1
|
Pan Y, Wang Y, Zheng Y, Chen J, Li J. A disproportionality analysis of FDA adverse event reporting system (FAERS) events for ticagrelor. Front Pharmacol 2024; 15:1251961. [PMID: 38655177 PMCID: PMC11035729 DOI: 10.3389/fphar.2024.1251961] [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: 07/03/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Background Ticagrelor is a commonly used antiplatelet agent, but due to the stringent criteria for trial population inclusion and the limited sample size, its safety profile has not been fully elucidated. Method We utilized OpenVigil 2.1 to query the FDA Adverse Event Reporting System database and retrieved reports by the generic name "ticagrelor" published between 1 October 2010 and 31 March 2023. Adverse drug events (ADEs) were classified and described according to the preferred terms and system organ classes in the Medical Dictionary of Regulatory Activity. Proportional reporting ratio (PRR), reporting odds ratio (ROR) and Bayesian Confidence Propagation Neural Network (BCPNN) were used to detect signals. Results The number of ADE reports with ticagrelor as the primary suspect drug was 12,909. The top three ADEs were dyspnea [1824 reports, ROR 7.34, PRR 6.45, information component (IC) 2.68], chest pain (458 reports, ROR 5.43, PRR 5.27, IC 2.39), and vascular stent thrombosis (406 reports, ROR 409.53, PRR 396.68, IC 8.02). The highest ROR, 630.24, was found for "vascular stent occlusion". Cardiac arrest (137 reports, ROR 3.41, PRR 3.39, IC 1.75), atrial fibrillation (99 reports, ROR 2.05, PRR 2.04, IC 1.03), asphyxia (101 reports, ROR 23.60, PRR 23.43, IC 4.51), and rhabdomyolysis (57 reports, ROR 2.75, PRR 2.75, IC 1.45) were suspected new adverse events of ticagrelor. Conclusion The FAERS database produced potential signals associated with ticagrelor that have not been recorded in the package inserts, such as cardiac arrest, atrial fibrillation, asphyxia, and rhabdomyolysis. Further clinical surveillance is needed to quantify and validate potential hazards associated with ticagrelor-related adverse events.
Collapse
Affiliation(s)
- Yunyan Pan
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yu Wang
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yifan Zheng
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Department of Clinical Pharmacy Translational Science, University of Michigan College of Pharmacy, Ann Arbor, MI, United States
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
2
|
Wang Y, Wu Y, Wang J, Zhang H, Du L, Wang K, Duan H. Predictors of gastrointestinal bleeding in patients with acute coronary syndrome and the optimal duration of dual antiplatelet therapy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:15. [PMID: 38808215 PMCID: PMC11132419 DOI: 10.4103/jrms.jrms_452_22] [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: 06/26/2022] [Revised: 11/05/2023] [Accepted: 11/13/2023] [Indexed: 05/30/2024]
Abstract
Background This study aims to estimate the risk factors of gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) and to evaluate the optimal duration of dual antiplatelet therapy (DAPT). Materials and Methods We enrolled 1266 patients with ACS in a telephone follow-up program to determine whether any of the patients were hospitalized for GI bleeding. We collected baseline data, laboratory tests, electrocardiograms, and echocardiography covering all ACS patients. Multivariable regression was performed to adjust for confounders and predictors of GI bleeding. At the same time, the optimal duration of DAPT for ACS patients was evaluated. Results A total of 1061 ACS patients were included in the study. After 13-68 months, 48 patients (4.5%) were hospitalized for GI bleeding. The risk of GI bleeding was significantly increased in patients treated with DAPT for more than 18 months (hazard ratio 12.792, 5.607-29.185, P < 0.01). Receiver Operating Characteristic curve showed that the duration of DAPT using a cutoff of 14.5 months resulted in a sensitivity of 66.7% and a specificity of 77%. Conclusion In patients with ACS, DAPT time are the main risk factors of GI bleeding. The optimal duration of DAPT is 14.5 months.
Collapse
Affiliation(s)
- Yanyu Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yingle Wu
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jingqiao Wang
- Henan Key Laboratory of Epigenetics, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Hengliang Zhang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Laijing Du
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Ke Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hongqiang Duan
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| |
Collapse
|
3
|
Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
Collapse
Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
| |
Collapse
|
4
|
Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V. Proton pump inhibitors and gastroprotection in patients treated with antithrombotic drugs: A cardiologic point of view. World J Cardiol 2023; 15:375-394. [PMID: 37771340 PMCID: PMC10523195 DOI: 10.4330/wjc.v15.i8.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/23/2023] [Accepted: 08/08/2023] [Indexed: 08/21/2023] Open
Abstract
Aspirin, other antiplatelet agents, and anticoagulant drugs are used across a wide spectrum of cardiovascular and cerebrovascular diseases. A concomitant proton pump inhibitor (PPI) treatment is often prescribed in these patients, as gastrointestinal complications are relatively frequent. On the other hand, a potential increased risk of cardiovascular events has been suggested in patients treated with PPIs; in particular, it has been discussed whether these drugs may reduce the cardiovascular protection of clopidogrel, due to pharmacodynamic and pharmacokinetic interactions through hepatic metabolism. Previously, the concomitant use of clopidogrel and omeprazole or esomeprazole has been discouraged. In contrast, it remains less known whether PPI use may affect the clinical efficacy of ticagrelor and prasugrel, new P2Y12 receptor antagonists. Current guidelines recommend PPI use in combination with antiplatelet treatment in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids, or non-steroidal anti-inflammatory drugs, and Helicobacter pylori (H. pylori) infection. In patients taking oral anticoagulant with risk factors for gastrointestinal bleeding, PPIs could be recommended, even if their usefulness deserves further data. H. pylori infection should always be investigated and treated in patients with a history of peptic ulcer disease (with or without complication) treated with antithrombotic drugs. The present review summarizes the current knowledge regarding the widespread combined use of platelet inhibitors, anticoagulants, and PPIs, discussing consequent clinical implications.
Collapse
Affiliation(s)
| | - Alberto Lombardo
- Operative Unit of Cardiology, S. Antonio Abate Hospital, ASP Trapani, Erice 91100, Trapani, Italy
| | - Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Italy
| | - Nicolò Renda
- Department of Direction, CTA Salus, Gibellina 91024, Trapani, Italy
| | - Vincenzo Abrignani
- Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Italy
| |
Collapse
|
5
|
Short dual antiplatelet therapy in patients with high bleeding risk undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Coron Artery Dis 2022; 33:580-589. [DOI: 10.1097/mca.0000000000001180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
6
|
Guo S, Zhang S, Chen K, Chen X, Hu F. Effects of diagnostic ultrasound with cRGD-microbubbles on simultaneous detection and treatment of atherosclerotic plaque in ApoE−/− mice. Front Cardiovasc Med 2022; 9:946557. [PMID: 35935617 PMCID: PMC9354833 DOI: 10.3389/fcvm.2022.946557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Atherosclerotic vulnerable plaque is the leading cause of acute fatal cardiovascular events. Thus, early rapid identification and appropriate treatment of atherosclerotic plaque maybe can prevent fatal cardiovascular events. However, few non–invasive molecular imaging techniques are currently available for the simultaneous detection and targeted treatment of atherosclerotic plaques. We hypothesized that diagnostic ultrasound (DU) combined with cyclic Arg-Gly-Asp-modified microbubbles (MBR) could provide targeted imaging and dissolution of activated platelets to identify advanced atherosclerotic plaques and improve plaque instability. Methods Three mouse models, apolipoprotein E-deficient mice on a hypercholesterolemic diet (HCD) or normal chow diet and wild-type mice on an HCD were used. The most appropriate ultrasonic mechanical index (MI) was determined based on the expression of GP IIb/IIIa in sham, DU alone and DUMBR-treated groups at MI values of 0.5, 1.5, and 1.9. The video intensity (VI) values, activated platelets and plaque instability were analyzed by ultrasound molecular imaging, scanning electron microscopy and histopathological methods. Results We found that the VI values of ultrasound molecular imaging of MBR were positively correlated with plaque GP IIb/IIIa expression, vulnerability index and necrotic center / fiber cap ratio. 24 h after treatment at different MIs, compared with those of the other groups, both the VI values and GP IIb/IIIa expression were significantly reduced in MI 1.5 and MI 1.9 DUMBR-treated groups. The plaque vulnerability index and necrotic center / fiber cap ratio were significantly decreased in MI 1.5-treated group, which may be due to targeted dissolution of activated platelets, with a reduction in von Willebrand factor expression. Conclusion DUMBR targeting GP IIb/IIIa receptors could rapidly detect advanced atherosclerotic plaques and simultaneously give targeted therapy by dissolving activated and aggregated platelets. This technology may represent a novel approach for the simultaneous identification and treatment of atherosclerotic plaques.
Collapse
|
7
|
Low-dose aspirin for the prevention of atherothrombosis across the cardiovascular risk continuum. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
8
|
Galusko V, Protty M, Haboubi HN, Verhemel S, Bundhoo S, Yeoman AD. Endoscopy findings in patients on dual antiplatelet therapy following percutaneous coronary intervention. Postgrad Med J 2021; 98:591-597. [PMID: 33879553 DOI: 10.1136/postgradmedj-2021-139928] [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: 02/09/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE OF STUDY This study examines the associations between dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB), to explore possible predictors of outcomes. STUDY DESIGN Retrospective analysis of 3342 patients who underwent PCI between 1 August 2011 and 31 December 2018 in a single centre was carried out. Oesophagogastroduodenoscopies (OGDs) for patients 12 months post-PCI were analysed. RESULTS Blood loss occurred in 2% of all (3342) patients post-PCI within 12 months. 128 patients (63% male, mean age (SD) of 69.8 (10) years) who had PCI subsequently underwent an OGD within 12 months of the index PCI procedure. GIB occurred within the first 30 days of DAPT in 36% (n=13/36) of cases. There were no thrombotic events associated with cessation of one antiplatelet agent. Increased age, haemoglobin (Hb) ≤109 g/L and Glasgow-Blatchford score ≥8 were associated with increased 12-month mortality. An Hb drop of ≥30 g/L was a sensitive and specific marker for significant pathology and evidence of bleeding on OGD (sensitivity=0.83, specificity=0.81). CONCLUSIONS GIB bleeding occurred infrequently in the patients post-PCI on DAPT. Risk assessment scores (such as Glasgow-Blatchford and Rockall scores) are useful tools to assess the urgency of OGD and need for endoscopic therapy.
Collapse
Affiliation(s)
- Victor Galusko
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Majd Protty
- Department of Cardiology, Royal Gwent Hospital, Newport, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Hasan N Haboubi
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sarah Verhemel
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Shantu Bundhoo
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Andrew D Yeoman
- Department of Gastroenterology, Royal Gwent Hospital, Newport, UK
| |
Collapse
|
9
|
Abrignani MG, Gatta L, Gabrielli D, Milazzo G, De Francesco V, De Luca L, Francese M, Imazio M, Riccio E, Rossini R, Scotto di Uccio F, Soncini M, Zullo A, Colivicchi F, Di Lenarda A, Gulizia MM, Monica F. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med 2021; 85:1-13. [PMID: 33279389 DOI: 10.1016/j.ejim.2020.11.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.
Collapse
Affiliation(s)
| | - Luigi Gatta
- Gastroenterogy Unit, Versilia Hospital, Lido di Camaiore, Italy
| | | | - Giuseppe Milazzo
- Department of Medicine, Ospedale Vittorio Emanuele III, Salemi, Italy
| | | | - Leonardo De Luca
- Dept. Of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Maura Francese
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
| | - Massimo Imazio
- Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elisabetta Riccio
- Department of Transplantation, UOSC of Gastroenterology and Endoscopy, AORN 'A. Cardarelli', Napoli, Italy
| | | | | | | | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy; President, Heart Care Foundation, Italy
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
| |
Collapse
|
10
|
Abstract
Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.
Collapse
Affiliation(s)
- Nicholas J Costable
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustav L Levy Place, New York, NY 10029, USA
| | - David A Greenwald
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 11th Floor, New York, NY 10029, USA.
| |
Collapse
|
11
|
Alexopoulos D. Ticagrelor and omeprazole: A desirable combination in post MI patients? Hellenic J Cardiol 2020; 61:311-312. [PMID: 33181277 DOI: 10.1016/j.hjc.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| |
Collapse
|
12
|
McFarlane M, Disney BR. Editorial - out with the old and in with the new? Gastrointestinal bleeding risk of P2Y 12 inhibitors following acute coronary syndrome. Aliment Pharmacol Ther 2020; 52:887-888. [PMID: 32852831 DOI: 10.1111/apt.15912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michael McFarlane
- Department of Gastroenterology, University Hospital Coventry, Coventry, UK
| | - Benjamin R Disney
- Department of Gastroenterology, University Hospital Coventry, Coventry, UK
| |
Collapse
|
13
|
Hara H, Takahashi K, Kogame N, Tomaniak M, Kerkmeijer LSM, Ono M, Kawashima H, Wang R, Gao C, Wykrzykowska JJ, de Winter RJ, Neumann FJ, Plante S, Lemos Neto PA, Garg S, Jüni P, Vranckx P, Windecker S, Valgimigli M, Hamm C, Steg PG, Onuma Y, Serruys PW. Impact of Bleeding and Myocardial Infarction on Mortality in All-Comer Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2020; 13:e009177. [PMID: 32838554 DOI: 10.1161/circinterventions.120.009177] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bleeding and myocardial infarction (MI) after percutaneous coronary intervention are independent risk factors for mortality. This study aimed to investigate the association of all-cause mortality after percutaneous coronary intervention with site-reported bleeding and MI, when considered as individual, repeated, or combined events. METHODS We used the data from the GLOBAL LEADERS trial (GLOBAL LEADERS: A Clinical Study Comparing Two Forms of Anti-Platelet Therapy After Stent Implantation), an all-comers trial of 15 968 patients undergoing percutaneous coronary intervention. Bleeding was defined as Bleeding Academic Research Consortium (BARC) 2, 3, or 5, whereas MI included periprocedural and spontaneous MIs according to the Third Universal Definition. RESULTS At 2-year follow-up, 1061 and 498 patients (6.64% and 3.12%) experienced bleeding and MI, respectively. Patients with a bleeding event had a 10.8% mortality (hazard ratio [HR], 5.97 [95% CI, 4.76-7.49]; P<0.001), and the mortality of patients with an MI was 10.4% (HR, 5.06 [95% CI, 3.72-6.90]; P<0.001), whereas the overall mortality was 2.99%. Albeit reduced over time, MI and even minor BARC 2 bleeding significantly influenced mortality beyond 1 year after adverse events (HR of MI, 2.32 [95% CI, 1.18-4.55]; P=0.014, and HR of BARC 2 bleeding, 1.79 [95% CI, 1.02-3.15]; P=0.044). The mortality rates in patients with repetitive bleeding, repetitive MI, and both bleeding and MI were 16.1%, 19.2%, and 19.0%, and their HRs for 2-year mortality were 8.58 (95% CI, 5.63-13.09; P<0.001), 5.57 (95% CI, 2.53-12.25; P<0.001), and 6.60 (95% CI, 3.44-12.65; P<0.001), respectively. De-escalation of antiplatelet therapy at the time of BARC 3 bleeding was associated with a lower subsequent bleeding or MI rate, compared with continuation of antiplatelet therapy (HR, 0.32 [95% CI, 0.11-0.92]; P=0.034). CONCLUSIONS The fatal impact of bleeding and MI persisted beyond one year. Additional bleeding or MIs resulted in a poorer prognosis. De-escalation of antiplatelet therapy at the time of BARC 3 bleeding could have a major safety merit. These results emphasize the importance of considering the net clinical benefit including ischemic and bleeding events. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01813435.
Collapse
Affiliation(s)
- Hironori Hara
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Kuniaki Takahashi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Norihiro Kogame
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands (M.T.)
- First Department of Cardiology, Medical University of Warsaw, Poland (M.T.)
| | - Laura S M Kerkmeijer
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Masafumi Ono
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Hideyuki Kawashima
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Rutao Wang
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Chao Gao
- Department of Cardiology, Radboud University, Nijmegen, the Netherlands (R.W., C.G.)
| | - Joanna J Wykrzykowska
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands (H.H., K.T., N.K., L.S.M.K., M.O., H.K. J.J.W., R.J.d.W.)
| | - Franz-Josef Neumann
- Division of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany (F.-J.N.)
| | - Sylvain Plante
- Division of Cardiology, Department of Medicine, Southlake Regional Health Center, Newmarket, ON, Canada (S.P.)
| | | | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom (S.G.)
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Canada (P.J.)
| | - Pascal Vranckx
- Department of Cardiology and Critical Care, Jessa Ziekenhuis Hasselt, Faculty of Medicine and Life Sciences, University of Hasselt, Belgium (P.V.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Switzerland (S.W., M.V.)
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Switzerland (S.W., M.V.)
| | - Christian Hamm
- Department of Cardiology, Kerckhoff Heart Center, Campus University of Giessen, Bad Nauheim, Germany (C.H.)
| | - Philippe Gabriel Steg
- FACT, Université Paris Diderot, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (Y.O., P.W.S.)
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (Y.O., P.W.S.)
- NHLI, Imperial College London, United Kingdom (P.W.S.)
| |
Collapse
|
14
|
Abraham NS, Yang EH, Noseworthy PA, Inselman J, Yao X, Herrin J, Sangaralingham LR, Ngufor C, Shah ND. Fewer gastrointestinal bleeds with ticagrelor and prasugrel compared with clopidogrel in patients with acute coronary syndrome following percutaneous coronary intervention. Aliment Pharmacol Ther 2020; 52:646-654. [PMID: 32657466 PMCID: PMC8183594 DOI: 10.1111/apt.15790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/21/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) frequently occurs following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) with the prescription of P2Y12 inhibiting antiplatelet agents. Compared with clopidogrel, the newer P2Y12 inhibitors lower major adverse cardiac events with similar or possibly higher major bleeding events. The comparative GIB rates of these medications remain poorly understood. AIM To compare GIB rates associated with clopidogrel, prasugrel and ticagrelor using national medical and pharmacy claims data from privately insured and Medicare Advantage enrollees . METHODS Propensity score and inverse probability treatment weighting were used to balance baseline characteristics among treatment groups. The 1-year GIB risk was calculated using weighted Cox proportional hazard models and expressed as hazard ratios (HR) with 95% confidence intervals (CI) and number needed to harm (NNH). RESULTS We identified 37 019 patients with ACS (non-ST elevation ACS [NSTE-ACS] and ST-elevation myocardial infarction [STEMI]) within 14 days of a PCI (mean age 63 years and 70% male). Clopidogrel prescription was most common (69%) with prasugrel (16%) and ticagrelor (14%) prescribed less frequently. When compared with clopidogrel, ticagrelor was associated with a 34% risk reduction (HR 0.66; 95% CI: 0.54-0.81) in GIB overall and with NSTE-ACS, and a 37% GIB risk reduction (HR 0.63; 95% CI: 0.42-0.93) in STEMI patients. When compared with clopidogrel, prasugrel was associated with a 21% risk reduction (HR 0.79; 95% CI: 0.64-0.97) overall, a 36% GIB risk reduction (HR 0.64; 95% CI: 0.49-0.85) in STEMI patients but no reduction of GIB risk in NSTE-ACS patients. CONCLUSIONS In the first year following PCI, ticagrelor or prasugrel are associated with fewer GIB events than clopidogrel.
Collapse
Affiliation(s)
- Neena S. Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Eric H. Yang
- Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Peter A. Noseworthy
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA,Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Inselman
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Xiaoxi Yao
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Jeph Herrin
- Division of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | - Lindsey R. Sangaralingham
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Che Ngufor
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA,OptumLabs, Cambridge, MA, USA
| |
Collapse
|
15
|
No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy. J Clin Med 2020; 9:jcm9051526. [PMID: 32443621 PMCID: PMC7290690 DOI: 10.3390/jcm9051526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022] Open
Abstract
The risk for gastrointestinal bleeding from dual antiplatelet therapy (DAPT) with new antiplatelets (prasugrel/ticagrelor) compared to clopidogrel is unclear. AIM To determine the risk and type of major (gastrointestinal bleeding requiring hospitalization) and minor (anemia and iron deficiency) gastrointestinal events with different types of DAPT. METHODS Retrospective observational cohort study of patients who started DAPT after percutaneous coronary intervention. Follow-up was censored after 12 months of DAPT, when a major gastrointestinal event occurred, or when DAPT was discontinued. RESULTS Among 1,327 patients (54.03% were treated with clopidogrel-based DAPT, 38.13% with ticagrelor-based DAPT, and 7.84% with prasugrel-based DAPT), 29.5% had at least one gastrointestinal event. Patients taking clopidogrel-DAPT were older, with more comorbidities, and higher gastrointestinal risk compared to those taking other DAPT regimens. Adjusted hazard ratios (HRs) showed no between-group differences in the risk for major (clopidogrel vs. new antiplatelets: HR 0.996; 95% confidence interval 0.497-1.996) and minor (HR 0.920; 0.712-1.189) gastrointestinal events. Most patients received proton pump inhibitors while on DAPT (93.3%) and after withdrawal (83.2%). CONCLUSION Prasugrel- or ticagrelor-based DAPT was not associated with increased gastrointestinal bleeding risk when compared to clopidogrel-DAPT. New antiplatelets do not necessarily need to be restricted to patients with low gastrointestinal risk.
Collapse
|
16
|
Zhang N, Xu W, Li O, Zhang B. The risk of dyspnea in patients treated with third-generation P2Y 12 inhibitors compared with clopidogrel: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2020; 20:140. [PMID: 32183711 PMCID: PMC7079377 DOI: 10.1186/s12872-020-01419-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background Ticagrelor and prasugrel are two third-generation oral P2Y12 inhibitors which are more commonly used in clinical practice. However, dyspnea has been consecutively reported in patients using third-generation oral P2Y12 inhibitors. This study aims to compare the risk of dyspnea in patients treated with third-generation P2Y12 inhibitors compared with clopidogrel. Methods We systematically searched the PubMed, Cochrane Central Register of Controlled Trials databases, ClinicalTrials.gov and Web of Science for randomized control trials (RCTs) comparing ticagrelor or prasugrel with clopidogrel until July 2019. The primary outcome was the incidence of dyspnea. The risk ratios (RR) and 95% confidence intervals (CI) were estimated using meta-analysis. Results We included 25 RCTs involving 63,484 patients in this meta-analysis, including 21 studies on ticagrelor and 4 studies on prasugrel. Compared to the clopidogrel group, third-generation oral P2Y12 inhibitors were associated with an increased risk of dyspnea compared with clopidogrel (RR 2.15, 95% CI 1.59–2.92), which was consistent in the analysis of ticagrelor (RR 2.65, 95% CI 1.87–3.76). However, the adverse effect was not found among patients receiving prasugrel therapy (RR 1.03, 95% CI 0.86–1.22). The increased dyspnea risk of ticagrelor was consistent in subgroups with different follow-up durations (≤ 1 month RR 1.87, 95% CI 1.56–2.24; 1–6 months RR 4.19, 95% CI 1.99–8.86; > 6 months 2.45, 95% CI 1.13–5.34). Conclusions Ticagrelor has a higher risk of dyspnea than clopidogrel, which was not observed in patients using prasugrel.
Collapse
Affiliation(s)
- Na Zhang
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China.
| | - Weisen Xu
- Department of Stomatology, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, 100029, China
| | - Ou Li
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China
| | - Bing Zhang
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China
| |
Collapse
|