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Abstract
BACKGROUND Acute coronary syndrome (ACS) is a highly thrombotic state, and a sustained antiplatelet effect is vital to the prevention of thrombotic complications. Clopidogrel, the most widely used oral P2Y12 receptor antagonist in ACS, has attracted considerable attention because of significant variability in antiplatelet effect depending on the presence of CYP2C19 allele. Other P2Y12 receptor antagonists offer sustained and more predictable antiplatelet effects than clopidogrel albeit at an increased cost. Several studies have demonstrated the promising application of pharmacogenetics in choosing personalized antiplatelet therapy using the point-of-care genotype assays. AREAS OF UNCERTAINTY Guidelines regarding the genotype-guided approach to the selection of antiplatelet therapy have been conflicting, and studies evaluating the effect of pharmacogenetic-guided selection of antiplatelet therapy on the outcomes have demonstrated mixed results. DATA SOURCES A literature search was conducted using MEDLINE and EMBASE for studies reporting the association of pharmacogenetic-guided selection of antiplatelet therapy and the outcomes in patients with ACS until December 2018. RESULTS Presence of specific CYP2C19 allele significantly influences clopidogrel metabolism and associated outcomes in patients with ACS. Thrombotic and bleeding complications are more common in patients with loss-of-function (LOF) and gain-of-function (GOF) alleles, respectively. Although the pharmacogenetic-guided approach to the selection of antiplatelet therapy appears promising in ACS, studies have shown conflicting results, and direct randomized evidence linking this approach with the better outcomes is lacking. CONCLUSIONS Genotype-guided selection of antiplatelet therapy is expected to be useful in patients undergoing percutaneous coronary intervention (PCI) with a high risk of adverse outcomes. The patient-physician discussion should be an essential part of this decision-making process. Large-scale multicenter randomized controlled trials using the point-of-care genotype assay are needed to investigate this approach further before its use can be recommended in all comers.
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2
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Abstract
Antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment of patients with atherothrombotic disease manifestations. Switching between P2Y12 inhibitors occurs commonly in clinical practice for a variety of reasons, including safety, efficacy, adherence, and economic considerations. There are concerns about the optimal approach for switching because of potential drug interactions, which may lead to ineffective platelet inhibition and thrombotic complications, or potential overdosing due to overlap in drug therapy, which might cause excessive platelet inhibition and increased bleeding. This review provides practical considerations of switching based on pharmacodynamic and clinical data available from the literature.
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Affiliation(s)
- Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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Liu L, Liao H, Zhong S, Liu Y, Xiao C. Effects of switching ticagrelor to clopidogrel on cardiovascular outcomes in patients with acute coronary syndrome. Medicine (Baltimore) 2018; 97:e13381. [PMID: 30508934 PMCID: PMC6283150 DOI: 10.1097/md.0000000000013381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Present study was to evaluate whether switching ticagrelor to clopidogrel would impact platelet reactivity and cardiovascular outcomes in acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI).A total of 202 ACS patients after PCI were enrolled and prescribed ticagrelor. Before discharge, 138 (68%) patients were switched to clopidogrel. Peripheral blood was obtained before switching and at 48 hours after switching to measure platelet reactivity. Patients were followed for 30 days to evaluate cardiovascular events.Compared to ticagrelor group, patients in clopidogrel group were more likely to be male (69.6% vs 65.6%), smokers (34.1% vs 31.3%) and had higher prevalence of hypertension (75.4% vs 71.9%). The frequency of right coronary artery lesion was significantly higher in ticagrelor group (34.4% vs 30.4%). There were no significant differences in baseline platelet reactivity (37.6 ± 5.2% vs 38.4 ± 4.9%). Forty-eight hours after switching to clopidogrel, platelet reactivity in clopidogrel group was significantly higher (46.3 ± 5.6% vs 38.1 ± 5.0%, P <.05). Patients in clopidogrel group had significantly higher incidence of cardiovascular events (3.6% vs 1.6%, P <.05). However, after further adjusted for platelet reactivity at 48 hours of switching, clopidogrel switching was not significantly associated with composite outcomes, with hazard ratio 1.08 (95% confidence interval 0.98-1.21, P = .063), indicating that platelet reactivity was a critical mediator between antiplatelet drug switching and cardiovascular outcomes.ACS patients after PCI treatment, early switching ticagrelor to clopidogrel results in increased platelet reactivity and higher incidence of short-term cardiovascular events.
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Saucedo JF, Cardillo TE, Jakubowski JA, Henneges C, Effron MB, Lipkin FR, Walker JR, Duvvuru S, Sundseth SS, Fisher HN, Angiolillo DJ, Diodati JG. Transferring from clopidogrel loading dose to prasugrel loading dose in acute coronary syndrome patients. Thromb Haemost 2017; 112:311-22. [DOI: 10.1160/th13-09-0747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 02/27/2014] [Indexed: 11/05/2022]
Abstract
SummaryHigh on-treatment platelet reactivity (HPR) has been identified as an independent risk factor for ischaemic events. The randomised, doubleblind, TRIPLET trial included a pre-defined comparison of HPR in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) following a placebo/600-mg clopidogrel loading dose (LD) immediately before a subsequent prasugrel 60-mg or 30-mg LD. Platelet reactivity was assessed using the VerifyNow® P2Y12 assay (P2Y12 Reaction Units, PRU) within 24 hours (h) following the placebo/clopidogrel LD (immediately prior to prasugrel LD), and at 2, 6, 24, 72 h following prasugrel LDs. The impact of CYP2C19 predicted metaboliser phenotype (extensive metaboliser [EM] and reduced metabolisers [RM]) on HPR status was also assessed. HPR (PRU ≥240) following the clopidogrel LD (prior to the prasugrel LD) was 58.5% in the combined clopidogrel LD groups. No significant difference was noted when stratified by time between the clopidogrel and prasugrel LDs (≤6 hs vs >6 h). At 6 h following the 2nd loading dose in the combined prasugrel LD groups, HPR was 7.1%, with 0% HPR by 72 h. There was no significant effect of CYP2C19 genotype on pharmacodynamic (PD) response following either prasugrel LD treatments at any time point, regardless of whether it was preceded by a clopidogrel 600-mg LD. In conclusion, in this study, patients with ACS intended for PCI showed a high prevalence of HPR after clopidogrel 600-mg LD regardless of metaboliser status. When prasugrel LD was added, HPR decreased substantially by 6 h, and was not seen by 72 h.
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Siller-Matula JM, Jilma B. Why have studies of tailored anti-platelet therapy failed so far? Thromb Haemost 2017; 110:628-31. [DOI: 10.1160/th13-03-0250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 07/02/2013] [Indexed: 11/05/2022]
Abstract
SummaryPublished data linking clopidogrel non-responsiveness to adverse ischaemic events lead to the suggestion that the magnitude of platelet inhibition by clopidogrel can be monitored and individually adjusted. This has been tested in randomised clinical trials (ARCTIC, GRAVITAS and TRIGGER-PCI), but despite reducing platelet reactivity, a strategy of therapy adjustment based on platelet function monitoring did not reduce the incidence of cardiac ischaemic events. Several critical issues regarding the design of these trials, which might in part have led to negative results, are discussed in this article.
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Tomiya A, Goto S. High on-treatment platelet reactivity (HPR): What does it mean, and does it matter? Thromb Haemost 2017; 109:177-8. [DOI: 10.1160/th12-12-0910] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 01/07/2013] [Indexed: 11/05/2022]
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Schrör K, Huber K. High on-treatment platelet reactivity - why should we be concerned? Thromb Haemost 2017; 109:789-91. [DOI: 10.1160/th13-04-0281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 11/05/2022]
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Angiolillo DJ, Rollini F, Storey RF, Bhatt DL, James S, Schneider DJ, Sibbing D, So DY, Trenk D, Alexopoulos D, Gurbel PA, Hochholzer W, De Luca L, Bonello L, Aradi D, Cuisset T, Tantry US, Wang TY, Valgimigli M, Waksman R, Mehran R, Montalescot G, Franchi F, Price MJ. International Expert Consensus on Switching Platelet P2Y
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Receptor–Inhibiting Therapies. Circulation 2017; 136:1955-1975. [DOI: 10.1161/circulationaha.117.031164] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - David J. Schneider
- Department of Medicine, Cardiology Unit, Cardiovascular Research Institute, University of Vermont, Burlington (D.J.S.)
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Germany (D.S.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (D.S.)
| | - Derek Y.F. So
- Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (D.Y.S.F.)
| | - Dietmar Trenk
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, National and Capodistrian University of Athens, Attikon University Hospital, Greece (D. Alexopoulos)
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Willibald Hochholzer
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Leonardo De Luca
- Division of Cardiology, Laboratory of Interventional Cardiology, San Giovanni Evangelista Hospital, Tivoli-Rome, Italy (L.D.L.)
- Mediterranean Academic Association for Research and Studies in Cardiology, Marseille, France (L.D.L.)
- Aix-Marseille University, INSERM UMRS 1076, Marseille, France (L.D.L.)
| | - Laurent Bonello
- Assistance Publique-Hôpitaux de Marseille, Department of Cardiology, Hôpital Nord, Marseille, France (L.B.)
| | - Daniel Aradi
- Heart Center Balatonfüred and Semmelweis University Budapest, Hungary (D. Aradi)
| | - Thomas Cuisset
- Department of Cardiology, CHU Timone, and Aix-Marseille Université, Faculté de Médecine, Marseille, France (T.C.)
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W.)
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (R.W.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York City, NY (R.M.)
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière, France (G.M.)
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
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Scherillo M, Cirillo P, Formigli D, Bonzani G, Calabrò P, Capogrosso P, Farina R, Lanzillo T, Mascia F, Mauro C, Tuccillo B, Bellis A, Bianchi R, Cimmino G, Piro O, Ravera A, Scotto di Uccio F, Tammaro P, Vetrano A, Trimarco B. Antiplatelet Therapy for Non-ST-Segment Elevation Myocardial Infarction in Complex "Real" Clinical Scenarios: A Consensus Document of the "Campania NSTEMI Study Group". Angiology 2017; 68:598-607. [PMID: 28660806 DOI: 10.1177/0003319716676721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The incidence of ST-segment elevation myocardial infarction (STEMI) has significantly decreased. Conversely, the rate of non-STEMI (NSTEMI) has increased. Patients with NSTEMI have lower short-term mortality compared to patients with STEMI, whereas at long-term follow-up, the mortality becomes comparable. This might be due to the differences in baseline characteristics, including older age and a greater prevalence of comorbidities in the NSTEMI population. Although antithrombotic strategies used in patients with NSTEMI have been well studied in clinical trials and updated guidelines are available, patterns of use and outcomes in clinical practice are less well described. Thus, a panel of Italian cardiology experts assembled under the auspices of the "Campania NSTEMI Study Group" for comprehensive discussion and consensus development to provide practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of antithrombotic therapy in patients with NSTEMI. This position article presents and discusses various clinical scenarios in patients with NSTEMI or unstable angina, including special subsets (eg, patients aged ≥85 years, patients with chronic renal disease or previous cerebrovascular events, and patients requiring triple therapy or long-term antithrombotic therapy), with the panel recommendations being provided for each scenario.
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Affiliation(s)
- Marino Scherillo
- 1 U.O.C. Cardiologia Interventistica ed UTIC. Azienda Ospedaliera "G.Rummo" di Benevento
| | - Plinio Cirillo
- 2 Division of Cardiology, Department of Advanced Biomedical Sciences, Universitaà di Napoli "Federico II," Napoli, Italy
| | - Dario Formigli
- 1 U.O.C. Cardiologia Interventistica ed UTIC. Azienda Ospedaliera "G.Rummo" di Benevento
| | - Giulio Bonzani
- 3 U.O.C. Cardiologia Interventistica. Azienda Ospedaliera Specialistica dei Colli, Napoli
| | - Paolo Calabrò
- 4 U.O.C. Cardiologia Interventistica ed UTIC. Seconda Università di Napoli, Napoli
| | - Paolo Capogrosso
- 5 U.O.C. Cardiologia ed UTIC, Ospedale San Giovanni Bosco, Napoli
| | - Rosario Farina
- 6 Cardiologia ed UTIC, Ospedale San Giovanni di Dio ed Ruggi d' Aragona, Salerno
| | - Tonino Lanzillo
- 7 Unità operativa di Cardiologia ed UTIC, Ospedale Moscati, Avellino
| | - Franco Mascia
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Ciro Mauro
- 9 U.O.C. Cardiologia Interventistica ed UTIC. Ospedale Cardarelli, Napoli
| | | | - Alessandro Bellis
- 9 U.O.C. Cardiologia Interventistica ed UTIC. Ospedale Cardarelli, Napoli
| | - Renato Bianchi
- 4 U.O.C. Cardiologia Interventistica ed UTIC. Seconda Università di Napoli, Napoli
| | - Giovanni Cimmino
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Orlando Piro
- 3 U.O.C. Cardiologia Interventistica. Azienda Ospedaliera Specialistica dei Colli, Napoli
| | - Amelia Ravera
- 6 Cardiologia ed UTIC, Ospedale San Giovanni di Dio ed Ruggi d' Aragona, Salerno
| | | | - Paolo Tammaro
- 5 U.O.C. Cardiologia ed UTIC, Ospedale San Giovanni Bosco, Napoli
| | - Alfredo Vetrano
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Bruno Trimarco
- 2 Division of Cardiology, Department of Advanced Biomedical Sciences, Universitaà di Napoli "Federico II," Napoli, Italy
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De Luca L, Colivicchi F, Gulizia MM, Pugliese FR, Ruggieri MP, Musumeci G, Cibinel GA, Romeo F. Clinical pathways and management of antithrombotic therapy in patients with acute coronary syndrome (ACS): a Consensus Document from the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Society of Emergency Medicine (SIMEU) and Italian Society of Interventional Cardiology (SICI-GISE). Eur Heart J Suppl 2017; 19:D130-D150. [PMID: 28751840 PMCID: PMC5520755 DOI: 10.1093/eurheartj/sux013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS). Over the last years, several studies have evaluated old and new oral or intravenous antiplatelet agents in ACS patients. In particular, research was focused on assessing superiority of two novel platelet ADP P2Y12 receptor antagonists (i.e., prasugrel and ticagrelor) over clopidogrel. Several large randomized controlled trials have been undertaken in this setting and a wide variety of prespecified and post-hoc analyses are available that evaluated the potential benefits of novel antiplatelet therapies in different subsets of patients with ACS. The aim of this document is to review recent data on the use of current antiplatelet agents for in-hospital treatment of ACS patients. In addition, in order to overcome increasing clinical challenges and implement effective therapeutic interventions, this document identifies all potential specific care pathway for ACS patients and accordingly proposes individualized therapeutic options.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, San Giovanni Evangelista Hospital, Via Parrozzani, 3, 00019 Tivoli, Rome, Italy
| | | | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | | | | | - Giuseppe Musumeci
- Division of Cardiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Franchi F, Rollini F. Switching from ticagrelor to clopidogrel: New answers and further questions. Thromb Haemost 2017; 117:207-208. [PMID: 28004060 DOI: 10.1160/th16-12-0909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Francesco Franchi
- Francesco Franchi, MD, University of Florida College of Medicine-Jacksonville, Division of Cardiology-ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL 32209, USA, Tel.: +1 904 244 2090, Fax: +1 904 244 3102, E-mail:
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12
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Morphine interaction with prasugrel: a double-blind, cross-over trial in healthy volunteers. Clin Res Cardiol 2015; 105:349-55. [PMID: 26493304 PMCID: PMC4805697 DOI: 10.1007/s00392-015-0927-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/15/2015] [Indexed: 01/01/2023]
Abstract
Background Morphine decreases the concentrations and effects of clopidogrel, which could lead to treatment failure in myocardial infarction. Objectives To clarify whether more potent P2Y12-inhibitors may provide an effective alternative, we examined drug–drug interactions between morphine and prasugrel. Methods Twelve healthy volunteers received 60 mg prasugrel with placebo or 5 mg morphine intravenously in a randomized, double-blind, placebo-controlled, cross-over trial. Pharmacokinetics were determined by liquid chromatography tandem mass spectrometry, and prasugrel effects were measured by platelet function tests. Results Morphine neither diminished total drug exposure (AUC), which was the primary endpoint, nor significantly delayed drug absorption of prasugrel. However, morphine reduced maximal plasma concentrations (Cmax) of prasugrel active metabolite by 31 % (p = 0.019). Morphine slightly, but not significantly, delayed the onset of maximal inhibition of platelet plug formation under high shear rates (30 vs. 20 min). Whole blood aggregation was not influenced. Conclusions Although morphine significantly decreases the maximal plasma concentrations of prasugrel active metabolite, it does not diminish its effects on platelets to a clinically relevant degree in healthy volunteers. However, it should be considered that the observed decrease in Cmax of prasugrel active metabolite caused by morphine co-administration may gain relevance in STEMI patients. Clinical Trial Registration: NCT01369186, EUDRA-CT#: 2010-023761-22.
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14
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Strisciuglio T, Di Gioia G, De Biase C, Esposito M, Franco D, Trimarco B, Barbato E. Genetically Determined Platelet Reactivity and Related Clinical Implications. High Blood Press Cardiovasc Prev 2015; 22:257-64. [PMID: 25986078 DOI: 10.1007/s40292-015-0104-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/12/2015] [Indexed: 01/06/2023] Open
Abstract
Many drugs are nowadays available to inhibit platelet activation and aggregation, especially in patients with acute coronary syndromes and undergoing percutaneous coronary intervention with stent implantation. Primary targets are represented by enzymes or receptors involved in platelet activation. Genetic mutations in these targets contribute to the inter-individual variability in platelet responses therefore weakening the efficacy of antiplatelet agents. High on treatment platelet reactivity is a condition characterized by low levels of platelet inhibition despite the use of antiplatelet drugs. This could be responsible for re-infarction, stent-thrombosis and strokes, affecting short and long-term prognosis after coronary revascularization. So far, to test antiplatelet resistance either the assessment of platelet function or the identification of genetic carriers of poly morphisms have been pursued. Although several methods are now available to test platelet reactivity, it is still debated whether its routine assessment gives real benefits in clinical practice. The present review aims at examining current evidences on genetic polymorphisms affecting optimal platelet inhibition.
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Affiliation(s)
- Teresa Strisciuglio
- Divisione di Cardiologia, Dipartimento di Scienze Biomediche Avanzate, Università Federico II Napoli, Naples, Italy
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15
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So DYF, Wells GA, McPherson R, Labinaz M, Le May MR, Glover C, Dick AJ, Froeschl M, Marquis JF, Gollob MH, Tran L, Bernick J, Hibbert B, Roberts JD. A prospective randomized evaluation of a pharmacogenomic approach to antiplatelet therapy among patients with ST-elevation myocardial infarction: the RAPID STEMI study. THE PHARMACOGENOMICS JOURNAL 2015; 16:71-8. [PMID: 25850030 DOI: 10.1038/tpj.2015.17] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 12/19/2014] [Accepted: 01/28/2015] [Indexed: 01/07/2023]
Abstract
Treatment of carriers of the CYP2C19*2 allele and ABCB1 TT genotype with clopidogrel is associated with increased ischemic complications after percutaneous coronary intervention (PCI). We sought to evaluate a pharmacogenomic strategy among patients undergoing PCI for ST-elevation myocardial infarction (STEMI), by performing a randomized trial, enrolling 102 patients. Point-of-care genetic testing for CYP2C19*2, ABCB1 TT and CYP2C19*17 was performed with carriers of either the CYP2C19*2 allele or ABCB1 TT genotype randomly assigned to a strategy of prasugrel 10 mg daily or an augmented dosing strategy of clopidogrel (150 mg daily for 6 days then 75 mg daily). The primary end point was the proportion of at-risk carriers exhibiting high on-treatment platelet reactivity (HPR), a marker associated with increased adverse cardiovascular events, after 1 month. Fifty-nine subjects (57.8%) were identified as carriers of at least one at-risk variant. Treatment with prasugrel significantly reduced HPR compared with clopidogrel by P2Y12 reaction unit (PRU) thresholds of >234 (0 vs 24.1%, P=0.0046) and PRU>208 (3.3 vs 34.5%, P=0.0025). The sensitivity of point-of-care testing was 100% (95% CI 88.0-100), 100% (86.3-100) and 96.9% (82.0-99.8) and specificity was 97.0% (88.5-99.5), 97.1% (89.0-99.5) and 98.5% (90.9-99.9) for identifying CYP2C19*2, ABCB1 TT and CYP2C19*17, respectively. Logistic regression confirmed carriers as a strong predictor of HPR (OR=6.58, 95% CI 1.24-34.92; P=0.03). We confirmed that concurrent identification of three separate genetic variants in patients with STEMI receiving PCI is feasible at the bedside. Among carriers of at-risk genotypes, treatment with prasugrel was superior to an augmented dosing strategy of clopidogrel in reducing HPR.
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Affiliation(s)
- D Y F So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - G A Wells
- Cardiovascular Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - R McPherson
- Canadian Cardiovascular Genetics Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - M Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - M R Le May
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - C Glover
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - A J Dick
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - M Froeschl
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - J-F Marquis
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - M H Gollob
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - L Tran
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - J Bernick
- Cardiovascular Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - B Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - J D Roberts
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Abstract
A significant percentage of patients demonstrate a poor antiplatelet response to clopidogrel. With the emergence of testing for genetic variations in drug-metabolizing enzyme function and testing for platelet function, it is becoming more common to identify patients as poor responders to clopidogrel. This leaves the clinician in a difficult situation when confronted with a patient deemed to be a poor clopidogrel responder as there is no clear therapeutic strategy for treating these patients. In this situation, a number of alternatives to conventional dosing of clopidogrel have been investigated, including increasing the dosage of clopidogrel, switching from clopidogrel to either prasugrel or ticagrelor, or adding cilostazol to clopidogrel therapy. All of these options have demonstrated pharmacologic benefit in terms of greater antiplatelet effects compared with standard clopidogrel dosing in patients with high on-treatment platelet reactivity or a genetic loss-of-function variant of CYP2C19, the main enzyme responsible for clopidogrel activation. However, the impact of each of these alternative therapies on clinical outcomes is poorly understood. Early studies have not shown a clinical benefit by increasing the clopidogrel dosage or switching to prasugrel although there is still much to be discovered in this area. Of the alternatives to standard dosing of clopidogrel, switching to either prasugrel or ticagrelor has the most potential benefit, but again, there is limited evidence to support this practice in patients who demonstrate high on-treatment platelet reactivity while on clopidogrel although the evidence is somewhat more supportive in patients who have a CYP2C19 loss-of-function variant allele. The evidence for increasing the dosage of clopidogrel or adding cilostazol is the least supportive, making these alternatives difficult to justify. Given the limited evidence to support switching treatments, some providers may simply opt to continue standard dosing of clopidogrel pending the results of ongoing trials. Much research is needed and is currently underway in this area, which will be helpful in establishing future treatment protocols for patients with poor clopidogrel response.
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Thomas MR, Storey RF. Genetics of Response to Antiplatelet Therapy. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2014; 124:123-53. [DOI: 10.1016/b978-0-12-386930-2.00006-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Angiolillo DJ, Curzen N, Gurbel P, Vaitkus P, Lipkin F, Li W, Jakubowski JA, Zettler M, Effron MB, Trenk D. Pharmacodynamic evaluation of switching from ticagrelor to prasugrel in patients with stable coronary artery disease: Results of the SWAP-2 Study (Switching Anti Platelet-2). J Am Coll Cardiol 2013; 63:1500-9. [PMID: 24333493 DOI: 10.1016/j.jacc.2013.11.032] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/15/2013] [Accepted: 11/26/2013] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the pharmacodynamic effects of switching patients from ticagrelor to prasugrel. BACKGROUND Clinicians may need to switch between more potent P2Y12 inhibitors because of adverse effects or switch to the use of a once-daily dosing regimen due to compliance issues. METHODS After a 3- to 5-day run-in phase with a ticagrelor 180-mg loading dose (LD) followed by a ticagrelor 90-mg twice-daily maintenance dose (MD), aspirin-treated patients (N = 110) with stable coronary artery disease were randomized to continue ticagrelor or switch to prasugrel 10-mg once-daily MD, with or without a 60-mg LD. Pharmacodynamic assessments were defined according to P2Y12 reaction unit (PRU) (P2Y12 assay) and platelet reactivity index (vasodilator-stimulated phosphoprotein phosphorylation assay) at baseline (before and after the run-in phase) and 2, 4, 24, and 48 h and 7 days after randomization. RESULTS Platelet reactivity was significantly greater at 24 and 48 h after switching to prasugrel versus continued therapy with ticagrelor, although to a lesser extent in those receiving an LD. Mean PRU remained significantly higher in the combined prasugrel groups versus the ticagrelor group (least-squares mean difference: 46 [95% confidence interval 25 to 67]) and did not meet the primary noninferiority endpoint (upper limit of the confidence interval ≤45), although PRU in the prasugrel cohort was lower at 7 days than at 24 or 48 h. Accordingly, rates of high on-treatment platelet reactivity were higher at 24 and 48 h in both prasugrel groups. At 7 days, there was no difference in high on-treatment platelet reactivity rate between the combined prasugrel and ticagrelor groups. CONCLUSIONS Compared with continued ticagrelor therapy, switching from ticagrelor to prasugrel therapy was associated with an increase in platelet reactivity that was partially mitigated by the administration of an LD.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Nicholas Curzen
- Southampton University Hospital, Southampton, United Kingdom
| | - Paul Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Paul Vaitkus
- Medical Affairs, Daiichi Sankyo, Inc., Parsippany, New Jersey
| | - Fred Lipkin
- Medical Affairs, Daiichi Sankyo, Inc., Parsippany, New Jersey
| | - Wei Li
- Medical Affairs, Daiichi Sankyo, Inc., Parsippany, New Jersey
| | | | - Marjorie Zettler
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Mark B Effron
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Dietmar Trenk
- Department of Clinical Pharmacology, Clinic for Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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