1
|
Cox DS, Rehman M, Khan T, Ginman K, Salageanu J, LaBadie RR, Wan K, Damle B. Effects of nirmatrelvir/ritonavir on midazolam and dabigatran pharmacokinetics in healthy participants. Br J Clin Pharmacol 2023; 89:3352-3363. [PMID: 37354048 DOI: 10.1111/bcp.15835] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023] Open
Abstract
AIMS To evaluate pharmacokinetics (PK) and safety after coadministration of nirmatrelvir/ritonavir or ritonavir alone with midazolam (a cytochrome P450 3A4 substrate) and dabigatran (a P-glycoprotein substrate). METHODS PK was studied in 2 phase 1, open-label, fixed-sequence studies in healthy adults. Single oral doses of midazolam 2 mg (n = 12) or dabigatran 75 mg (n = 24) were administered alone and after steady state (i.e. ≥2 days) of nirmatrelvir/ritonavir 300 mg/100 mg and ritonavir 100 mg. Midazolam and dabigatran plasma concentrations and adverse events were analysed for each treatment. RESULTS After administration of midazolam with nirmatrelvir/ritonavir (test) or alone (reference), midazolam geometric mean area under the concentration-time curve extrapolated to infinity (AUCinf ) and maximum plasma concentration (Cmax ) increased 14.3-fold and 3.7-fold, respectively. Midazolam coadministered with ritonavir (test) or alone (reference) resulted in 16.5-fold and 3.9-fold increases in midazolam geometric mean AUCinf and Cmax , respectively. After administration of dabigatran with nirmatrelvir/ritonavir (test) or alone (reference), dabigatran geometric mean AUCinf and Cmax increased 1.9-fold and 2.3-fold, respectively. Dabigatran coadministered with ritonavir (test) or alone (reference) resulted in a 1.7-fold increase in dabigatran geometric mean AUCinf and Cmax . Midazolam or dabigatran exposures were generally comparable when coadministered with nirmatrelvir/ritonavir or ritonavir alone, with a slightly higher dabigatran Cmax with nirmatrelvir/ritonavir vs. ritonavir alone. Nirmatrelvir/ritonavir was generally safe when administered with or without midazolam or dabigatran. No serious or severe adverse events were reported. CONCLUSION Coadministration of midazolam or dabigatran with nirmatrelvir/ritonavir increased systemic exposure of midazolam or dabigatran. Midazolam exposures were comparable when coadministered with nirmatrelvir/ritonavir or ritonavir alone, suggesting no incremental effect of nirmatrelvir. Dabigatran Cmax was slightly higher when coadministered with nirmatrelvir/ritonavir compared with of ritonavir alone, suggesting a minor incremental effect of nirmatrelvir.
Collapse
Affiliation(s)
- Donna S Cox
- Pfizer Inc. Global Product Development, Collegeville, Pennsylvania, USA
| | - Muhammad Rehman
- Pfizer Inc. Global Product Development, Andover, Massachusetts, USA
| | - Tahira Khan
- Pfizer Inc. Global Product Development, Groton, Connecticut, USA
| | - Katherine Ginman
- Pfizer Inc. Global Product Development, Groton, Connecticut, USA
| | - Joanne Salageanu
- Pfizer Inc. Global Product Development, Collegeville, Pennsylvania, USA
| | | | - Katty Wan
- Pfizer Inc. Global Product Development, Collegeville, Pennsylvania, USA
| | - Bharat Damle
- Pfizer Inc. Global Product Development, New York, New York, USA
| |
Collapse
|
2
|
Udomnilobol U, Jianmongkol S, Prueksaritanont T. The Potentially Significant Role of CYP3A-Mediated Oxidative Metabolism of Dabigatran Etexilate and Its Intermediate Metabolites in Drug-Drug Interaction Assessments Using Microdose Dabigatran Etexilate. Drug Metab Dispos 2023; 51:1216-1226. [PMID: 37230768 DOI: 10.1124/dmd.123.001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/06/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
Dabigatran etexilate (DABE), a double ester prodrug of dabigatran, is a probe substrate of intestinal P-glycoprotein (P-gp) commonly used in clinical drug-drug interaction (DDI) studies. When compared with its therapeutic dose at 150 mg, microdose DABE (375 µg) showed approximately 2-fold higher in DDI magnitudes with CYP3A/P-gp inhibitors. In this study, we conducted several in vitro metabolism studies to demonstrate that DABE, at a theoretical gut concentration after microdosing, significantly underwent NADPH-dependent oxidation (~40%-50%) in parallel to carboxylesterase-mediated hydrolysis in human intestinal microsomes. Furthermore, NADPH-dependent metabolism of its intermediate monoester, BIBR0951, was also observed in both human intestinal and liver microsomes, accounting for 100% and 50% of total metabolism, respectively. Metabolite profiling using high resolution mass spectrometry confirmed the presence of several novel oxidative metabolites of DABE and of BIBR0951 in the NADPH-fortified incubations. CYP3A was identified as the major enzyme catalyzing the oxidation of both compounds. The metabolism of DABE and BIBR0951 was well described by Michaelis-Menten kinetics, with Km ranging 1-3 µM, significantly below the expected concentrations following the therapeutic dose of DABE. Overall, the present results suggested that CYP3A played a significant role in the presystemic metabolism of DABE and BIBR0951 following microdose DABE administration, thus attributing partly to the apparent overestimation in the DDI magnitude observed with the CYP3A/P-gp inhibitors. Therefore, DABE at the microdose, unlike the therapeutic dose, would likely be a less predictive tool and should be considered as a clinical dual substrate for P-gp and CYP3A when assessing potential P-gp-mediated impacts by dual CYP3A/P-gp inhibitors. SIGNIFICANT STATEMENT: This is the first study demonstrating a potentially significant role of cytochrome P450-mediated metabolism of the prodrug DABE following a microdose but not a therapeutic dose. This additional pathway, coupled with its susceptibility to P-glycoprotein (P-gp), may make DABE a clinical dual substrate for both P-gp and CYP3A at a microdose. The study also highlights the need for better characterization of the pharmacokinetics and metabolism of a clinical drug-drug interaction probe substrate over the intended study dose range for proper result interpretations.
Collapse
Affiliation(s)
- Udomsak Udomnilobol
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences (U.U., S.J.) and Chulalongkorn University Drug Discovery and Drug Development Research Center (Chula4DR) (U.U., T.P.), Chulalongkorn University, Bangkok, Thailand
| | - Suree Jianmongkol
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences (U.U., S.J.) and Chulalongkorn University Drug Discovery and Drug Development Research Center (Chula4DR) (U.U., T.P.), Chulalongkorn University, Bangkok, Thailand
| | - Thomayant Prueksaritanont
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences (U.U., S.J.) and Chulalongkorn University Drug Discovery and Drug Development Research Center (Chula4DR) (U.U., T.P.), Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
3
|
Yalkinoglu Ö, Becker A, Krebs-Brown A, Vetter C, Lüpfert C, Perrin D, Heuer J, Biedert H, Hirt S, Bytyqi A, Bachmann A, Strotmann R. Assessment of the potential of the MET inhibitor tepotinib to affect the pharmacokinetics of CYP3A4 and P-gp substrates. Invest New Drugs 2023; 41:596-605. [PMID: 37415001 PMCID: PMC10447267 DOI: 10.1007/s10637-023-01378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Tepotinib is a highly selective, potent, mesenchymal-epithelial transition factor (MET) inhibitor, approved for the treatment of non-small cell lung cancer harboring MET exon 14 skipping alterations. The aims of this work were to investigate the potential for drug-drug interactions via cytochrome P450 (CYP) 3A4/5 or P-glycoprotein (P-gp) inhibition. In vitro studies were conducted in human liver microsomes, human hepatocyte cultures and Caco-2 cell monolayers to investigate whether tepotinib or its major metabolite (MSC2571109A) inhibited or induced CYP3A4/5 or inhibited P-gp. Two clinical studies were conducted to investigate the effect of multiple dose tepotinib (500 mg once daily orally) on the single dose pharmacokinetics of a sensitive CYP3A4 substrate (midazolam 7.5 mg orally) and a P-gp substrate (dabigatran etexilate 75 mg orally) in healthy participants. Tepotinib and MSC2571109A showed little evidence of direct or time-dependent CYP3A4/5 inhibition (IC50 > 15 μM) in vitro, although MSC2571109A did show mechanism-based CYP3A4/5 inhibition. Tepotinib did not induce CYP3A4/5 activity in vitro, although both tepotinib and MSC2571109A increased CYP3A4 mRNA. In clinical studies, tepotinib had no effect on the pharmacokinetics of midazolam or its metabolite 1'-hydroxymidazolam. Tepotinib increased dabigatran maximum concentration and area under the curve extrapolated to infinity by 38% and 51%, respectively. These changes were not considered to be clinically relevant. Tepotinib was considered safe and well tolerated in both studies. The potential of tepotinib to cause clinically relevant DDI with CYP3A4- or P-gp-dependent drugs at the clinical dose is considered low. Study 1 (midazolam): NCT03628339 (registered 14 August 2018). Study 2 (dabigatran): NCT03492437 (registered 10 April 2018).
Collapse
Affiliation(s)
- Özkan Yalkinoglu
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Andreas Becker
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Axel Krebs-Brown
- Global Biostatistics, Epidemiology and Medical Writing, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Claudia Vetter
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Christian Lüpfert
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Dominique Perrin
- NCE DMPK, Discovery and Development Technologies, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Jürgen Heuer
- Clinical Services, Nuvisan GmbH, Neu-Ulm, Germany
| | | | - Stefan Hirt
- LC/MS Bioanalysis, Nuvisan GmbH, Neu-Ulm, Germany
| | - Afrim Bytyqi
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Angelika Bachmann
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany
| | - Rainer Strotmann
- Clinical Pharmacology, Quantitative Pharmacology, the healthcare business of Merck KGaA, Darmstadt, Germany.
| |
Collapse
|
4
|
Bykov K, Li H, Kim S, Vine SM, Re VL, Gagne JJ. Drug-Drug Interaction Surveillance Study: Comparing Self-Controlled Designs in Five Empirical Examples in Real-World Data. Clin Pharmacol Ther 2021; 109:1353-1360. [PMID: 33245789 PMCID: PMC8058240 DOI: 10.1002/cpt.2119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022]
Abstract
Self-controlled designs, specifically the case-crossover (CCO) and the self-controlled case series (SCCS), are increasingly utilized to generate real-world evidence (RWE) on drug-drug interactions (DDIs). Although these designs share the advantages and limitations of within-individual comparison, they also have design-specific assumptions. It is not known to what extent the differences in assumptions lead to different results in RWE DDI analyses. Using a nationwide US commercial healthcare insurance database (2006-2016), we compared the CCO and SCCS designs, as they are implemented in DDI studies, within five DDI-outcome examples: (1) simvastatin + clarithromycin and muscle-related toxicity; (2) atorvastatin + valsartan, and muscle-related toxicity; and (3-5) dabigatran + P-glycoprotein inhibitor (clarithromycin, amiodarone, and verapamil) and bleeding. Analyses were conducted within person-time exposed to the object drug (statins and dabigatran) and adjusted for bias associated with the inhibiting drugs via control groups of individuals unexposed to the object drug. The designs yielded similar estimates in most examples, with SCCS displaying better statistical efficiency. With both designs, results varied across sensitivity analyses, particularly in CCO analyses with small number of exposed individuals. Analyses in controls revealed substantial bias that may be differential across DDI-exposed and control individuals. Thus, both designs showed no association between amiodarone or verapamil and bleeding in dabigatran-exposed but revealed strong positive associations in controls. Overall, bias adjustment via a control group had a larger impact on results than the choice of a design, highlighting the importance and challenges of appropriate control group selection for adequate bias control in self-controlled analyses of DDIs.
Collapse
Affiliation(s)
- Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hu Li
- Global Patient Safety, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Sangmi Kim
- Global Patient Safety, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Seanna M. Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine and Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
Collapse
Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| |
Collapse
|
6
|
Wu T, Xia X, Fu J, Chen W, Zhang J. Left atrial appendage thrombus formation in a patient with atrial fibrillation on dabigatran therapy associated with CES1 and ABCB1 genetic polymorphisms: A case report. Medicine (Baltimore) 2020; 99:e22084. [PMID: 32899083 PMCID: PMC7478673 DOI: 10.1097/md.0000000000022084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
RATIONALE Dabigatran is a direct thrombin inhibitor that is widely used to prevent the formation of thrombus formation. Amiodarone can increase the plasma concentration of dabigatran. CES1 (carboxylesterase 1) and ABCB1 (ATP-binding cassette subfamily B member 1) genetic polymorphisms associate with the pharmacokinetics of dabigatran. PATIENT CONCERNS A 62-year-old woman was admitted to the hospital due to chest tightness, fatigue, and discomfort despite long-term anticoagulation with dabigatran 110 mg twice daily for 6 months, with concomitant use of amiodarone. DIAGNOSES Left atrial appendage thrombus formation with a history of atrial fibrillation. INTERVENTIONS The clinician changed dabigatran to warfarin. To explore the causes of insufficient anticoagulation using dabigatran in this patient, we examined the ABCB1 and CES1 genes. Results showed that she carried ABCB1 variant alleles with 3 heterozygote single nucleotide polymorphisms (SNPs: rs4148738, rs1045642, rs2032582) and CES1 variant alleles with 2 heterozygote SNPs (rs2244613, rs4580160). OUTCOMES The left atrial appendage thrombus disappeared. LESSONS Multiple mutations in the ABCB1 and CES1 genes may influence the pharmacokinetics of dabigatran and could have contributed to the thrombus formation in the left atrial appendage.
Collapse
Affiliation(s)
- Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaotong Xia
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jinglan Fu
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|
7
|
Diener HC, Sacco RL, Easton JD, Granger CB, Bar M, Bernstein RA, Brainin M, Brueckmann M, Cronin L, Donnan G, Gdovinová Z, Grauer C, Kleine E, Kleinig TJ, Lyrer P, Martins S, Meyerhoff J, Milling T, Pfeilschifter W, Poli S, Reif M, Rose DZ, Šaňák D, Schäbitz WR. Antithrombotic Treatment of Embolic Stroke of Undetermined Source: RE-SPECT ESUS Elderly and Renally Impaired Subgroups. Stroke 2020; 51:1758-1765. [PMID: 32404035 PMCID: PMC7379165 DOI: 10.1161/strokeaha.119.028643] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/23/2020] [Indexed: 12/04/2022]
Abstract
Background and Purpose- The RE-SPECT ESUS trial (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) tested the hypothesis that dabigatran would be superior to aspirin for the prevention of recurrent stroke in patients with embolic stroke of undetermined source. This exploratory subgroup analysis investigates the impact of age, renal function (both predefined), and dabigatran dose (post hoc) on the rates of recurrent stroke and major bleeding. Methods- RE-SPECT ESUS was a multicenter, randomized, double-blind trial of dabigatran 150 or 110 mg (for patients aged ≥75 years and/or with creatinine clearance 30 to <50 mL/minute) twice daily compared with aspirin 100 mg once daily. The primary outcome was recurrent stroke. Results- The trial, which enrolled 5390 patients from December 2014 to January 2018, did not demonstrate superiority of dabigatran versus aspirin for prevention of recurrent stroke in patients with embolic stroke of undetermined source. However, among the population qualifying for the lower dabigatran dose, the rate of recurrent stroke was reduced with dabigatran versus aspirin (7.4% versus 13.0%; hazard ratio, 0.57 [95% CI, 0.39-0.82]; interaction P=0.01). This was driven mainly by the subgroup aged ≥75 years (7.8% versus 12.4%; hazard ratio, 0.63 [95% CI, 0.43-0.94]; interaction P=0.10). Stroke rates tended to be lower with dabigatran versus aspirin with declining renal function. Risks for major bleeding were similar between treatments, irrespective of renal function, but with a trend for lower bleeding rates with dabigatran versus aspirin in older patients. Conclusions- In subgroup analyses of RE-SPECT ESUS, dabigatran reduced the rate of recurrent stroke compared with aspirin in patients qualifying for the lower dose of dabigatran. These results are hypothesis-generating. Aspirin remains the standard antithrombotic treatment for patients with embolic stroke of undetermined source. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239120.
Collapse
Affiliation(s)
- Hans-Christoph Diener
- From the Faculty of Medicine, Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Germany (H.-C.D.)
| | - Ralph L Sacco
- Clinical and Translational Science, Miller School of Medicine, University of Miami, FL (R.L.S.)
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco (J.D.E.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (C.B.G.)
| | - Michal Bar
- Department of Neurology, University Hospital Ostrava, Ostrava-Poruba-Poruba, Czech Republic (M. Bar)
| | | | - Michael Brainin
- Department of Neurosciences and Preventive Medicine, Danube University Krems, Krems an der Donau, Austria (M. Brainin)
| | - Martina Brueckmann
- Metabolism Medicine, Boehringer Ingelheim International GmbH, Germany (M. Brueckmann)
- Faculty of Medicine Mannheim of the University of Heidelberg, Germany (M. Brueckmann)
| | - Lisa Cronin
- Cardiometabolic Medicine, Boehringer Ingelheim Ltd, Burlington, ON, Canada (L.C.)
| | - Geoffrey Donnan
- Department of Neurology, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia (G.D.)
| | - Zuzana Gdovinová
- Department of Neurology, Pavol Jozef Šafárik University in Košice, University Hospital L. Pasteur, Košice, Slovak Republic (Z.G.)
| | - Claudia Grauer
- Clinical Operations Global, Boehringer Ingelheim Pharma GmbH & Co. K.G., Biberach, Germany (C.G.)
| | - Eva Kleine
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. K.G., Ingelheim, Germany (E.K.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia (T.J.K.)
| | - Philippe Lyrer
- Division of Neurology, Stroke Center, University Hospital Basel, Switzerland (P.L.)
| | - Sheila Martins
- Neurology Service, Hospital de Clínicas de Porto Alegre, Brazil (S.M.)
| | - Juliane Meyerhoff
- Cardiology Medicine, Boehringer Ingelheim International GmbH, Germany (J.M.)
| | - Truman Milling
- Department of Neurology, Department of Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX (T.M.)
| | - Waltraud Pfeilschifter
- Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany (W.P.)
| | - Sven Poli
- Department of Neurology with Focus on Neurovascular Diseases and Neurooncology, University of Tübingen, and Hertie Institute for Clinical Brain Research, Germany (S.P.)
| | - Michal Reif
- Department of Neurology, Cerebrovaskulární ambulance s.r.o., Brno, Czech Republic (M.R.)
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa (D.Z.R.)
| | - Daniel Šaňák
- Comprehensive Stroke Center, Department of Neurology, Palacky University, Olomouc, Czech Republic (D.S.)
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Bielefeld, Germany (W.-R.S.)
| |
Collapse
|
8
|
Li X, Liu L, Xu B, Xiang Q, Li Y, Zhang P, Wang Y, Xie Q, Mao Y, Cui Y. Bioequivalence and pharmacodynamics of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. Pharmacol Res Perspect 2020; 8:e00593. [PMID: 32338459 PMCID: PMC7184321 DOI: 10.1002/prp2.593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
To assess bioequivalence of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. This was an open-label, single-center, randomized four-period crossover study with a 7-day washout period. A single oral dose of 150 mg generic dabigatran etexilate capsule (test drug) or a commercial dabigatran etexilate capsule (Pradaxa® , reference drug) was given to healthy volunteers under the fasting and fed conditions. Plasma concentrations of total and free dabigatran were detected using a validated HPLC-MS/MS method. A noncompartmental method was used for pharmacokinetic analysis and established coagulation assays were applied for pharmacodynamic analysis. The 90% CIs of the test/reference ratios of Cmax , AUC0-t , and AUC0-∞ for the total dabigatran concentration were 92.57%-106.58%, 91.63%-106.32%, and 92.54%-106.17%, respectively, under fasting condition, and 99.30%-110.74%, 98.58%-105.37%, and 97.75%-103.99%, respectively, under fed conditions. The 90% CIs of the ratios of the parameters for the free dabigatran were 93.18%-106.98%, 92.13%-107.10%, 92.89%-106.48%, respectively, under fasting condition, and 100.05%-110.89%, 99.37%-106.23%, 97.59%-103.98%, respectively, under the fed condition. Additionally, the upper limit of the 90% CIs for σWT/σWR was below 2.5. There were no significant differences in the coagulation parameters including thrombin clotting time, activated partial thromboplastin time, and anti-IIa activity between the two preparations. The generic dabigatran etexilate capsule is bioequivalent to the brand-named product in healthy Chinese volunteers under fasting and fed conditions. The two products have comparable pharmacodynamic parameters, with a good safety profile. In addition, food intake influences absorption of both products in a similar way.
Collapse
Affiliation(s)
- Xin Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Lihua Liu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Bing Xu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qian Xiang
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yuan Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Ping Zhang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Yangyang Wang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qiufen Xie
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yong Mao
- Chengdu Brilliant Pharmaceutical Co. LtdChengduThe People’s Republic of China
| | - Yimin Cui
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| |
Collapse
|
9
|
Sychev D, Skripka A, Ryzhikova K, Bochkov P, Shevchenko R, Krupenin P, Ivashchenko D, Kogay V, Listratov A, Krainyaya A, Gurinovich O, Sokolova A, Napalkov D, Fomin V. Effect of CES1 and ABCB1 genotypes on the pharmacokinetics and clinical outcomes of dabigatran etexilate in patients with atrial fibrillation and chronic kidney disease. Drug Metab Pers Ther 2020; 35:/j/dmdi.ahead-of-print/dmpt-2019-0029/dmpt-2019-0029.xml. [PMID: 32134727 DOI: 10.1515/dmpt-2019-0029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/17/2020] [Indexed: 06/10/2023]
Abstract
Background Despite the well-studied safety profile of dabigatran, its interactions with genetic polymorphism parameters are poorly understood, especially in patients with moderate chronic kidney disease (CKD). The study assessed whether genetic factors can contribute to CKD and alter dabigatran concentration. Methods Patients with atrial fibrillation (AF) and stage 3 CKD treated with dabigatran 110 or 150 mg have been included in the study. Real-time polymerase chain reaction was used to evaluate single-nucleotide polymorphisms of the ABCB1 gene (rs1045642 and rs4148738) and CES1 gene (rs2244613). A plasma trough concentration/dose (C/D) ratio was used as a pharmacokinetic index. Results A total of 96 patients aged 51-89 years (median age: 75 years) were evaluated. Patients on a reduced regimen of 110 mg twice a day were older (79.8 vs. 67.9, p < 0.0001) and had lower creatinine clearance (49.7 vs. 62.3 mL/min/1.73 m2, p = 0.015). Patients with the rs2244613 CC genotype had lower C/D values (70% reduction in the mean C/D vs. AA genotype, p = 0.001). Linear stepwise regression has shown the CKD epidemiology collaboration to be the only significant predictor of C/D among genetic factors and kidney function characteristics. During the median follow-up of 15 months, there were 15 bleedings in 13 patients. Conclusions Polymorphism of CES1 rs2244613 can contribute to the safety of dabigatran in patients with AF and CKD. There was no influence of the aforementioned polymorphisms of ABCB1 on dabigatran trough plasma concentrations and C/D. Kidney function is a mainstay of clinical decision-making on direct oral anticoagulant (DOAC) dose, and further knowledge should be accumulated on the role of genetic factors.
Collapse
Affiliation(s)
- Dmitriy Sychev
- Russian Medical Academy of Continuous Professional Education, FGBOU DPO of the Ministry of Health of Russia, Department of Clinical Pharmacology and Therapy, Moscow, Russian Federation
| | - Alena Skripka
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Kristina Ryzhikova
- Russian Medical Academy of Continuous Professional Education, FGBOU DPO of the Ministry of Health of Russia, Department of Personalized Medicine, Research Center, Moscow, Russian Federation
| | - Pavel Bochkov
- Russian Medical Academy of Continuous Professional Education, FGBOU DPO of the Ministry of Health of Russia, Department of Personalized Medicine, Research Center, Moscow, Russian Federation
| | - Roman Shevchenko
- Russian Medical Academy of Continuous Professional Education, FGBOU DPO of the Ministry of Health of Russia, Department of Personalized Medicine, Research Center, Moscow, Russian Federation
| | - Pavel Krupenin
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Dmitriy Ivashchenko
- FGBOU DPO of the Ministry of Health of Russia, Department of Personalized Medicine, Department of Child Psychiatry and Psychotherapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Veronika Kogay
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Alexander Listratov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Arina Krainyaya
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Olga Gurinovich
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Anastasiya Sokolova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Dmitriy Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| | - Viktor Fomin
- I.M. Sechenov First Moscow State Medical University (Sechenov University), FGAOU VO of the Ministry of Health of Russia, Department of Faculty Therapy N1, Moscow, Russian Federation
| |
Collapse
|
10
|
Drugs for atrial fibrillation. Med Lett Drugs Ther 2019; 61:137-44. [PMID: 31599871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
11
|
Huang S, Ren Y, Peng X, Qian P, Meng L. Computer-aid drug design, synthesis, and anticoagulant activity evaluation of novel dabigatran derivatives as thrombin inhibitors. Eur J Pharm Sci 2019; 137:104965. [PMID: 31247296 DOI: 10.1016/j.ejps.2019.104965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 12/11/2022]
Abstract
In this study, computer-aided drug design techniques were adopted to explore the structural and chemical features for dabigatran and design novel derivatives. The built 3D-QSAR models demonstrated significant statistical quality and excellent predictive ability by internal and external validation. Based on QSAR information, 11 novel dabigatran derivatives (12a-12k) were designed and predicted, then ADME prediction and molecular docking were performed. Furthermore, all designed compounds were synthesized and characterized by 1H NMR, 13C NMR and HR-MS. Finally, they were evaluated for anticoagulant activity in vitro. The activity results showed that the 10 obtained compounds exhibited comparable activity to the reference dabigatran (IC50 = 9.99 ± 1.48 nM), except for compound 12i. Further analysis on molecular docking was performed on three compounds (12a, 12c and 12g) with better activity (IC50 = 11.19 ± 1.70 nM, IC50 = 10.94 ± 1.85 nM and IC50 = 11.19 ± 1.70 nM). MD simulations (10 ns) were carried out, and their binding free energies were calculated, which showed strong hydrogen bond and pi-pi stacking interactions with key residues Gly219, Asp189 and Trp60D. The 10 novel dabigatran derivatives obtained can be further studied as anticoagulant candidate compounds.
Collapse
Affiliation(s)
- Shanshan Huang
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Yujie Ren
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China.
| | - Xiuxiu Peng
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Pingping Qian
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Lingwei Meng
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| |
Collapse
|
12
|
Bolek T, Samoš M, Škorňová I, Schnierer M, Lipták P, Bánovčin P, Urban L, Staško J, Kubisz P, Galajda P, Mokán M. Dabigatran levels in omeprazole versus pantoprazole-treated patients with atrial fibrillation: is there a difference? Eur J Clin Pharmacol 2019; 75:875-877. [PMID: 30747244 DOI: 10.1007/s00228-019-02647-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovak Republic.
| | - Ingrid Škorňová
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Martin Schnierer
- Department of Gastroenterology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Lipták
- Department of Gastroenterology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Bánovčin
- Department of Gastroenterology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Lukáš Urban
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Ján Staško
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- National Centre of Hemostasis and Thrombosis, Department of Hematology and Blood Transfusion, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Galajda
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Marián Mokán
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, 036 59, Martin, Slovak Republic
| |
Collapse
|
13
|
Grottke O, van Ryn J, Zentai C, Gan G, Honickel M, Rossaint R, ten Cate H, Spronk HMH. Volume replacement strategies do not impair the binding of dabigatran to idarucizumab: Porcine model of hemodilution. PLoS One 2019; 14:e0209350. [PMID: 30615630 PMCID: PMC6322768 DOI: 10.1371/journal.pone.0209350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022] Open
Abstract
Background Idarucizumab is a humanized Fab fragment that specifically reverses dabigatran anticoagulation. In trauma, volume expanders are used for resuscitation to compensate for blood loss and hemorrhagic shock, but it is unknown whether volume expanders influence the binding of dabigatran to its antidote. Using a porcine dilutional coagulopathy model, this study investigated whether volume replacement strategies affect binding of dabigatran to idarucizumab. Methods Twenty-five male pigs were treated orally with dabigatran etexilate (30 mg/kg bid) for 3 days. The following day, animals were anesthetized, infused with dabigatran (total dose 0.645 mg/kg) to achieve supratherapeutic concentrations, and randomized 1:1:1:1:1 (n = 5 per group) to control (no hemodilution) or hemodilution where ~50% of blood volume was substituted with Ringer’s solution, 6% hydroxyethyl starch 130/0.4, 6% hydroxyethyl starch 200/0.5 or 4% gelatin. Idarucizumab was then administered intravenously (30 mg/kg) and serial blood samples were taken for up to 24 hours to measure diluted thrombin time (corresponding with dabigatran activity), total dabigatran (bound to antidote and free drug) and a panel of coagulation parameters. Results Mean plasma dabigatran levels were 617 ± 16 ng/mL after infusion and 600 ± 114 ng/mL after ~50% hemodilution with no significant differences between groups. Following treatment with idarucizumab, plasma concentrations of unbound dabigatran decreased markedly, with similar reductions in all groups. Dabigatran-induced prolongation of coagulation parameters was rapidly reversed in all groups. Conclusion This study indicates that several volume expanders used for resuscitation in trauma do not interfere with the binding of idarucizumab to dabigatran.
Collapse
Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
- * E-mail:
| | - Joanne van Ryn
- Department of CardioMetabolic Diseases Research, Boehringer Ingelheim GmbH & Co. KG, Biberach, Germany
| | - Christian Zentai
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Guanfa Gan
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States of America
| | - Markus Honickel
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henri M. H. Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
14
|
Testa S, Ageno W, Antonucci E, Morandini R, Beyer-Westendorf J, Paciaroni M, Righini M, Sivera P, Verhamme P, Pengo V, Poli D, Palareti G. Management of major bleeding and outcomes in patients treated with direct oral anticoagulants: results from the START-Event registry. Intern Emerg Med 2018; 13:1051-1058. [PMID: 29790125 DOI: 10.1007/s11739-018-1877-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/07/2018] [Indexed: 01/22/2023]
Abstract
The management of major bleeding in patients treated with direct oral anticoagulants (DOACs) is still not well established. START-Events, a branch of the START registry (Survey on anTicoagulated pAtients RegisTer) (NCT02219984), aims to describe the actual management of bleeding or recurrent thrombotic events in routine clinical practice. We here present the results of the management of bleeding patients. The START-Event registry is a prospective, observational, multicenter, international study. Baseline characteristics (demographic, clinical, risk factors) of patients, laboratory data at admission and during follow-up, site of bleeding, therapeutic strategies, and outcomes at the time of hospital discharge and after 6 months were recorded on a web-based case report form. Between January 2015 and December 2016, 117 patients with major bleeding events were enrolled. Non-valvular atrial fibrillation (NVAF) was the indication for treatment in 84% (62% males); 53 patients had intracranial bleeding (13 fatal), 42 had gastrointestinal bleeding (1 fatal), and 22 had bleeding in other sites. Therapeutic interventions for the management of bleeding were performed in 71% of patients. Therapeutic strategies with/without surgery or invasive procedures included: fluid replacement or red blood cells transfusion, prothrombin complex concentrates (3 or 4 factors), antifibrinolytic drugs, and the administration of idarucizumab. Creatinine, blood cell count, and PT/aPTT were the most frequent tests requested, while specific DOAC measurements were performed in 23% of patients. Mortality during hospitalization was 11.9%, at 6-month follow-up 15.5%. Our data confirm a high heterogeneity in the management of bleeding complications in patients treated with DOACs.
Collapse
Affiliation(s)
- Sophie Testa
- Haemostasis and Thrombosis Center, Ospedale di Cremona, Viale Concordia 1, 26100, Cremona, Italy.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Rossella Morandini
- Haemostasis and Thrombosis Center, Ospedale di Cremona, Viale Concordia 1, 26100, Cremona, Italy
| | | | | | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | | | | | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | |
Collapse
|
15
|
Kooiman J, van der Hulle T, Maas H, Wiebe S, Formella S, Clemens A, van Buren M, Janssen M, Rabelink TJ, Huisman MV. Pharmacokinetics and Pharmacodynamics of Dabigatran 75 mg b.i.d. in Patients With Severe Chronic Kidney Disease. J Am Coll Cardiol 2018; 67:2442-2444. [PMID: 27199067 DOI: 10.1016/j.jacc.2016.03.516] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/24/2016] [Accepted: 03/01/2016] [Indexed: 11/19/2022]
|
16
|
Liu J, Xu D, Xia N, Hou K, Chen S, Wang Y, Li Y. Anticoagulant Activities of Indobufen, an Antiplatelet Drug. Molecules 2018; 23:molecules23061452. [PMID: 29914049 PMCID: PMC6099839 DOI: 10.3390/molecules23061452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/09/2018] [Accepted: 06/12/2018] [Indexed: 01/08/2023] Open
Abstract
Indobufen is a new generation of anti-platelet aggregation drug, but studies were not sufficient on its anticoagulant effects. In the present study, the anticoagulant activity of indobufen was determined by monitoring the activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT) in rabbit plasma. We evaluated the anticoagulant mechanisms on the content of the platelet factor 3,4 (PF3,4), and the coagulation factor 1, 2, 5, 8, 10 (FI, II, V, VIII, X) in rabbits, as well as the in vivo bleeding time and clotting time in mice. The pharmacodynamic differences between indobufen and warfarin sodium, rivaroxaban, and dabigatran were further studied on thrombus formation and the content of FII and FX in rats. Animal experiments showed that intragastric-administrated indobufen can significantly reduce the APTT, PT, TT, PF3, FI, II, V, VIII, and X plasma contents. Its inhibitory effect on plasma FII was better than thrombin inhibitor dabigatran with effect on FX better than FXa inhibitor rivaroxaban. These results suggest that indobufen has some anticoagulant effects as strong as some conventional anticoagulants. The mechanism may be related to both exogenous and endogenous coagulation system.
Collapse
Affiliation(s)
- Jia Liu
- Department of Marketing, Hangzhou Zhongmei Huadong Pharmaceutical Company, Hangzhou 310011, China.
| | - Dan Xu
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Nian Xia
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Kai Hou
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Shijie Chen
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Yu Wang
- Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Department of Pharmacology, Nanjing Medical University, 140 Hanzhong Road, Nanjing 210029, China.
| | - Yunman Li
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| |
Collapse
|
17
|
Abstract
The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.
Collapse
Affiliation(s)
- Nilufar Mohebbi
- 1 Klinik für Nephrologie, Universitätsspital Zürich und Praxis und Dialysezentrum Zürich-City
| |
Collapse
|
18
|
Dülgeroglu J, Schmidt D. [Peri-Interventional Management of Direct Oral Anticoagulants - Balancing Benefits and Risks]. Praxis (Bern 1994) 2018; 107:485-493. [PMID: 29690851 DOI: 10.1024/1661-8157/a002963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Zusammenfassung. Das periprozedurale Management von direkten oralen Antikoagulanzien löst bei vielen Klinikern noch Unsicherheit aus. Dies mag daran liegen, dass mit Apixaban, Dabigatran, Edoxaban und Rivaroxaban Substanzen mit unterschiedlichen Wirkansätzen und Pharmakokinetik auf dem Markt vertreten sind. Der Umgang mit DOAK bedarf einer individuellen Risikoeinschätzung betreffend Blutungen und Thromboembolien, insbesondere im perioperativen/periinterventionellen Management. Ein Therapie-Monitoring ist im Regelfall nicht erforderlich. Situativ kann die Bestimmung der Serumkonzentration von Interesse sein. Es stehen für die einzelnen Substanzen hierfür unterschiedliche Verfahren zur Verfügung. Die Möglichkeit einer Verfälschung weiterer Gerinnungsmarker muss berücksichtigt werden. Im Falle einer schweren Blutungskomplikation muss PPSB angewendet werden. Das einzige bisweilen verfügbare Antidot stellt Praxbind® (Idarucizumab) dar. Aktuelle Forschungsergebnisse lassen aber mutmassen, dass zukünftig weitere Therapieoptionen auch für Substanzen, welche den Faktor Xa hemmen, bald zur Verfügung stehen werden.
Collapse
Affiliation(s)
| | - Dörthe Schmidt
- 1 Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
| |
Collapse
|
19
|
Sciascia S, Radin M, Schreiber K, Fenoglio R, Baldovino S, Roccatello D. Chronic kidney disease and anticoagulation: from vitamin K antagonists and heparins to direct oral anticoagulant agents. Intern Emerg Med 2017; 12:1101-1108. [PMID: 28929298 DOI: 10.1007/s11739-017-1753-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 01/18/2023]
Abstract
Anticoagulation in patients with impaired kidney function can be challenging since drugs' pharmacokinetics and bioavailability are altered in this setting. Patients with chronic kidney disease (CKD) treated with conventional anticoagulant agents [vitamin K antagonist (VKA), low-molecular weight heparin (LMWH) or unfractionated heparin (UFH)] are at high risk of bleeding events (both non-major and major clinically relevant bleeding). While anticoagulation reduces the risk of thromboembolic events, the co-existing bleeding risk and the fact that the most commonly used anticoagulation agents are eliminated via the kidneys pose additional challenges. More recently, two classes of direct oral anticoagulant agents (DOACs) have been investigated for the prevention and management of venous thromboembolic events: the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran. In this review, we discuss the complex challenges and the practical considerations associated with the management of anticoagulation treatment in patients with CKD, with a special focus on DOACs.
Collapse
Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Karen Schreiber
- Centre for Thrombosis and Haemostasis, St. Thomas' Hospital, London, UK
- Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Copenhagen, Denmark
| | - Roberta Fenoglio
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| |
Collapse
|
20
|
Halton JML, Albisetti M, Biss B, Bomgaars L, Brueckmann M, Gropper S, Harper R, Huang F, Luciani M, Maas H, Tartakovsky I, Mitchell LG. Phase IIa study of dabigatran etexilate in children with venous thrombosis: pharmacokinetics, safety, and tolerability. J Thromb Haemost 2017; 15:2147-2157. [PMID: 28921890 DOI: 10.1111/jth.13847] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Indexed: 11/30/2022]
Abstract
Essentials Dabigatran etexilate may provide a new treatment option for pediatric venous thromboembolism. Children aged 1 to < 12 years were given dabigatran etexilate in an open-label, single-arm study. The pharmacokinetic-pharmacodynamic relationship was similar to that seen in adult patients. There were no serious adverse events, bleeding events or recurrent venous thromboembolism. SUMMARY Background The current standard-of-care treatments for pediatric venous thromboembolism (VTE) have limitations. Dabigatran etexilate (DE), a direct thrombin inhibitor, may offer an alternative therapeutic option. Objectives To assess the pharmacokinetics, pharmacodynamics, safety, and tolerability of a DE oral liquid formulation (OLF) in pediatric patients with VTE. Patients/Methods Patients who had completed planned treatment with low molecular weight heparin or oral anticoagulants for VTE were enrolled in two age groups (2 to < 12 years and 1 to < 2 years), and received a DE OLF based on an age-adjusted and weight-adjusted nomogram. Originally, patients were to receive a DE OLF twice daily for 3 days, but the protocol was amended to a single dose on day 1. The primary endpoints were pharmacokinetics/pharmacodynamics-related: plasma concentrations of DE and its metabolites; activated partial thromboplastin time (APTT), ecarin clotting time (ECT), and dilute thrombin time (dTT); and pharmacokinetic (PK)-pharmacodynamic (PD) correlation. Safety endpoints included incidence rates of bleeding events and all other adverse events (AEs). Results Eighteen patients entered the study and received the DE OLF (an exposure equivalent to a dose of 150 mg twice daily in adults). The projected steady-state dabigatran trough concentrations were largely comparable between pediatric patients and adults. The PK/PD relationship was linear for ECT and dTT, and non-linear for APTT. No serious or severe AEs, bleeding events, or recurrent VTEs were reported. Mild AEs were reported in three patients in the single-dose group (screening period) and in one patient in the multiple-dose group (on-treatment period). Conclusion The current study supports the further evaluation of DE OLFs in pediatric patients with VTE.
Collapse
Affiliation(s)
- J M L Halton
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - M Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - B Biss
- Clinical Development, Boehringer Ingelheim RCV, Vienna, Austria
| | - L Bomgaars
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - M Brueckmann
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma, Ingelheim, Germany
- Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - S Gropper
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma, Ingelheim, Germany
| | - R Harper
- Clinical Operations, Boehringer Ingelheim, Bracknell, UK
| | - F Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - M Luciani
- OncoHematology Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - H Maas
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma, Biberach, Germany
| | - I Tartakovsky
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma, Ingelheim, Germany
| | - L G Mitchell
- University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
21
|
Abstract
Bleeding complications are a common concern with the use of anticoagulant agents. In many situations, reversing of neutralizing their effects may be warranted. Prothrombin complex concentrate replaces coagulation factors lowered by warfarin, as does fresh frozen plasma, but in a more concentrated form. Protamine negates the effect of heparin and combines chemically with heparin molecules to form an inactive salt. It also partially reverses the effects of low-molecular-weight heparin. Recombinant activated factor VII is a nonspecific procoagulant that activates the extrinsic clotting pathway, resulting in thrombin generation, but does not directly neutralize the activity of any of the new oral anticoagulants.
Collapse
Affiliation(s)
- Joseph Meltzer
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
| | - Joseph R Guenzer
- Department of Anesthesiology, University of Utah Medical School, 30 North 1900 East, Room 3C444, Salt Lake City, UT 84132-2501, USA
| |
Collapse
|
22
|
Di Lullo L, Ronco C, Cozzolino M, Russo D, Russo L, Di Iorio B, De Pascalis A, Barbera V, Galliani M, Vitaliano E, Campana C, Santoboni F, Bellasi A. Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation. Thromb Res 2017; 155:38-47. [PMID: 28482261 DOI: 10.1016/j.thromres.2017.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49ml/min) and those on dialysis.
Collapse
Affiliation(s)
- L Di Lullo
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy.
| | - C Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | - M Cozzolino
- Department of Health Sciences, Renal Division, S. Paolo Hospital, Milano, Italy
| | - D Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - L Russo
- Division of Nephrology, University Federico II, Napoli, Italy
| | - B Di Iorio
- Department of Nephrology and Dialysis, Landolfi Hospital, Solofra, Italy
| | - A De Pascalis
- Department of Nephrology and Dialysis, V. Fazzi Hospital, Lecce, Italy
| | - V Barbera
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - M Galliani
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - E Vitaliano
- Department of Nephrology and Dialysis, S. Pertini Hospital, Roma, Italy
| | - C Campana
- Cardiology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
| | - F Santoboni
- Department of Nephrology and Dialysis, Parodi - Delfino Hospital, Colleferro, Italy
| | - A Bellasi
- Nephrology Unit, S. Anna Hospital, ASST - Lariana, Como, Italy
| |
Collapse
|
23
|
Gouin-Thibault I, Delavenne X, Blanchard A, Siguret V, Salem JE, Narjoz C, Gaussem P, Beaune P, Funck-Brentano C, Azizi M, Mismetti P, Loriot MA. Interindividual variability in dabigatran and rivaroxaban exposure: contribution of ABCB1 genetic polymorphisms and interaction with clarithromycin. J Thromb Haemost 2017; 15:273-283. [PMID: 27893182 DOI: 10.1111/jth.13577] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Indexed: 12/01/2022]
Abstract
Essentials Rivaroxaban and dabigatran are substrates of the P-glycoprotein (P-gp) encoded by the ABCB1 gene. We tested the effect of ABCB1 polymorphisms and of a P-gp inhibitor on both drugs' pharmacokinetics. The ABCB1 genotype was not a clinically relevant determinant of both drugs' pharmacokinetics. Administration of P-gp inhibitors with dabigatran or rivaroxaban should be exercised with caution. SUMMARY Background The direct oral anticoagulants (DOACs) dabigatran and rivaroxaban are both substrates of the P-glycoprotein (P-gp) transporter, encoded by the ABCB1 gene. Rivaroxaban is metabolized by cytochrome P450 A4 (CYP3A4). Interindividual variability in DOAC exposure and frequent P-gp-associated drug-drug interactions have been described in patients. Objective To assess the influence of ABCB1 polymorphisms on the pharmacokinetics of dabigatran and rivaroxaban, associated or not with clarithromycin, a P-gp and CYP3A4 inhibitor. Methods Sixty healthy male volunteers, selected according to ABCB1 genotype (20 homozygous mutated, 20 heterozygous mutated, and 20 wild-type for haplotype 2677-3435), were included in this randomized, two-center, crossover study. All received sequentially a single dose of dabigatran etexilate (300 mg) and rivaroxaban (40 mg) associated or not with clarithromycin. Peak plasma concentration and area under the curve (AUC) were compared across the three ABCB1 genotypes. The effect of clarithromycin on dabigatran or rivaroxaban pharmacokinetics was assessed. Results Interindividual coefficients of variation for AUC were 77% for dabigatran and 51% for rivaroxaban. ABCB1 genotype did not significantly affect drug pharmacokinetics: AUC ratios between mutant-allele carriers and wild-type volunteers were 1.27 (95% confidence interval [CI] 0.84-1.92) and 1.20 (95% CI 0.96-1.51) for dabigatran and rivaroxaban, respectively. Clarithromycin coadministration led to a two-fold increase in both drugs' AUC, irrespective of ABCB1 genotype: ratios of geometric means were 2.0 (95% CI 1.15-3.60) and 1.94 (95% CI 1.42-2.63) for dabigatran and rivaroxaban, respectively. Conclusions ABCB1 genotype is not a significant determinant of interindividual variability in dabigatran and rivaroxaban pharmacokinetics. The levels of one drug did not predict the levels of the other. Coadministration of a P-gp/CYP3A4 inhibitor with dabigatran or rivaroxaban may warrant caution in patients at risk of overexposure.
Collapse
Affiliation(s)
- I Gouin-Thibault
- INSERM UMR_S1140, Faculté de Pharmacie, Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- Laboratoire d'Hématologie Biologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - X Delavenne
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
- Groupe de Recherche sur la Thrombose, Université Jean Monnet, Saint-Etienne, France
| | - A Blanchard
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- Hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, CIC-1418, Paris, France
| | - V Siguret
- INSERM UMR_S1140, Faculté de Pharmacie, Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- Hôpital Lariboisière, Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - J E Salem
- Département de Pharmacologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, CIC-1421 and Institut de Cardiométabolisme et Nutrition (ICAN) UMR ICAN_1166, Paris, France
- Sorbonne Universités, UPMC Université Paris 6, Paris, France
| | - C Narjoz
- INSERM UMR_S1147, Centre Universitaire des Saints-Pères, Paris, France
- Hôpital Européen Georges Pompidou, Service de Biochimie, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - P Gaussem
- INSERM UMR_S1140, Faculté de Pharmacie, Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- Hôpital Européen Georges Pompidou, Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - P Beaune
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- INSERM UMR_S1147, Centre Universitaire des Saints-Pères, Paris, France
- Hôpital Européen Georges Pompidou, Service de Biochimie, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - C Funck-Brentano
- Département de Pharmacologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, CIC-1421 and Institut de Cardiométabolisme et Nutrition (ICAN) UMR ICAN_1166, Paris, France
- Sorbonne Universités, UPMC Université Paris 6, Paris, France
| | - M Azizi
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- Hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, CIC-1418, Paris, France
- Hôpital Européen Georges Pompidou, Unité d'Hypertension Artérielle, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - P Mismetti
- Groupe de Recherche sur la Thrombose, Université Jean Monnet, Saint-Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint Etienne, Saint Etienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalier Universitaire de Saint Etienne, Saint Etienne, France
| | - M A Loriot
- Sorbonne Paris Cité, Université Paris Descartes, Paris, France
- INSERM UMR_S1147, Centre Universitaire des Saints-Pères, Paris, France
- Hôpital Européen Georges Pompidou, Service de Biochimie, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| |
Collapse
|
24
|
Punčochová K, Prajzlerová M, Beránek J, Štěpánek F. The impact of polymeric excipients on the particle size of poorly soluble drugs after pH-induced precipitation. Eur J Pharm Sci 2016; 95:138-144. [PMID: 27539142 DOI: 10.1016/j.ejps.2016.08.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/24/2016] [Accepted: 08/13/2016] [Indexed: 01/25/2023]
Abstract
Active pharmaceutical ingredients (APIs) with strongly pH-dependent aqueous solubility can face the problem of precipitating from solution when the pH changes from acidic in the stomach to neutral in the intestine. The present work investigates the effect of two polymeric excipients - polyvinylpyrrolidone (PVP) and Soluplus - on the ability to either prevent precipitation, or to control the size distribution of precipitated particles when precipitation cannot be prevented. Two different APIs were compared, Dabigatran etexilate mesylate and Rilpivirine hydrochloride. The effect of excipient concentration on the precipitation behaviour during pH titration was systematically investigated and qualitatively different trends were observed: in case of Soluplus, which forms a micellar solution when critical micelle concentration is exceeded, precipitation was inhibited in the case of Dabigatran etexilate, which partitioned into the micelles. On the other hand, Rilpivirine precipitated independently of Soluplus concentration. In the case of PVP, which does not form micelles, precipitation could not be avoided. Increased polymer concentration, however prevented the aggregation of precipitated particles into larger cluster. The observed effect of PVP was especially pronounced for Rilpivirine. The main conclusion of this study is that a suitably chosen polymeric excipient can either prevent precipitation altogether or reduce the size of the resulting particles. The mechanism of action, however, seems-specific to a given molecule. It was also shown that the polymer-stabilised particles have a potential to redissolve.
Collapse
Affiliation(s)
- Kateřina Punčochová
- Department of Chemical Engineering, University of Chemistry and Technology Prague, Prague 6, Czech Republic; Zentiva, k.s., U Kabelovny 130, Prague 10, Czech Republic
| | - Marie Prajzlerová
- Department of Chemical Engineering, University of Chemistry and Technology Prague, Prague 6, Czech Republic
| | - Josef Beránek
- Zentiva, k.s., U Kabelovny 130, Prague 10, Czech Republic
| | - František Štěpánek
- Department of Chemical Engineering, University of Chemistry and Technology Prague, Prague 6, Czech Republic.
| |
Collapse
|
25
|
Pan EY, Sobieraj DM. Considerations for Prescribing Target-Specific Oral Anticoagulants in the Setting of Renal Dysfunction or Drug Interactions. Conn Med 2016; 80:105-111. [PMID: 27024982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|
26
|
Abstract
Several pharmacokinetic studies have suggested that dabigatran possesses a number of ideal properties for expedited removal via extracorporeal methods. However, this practice has not been prospectively evaluated in patients with life-threatening bleeding or requiring emergency surgery secondary to dabigatran-associated coagulopathy. The purpose of this literature review is to evaluate the published evidence surrounding extracorporeal removal of dabigatran in the setting of emergency surgery or life-threatening bleeding. A query of MEDLINE, Web of Science, International Pharmaceutical Abstracts, and Google Scholar using the terms dabigatran, dabigatran etexilate, hemodialysis, renal replacement therapy, hemorrhage, and atrial fibrillation was used to retrieve relevant literature. Furthermore, a manual search of the references of the identified literature was performed to capture additional data. Current evidence suggests that extracorporeal removal of dabigatran may play a role in the setting of life-threatening bleeding and emergent surgery. Conflicting evidence exists with regard to the potential for redistribution based on serum dabigatran concentrations. In addition, a number of practicalities must be considered before incorporating this technique in the clinical setting. Extracorporeal removal of dabigatran may be a treatment modality in selected patients who require emergency reversal.
Collapse
Affiliation(s)
- Nadia I Awad
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Room 423, Piscataway, NJ, USA,
| | | | | |
Collapse
|
27
|
Lehman N, Bryant G, Bender J, Koenigsfeld C, Logemann C, Sayler M. Left subconjunctival hemorrhage · renal dysfunction · international normalized ratio of 4.5 · Dx? J Fam Pract 2015; 64:E3-E4. [PMID: 26551480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Nicholas Lehman
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA, USA.
| | - Ginelle Bryant
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA, USA
| | - Jenna Bender
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Carrie Koenigsfeld
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA, USA
| | | | - Morgan Sayler
- University of Iowa College of Pharmacy, Iowa City, IA, USA
| |
Collapse
|