High incidence of major bleeding with off-label use of edoxaban.

In clinical practice, edoxaban is sometimes prescribed for off-label use based on the hypothesis that it is as safe and effective as warfarin. However, there is limited safety information on off-label use due to lack of clinical trial. We aimed to analyze the tolerability of off-label use of edoxaban and to identify patient characteristics associated with major bleeding as adverse effects. Patients under edoxaban treatment between January 2017 and December 2017 were enrolled in this retrospective cohort study. The incidence of major bleeding with off-label use compared with on-label use was analyzed using by log-rank test. Univariate and multivariate regression analysis were undertaken to detect independent variables with significant odds ratio that associated with major bleeding. After the exclusion criteria were applied, the patients were divided into two groups: off-label group (n = 30) and on-label group (n = 161). Incidence of major bleeding was found to be higher in the off-label group (13.3%) than in the on-label group (3.7%) (p<0.05). Multivariate adjustment showed that the off-label use or portal vein thrombosis and patients with history of major bleeding has significantly higher incidence of major bleeding. We demonstrated that off-label use of edoxaban may be a significant risk factor for major bleeding.

Population Pharmacokinetics and Pharmacodynamics of Apixaban Linking Its Plasma Concentration to Intrinsic Activated Coagulation Factor X Activity in Japanese Patients with Atrial Fibrillation.

Apixaban is used in the prevention and treatment of patients with deep vein thrombosis or pulmonary embolism, and in the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF). In this study, we aimed to elucidate intrinsic factors affecting efficacy of apixaban by conducting population pharmacokinetic and pharmacodynamic analysis using data from 81 Japanese AF patients. The intrinsic FXa activity was determined to assess the pharmacodynamic effect of apixaban. The pharmacokinetic and pharmacodynamic profiles were described based on a one-compartment model with first-order absorption and a maximum inhibitory model, respectively. Pharmacokinetic and pharmacodynamic analysis was conducted using a nonlinear mixed effect modeling program. The population pharmacokinetic parameters of apixaban were fixed at the reported values in our recent study. The population mean of half-maximal inhibitory concentration (IC50) of apixaban was estimated to be 45.3 ng/mL. The population mean IC50 decreased 27.7% for patients with heart failure, but increased 55% for patients with a medical history of cerebral infarction. In contrast, no covariates affected the population mean of baseline of intrinsic FXa activity (BASE) and maximum effect (Imax) value of apixaban. The population mean of BASE and Imax value were estimated to be 40.2 and 38.4 nmol/min/mg protein, respectively. The present study demonstrates for the first time that the co-morbidity of heart failure as well as the medical history of cerebral infarction are an intrinsic factor affecting the pharmacodynamics of apixaban.

Population pharmacokinetics and pharmacogenomics of apixaban in Japanese adult patients with atrial fibrillation.

AIMS: This study aimed to analyse the effects of genetic polymorphisms in drug transporters and metabolizing enzymes, and clinical laboratory data on the pharmacokinetic parameters of apixaban. METHODS: Data were collected from 81 Japanese patients with atrial fibrillation. Pharmacogenomic data were stratified by ABCB1, ABCG2 and CYP3A5 polymorphisms. The pharmacokinetic profile of apixaban was described by a one-compartment model with first-order absorption. Population pharmacokinetic analysis was conducted using a nonlinear mixed effect modelling (NONMEM™) program. RESULTS: The nonlinear relationship between oral clearance (CL/F) of apixaban and creatinine clearance (Ccr) was observed. The population mean of CL/F for a typical patient (Ccr value of 70 ml min-1 ) with the CYP3A5*1/*1 and ABCG2 421C/C or C/A genotypes was estimated to be 3.06 l h-1 . When Ccr values were set to the typical value, the population mean of CL/F was 1.52 times higher in patients with the CYP3A5*1/*1 genotype compared with patients with the CYP3A5*1/*3 or *3/*3 genotype, while the population mean of CL/F was 1.49 times higher in patients with the ABCG2 421C/C or C/A genotype compared with patients with the ABCG2 421A/A genotype. However, no covariates affected the population mean of the apparent volume of distribution (Vd/F) of apixaban. The population mean of Vd/F was estimated to be 24.7 l. CONCLUSION: The present study suggests that the ABCG2 421A/A and CYP3A5*3 genotypes and renal function are intrinsic factors affecting apixaban pharmacokinetics. These findings may provide useful information for precision medicine using apixaban, to avoid the risk of adverse reactions.

Impact of ABCB1, ABCG2, and CYP3A5 polymorphisms on plasma trough concentrations of apixaban in Japanese patients with atrial fibrillation.

OBJECTIVES: During anticoagulant therapy, major bleeding is one of the most severe adverse effects. This study aimed to evaluate the relationships between ABCB1, ABCG2, and CYP3A5 polymorphisms and plasma trough concentrations of apixaban, a direct inhibitor of coagulation factor X. PATIENTS AND METHODS: A total of 70 plasma concentrations of apixaban from 44 Japanese patients with atrial fibrillation were analyzed. In these analyses, the plasma trough concentration/dose (C/D) ratio of apixaban was used as a pharmacokinetic index and all data were stratified according to the presence of ABCB1 (ABCB1 1236C>T, 2677G>T/A, and 3435C>T), ABCG2 (ABCG2 421C>A), and CYP3A5 (CYP3A5*3) polymorphisms. Influences of various clinical laboratory parameters (age, serum creatinine, estimated glomerular filtration rate, aspartate amino transferase, and alanine amino transferase) on the plasma trough C/D ratio of apixaban were included in analyses. RESULTS: Although no ABCB1 polymorphisms affected the plasma trough C/D ratio of apixaban, the plasma trough C/D ratio of apixaban was significantly higher in patients with the ABCG2 421A/A genotype than in patients with the ABCG2 421C/C genotype (P<0.01). The plasma trough C/D ratio of apixaban in patients with CYP3A5*1/*3 or *3/*3 genotypes was also significantly higher than that in patients with the CYP3A5*1/*1 genotype (P<0.05). Furthermore, the plasma trough C/D ratio of apixaban decreased with increased estimated glomerular filtration rate. CONCLUSION: These results indicate that ABCG2 421A/A and CYP3A5*3 genotypes and renal function are considered potential factors affecting trough concentrations of apixaban.

Crystal structures of hydrogen-bonded co-crystals as liquid crystal precursors: 4-(n-pent-yloxy)benzoic acid-(E)-1,2-bis-(pyridin-4-yl)ethene (2/1) and 4-(n-hex-yloxy)benzoic acid-(E)-1,2-bis-(pyridin-4-yl)ethene (2/1).

The crystal structures of title hydrogen-bonded co-crystals, 2C12H16O3·C12H10N2, (I), and 2C13H18O3·C12H10N2, (II), have been determined at 93 K. In (I), the asymmetric unit consists of one 4-(n-pent-yloxy)benzoic acid mol-ecule and one half-mol-ecule of (E)-1,2-bis-(pyridin-4-yl)ethene, which lies about an inversion centre. The asymmetric unit of (II) comprises two crystallographically independent 4-(n-hex-yloxy)benzoic acid mol-ecules and one 1,2-bis-(pyridin-4-yl)ethene mol-ecule. In each crystal, the acid and base components are linked by O-H⋯N hydrogen bonds, forming a linear hydrogen-bonded 2:1 unit of the acid and the base. The 2:1 units are linked via C-H⋯π and π-π inter-actions [centroid-centroid distances of 3.661 (2) and 3.909 (2) Šfor (I), and 3.546 (2)-3.725 (4) Šfor (II)], forming column structures. In (II), the base mol-ecule is orientationally disordered over two sets of sites approximately around the N⋯N mol-ecular axis, with an occupancy ratio of 0.647 (4):0.353 (4), and the average structure of the 2:1 unit adopts nearly pseudo-C2 symmetry. Both compounds show liquid-crystal behaviour.

Crystal structures of four co-crystals of (E)-1,2-di(pyridin-4-yl)ethene with 4-alk-oxy-benzoic acids: 4-meth-oxy-benzoic acid-(E)-1,2-di(pyridin-4-yl)ethene (2/1), 4-eth-oxy-benzoic acid-(E)-1,2-di(pyridin-4-yl)ethene (2/1), 4-n-propoxybenzoic acid-(E)-1,2-di(pyridin-4-yl)ethene (2/1) and 4-n-but-oxy-benzoic acid-(E)-1,2-di(pyridin-4-yl)ethene (2/1).

The crystal structures of four hydrogen-bonded co-crystals of 4-alk-oxy-benzoic acid-(E)-1,2-di(pyridin-4-yl)ethene (2/1), namely, 2C8H8O3·C12H10N2, (I), 2C9H10O3·C12H10N2, (II), 2C10H12O3·C12H10N2, (III) and 2C11H14O3·C12H10N2, (IV), have been determined at 93 K. In compounds (I) and (IV), the asymmetric units are each composed of one 4-alk-oxy-benzoic acid mol-ecule and one half-mol-ecule of (E)-1,2-di(pyridin-4-yl)ethene, which lies on an inversion centre. The asymmetric unit of (II) consists of two crystallographically independent 4-eth-oxy-benzoic acid mol-ecules and one 1,2-di(pyridin-4-yl)ethene mol-ecule. Compound (III) crystallizes in a non-centrosymmetric space group (Pc) and the asymmetric unit comprises four 4-n-propoxybenzoic acid mol-ecules and two (E)-1,2-di(pyridin-4-yl)ethane mol-ecules. In each crystal, the acid and base components are linked by O-H⋯N hydrogen bonds, forming a linear hydrogen-bonded 2:1 unit of the acid and the base. In (I), (II) and (III), inter-molecular C-H⋯O inter-actions are observed. The 2:1 units of (I) and (II) are linked via C-H⋯O hydrogen bonds, forming tape structures. In (III), the C-H⋯O hydrogen bonds, except for those formed in the units, link the two crystallographically independent 2:1 units. In (IV), no C-H⋯O inter-actions are observed, but π-π and C-H⋯π inter-actions link the units into a column structure.

Crystal structures of three co-crystals of 4,4'-bipyridyl with 4-alk-oxy-benzoic acids: 4-eth-oxy-benzoic acid-4,4'-bipyridyl (2/1), 4-n-propoxybenzoic acid-4,4'-bipyridyl (2/1) and 4-n-but-oxy-benzoic acid-4,4'-bipyridyl (2/1).

The crystal structures of three hydrogen-bonded co-crystals of 4-alk-oxy-benzoic acid-4,4'-bipyridyl (2/1), namely, 2C9H10O3·C10H8N2, (I), 2C10H12O3·C10H8N2, (II) and 2C11H14O3·C10H8N2, (III), have been determined at 93 K. Although the structure of (I) has been determined in the space group P21 with Z = 4 [Lai et al. (2008 ▸). J. Struct. Chem. 49, 1137-1140], the present study shows that the space group is P21/n with Z = 4. In each crystal, the components are linked by O-H⋯N hydrogen bonds, forming a linear hydrogen-bonded 2:1 unit of the acid and the base. The 2:1 unit of (I) adopts nearly pseudo-C 2 symmetry, viz. twofold rotation around an axis passing through the mid-point of the central C-C bond of 4,4'-bipyridyl, while the units of (II) and (III), except for the terminal alkyl chains, have pseudo-inversion symmetry. The 2:1 units of (I), (II) and (III) are linked via C-H⋯O hydrogen bonds, forming sheet, double-tape and tape structures, respectively.

Crystal structures of three co-crystals of 1,2-bis-(pyridin-4-yl)ethane with 4-alk-oxy-benzoic acids: 4-eth-oxy-benzoic acid-1,2-bis-(pyridin-4-yl)ethane (2/1), 4-n-propoxybenzoic acid-1,2-bis(pyridin-4-yl)ethane (2/1) and 4-n-but-oxy-benzoic acid-1,2-bis-(pyridin-4-yl)ethane (2/1).

The crystal structures of three hydrogen-bonded co-crystals of 4-alk-oxy-benzoic acid-1,2-bis-(pyridin-4-yl)ethane (2/1), namely, 2C9H10O3·C12H12N2, (I), 2C10H12O3·C12H12N2, (II), and 2C11H14O3·C12H12N2, (III), have been determined at 93, 290 and 93 K, respectively. In (I), the asymmetric unit consists of one 4-eth-oxy-benzoic acid mol-ecule and one half-mol-ecule of 1,2-bis-(pyridin-4-yl)ethane, which lies on an inversion centre. In (II) and (III), the asymmetric units each comprise two crystallographically independent 4-alk-oxy-benzoic acid mol-ecules and one 1,2-bis-(pyridin-4-yl)ethane mol-ecule. In each crystal, the two components are linked by O-H⋯N hydrogen bonds, forming a linear hydrogen-bonded 2:1unit of the acid and the base. Similar to the structure of 2:1 unit of (I), the units of (II) and (III) adopt nearly pseudo-inversion symmetry. The 2:1 units of (I), (II) and (III) are linked via C-H⋯O hydrogen bonds, forming tape structures.