA
| | - Mia Wadelius
- Department of Medical Sciences Clinical Pharmacogenomics & Science for Life Laboratory Uppsala University Uppsala Sweden
| | - Eric A. Larson
- Department of Internal Medicine University of South Dakota Sanford School of Medicine Sioux Falls South Dakota USA
| | - Dan M. Roden
- Division of Cardiovascular Medicine and Division of Clinical Pharmacology Department of Medicine Vanderbilt University Medical Center Nashville TN USA
- Department of Pharmacology and Department of Biomedical Informatics Vanderbilt University Medical Center Nashville TN USA
| | - Teri E. Klein
- Department of Biomedical Data Science School of Medicine Stanford University Stanford California USA
| | - Sook Wah Yee
- Department of Bioengineering and Therapeutic Sciences University of California San Francisco San Francisco California USA
| | - Ronald M. Krauss
- Departments of Pediatrics and Medicine University of California San Francisco CA USA
| | - Richard M. Turner
- The Wolfson Centre for Personalised Medicine University of Liverpool Liverpool UK
| | - Latha Palaniappan
- Division of Primary Care and Population Health Stanford University School of Medicine Stanford CA USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation Children's Mercy Kansas City and School of Medicine University of Missouri‐Kansas City Kansas City MO USA
| | - Kathleen M. Giacomini
- Department of Bioengineering and Therapeutic Sciences University of California San Francisco San Francisco California USA
| | - Kelly E. Caudle
- Division of Pharmaceutical Sciences Department of Pharmacy and Pharmaceutical Sciences St. Jude Children’s Research Hospital Memphis TN USA
| | - Deepak Voora
- Department of Medicine Duke Center for Applied Genomics & Precision Medicine Duke University School of Medicine Durham NC USA
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Susekov AV. Topical issues concerning modern lipid-lowering therapy. CONSILIUM MEDICUM 2022. [DOI: 10.26442/20751753.2022.1.201484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hypercholesterolemia (high levels of atherogenic lipoproteins) is the main modifiable cardiovascular risk factor in most of the populations, including the Russian population. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have been used in clinical practice for more than 40 years and have a substantial evidence-based proof of efficacy and safety. Unfortunately, the most of the patients with high cardiovascular risk, including the Russian Federation, still receive initial statin doses and only in 10% of the cases we can reach the recommended target level of low-density lipoprotein cholesterol. This article deals with the current principles of statin therapy according to the latest guidelines and shows updated information concerning the optimization of statin therapy in the elderly and in patients with chronic kidney disease. This article, as well, shows the safety of applying HMG-CoA reductase inhibitors (impact on muscles, liver and cognitive impairments). In addition, the review presents the algorithms for the combination therapy of statins and ezetimibe.
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Luciano CA, Caraballo-Cartagena S. Treatment and Management of Infectious, Granulomatous, and Toxic Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vinci P, Panizon E, Tosoni LM, Cerrato C, Pellicori F, Mearelli F, Biasinutto C, Fiotti N, Di Girolamo FG, Biolo G. Statin-Associated Myopathy: Emphasis on Mechanisms and Targeted Therapy. Int J Mol Sci 2021; 22:11687. [PMID: 34769118 PMCID: PMC8583847 DOI: 10.3390/ijms222111687] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 12/25/2022] Open
Abstract
Hyperlipidemia is a major risk factor for cardiovascular morbidity and mortality. Statins are the first-choice therapy for dyslipidemias and are considered the cornerstone of atherosclerotic cardiovascular disease (ASCVD) in both primary and secondary prevention. Despite the statin-therapy-mediated positive effects on cardiovascular events, patient compliance is often poor. Statin-associated muscle symptoms (SAMS) are the most common side effect associated with treatment discontinuation. SAMS, which range from mild-to-moderate muscle pain, weakness, or fatigue to potentially life-threatening rhabdomyolysis, are reported by 10% to 25% of patients receiving statin therapy. There are many risk factors associated with patient features and hypolipidemic agents that seem to increase the risk of developing SAMS. Due to the lack of a "gold standard", the diagnostic test for SAMS is based on a clinical criteria score, which is independent of creatine kinase (CK) elevation. Mechanisms that underlie the pathogenesis of SAMS remain almost unclear, though a high number of risk factors may increase the probability of myotoxicity induced by statin therapy. Some of these, related to pharmacokinetic properties of statins and to concomitant therapies or patient characteristics, may affect statin bioavailability and increase vulnerability to high-dose statins.
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Affiliation(s)
- Pierandrea Vinci
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Emiliano Panizon
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Letizia Maria Tosoni
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Carla Cerrato
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Federica Pellicori
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Mearelli
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Chiara Biasinutto
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Nicola Fiotti
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
| | - Filippo Giorgio Di Girolamo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy;
| | - Gianni Biolo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical ad Health Science, University of Trieste, 34149 Trieste, Italy; (E.P.); (L.M.T.); (C.C.); (F.P.); (F.M.); (N.F.); (F.G.D.G.); (G.B.)
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Melhem AL, Chourasia MK, Bigossi M, Maroteau C, Taylor A, Pola R, Dawed AY, Tornio A, Palmer CNA, Siddiqui MK. Common Statin Intolerance Variants in ABCB1 and LILRB5 Show Synergistic Effects on Statin Response: An Observational Study Using Electronic Health Records. Front Genet 2021; 12:713181. [PMID: 34659336 PMCID: PMC8517257 DOI: 10.3389/fgene.2021.713181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Statin intolerance impacts approximately 10% of statin users, with side effects ranging from mild myalgia to extreme intolerance resulting in myopathy and rhabdomyolysis. Statin intolerance results in poor adherence to therapy and can impact statin efficacy. Many genetic variants are associated with statin intolerance. The effect of these variants on statin efficacy has not been systematically explored. Methods: Using longitudinal electronic health records and genetic biobank data from Tayside, Scotland, we examined the effect of seven genetic variants with previously reported associations with simvastatin or atorvastatin intolerance on the outcome of statin response. Statin response was measured by the reduction achieved when comparing pre- and post-statin non-high-density lipoprotein-cholesterol (non-HDL-C). Post-treatment statin response was limited to non-HDL-C measured within 6months of therapy initiation. Univariate and multivariable linear regression models were used to assess the main and adjusted effect of the variants on statin efficacy. Results: Around 9,401 statin users met study inclusion criteria, of whom 8,843 were first prescribed simvastatin or atorvastatin. The average difference in post-treatment compared to pre-treatment non-HDL-cholesterol was 1.45 (±1.04) mmol/L. In adjusted analyses, only two variants, one in the gene ATP-binding cassette transporter B1 (ABCB1; rs1045642), and one in leukocyte immunoglobulin like receptor B5 (LILRB5; rs12975366), were associated with statin efficacy. In ABCB1, homozygous carriers of the C allele at rs1045642 had 0.06mmol/L better absolute reduction in non-HDL-cholesterol than carriers of the T allele (95% CI: 0.01, 0.1). In LILRB5 (rs12975366), carriers of the C allele had 0.04mmol/L better absolute reduction compared to those homozygous for the T allele (95% CI: 0.004, 0.08). When combined into a two-variant risk score, individuals with both the rs1045642-CC genotype and the rs12975366-TC or CC genotype had a 0.11mmol/L greater absolute reduction in non-HDL-cholesterol compared to those with rs1045642-TC or TT genotype and the rs12975366-TT genotype (95% CI: 0.05, 0.16; p<0.001). Conclusion: We report two genetic variants for statin adverse drug reactions (ADRs) that are associated with statin efficacy. While the ABCB1 variant has been shown to have an association with statin pharmacokinetics, no similar evidence for LILRB5 has been reported. These findings highlight the value of genetic testing to deliver precision therapeutics to statin users.
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Affiliation(s)
- Alaa' Lutfi Melhem
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Mehul Kumar Chourasia
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Margherita Bigossi
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom.,Section of Internal Medicine and Thromboembolic Diseases, Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cyrielle Maroteau
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Alasdair Taylor
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases, Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Adem Y Dawed
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Aleksi Tornio
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom.,Integrative Physiology and Pharmacology Unit, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Colin N A Palmer
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
| | - Moneeza K Siddiqui
- Division of Population Health & Genomics, Pat McPherson Centre for Pharmacogenetics & Pharmacogenomics, School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, United Kingdom
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Loss of function polymorphisms in SLCO1B1 (c.521T>C, rs4149056) and ABCG2 (c.421C>A, rs2231142) genes are associated with adverse events of rosuvastatin: a case-control study. Eur J Clin Pharmacol 2021; 78:227-236. [PMID: 34668025 DOI: 10.1007/s00228-021-03233-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE The study aims to evaluate relationship between polymorphisms associated with a reduced function of two transporter proteins resulting in increased exposure to rosuvastatin - organic anion transporter 1B1 (OATP1B1) (SLCO1B1 c.521T>C) and ATP binding cassette subfamily G member 2 (ABCG2) (ABCG2 c.421C>A) and occurrence of rosuvastatin related myotoxicity/hepatotoxicity. METHODS In a case-control study, cases (rosuvastatin treated patients developing myotoxicity or hepatotoxicity) and controls (concurrent rosuvastatin treated patients free of adverse events) were prospectively recruited over a 2 year period in a single tertiary center specialized in treatment of metabolic disorders. Subjects were evaluated for clinical, comorbidity, and comedication characteristics and for genotype predicted metabolizing phenotypes regarding cytochrome P450 enzymes CYP2C9 and CYP2C19. Standard regression analysis and analysis in matched sets of cases and controls (optimal full matching) were undertaken by fitting frequentist and Bayesian models (covariates/matching variables: age, sex, diabetes, liver/renal disease, hypertension, CYP2C9 and C19 phenotype, use of CYP or transporter inhibitors, non evaluated transporter genotype). RESULTS A total of 88 cases (81 with myotoxicity, 6 with hepatotoxicity, 1 with both) and 129 controls were recruited. Odds of variant SLCO1B1 c.521T>C allele were 2.2-2.5 times higher in cases than in controls (OR = 2.45, 95% CI 1.34-4.48; Bayesian OR = 2.59, 95% CrI 1.42-4.90 in regression analysis; OR = 2.20, 1.10-4.42; Bayesian OR = 2.26, 1.28-4.41 in matched analysis). Odds of variant ABCG2 c.421C>A allele were 2.1-2.3 times higher in cases than in controls (OR = 2.24, 1.04-4.83; Bayesian OR = 2.35, 1.09-4.31 in regression analysis; OR = 2.10, 0.83-5.31; Bayesian OR = 2.17, 1.07-4.35 in matched analysis). CONCLUSION Loss of function polymorphisms in SLCO1B1 c.521T>C and ABCG2 c.421C>A genes are associated with the presence of rosuvastatin related myotoxicity and/or hepatotoxicity.
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Drobni ZD, Murphy SP, Alvi RM, Lee C, Gong J, Mosarla RC, Rambarat PK, Hartmann SB, Gilman HK, Zubiri L, Raghu VK, Sullivan RJ, Zafar A, Zlotoff DA, Sise ME, Guidon AC, Reynolds KL, Dougan M, Neilan TG. Association between incidental statin use and skeletal myopathies in patients treated with immune checkpoint inhibitors. IMMUNOTHERAPY ADVANCES 2021; 1:ltab014. [PMID: 34541581 PMCID: PMC8444991 DOI: 10.1093/immadv/ltab014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/23/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022] Open
Abstract
Objectives Skeletal myopathies are highly morbid, and in rare cases even fatal, immune-related adverse events (irAE) associated with immune checkpoint inhibitors (ICI). Skeletal myopathies are also a recognized statin-associated side effect. It is unknown whether concurrent use of statins and ICIs increases the risk of skeletal myopathies. Methods This was a retrospective cohort study of all patients who were treated with an ICI at a single academic institution (Massachusetts General Hospital, Boston, MA, USA). The primary outcome of interest was the development of a skeletal myopathy. The secondary outcome of interest was an elevated creatine kinase level (above the upper limit of normal). Results Among 2757 patients, 861 (31.2%) were treated with a statin at the time of ICI start. Statin users were older, more likely to be male and had a higher prevalence of cardiovascular and non-cardiovascular co-morbidities. During a median follow-up of 194 days (inter quartile range 65–410), a skeletal myopathy occurred in 33 patients (1.2%) and was more common among statin users (2.7 vs. 0.9%, P < 0.001). Creatine kinase (CK) elevation was present in 16.3% (114/699) and was higher among statin users (20.0 vs. 14.3%, P = 0.067). In a multivariable Cox model, statin therapy was associated with a >2-fold higher risk for skeletal myopathy (HR, 2.19; 95% confidence interval, 1.07–4.50; P = 0.033). Conclusion In this large cohort of ICI-treated patients, a higher risk was observed for skeletal myopathies and elevation in CK levels in patients undergoing concurrent statin therapy. Prospective observational studies are warranted to further elucidate the potential association between statin use and ICI-associated myopathies.
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Affiliation(s)
- Zsofia D Drobni
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean P Murphy
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlotte Lee
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jingyi Gong
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ramya C Mosarla
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paula K Rambarat
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah B Hartmann
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hannah K Gilman
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Leyre Zubiri
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vineet K Raghu
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amna Zafar
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meghan E Sise
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda C Guidon
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Zeng W, Tomlinson B. Causes and outcome of rhabdomyolysis in patients admitted to medical wards in the Prince of Wales Hospital. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1329. [PMID: 34532466 PMCID: PMC8422091 DOI: 10.21037/atm-21-3660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/05/2021] [Indexed: 01/04/2023]
Abstract
Background Rhabdomyolysis with a marked elevation of serum creatine kinase (CK) can be caused by various conditions. Acute kidney injury (AKI) is a potential complication of severe rhabdomyolysis and leads to a rapid increase in serum creatinine. Methods This study was performed to identify medical cases diagnosed with rhabdomyolysis and to examine the likely causes. Patients diagnosed with rhabdomyolysis during admission to the medical wards of Prince of Wales Hospital (PWH) in Hong Kong from January 1, 2004 to May 31, 2012 were identified by searching computer records. Details of hospital admissions were retrieved, and the underlying causes of the rhabdomyolysis and clinical outcomes were analyzed. Results There were 95 Chinese patients with a median age of 72 years (range, 22–92 years) assigned a diagnosis of rhabdomyolysis. A mild degree of AKI was defined as an increase of serum creatinine more than 20% above the baseline value before onset of acute illness and with the highest creatinine greater than 120 µmol/L. Mild AKI was identified in 63 patients. Rhabdomyolysis appeared to contribute to a fatal outcome in eight patients who had multiple preexisting morbidities. The maximum CK had a median value of 9,829 U/L (range, 472–258,100 U/L). Twelve patients with peak CK levels <10× the upper limit of normal (ULN) may not have had rhabdomyolysis by this standard definition. Of the remaining 83 patients with maximum CK values >10× the ULN, the most common contributing factors were trauma (n=19) and infection (n=17). Other common underlying causes included drug abuse (heroin and alcohol) and ischemia/immobility. Conclusions Most patients recovered with appropriate medical interventions and had a median hospital stay of 13 days. One patient was thought to have drug-related rhabdomyolysis due to taking bezafibrate during an episode of renal impairment.
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Affiliation(s)
- Weiwei Zeng
- Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, China
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China.,Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Pariente A, Labat V, Mansiaux Y, Salvo F, Bégaud B, Raschi E, Faillie JL, Létinier L, Bezin J. DPP-4 Inhibitors in Combination with Lipid-Lowering Agents and Risk of Serious Muscular Injury: A Nested Case-Control Study in a Nationwide Cohort of Patients with Type 2 Diabetes Mellitus. Drug Saf 2021; 43:767-774. [PMID: 32306223 DOI: 10.1007/s40264-020-00936-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION After a safety warning was issued for a risk of muscular injury associated with dipeptidyl peptidase-4 (DPP-4) inhibitor use, especially when co-prescribed with statins, spontaneous reporting analyses provided conflicting results. OBJECTIVE The aim of this study was to investigate the association between DPP-4 inhibitor use and the risk of muscular injury in individuals with type 2 diabetes mellitus using statins or fibrates. METHODS We conducted a nested case-control study amongst a cohort of individuals with type 2 diabetes using statins or fibrates, identified from a nationwide French health insurance database (2009-2014). Cases of serious muscular injury were defined as subjects hospitalized for rhabdomyolysis or myopathy, or for whom testing for myoglobin or creatine phosphokinase followed by a change in statin or fibrate prescription (dose decrease, treatment switch, or stop) was identified. Up to ten controls were matched to each case according to sex, age, and type of lipid-lowering agent. Associations between DPP-4 inhibitor use and serious muscular injury were estimated using a multivariate conditional logistic regression model, providing odds ratios (ORs) adjusted for alcoholism, chronic renal failure, hypothyroidism, and number of concomitant drugs. RESULTS Within the 35,117 individuals with type 2 diabetes mellitus constituting the source cohort, 437 statin-user cases were identified who were matched to 4358 statin-user controls. Similarly, 54 fibrate-user cases were identified who were matched to 540 fibrate-user controls. The adjusted OR for DPP-4 inhibitor use and serious muscular injury was estimated at 1.0 (95% confidence interval [CI] 0.7-1.2) in statin users and 0.8 (95% CI 0.4-1.9) in fibrate users. CONCLUSION In this study, DPP-4 inhibitor use was not associated with an increased risk of serious muscular injury among patients with type 2 diabetes mellitus using statins or fibrates.
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Affiliation(s)
- Antoine Pariente
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France. .,Centre Régional de Pharmacovigilance et d'Information sur le Médicament de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, CHU Bordeaux, 33000, Bordeaux, France.
| | - Vanessa Labat
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France
| | - Yohann Mansiaux
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France
| | - Francesco Salvo
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France.,Centre Régional de Pharmacovigilance et d'Information sur le Médicament de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, CHU Bordeaux, 33000, Bordeaux, France
| | - Bernard Bégaud
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France.,Centre Régional de Pharmacovigilance et d'Information sur le Médicament de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, CHU Bordeaux, 33000, Bordeaux, France
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, 40126, Bologna, Italy
| | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, Univ. Montpellier, CHU Montpellier, 34295, Montpellier, France
| | - Louis Létinier
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France
| | - Julien Bezin
- Team Pharmacoepidemiology, Bordeaux Population Health Research Center, Inserm U1219, Univ. Bordeaux, 33000, Bordeaux, France
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42
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Gibson TB, Nguyen MD, Burrell T, Yoon F, Wong J, Dharmarajan S, Ouellet-Hellstrom R, Hua W, Ma Y, Baro E, Bloemers S, Pack C, Kennedy A, Toh S, Ball R. Electronic phenotyping of health outcomes of interest using a linked claims-electronic health record database: Findings from a machine learning pilot project. J Am Med Inform Assoc 2021; 28:1507-1517. [PMID: 33712852 DOI: 10.1093/jamia/ocab036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/19/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Claims-based algorithms are used in the Food and Drug Administration Sentinel Active Risk Identification and Analysis System to identify occurrences of health outcomes of interest (HOIs) for medical product safety assessment. This project aimed to apply machine learning classification techniques to demonstrate the feasibility of developing a claims-based algorithm to predict an HOI in structured electronic health record (EHR) data. MATERIALS AND METHODS We used the 2015-2019 IBM MarketScan Explorys Claims-EMR Data Set, linking administrative claims and EHR data at the patient level. We focused on a single HOI, rhabdomyolysis, defined by EHR laboratory test results. Using claims-based predictors, we applied machine learning techniques to predict the HOI: logistic regression, LASSO (least absolute shrinkage and selection operator), random forests, support vector machines, artificial neural nets, and an ensemble method (Super Learner). RESULTS The study cohort included 32 956 patients and 39 499 encounters. Model performance (positive predictive value [PPV], sensitivity, specificity, area under the receiver-operating characteristic curve) varied considerably across techniques. The area under the receiver-operating characteristic curve exceeded 0.80 in most model variations. DISCUSSION For the main Food and Drug Administration use case of assessing risk of rhabdomyolysis after drug use, a model with a high PPV is typically preferred. The Super Learner ensemble model without adjustment for class imbalance achieved a PPV of 75.6%, substantially better than a previously used human expert-developed model (PPV = 44.0%). CONCLUSIONS It is feasible to use machine learning methods to predict an EHR-derived HOI with claims-based predictors. Modeling strategies can be adapted for intended uses, including surveillance, identification of cases for chart review, and outcomes research.
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Affiliation(s)
- Teresa B Gibson
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | | | - Timothy Burrell
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Frank Yoon
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Jenna Wong
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Sai Dharmarajan
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rita Ouellet-Hellstrom
- Division of Epidemiology II, Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wei Hua
- Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yong Ma
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elande Baro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Sarah Bloemers
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Cory Pack
- Government Health and Human Services, IBM Watson Health, Bethesda, Maryland, USA
| | - Adee Kennedy
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Sengwee Toh
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Ball
- Office of Surveillance and Epidemiology Center for Drug Evaluation and Research U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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43
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Casula M, Gazzotti M, Bonaiti F, OImastroni E, Arca M, Averna M, Zambon A, Catapano AL. Reported muscle symptoms during statin treatment amongst Italian dyslipidaemic patients in the real-life setting: the PROSISA Study. J Intern Med 2021; 290:116-128. [PMID: 33259671 PMCID: PMC8359216 DOI: 10.1111/joim.13219] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/14/2020] [Accepted: 11/05/2020] [Indexed: 12/31/2022]
Abstract
AIM Statin-associated muscle symptoms (SAMS) are a major determinant of poor treatment adherence and/or discontinuation, but a definitive diagnosis of SAMS is challenging. The PROSISA study was an observational retrospective study aimed to assess the prevalence of reported SAMS in a cohort of dyslipidaemic patients. METHODS Demographic/anamnestic data, biochemical values and occurrence of SAMS were collected by 23 Italian Lipid Clinics. Adjusted logistic regression was performed to estimate odds ratio (OR) and 95% confidence intervals for association between probability of reporting SAMS and several factors. RESULTS Analyses were carried out on 16 717 statin-treated patients (mean ± SD, age 60.5 ± 12.0 years; 52.1% men). During statin therapy, 9.6% (N = 1599) of patients reported SAMS. Women and physically active subjects were more likely to report SAMS (OR 1.23 [1.10-1.37] and OR 1.35 [1.14-1.60], respectively), whist age ≥ 65 (OR 0.79 [0.70-0.89]), presence of type 2 diabetes mellitus (OR 0.62 [0.51-0.74]), use of concomitant nonstatin lipid-lowering drugs (OR 0.87 [0.76-0.99]), use of high-intensity statins (OR 0.79 [0.69-0.90]) and use of potential interacting drugs (OR 0.63 [0.48-0.84]) were associated with lower probability of reporting SAMS. Amongst patients reporting SAMS, 82.2% underwent dechallenge (treatment interruption) and/or rechallenge (change or restart of statin therapy), with reappearance of muscular symptoms in 38.4% (3.01% of the whole cohort). CONCLUSIONS The reported prevalence of SAMS was 9.6% of the whole PROSISA cohort, but only a third of patients still reported SAMS after dechallenge/rechallenge. These results emphasize the need for a better management of SAMS to implement a more accurate diagnosis and treatment re-evaluation.
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Affiliation(s)
- M Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.,IRCCS MultiMedica, Milan, Italy
| | - M Gazzotti
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - F Bonaiti
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - E OImastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - M Arca
- Department of Translational and Precision Medicine, Unit of Internal Medicine and Metabolic Diseases, Sapienza University, Rome, Italy
| | - M Averna
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialities, University of Palermo, Palermo, Italy
| | - A Zambon
- IRCCS MultiMedica, Milan, Italy.,Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - A L Catapano
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.,IRCCS MultiMedica, Milan, Italy
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44
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Brunette CA, Vassy JL. The role of SLCO1B1 genotyping in lowering cardiovascular risk. Pharmacogenomics 2021; 22:649-656. [PMID: 34196599 DOI: 10.2217/pgs-2021-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Charles A Brunette
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA 52242, USA
| | - Jason L Vassy
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA 02115, USA.,Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA 02115, USA.,Population Precision Health, Ariadne Labs, Boston, MA 02215, USA
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45
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Kim EJ, Wierzbicki AS. Investigating raised creatine kinase. BMJ 2021; 373:n1486. [PMID: 34162592 DOI: 10.1136/bmj.n1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Eun Ji Kim
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
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46
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McEvoy L, Carr DF, Pirmohamed M. Pharmacogenomics of NSAID-Induced Upper Gastrointestinal Toxicity. Front Pharmacol 2021; 12:684162. [PMID: 34234675 PMCID: PMC8256335 DOI: 10.3389/fphar.2021.684162] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs which are widely used globally for the treatment of pain and inflammation, and in the case of aspirin, for secondary prevention of cardiovascular disease. Chronic non-steroidal anti-inflammatory drug use is associated with potentially serious upper gastrointestinal adverse drug reactions (ADRs) including peptic ulcer disease and gastrointestinal bleeding. A few clinical and genetic predisposing factors have been identified; however, genetic data are contradictory. Further research is needed to identify clinically relevant genetic and non-genetic markers predisposing to NSAID-induced peptic ulceration.
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Affiliation(s)
- L McEvoy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - D F Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - M Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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47
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C2C12 myoblasts are more sensitive to the toxic effects of simvastatin than myotubes and show impaired proliferation and myotube formation. Biochem Pharmacol 2021; 190:114649. [PMID: 34111424 DOI: 10.1016/j.bcp.2021.114649] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022]
Abstract
Statins reduce cardiovascular complications in patients with high LDL-cholesterol but are associated with myopathy. We compared the toxicity of simvastatin of C2C12 myoblasts and myotubes. Since myoblasts can proliferate and fuse to myotubes, myoblasts can be considered as satellite cells and myotubes as mature muscle fibers. Simvastatin increased plasma membrane permeability and decreased the cellular ATP content in both myoblasts and myotubes, but with a stronger effect on myoblasts. While insulin prevented cytotoxicity up to 8 h after addition of simvastatin to myotubes, prevention in myoblasts required simultaneous addition. Mevalonate and geranylgeraniol prevented simvastatin-associated cytotoxicity in both myoblasts and myotubes. Simvastatin impaired the phosphorylation of the insulin receptor (IR β), Akt ser473 and S6rp, and increased phosphorylation of AMPK thr172 in both myotubes and myoblasts, which was prevented by insulin and mevalonate. Simvastatin impaired oxygen consumption and increased superoxide production by myoblasts and myotubes and induced apoptosis via cytochrome c release. In addition, simvastatin impaired proliferation and fusion of myoblasts to myotubes by inhibiting the expression of the nuclear transcription factor MyoD and of the metalloprotease ADAM-12. Decreased expression of the proliferation factor Ki-67 and of ADAM-12 were also observed in gastrocnemius of mice treated with simvastatin. In conclusion, myoblasts were more susceptible to the toxic effects of simvastatin and simvastatin impaired myoblast proliferation and myotube formation. Impaired muscle regeneration may represent a new mechanism of statin myotoxicity.
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48
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Gupta A, Thorson P, Penmatsa KR, Gupta P. Rhabdomyolysis: Revisited. THE ULSTER MEDICAL JOURNAL 2021; 90:61-69. [PMID: 34276082 PMCID: PMC8278949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/21/2022]
Abstract
Rhabdomyolysis (RML) is a pathological entity characterized by symptoms of myalgia, weakness and dark urine (which is often not present) resulting in respiratory failure and altered mental status. Laboratory testing for myoglobinuria is pathognomonic but so often not present during the time of testing that serum creatine kinase should always be sent when the diagnosis is suspected. Kidney injury from RML progresses through multiform pathways resulting in acute tubular necrosis. Early treatment (ideally<6 hoursfrom onset) is needed with volume expansion of all non-overloaded patients along with avoidance of nephrotoxins. There is insufficient data to recommend any specific fluid. The mortality rate ranges from 10% to up to 50% with severe AKI, so high index of suspicion and screening should be in care plan of seriously ill patients at risk for RML.
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Affiliation(s)
- Ankur Gupta
- Department of Medicine, Whakatane Hospital PO BOX 241, Whakatane 3158, New Zealand
| | - Peter Thorson
- Department of Medicine, Whakatane Hospital PO BOX 241, Whakatane 3158, New Zealand
| | - Krishnam R Penmatsa
- Department of Medicine, Whakatane Hospital PO BOX 241, Whakatane 3158, New Zealand
| | - Pritam Gupta
- Department of Medicine, Whakatane Hospital PO BOX 241, Whakatane 3158, New Zealand
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49
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Mitaritonno M, Lupo M, Greco I, Mazza A, Cervellin G. Severe rhabdomyolysis induced by co-administration of cocaine and heroin in a 45 years old man treated with rosuvastatin: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021089. [PMID: 33944852 PMCID: PMC8142779 DOI: 10.23750/abm.v92is1.8858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/19/2019] [Indexed: 01/04/2023]
Abstract
The term rhabdomyolysis describes a damage involving striated muscle cells or fibers, often complicated by acute kidney injury. This syndrome can have different causes, but it is generally divided into two main categories: traumatic and non-traumatic rhabdomyolysis. Among medical causes, drugs and abuse substances play a pivotal role, being opioids, alcohol, cocaine and other substances of abuse. Among drugs, the case of statins is certainly the best known. Here we describe a paradigmatic case of a man treated with success and good tolerance for years with rosuvastatin, who developed a severe rhabdomyolysis complicated by AKI needing hemodialysis, after the assumption of two substances of abuse (cocaine and heroin). Emergency physicians need to be aware of this syndrome, since it must be clinically suspected in order to ask the Laboratory for appropriate tests. Given that troponins are now widely accepted as the unique biochemical "gold standard" for diagnosing acute coronary syndromes, CK and myoglobin (the "gold standard" tests for diagnosing rhabdomyolysis) have been erased from admission test panels of the vast majority of emergency departments.
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Affiliation(s)
| | | | - Ivana Greco
- Emergency Department, "S.S. Annunziata" Hospital, Cosenza, Italy.
| | - Angela Mazza
- Emergency Department, "S.S. Annunziata" Hospital, Cosenza, Italy.
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50
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Ooi BNS, Raechell, Ying AF, Koh YZ, Jin Y, Yee SWL, Lee JHS, Chong SS, Tan JWC, Liu J, Lee CG, Drum CL. Robust Performance of Potentially Functional SNPs in Machine Learning Models for the Prediction of Atorvastatin-Induced Myalgia. Front Pharmacol 2021; 12:605764. [PMID: 33967749 PMCID: PMC8100589 DOI: 10.3389/fphar.2021.605764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 03/08/2021] [Indexed: 12/20/2022] Open
Abstract
Statins can cause muscle symptoms resulting in poor adherence to therapy and increased cardiovascular risk. We hypothesize that combinations of potentially functional SNPs (pfSNPs), rather than individual SNPs, better predict myalgia in patients on atorvastatin. This study assesses the value of potentially functional single nucleotide polymorphisms (pfSNPs) and employs six machine learning algorithms to identify the combination of SNPs that best predict myalgia. Methods: Whole genome sequencing of 183 Chinese, Malay and Indian patients from Singapore was conducted to identify genetic variants associated with atorvastatin induced myalgia. To adjust for confounding factors, demographic and clinical characteristics were also examined for their association with myalgia. The top factor, sex, was then used as a covariate in the whole genome association analyses. Variants that were highly associated with myalgia from this and previous studies were extracted, assessed for potential functionality (pfSNPs) and incorporated into six machine learning models. Predictive performance of a combination of different models and inputs were compared using the average cross validation area under ROC curve (AUC). The minimum combination of SNPs to achieve maximum sensitivity and specificity as determined by AUC, that predict atorvastatin-induced myalgia in most, if not all the six machine learning models was determined. Results: Through whole genome association analyses using sex as a covariate, a larger proportion of pfSNPs compared to non-pf SNPs were found to be highly associated with myalgia. Although none of the individual SNPs achieved genome wide significance in univariate analyses, machine learning models identified a combination of 15 SNPs that predict myalgia with good predictive performance (AUC >0.9). SNPs within genes identified in this study significantly outperformed SNPs within genes previously reported to be associated with myalgia. pfSNPs were found to be more robust in predicting myalgia, outperforming non-pf SNPs in the majority of machine learning models tested. Conclusion: Combinations of pfSNPs that were consistently identified by different machine learning models to have high predictive performance have good potential to be clinically useful for predicting atorvastatin-induced myalgia once validated against an independent cohort of patients.
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Affiliation(s)
- Brandon N S Ooi
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Dundee, Singapore
| | - Raechell
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Dundee, Singapore
| | | | - Yong Zher Koh
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Dundee, Singapore
| | - Yu Jin
- Division of Cellular and Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore, Singapore
| | - Sherman W L Yee
- Department of Medicine, Yong Loo Lin School of Medicine, Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | | | - Samuel S Chong
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jack W C Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Jianjun Liu
- Genome Institute of Singapore, Singapore, Singapore
| | - Caroline G Lee
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Dundee, Singapore.,Duke-NUS Graduate School, Singapore, Singapore.,Division of Cellular and Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore, Singapore.,NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, Singapore
| | - Chester L Drum
- Department of Medicine, Yong Loo Lin School of Medicine, Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore.,Translational Laboratory in Genetic Medicine, Singapore, Singapore
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