氯吡格雷药物基因组学及个体化治疗研究进展与展望

Clopidogrel pharmacogenomics and individualized therapy: evidence and perspectives

摘要:

通过与阿司匹林联合应用，氯吡格雷已经成为治疗急性冠脉综合征和预防经皮冠状动脉介入术后支架内血栓形成和再发缺血事件的经典口服抗血小板药物。尽管如此，氯吡格雷抗血小板的反应性和疗效存在显著的个体间差异。近年来的研究证实，除临床环境因素外，遗传变异是导致氯吡格雷抗血小板反应性个体间差异的重要因素之一。多项大规模临床药物基因组学研究发现，参与氯吡格雷代谢的关键酶——CYP2C19功能缺失型等位基因与氯吡格雷治疗期间高血小板反应性及心血管一级缺血终点事件的发生密切相关。另外，与氯吡格雷代谢相关的其他基因变异型也被证实可能与氯吡格雷抗血小板反应性及不良心血管事件相关。在此基础上，利用药物基因组学基因型检测指导氯吡格雷个体化抗血小板治疗，可能部分克服氯吡格雷治疗期间的高血小板反应性，但研究结果之间仍存在争议，尚需深入研究以提供更有力的证据。除此之外，未来有必要进一步深入研究基因型检测联合血小板功能监测共同指导氯吡格雷抗血小板个体化治疗的效果。

Abstract:

Dual antiplatelet therapy with aspirin and clopidogrel is the standard care to prevent stent thrombosis and recurrent ischemic events after acute coronary syndrome or stent placement. However, there is a large inter-individual variability in biological anti-platelet responsiveness and clinical outcomes in patients after clopidogrel treatment. Apart from clinical and environmental factors, recently accumulated evidence strongly confirms the pivotal role of genetic factors for the variability of clopidogrel responsiveness. Several large-scale pharmacogenomic studies found that the loss-of-function alleles of CYP2C19 and the key enzyme in clopidogrel metabolism are the predominant genetic mediators of low clopidogrel responsiveness and recurrent cardiovascular events. Other genetic polymorphisms related with clopidogrel metabolism may also contribute to the variability of clopidogrel efficacy. On the basis of these observations, it is still in controversy whether CYP2C19-genotype-guided individualized clopidogrel therapy could overcome the high on-treatment platelet reactivity to clopidogrel. In the future, it is necessary to combine genotyping and platelet function testing to guide the individualized clopidogrel therapy.