title: Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative.
abstract: BACKGROUND
  Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS); their safe use in women, however, remains a concern. The contribution of dosing to the observed sex-related differences in bleeding is unknown.
  
  
  RESULTS
  We explored the relationship between patient sex, GP IIb/IIIa inhibitor use, dose, and bleeding in 32 601 patients with NSTE ACS across 400 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) hospitals, of whom 18 436 were treated. GP IIb/IIIa inhibitor dose was defined as excessive if not reduced when creatinine clearance was < 50 mL/min for eptifibatide or < 30 mL/min for tirofiban. Major bleeding was defined as a hematocrit drop > or = 0.12, need for transfusion, or intracranial bleeding. Major bleeding was adjusted for clinical factors and antithrombotic dose. The risk for bleeding attributable to excess GP IIb/IIIa dose was determined by sex using prevalence and adjusted odds ratios (ORs). Women had higher rates of major bleeding than men among those treated with GP IIb/IIIa inhibitors (15.7% versus 7.3%, P<0.0001) and among those not treated (8.5% versus 5.4%, P<0.0001). Despite similar serum creatinine levels, creatinine clearance averaged 20 points lower among treated women than men. Treated women were also more likely to receive excess GP IIb/IIIa doses than men (46.4% versus 17.2%, P<0.0001; adjusted OR 3.81, 95% confidence interval [CI] 3.39 to 4.27). Excess dosing was associated with increased risk of bleeding in women (OR 1.72, 95% CI 1.30 to 2.28) and men (OR 1.27, 95% CI 0.97 to 1.66); however, bleeding risk attributable to dosing was much higher in women (25.0% versus 4.4%).
  
  
  CONCLUSIONS
  Women experience more bleeding than men whether or not they are treated with GP IIb/IIIa inhibitors; however, because of frequent excessive dosing in women, up to one fourth of this sex-related risk difference in bleeding is avoidable. Appropriate dosing will improve care of all patients with NSTE ACS, with a particular benefit for women.
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA. karen.alexander@duke.edu
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
authors.forename: Anita Y
authors.initials: AY
authors.lastname: Chen
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: Janice B
authors.initials: JB
authors.lastname: Schwartz
authors.forename: Rita F
authors.initials: RF
authors.lastname: Redberg
authors.forename: Judith S
authors.initials: JS
authors.lastname: Hochman
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: W Brian
authors.initials: WB
authors.lastname: Gibler
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
mesh_terms: D000208:Acute Disease; D000328:Adult; D000789:Angina, Unstable / Q000150:complications / Q000188:drug therapy; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002543:Cerebral Hemorrhage / Q000139:chemically induced; D003404:Creatinine / Q000097:blood; D004198:Disease Susceptibility; D004305:Dose-Response Relationship, Drug; D000077542:Eptifibatide; D005919:Glomerular Filtration Rate; D006470:Hemorrhage / Q000139:chemically induced* / Q000209:etiology / Q000628:therapy; D006474:Hemorrhagic Disorders / Q000150:complications / Q000453:epidemiology; D006801:Humans; D007674:Kidney Diseases / Q000150:complications / Q000178:diet therapy / Q000503:physiopathology; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy; D010455:Peptides / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects* / Q000493:pharmacokinetics / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D017410:Practice Guidelines as Topic; D012042:Registries; D012727:Sex Characteristics; D000077466:Tirofiban; D014443:Tyrosine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000493:pharmacokinetics / Q000627:therapeutic use
chemical_list: D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D003404:Creatinine; D000077466:Tirofiban; D000077542:Eptifibatide