L’angioplastie coronaire est la première forme de revascularisation coronaire. Elle présente cependant 2 limites qui restreignent encore son utilisation : la thrombose et la resténose de stent. La thrombose de stent est un événement précoce associé à une mortalité élevée. Les plaquettes y jouent un rôle déterminant. Le développement de tests fonctionnels plaquettaires permettant d’analyser le niveau de réactivité plaquettaire sous traitement a permis de mettre en évidence les limites de celui-ci sur le plan biologique. Nous avons démontré l’impact clinique de l’utilisation de ces tests dans la prédiction et la réduction du risque de thrombose de stent chez des patients traités par angioplastie coronaire. La resténose est quant à elle une complication tardive de l’angioplastie coronaire avec implantation d’un stent non-actif. Sa physiopathologie repose sur des mécanismes de lésion et de régénération endothéliale. Des marqueurs endothéliaux circulants ont récemment été développés. Nous avons montré qu’ils pouvaient permettre d’évaluer la lésion et la régénération endothéliale induite par une angioplastie coronaire. Les cellules endothéliales circulantes s’élèvent transitoirement après l’angioplastie et ce de façon variable en fonction de la réactivité plaquettaire sous traitement démontrant les interactions étroites entre ces différents acteurs. Dans le même temps, on observe une mobilisation de progéniteurs d’origine médullaire suite à l’angioplastie. Nos travaux suggèrent un rôle clé de la régénération endothéliale dans la cicatrisation vasculaire après angioplastie. En effet, il apparait que la proportion de progéniteurs de profil de différenciation endothélial en réponse à l’angioplastie coronaire détermine la survenue d’une resténose intra-stent. Ces données ouvrent la voie à une meilleure compréhension des mécanismes physiopathologie menant à la resténose mais aussi à des perspectives thérapeutiques intéressantes. / Percutaneous coronary intervention is the most commonly used revascularization technique. However it has 2 main complications limiting its widespread: stent thrombosis and in stent restenosis. Stent thrombosis is an early event associated with a high mortality rate. Platelets are key in its physiopathology. The availability of platelet function tests allowing to determine platelet reactivity levels under therapy showed a variable ant platelet effect following aspirin and clopidogrel intake. We further demonstrated that tailoring anti platelet therapy according to platelet function tests results decrease the rate of stent thrombosis following PCI without increasing bleedings. In stent-restenosis is a late complication of PCI with bare metal stents. The pathophysiology of in-stent restenosis is dependent on the lesion and regeneration of the endothelium. Circulating endothelial biomarkers have recently been developed. We have demonstrated that this marker allow to evaluate the lesion and regeneration of the endothelium following PCI. We evidenced a transient increase in circulating endothelial cells following PCI which is dependent on the level of platelet reactivity inhibition demonstrating the interaction between platelets and the endothelium. At the same time, PCI induces mobilization of progenitor cells which is detectable early after the intervention. Our work suggests that these progenitor cells have a key role in endothelial regeneration after PCI. We evidenced for the first time that the proportion of endothelial progenitor cells among progenitor cells mobilized after PCI determine the occurrence of in stent restenosis. Altogether these data give critical inside into vascular regeneration after PCI in human and on the mechanisms associated with in stent restenosis thus providing new potential therapeutic target.

O clopidogrel é um fármaco antiplaquetário, pertencente à classe das tienopiridinas. A literatura relata poucos trabalhos para a determinação deste fármaco em preparações farmacêuticas. Este trabalho teve como objetivos desenvolver métodos para a análise quali e quantitativa do bissulfato de clopidogrel, bem como, avaliar de forma preliminar a estabilidade da substância. A caracterização da substância química de referência (SQR) foi realizada por Calorimetria Exploratória Diferencial (DSC), Espectrofotometria Infravermelho, e Espectroscopia de RMN 13C e 1H. Os métodos desenvolvidos para a identificação do clopidogrel nos comprimidos revestidos foram a Cromatografia em Camada Delgada (CCD), Espectrofotometria Ultravioleta (UV), CLAE e Eletroforese Capilar (EC). Para a quantificação do clopidogrel nos comprimidos revestidos foram validados os métodos de UV, CLAE e EC de acordo com os parâmetros preconizados pelas Guias Oficiais. Todos os métodos atenderam aos requisitos de validação avaliados, sendo, portanto, adequados para a determinação do clopidogrel em comprimidos revestidos. Os estudos de degradação forçada demonstraram que a substância sofre degradação em condições alcalinas e quando exposta à luz ultravioleta a 254 nm. Na determinação da cinética de degradação foi possível verificar que o clopidogrel, em solução ácida, quando exposto à luz ultravioleta, apresenta T90% de 12,25 min, e possui cinética de reação de segunda ordem. / Clopidogrel is an antiplatelet drug that belongs to the class of thienopyridines. There are few reports in the literature about the determination of this drug in formulations. The aim of this work was to develop methods for qualitative and quantitative analysis of clopidogrel hydrogensulphate, and a preliminary evaluation of the stability of the substance. The characterization of the reference standard was made by Infrared Spectroscopy, Differential Scanning Calorimetry and 13C and 1H Nuclear Magnetic Resonance. The developed methods for the identification of clopidogrel in coated tablets were Thin-layer Chromatography, Ultraviolet Spectrophotometry, HPLC and Capillary Electrophoresis. For the quantification of clopidogrel UV Spectrophotometry, HPLC and Capillary Electrophoresis methods were validated according to the parameters of the Official Guidelines. All the methods attended to the validation specifications, and so they are adequate to the determination of clopidogrel in coated tablets. Accelerated degradation studies demonstrated that the drug suffers degradation in alkaline conditions and when exposed at UV light at 254 nm. In the study of degradation kinetics it was possible to verify that clopidogrel, in acid solution, exposed to UV radiation, presents T90% of 12.25 minutes and has a second order degradation kinetics.

O clopidogrel é um fármaco antiplaquetário, pertencente à classe das tienopiridinas. A literatura relata poucos trabalhos para a determinação deste fármaco em preparações farmacêuticas. Este trabalho teve como objetivos desenvolver métodos para a análise quali e quantitativa do bissulfato de clopidogrel, bem como, avaliar de forma preliminar a estabilidade da substância. A caracterização da substância química de referência (SQR) foi realizada por Calorimetria Exploratória Diferencial (DSC), Espectrofotometria Infravermelho, e Espectroscopia de RMN 13C e 1H. Os métodos desenvolvidos para a identificação do clopidogrel nos comprimidos revestidos foram a Cromatografia em Camada Delgada (CCD), Espectrofotometria Ultravioleta (UV), CLAE e Eletroforese Capilar (EC). Para a quantificação do clopidogrel nos comprimidos revestidos foram validados os métodos de UV, CLAE e EC de acordo com os parâmetros preconizados pelas Guias Oficiais. Todos os métodos atenderam aos requisitos de validação avaliados, sendo, portanto, adequados para a determinação do clopidogrel em comprimidos revestidos. Os estudos de degradação forçada demonstraram que a substância sofre degradação em condições alcalinas e quando exposta à luz ultravioleta a 254 nm. Na determinação da cinética de degradação foi possível verificar que o clopidogrel, em solução ácida, quando exposto à luz ultravioleta, apresenta T90% de 12,25 min, e possui cinética de reação de segunda ordem. / Clopidogrel is an antiplatelet drug that belongs to the class of thienopyridines. There are few reports in the literature about the determination of this drug in formulations. The aim of this work was to develop methods for qualitative and quantitative analysis of clopidogrel hydrogensulphate, and a preliminary evaluation of the stability of the substance. The characterization of the reference standard was made by Infrared Spectroscopy, Differential Scanning Calorimetry and 13C and 1H Nuclear Magnetic Resonance. The developed methods for the identification of clopidogrel in coated tablets were Thin-layer Chromatography, Ultraviolet Spectrophotometry, HPLC and Capillary Electrophoresis. For the quantification of clopidogrel UV Spectrophotometry, HPLC and Capillary Electrophoresis methods were validated according to the parameters of the Official Guidelines. All the methods attended to the validation specifications, and so they are adequate to the determination of clopidogrel in coated tablets. Accelerated degradation studies demonstrated that the drug suffers degradation in alkaline conditions and when exposed at UV light at 254 nm. In the study of degradation kinetics it was possible to verify that clopidogrel, in acid solution, exposed to UV radiation, presents T90% of 12.25 minutes and has a second order degradation kinetics.

O clopidogrel é um fármaco antiplaquetário, pertencente à classe das tienopiridinas. A literatura relata poucos trabalhos para a determinação deste fármaco em preparações farmacêuticas. Este trabalho teve como objetivos desenvolver métodos para a análise quali e quantitativa do bissulfato de clopidogrel, bem como, avaliar de forma preliminar a estabilidade da substância. A caracterização da substância química de referência (SQR) foi realizada por Calorimetria Exploratória Diferencial (DSC), Espectrofotometria Infravermelho, e Espectroscopia de RMN 13C e 1H. Os métodos desenvolvidos para a identificação do clopidogrel nos comprimidos revestidos foram a Cromatografia em Camada Delgada (CCD), Espectrofotometria Ultravioleta (UV), CLAE e Eletroforese Capilar (EC). Para a quantificação do clopidogrel nos comprimidos revestidos foram validados os métodos de UV, CLAE e EC de acordo com os parâmetros preconizados pelas Guias Oficiais. Todos os métodos atenderam aos requisitos de validação avaliados, sendo, portanto, adequados para a determinação do clopidogrel em comprimidos revestidos. Os estudos de degradação forçada demonstraram que a substância sofre degradação em condições alcalinas e quando exposta à luz ultravioleta a 254 nm. Na determinação da cinética de degradação foi possível verificar que o clopidogrel, em solução ácida, quando exposto à luz ultravioleta, apresenta T90% de 12,25 min, e possui cinética de reação de segunda ordem. / Clopidogrel is an antiplatelet drug that belongs to the class of thienopyridines. There are few reports in the literature about the determination of this drug in formulations. The aim of this work was to develop methods for qualitative and quantitative analysis of clopidogrel hydrogensulphate, and a preliminary evaluation of the stability of the substance. The characterization of the reference standard was made by Infrared Spectroscopy, Differential Scanning Calorimetry and 13C and 1H Nuclear Magnetic Resonance. The developed methods for the identification of clopidogrel in coated tablets were Thin-layer Chromatography, Ultraviolet Spectrophotometry, HPLC and Capillary Electrophoresis. For the quantification of clopidogrel UV Spectrophotometry, HPLC and Capillary Electrophoresis methods were validated according to the parameters of the Official Guidelines. All the methods attended to the validation specifications, and so they are adequate to the determination of clopidogrel in coated tablets. Accelerated degradation studies demonstrated that the drug suffers degradation in alkaline conditions and when exposed at UV light at 254 nm. In the study of degradation kinetics it was possible to verify that clopidogrel, in acid solution, exposed to UV radiation, presents T90% of 12.25 minutes and has a second order degradation kinetics.

Η καρδιαγγειακή νοσηρότητα είναι πολύ υψηλή στους ασθενείς με Χρόνια Νεφρική Νόσο (ΧΝΝ) τελικού σταδίου οι οποίοι υποβάλλονται σε αιμοκάθαρση και πολλοί ασθενείς έχουν ένδειξη χορήγησης αντι-αιμοπεταλικής αγωγής. Παρόλα αυτά, η αυξημένη αντιδραστικότητα των αιμοπεταλίων είναι συχνή σε ασθενείς που υποβάλλονται σε αιμοκάθαρση. Σκοπός: Σκοπός της μελέτης είναι η σύγκριση της αποτελεσματικότητας της πρασουγρέλης σε σχέση με υψηλή δόση κλοπιδογρέλης σε ασθενείς οι οποίοι υποβάλλονται σε αιμοκάθαρση και παρουσιάζουν υψηλή αντιδραστικότητα αιμοπεταλίων. Υλικό/Μέθοδος: Προοπτική, τυχαιοποιημένη, διασταυρούμενη (cross-over) μελέτη που περιέλαβε 25 αιμοκαθαιρόμενους ασθενείς που λάμβαναν κλοπιδογρέλην σε δόση 75 mg/ημέρα. Οι 21 (84%) εξ αυτών παρουσίαζαν αυξημένη αντιδραστικότητα αιμοπεταλίων και τυχαιοποιήθηκαν σε πρασουγρέλη 10 mg/ημέρα ή κλοπιδογρέλη 150 mg/ημέρα. Οι μετρήσεις της αντιδραστικότητας έγιναν με τη συσκευή VerifyNow© (Accumetrics, San Diego, USA). Ως αυξημένη αντιδραστικότητα των αιμοπεταλίων καθορίστηκε η τιμή PRU (P2Y12 reaction units) ≥235. Επίσης μελετήθηκε η παρουσία του CYP2C19*2 loss-of-function αλληλίου ως πιθανού παράγοντα που σχετίζεται με την αντιδραστικότητα των αιμοπεταλίων. Αποτελέσματα: Το πρωτεύον καταληκτικό σημείο της αντιδραστικότητας των αιμοπεταλίων ήταν χαμηλότερο στους ασθενείς που έλαβαν πρασουγρέλη (least square 156,7, 95% CI 132,2-181,1) σε σχέση με όσους έλαβαν διπλή δόση κλοπιδογρέλης (least square 279,9, 95% CI 255,5-304,4, p<0,001). Η διαφορά ελαχίστων τετραγώνων μεταξύ των δύο ομάδων ήταν -113,4, 95% CI -152,9 έως -73,8, p<0,001 και -163,8, 95% CI -218,1 έως -109,2, p<0,001 σε μη φορείς και σε φορείς τουλάχιστον ενός CYP2C19*2 αλληλίου αντίστοιχα. Η αυξημένη αντιδραστικότητα ήταν χαμηλότερη στην πρασουγρέλη σε σχέση με την κλοπιδογρέλη σε όλους τους ασθενείς (19% έναντι 85,7%, p<0,001) και στους μη φορείς (25,7% έναντι 80%, p=0,003). Όλοι οι φορείς του αλληλίου που ήταν σε θεραπεία με διπλάσια δόση κλοπιδογρέλης συνέχιζαν να εμφανίζουν υψηλή αντιδραστικότητα των αιμοπεταλίων αλλά κανείς από τους λαμβάνοντες πρασουγρέλη (p=0,07). Συμπεράσματα: Σε ασθενείς που υποβάλλονται σε αιμοκάθαρση και εμφανίζουν αυξημένη αντιδραστικότητα αιμοπεταλίων στη συνήθη δόση κλοπιδογρέλης, ο διπλασιασμός της δόσης είναι ιδιαίτερα αναποτελεσματικός. Αντιθέτως, η πρασουγρέλη σε δόση 10 mg ημερησίως οδηγεί σε επαρκή αναστολή. Η παρουσία ή όχι του αλληλίου του γονιδίου CYP2C19*2 δεν επηρεάζει αυτή την απάντηση. / High on treatment platelet reactivity (HTPR) during clopidogrel administration is frequent in patients undergoing chronic maintenance hemodialysis (HD). Objectives: The primary aim of the study was to determine the antiplatelet effects of prasugrel (10 mg/day) versus high-dose clopidogrel (150 mg/day) in HD patients who present HTPR (“High on-Treatment Platelet Reactivity”) under standard dose of clopidogrel (75 mg/day). Patients/Methods: We performed a prospective, single-center, single-blinded, investigator-initiated, randomized, cross-over study to compare platelet inhibition by prasugrel 10 mg/day versus high-dose 150 mg/day clopidogrel in 21 chronic HD patients with HTPR. Platelet function was assessed by the VerifyNow assay and genotyping was performed for CYP2C19*2 carriage. Results: The primary end point of platelet reactivity (PR, measured in PRU) was lower in patients receiving prasugrel (least squares estimates (LS) 156.6, 95% CI 132.2-181.1) compared with high dose clopidogrel (LS 279.9, 95% CI 255.4-304.3), p<0.001). The LS mean difference between the two treatments was -113.4 PRU (95% CI -152.9 to -73.8, p<0.001) and -163.8 PRU (95% CI -218.1 to -109.2, p<0.001) in non-carriers and carriers of at least one CYP2C19*2 allele, respectively. HTPR rates were lower for prasugrel than clopidogrel, in all patients (19% vs 85.7%%, p<0.001) and in non-carriers (25.7% vs 80%, p=0.003). All carriers continued to demonstrate HTPR on high clopidogrel, but none while on prasugrel. Conclusions: In HD patients exhibiting HTPR following standard clopidogrel treatment, prasugrel 10 mg/d is significantly more efficient than doubling the clopidogrel dosage, in achieving adequate platelet inhibition. Both effects seem not to be influenced by the presence of the loss-of-function CYP2C19*2 allele carriage.

Submitted by PPG Biologia Celular e Molecular (bcm@pucrs.br) on 2017-10-11T12:59:22Z No. of bitstreams: 1 PEDRO_VARGAS_DIS.pdf: 3468332 bytes, checksum: 563022a7fa710bed810c652069a0777c (MD5) / Approved for entry into archive by Caroline Xavier (caroline.xavier@pucrs.br) on 2017-10-11T20:09:27Z (GMT) No. of bitstreams: 1 PEDRO_VARGAS_DIS.pdf: 3468332 bytes, checksum: 563022a7fa710bed810c652069a0777c (MD5) / Made available in DSpace on 2017-10-11T20:19:08Z (GMT). No. of bitstreams: 1 PEDRO_VARGAS_DIS.pdf: 3468332 bytes, checksum: 563022a7fa710bed810c652069a0777c (MD5) Previous issue date: 2017-03-10 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / Glioblastoma multiform (GBM) is considered the most aggressive tumors of central nervous system (CNS), and the most lethal among primary tumors presenting low survival prognosis, resistance to radiotherapy and chemotherapy. P2Y12 is considered a chemoreceptor for adenosine diphosphate (ADP). Its expression is documented in some cancer types, such as the C6 lineage of rat glioma, renal carcinoma and colon carcinoma. However, its role in the development of tumour progression and the resistance mechanism in chemotherapy are not well elucidated. Currently, it is well established that normal platelet function is an important factor for the progression of tumors, with thrombocytopenic rats demonstrating a significant reduction of metastases. Clopidogrel bisulfate is a drug, which belongs to the class of antiplatelet agents, being a P2Y12 receptor antagonist whose endogenous ligand is ADP. The aim of the present study was to determine the effects of tumor cells exposed to the treatment with clopidogrel. The C6 rat cell line was sensitive to the drug tested (150 ?M) in the viability and cell counts (69.63 ? 8.70) and (53.05 ? 20.06). Both cell lines showed a significant reduction in the number of colonies after 10 days of treatment with clopidogrel. The U251-MG strain demonstrated a significant increase in the G1 phase and a significant reduction in the S phase in the cell cycle (20.32 ? 3.05) and (19.45 ? 2.35) in the concentration of 500 ?M. Other results demonstrate important antiproliferative activity in both tumor lines, suggesting an important participation of the P2Y12 receptor in this process. / O glioblastoma multiforma (GBM) ? considerado o mais agressivo dos tumores do sistema nervoso central (SNC) e o mais letal entre os tumores prim?rios apresentando baixo progn?stico de sobrevida, resist?ncia ? radioterapia e a quimioterapia. O P2Y12 ? considerado um quimiorreceptor para a adenosina difosfato (ADP). Sua express?o ? documentada em algumas linhagens de c?ncer, como a linhagem C6 de glioma de rato, carcinoma renal e carcinoma de c?lon. Contudo, seu papel no desenvolvimento da sinaliza??o e resposta ? quimioterapia n?o est? bem elucidado. Atualmente, est? bem estabelecido que o funcionamento normal das plaquetas ? um importante fator para a progress?o de tumores, sendo que ratos com trombocitopenia demonstraram uma redu??o significativa de met?stases. O bissulfato de clopidogrel ? um f?rmaco pertencente ? classe dos antiagregantes plaquet?rios, sendo um antagonista do receptor P2Y12, cujo ligante end?geno ? o ADP. O presente trabalho teve como objetivo averiguar quais os efeitos ocasionados ?s c?lulas de gliomas quando expostas ao clopidogrel. Para isto, foram utilizadas duas linhagens de gliomas, U251-MG de glioma humano e C6 de ratos, e o tratamento com clopidogrel (150, 300, e 500 ?M), foi avaliado nos par?metros de viabilidade celular, contagem de c?lulas, RT-PCR e citometria de fluxo. A linhagem de rato C6 mostrou-se sens?vel ao f?rmaco testado (150 ?M) com redu??o da viabilidade e contagem celular (69.63?8,70) e (53,05 ? 20.06), respectivamente. Ambas as linhagens tapresentaram uma redu??o significativa no n?mero de col?nias ap?s 10 dias tratamento com clopidogrel. A linhagem U251-MG demonstrou um aumento significativo na fase G1 e uma redu??o significativa na fase S e do ciclo celular (20,32 ? 3.05) e (19.45? 2.35 ) na concentra??o de 500 ?M, por?m nos ensaios de viabilidade e contagem n?o houve diferen?a significativa. Nossos resultados demonstram atividade antiproliferativa importante em ambas as linhagens tumorais, sugerindo uma participa??o importante do receptor P2Y12 neste processo.

Σκοπός: Τα επιστημονικά δεδομένα για το κλινικό όφελος που μπορεί να έχει η στρατηγική καθυστέρησης της αγγειοπλαστικής των στεφανιαίων αρτηριών μετά τη χορήγηση δόσης φόρτισης κλοπιδογρέλης παραμένουν ασαφή. Συγκρίναμε σε ασθενείς με σταθερή ή ασταθή στηθάγχη, οι οποίοι δεν λάμβαναν προηγουμένως κλοπιδογρέλη, την αγγειοπλαστική που πραγματοποιείται με καθυστέρηση 2 ωρών, μετά τη στεφανιογραφία και τη χορήγηση δόσης φόρτισης κλοπιδογρέλης 900 mg, με την αγγειοπλαστική που πραγματοποιείται αμέσως μετά τον καθετηριασμό και τη λήψη των 900 mg κλοπιδογρέλης. Μέθοδοι: Στα πλαίσια τυχαιοποιημένης προοπτικής μελέτης, 199 ασθενείς υποβλήθηκαν είτε σε άμεση αγγειοπλαστική (ομάδα Α, n=103), είτε σε καθυστερημένη επέμβαση (ομάδα Β ή ομάδα προθεραπείας, n=96). Μετρήθηκαν οι βασικές τιμές, οι τιμές αμέσως πριν την αγγειοπλαστική, στις 6-8 ώρες και στις 24 ώρες μετά την επέμβαση, της καρδιακής τροπονίνης Ι (cTnI) , της κινάσης της κρεατίνης MB (CK-MB) και της μυοσφαιρίνης, οι οποίες είναι δείκτες μυοκαρδιακής νέκρωσης, καθώς και οι τιμές της υψηλής ευαισθησίας C αντιδρώσας πρωτεΐνης (hs-CRP) και της διαλυτής P-σελεκτίνης (sPS), οι οποίες είναι δείκτες φλεγμονώδους αντίδρασης και ενεργοποίησης των αιμοπεταλίων αντίστοιχα. Το σύνθετο κύριο καταληκτικό σημείο της μελέτης ήταν ο συνδυασμός καρδιαγγειακού θανάτου, περιεπεμβατικού εμφράγματος του μυοκαρδίου (ΕΜ), αγγειακού εγκεφαλικού επεισοδίου (ΑΕΕ) και επείγουσας επαναγγείωσης, εντός 30 ημερών από την αγγειοπλαστική. Ως περιεπεμβατικό ΕΜ ορίσθηκε το κλινικώς προφανές έμφραγμα και/ή η τριπλάσια της ανώτερης φυσιολογικής τιμής (ΑΦΤ) τουλάχιστον αύξηση της cTnI. Ως δευτερεύοντα καταληκτικά σημεία θεωρήθηκαν οποιαδήποτε περιεπεμβατική αύξηση της CK-MB μεγαλύτερη του τριπλασίου της ΑΦΤ, οποιαδήποτε περιεπεμβατική αύξηση των δεικτών μυοκαρδιακής νέκρωσης μεγαλύτερη της ΑΦΤ, η μη βέλτιστη ροή στο αγγείο μετά την επέμβαση (ροή κατά TIMI <3), οποιαδήποτε μείζων αιμορραγία κατά ΤΙΜΙ, η θρομβοκυττοπενία με αριθμό αιμοπεταλίων <70.000/ml και οποιαδήποτε αύξηση της hs-CRP και της sPS. Αποτελέσματα : Το σύνθετο κύριο καταληκτικό σημείο συνέβη στο 12,6% της ομάδας άμεσης αγγειοπλαστικής έναντι του 15,6% των ασθενών της ομάδας της προθεραπείας (p=0,34). Δύο ασθενείς της ομάδας Α απεβίωσαν εντός 24ώρου από την επέμβαση, ενώ ουδείς απεβίωσε στην ομάδα της καθυστερημένης αγγειοπλαστικής (p=0,49). Το συχνότερο μεμονωμένο κύριο καταληκτικό σημείο ήταν το περιεπεμβατικό έμφραγμα (12,6% έναντι 14,6%, p=0,42). ΑΕΕ συνέβη σε έναν ασθενή της ομάδας της προθεραπείας και σε κανέναν της ομάδας της άμεσης αγγειοπλαστικής. Επείγουσα επαναγγείωση χρειάσθηκε ένας ασθενής της ομάδας Β και κανείς της ομάδας Α . Η hs-CRP αυξήθηκε μετά την αγγειοπλαστική και στις δύο ομάδες (p<0,0001), χωρίς να υπάρχει διαφορά στις τιμές της μεταξύ των δύο ομάδων (p=0,5). Οι αρχικές τιμές της sPS δεν διέφεραν μεταξύ των δύο ομάδων (p=0,5), και επίσης δεν υπήρχε μεταβολή στις τιμές της sPS μετά την αγγειοπλαστική. Μείζων αιμορραγία καταγράφηκε στο 2,9% των ασθενών της ομάδας της άμεσης αγγειοπλαστικής και στο 3,1% των ασθενών της ομάδας της προθεραπείας (p=0,9). Kαμία στατιστικά σημαντική διαφορά δεν υπήρξε επίσης στα υπόλοιπα δευτερεύοντα καταληκτικά σημεία μεταξύ των δύο ομάδων. Συμπέρασμα: Σε ασθενείς με σταθερή ή ασταθή στηθάγχη, οι οποίοι δεν λάμβαναν προηγουμένως κλοπιδογρέλη και υποβλήθηκαν σε αγγειοπλαστική των στεφανιαίων αρτηριών, η στρατηγική καθυστέρησης της αγγειοπλαστικής για 2 ώρες μετά τη χορήγηση υψηλής δόσης φόρτισης κλοπιδογρέλης 900 mg, δεν φαίνεται να προσφέρει επιπλέον κλινικό όφελος, συγκριτικά με την άμεση αγγειοπλαστική. / Aim: Εvidence that the strategy of delaying percutaneous coronary intervention (PCI) after clopidogrel loading is beneficial remains inconclusive. We compared the delayed for 2 hours PCI with the ad-hoc PCI, after loading with 900 mg of clopidogrel, in clopidogrel-naive patients with stable or unstable angina who had already underwent coronary angiography and were subjected to PCI. Methods: In a prospective randomized study 199 patients underwent either ad-hoc PCI (group A, n=103) or delayed PCI ( pretreatment group, group B, n=96). Cardiac troponin I (cTnI), creatine kinase-MB (CK-MB), myoglobin which are biomarkers of myocardial injury, high sensitivity C-reactive protein (hs-CRP), a marker of inflammatory status and soluble P-selectin (sPS), a marker of platelets activation were measured baseline, just before PCI, 6-8 hours after PCI and 24 hours later. Combined primary end point was the composite of cardiovascular death, periprocedural myocardial infarction (MI), stroke and urgent revascularization within 30 days after PCI. Periprocedural MI was defined as any clinical apparent MI and/or the increase of cTnI >3 times above the upper limit of normal (ULN). Secondary endpoints were considered any periprocedural increase of CK-MB above x3 ULN, any periprocedural increase of myocardial injury biomarkers above ULN, TIMI flow <3 after PCI, any major bleeding (TIMI criteria), thrombocytopenia with platelet count <70,000/mL and any elevation of hs-CRP and sPS. Results: The combined primary end point occurred in 12.6% of ad-hoc PCI group versus 15.6% of pretreatment group patients (p=0.34). There were 2 deaths in group A, which occurred within 24 hours post-PCI and no death in the delayed PCI group (p=0.49). Among the components of the combined primary end point, periprocedural MI was the most frequently encountered event (12.6% versus 14.6%, p=0.42). Stroke occurred in one patient of the pretreatment group, and in no patient of the ad-hoc PCI group. Urgent revascularization was performed in one patient of group B and in no patient of group A. High sensitivity CRP increased in both groups after PCI (p<0.0001) without difference between groups (p=0.5). Baseline sPS levels did not differ between the 2 groups (p=0.5) and there was no significant change of sPS over time. Major bleeding occurred in 2.9% ad-hoc PCI group versus 3.1% pretreatment group patients (p=0.9). There was also no difference in any other secondary end point between the two groups. Conclusion: In clopidogrel-naive patients with stable or unstable angina, a strategy of delaying PCI for 2 hours after high-dose clopidogrel loading of 900 mg does not seem to confer any benefit compared to ad-hoc PCI.

Orientador: Antônio José Maria Cataneo / Resumo: Introdução: O risco de sangramento em cirurgias realizadas na vigência de antitrombóticos preocupa o cirurgião, em contrapartida, a suspensão do agente antitrombótico aumenta o risco de trombose. Esse dilema levou a realização desta revisão. Objetivo: avaliar, por meio de revisão sistemática e metanálise, se há ou não necessidade de suspender medicamentos antitrombóticos orais (varfarina, fluindiona, acenocumarol, AAS e clopidogrel) para a realização de procedimentos eletivos de cirurgia do punho e da mão. Métodos: revisão sistemática de estudos experimentais ou observacionais que tenham avaliado cirurgias de mão e punho na vigência do agente antitrombótico. Foram pesquisadas as bases de dados LILACS, Pubmed, Embase, Cochrane e Scopus, sendo selecionados series com cinco ou mais cirurgias . Os desfechos avaliados foram: complicações graves (necessidade de tratamento cirúrgico) e leves (sem necessidade de tratamento cirúrgico). Resultados : foram selecionados 10 estudos observacionais para análise qualitativa envolvendo 2971 cirurgias. Seis desses estudos foram selecionados para análise quantitativa, envolvendo 319 cirurgias do punho e da mão realizadas na vigência de varfarina, fluindiona, acenocumarol, AAS e clopidogrel e 629 cirurgias realizadas em pacientes sem uso dos antitrombóticos. O risco de complicações leves foi maior nos pacientes que estavam recebendo antitrombóticos ( RR 1,55, IC 95% 1,02 a 2,35; I 2 = 23%, 948 cirurgias), e o risco de complicações graves foi sem... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction : The risks of bleeding in surgeries performed during the antithrombotic period are of concern to the surgeon, and on the other hand, the suspension of the antithrombotic agent increases the risk of thrombosis. This dilemma led to this review. Objective: to evaluate, through a systematic review, whether or not there is a need to suspend antithrombotic drugs (warfarin, fluindione, acenocumarol, ASA and clopidogrel) to perform elective procedures for wrist and hand surgery. Methods: systematic review of experimental or observational studies that have evaluated hand and wrist surgeries during the antithrombotic agent. The databases LILACS, Pubmed, Embase, Cochrane and Scopus were searched, being selected series with five or more surgeries. The outcomes evaluated were: severe complications (need for surgical treatment) and mild complications (no need for surgical treatment). Results: 10 observational studies were selected for qualitative analysis involving 2971 surgeries. Six of these studies were selected for quantitative analysis, involving 319 wrist and hand surgeries performed during warfarin, fluindione, acenocumarol, ASA and clopidogrel and 629 surgeries performed in patients without antithrombotic drugs. The risk of mild complications was greater in patients receiving antithrombotic drugs (RR 1.55, 95% CI 1.02 to 2.35, I 2 = 23%, 948 surgeries), and the risk of severe complications was similar in both groups (RR 1.83, 95% CI 0.32 to 10.29, I 2 = 0%, 948 surger... (Complete abstract click electronic access below) / Mestre

Submitted by FRANCISCO SIMOES DEIENNO (frandeienno@hotmail.com) on 2018-08-14T12:57:37Z No. of bitstreams: 1 Tese Final para Repositorio.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) / Approved for entry into archive by Sulamita Selma C Colnago null (sulamita@btu.unesp.br) on 2018-08-14T17:14:35Z (GMT) No. of bitstreams: 1 deienno_fs_me_bot.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) / Made available in DSpace on 2018-08-14T17:14:35Z (GMT). No. of bitstreams: 1 deienno_fs_me_bot.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) Previous issue date: 2018-07-19 / Introdução: O risco de sangramento em cirurgias realizadas na vigência de antitrombóticos preocupa o cirurgião, em contrapartida, a suspensão do agente antitrombótico aumenta o risco de trombose. Esse dilema levou a realização desta revisão. Objetivo: avaliar, por meio de revisão sistemática e metanálise, se há ou não necessidade de suspender medicamentos antitrombóticos orais (varfarina, fluindiona, acenocumarol, AAS e clopidogrel) para a realização de procedimentos eletivos de cirurgia do punho e da mão. Métodos: revisão sistemática de estudos experimentais ou observacionais que tenham avaliado cirurgias de mão e punho na vigência do agente antitrombótico. Foram pesquisadas as bases de dados LILACS, Pubmed, Embase, Cochrane e Scopus, sendo selecionados series com cinco ou mais cirurgias . Os desfechos avaliados foram: complicações graves (necessidade de tratamento cirúrgico) e leves (sem necessidade de tratamento cirúrgico). Resultados : foram selecionados 10 estudos observacionais para análise qualitativa envolvendo 2971 cirurgias. Seis desses estudos foram selecionados para análise quantitativa, envolvendo 319 cirurgias do punho e da mão realizadas na vigência de varfarina, fluindiona, acenocumarol, AAS e clopidogrel e 629 cirurgias realizadas em pacientes sem uso dos antitrombóticos. O risco de complicações leves foi maior nos pacientes que estavam recebendo antitrombóticos ( RR 1,55, IC 95% 1,02 a 2,35; I 2 = 23%, 948 cirurgias), e o risco de complicações graves foi semelhante nos dois grupos (RR 1,83, IC 95% 0,32 a 10,29; I 2 = 0%, 948 cirurgias). Conclusões: Pacientes em uso de anticoagulantes orais ou antiplaquetários orais tem um risco maior de desenvolver complicações leves, isto é aquelas que não necessitam de reintervenção cirúrgica , quando submetidos a cirurgias do punho e da mão na vigência de tratamento antitrombótico. / Introduction : The risks of bleeding in surgeries performed during the antithrombotic period are of concern to the surgeon, and on the other hand, the suspension of the antithrombotic agent increases the risk of thrombosis. This dilemma led to this review. Objective: to evaluate, through a systematic review, whether or not there is a need to suspend antithrombotic drugs (warfarin, fluindione, acenocumarol, ASA and clopidogrel) to perform elective procedures for wrist and hand surgery. Methods: systematic review of experimental or observational studies that have evaluated hand and wrist surgeries during the antithrombotic agent. The databases LILACS, Pubmed, Embase, Cochrane and Scopus were searched, being selected series with five or more surgeries. The outcomes evaluated were: severe complications (need for surgical treatment) and mild complications (no need for surgical treatment). Results: 10 observational studies were selected for qualitative analysis involving 2971 surgeries. Six of these studies were selected for quantitative analysis, involving 319 wrist and hand surgeries performed during warfarin, fluindione, acenocumarol, ASA and clopidogrel and 629 surgeries performed in patients without antithrombotic drugs. The risk of mild complications was greater in patients receiving antithrombotic drugs (RR 1.55, 95% CI 1.02 to 2.35, I 2 = 23%, 948 surgeries), and the risk of severe complications was similar in both groups (RR 1.83, 95% CI 0.32 to 10.29, I 2 = 0%, 948 surgeries). Conclusions: Patients taking oral anticoagulants or oral antiplatelet agents may be at increased risk of developing mild complications , that is, those that do not require surgical reintervention, when undergoing hand and wrist surgeries during antithrombotic treatment

Abstract Metabolism is a major determinant of the pharmacokinetic properties of most drugs and is often behind bioavailability problems, drug-drug interactions, and metabolic idiosyncrasies. Cytochrome P450 (CYP) enzymes are a superfamily of microsomal hemoproteins catalysing the metabolic reactions of several exogenous compounds. The majority of crucial steps within drug metabolism are in connection with CYP enzymes. In the present study, in vivo, in vitro, and in silico approaches were applied and characterised to evaluate the effects of chemical entities on CYP-mediated metabolism. CYP2B6 was used as a target enzyme for these studies. For evaluation of the CYP inhibition potential of new chemical entities, a novel in vitro test system utilising the n-in-one approach was developed. This method proved to be robust and applicable to screening purposes. Validation of the n-in-one assay was done by comparing its performance to commonly used in vitro techniques using six structurally diverse drugs. All assay types yield remarkably similar results with the majority of the CYP forms tested. Several chemicals were screened in vitro and in silico in order to find potent and selective chemical inhibitors for CYP2B6. Ticlopidine, thioTEPA and 4-(4-chlorobenzylpyridine) were found to be highly effective inhibitors of CYP2B6. The selectivity of thioTEPA proved to be very high, whereas ticlopidine and 4-(4-chlorobenzylpyridine) also inhibited other CYPs. At a concentration level of 1 μM for ticlopidine and 0.1 μM for 4-(4-chlorobenzylpyridine), the inhibitory effect towards other CYPs was negligible. Due to wide clinical use and relevance, clopidogrel and ticlopidine were selected for further in vivo interaction studies. Both clopidogrel and ticlopidine significantly inhibited the CYP2B6-catalysed bupropion hydroxylation and patients receiving either clopidogrel or ticlopidine are likely to need dose adjustments when treated with drugs primarily metabolised by CYP2B6. The effect of impaired kidney function on CYP2B6 activity and on bupropion pharmacokinetics was also explored. In patients with kidney disease, the bupropion AUC and Cmax were significantly higher and the apparent oral clearance of bupropion was notably lower compared to healthy controls. The present results indicate that the in silico and in vitro methods used are helpful in predicting in vivo drug-drug interactions. The effective utilisation of these models in the early phases of drug discovery could therefore help to target the in vivo studies and to eliminate metabolically unfavourable drug candidates.