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Antiplatelet therapy: A step forward with individualized medicine

Posted Sep 22, 2009 at 10:30 AM, EDT by Eric Topol

The Scripps clinic and health system is announcing at TCT this week routine genotyping of all patients undergoing stenting after concluding that this data is vital in selecting antiplatelet therapy. What are your thoughts? How do you follow patients who take clopidogrel and have shown a potential increased risk for stent thrombosis or other events?

See:

Genetic Determinants of Response to Clopidogrel and Cardiovascular Events N Engl J Med. 2009 Jan 22;360(4):363-75. Epub 2008 Dec 22.

Cytochrome p-450 polymorphisms and response to clopidogrel. N Engl J Med. 2009 Jan 22;360(4):354-62. Epub 2008 Dec 22.

Association of cytochrome P450 2C19 genotype with the antiplatelet effect and clinical efficacy of clopidogrel therapy. JAMA. 2009 Aug 26;302(8):849-57. 

Gene variants affecting response to clopidogrel not a factor with prasugrel . theheart.org. [Clinical Conditions > Acute Coronary Syndromes > Acute coronary syndromes]; May 8, 2009.

Evidence growing for personalized antiplatelet therapy . theheart.org. [Clinical Conditions > Interventional/Surgery > Interventional/Surgery]; Mar 28, 2009.

Clopidogrel gene mutation linked to higher rate of stent thrombosis . theheart.org. [Clinical Conditions > Acute Coronary Syndromes > Acute coronary syndromes]; Feb 12, 2009.

Genetic variant linked with worse clinical outcomes in MI patients treated with clopidogrel. theheart.org. [Clinical Conditions > Acute Coronary Syndromes > Acute coronary syndromes]; Dec 24, 2008.

6 Comments | Add your own comments | Permalink

Comments

I am surprised to see Scripts making this sweeping change regarding post stent treatment without the benefit of a controlled tiral showing value.  I am surprised and pleased. 

 It seems to me that rational thought has largely been abandoned by the medical "thought leaders" with their need for massive controlled tirals prior to initiation of a new technology.  Considering the bad outcomes associated with this genetic marker, proactive intervention seems to make sense.  I am curious if the starched collars from the east coast will agree.


Posted by William Blanchet, Sep 24, 2009 at 01:46 AM, EDT
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Eric, I am interested in whether you will match your hematologic data with available bedside monitoring devices. As we know thromboelastography is the gold standard but not a bedside tool. TEG and VerifyNow have yet to be trialed in the large PCI population and are at least relatively unproven but provide reasonable rapid assessment of platelet function.

Look forward to seeing the registry data as well as how Scripps handles the asymptomatic non/low responder.

WSS


Posted by Scott Sheldon, Sep 24, 2009 at 12:40 PM, EDT
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Yes, I aggree with William above.  I am a hematologist, and I recently reviewed this topic for a lecture I gave on genetic profiling in individualized drug dosing.  The randomized trials fail to show a benefit for genotyping Plavix, so I wonder whether you plan to give us a rationale for your current testing strategy.

 

Regards,

InteractMD.com


Posted by InteractMD.com, Sep 28, 2009 at 12:13 AM, EDT
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Plavix is a mutimillions dollars bussiness. Anyone talking about anti-platletsaggregation should  first make it clear in the first line - not at the bottom- that they have no finantial connection even indirectly with the Plavix empire.

giorgioMD


Posted by giorgioMD, Sep 29, 2009 at 08:54 PM, EDT
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Eric,

 I am surprised that you recommend this now without randomized trials. This is observational data. The recent trial presented at  TCT (randomized COGENT trial) showed that the concern from observational data about the negative interaction of PPIs and plavix appear to be unfounded- there is a disconnect between lab data and clinical outcome.

You may be right, but hate to change practice before the data is in.


Posted by SJ, Oct 01, 2009 at 04:38 PM, EDT
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Please see the article posted on theheart.org Oct 14th to respond to the queries and crtique

Thanks for writing!


Posted by Eric Topol, Oct 14, 2009 at 04:23 PM, EDT
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