DCB

Q: 58-year-old male with a severe history of bleeding peptic ulcer is admitted to the coronary ICU with acute coronary syndrome. The patient is stabilized with standard anti-anginal treatment. Cardiology is considering Drug-coated balloon angioplasty (DCB) instead of a drug-eluting stent due to his known history. Which drugs are used in DCB?

Answer: Paclitaxel with either iopromode or urea

DCB is getting increasing popularity instead of DES in patients with in-stent restenosis, de novo lesions in small coronary arteries, and in patients with high risk of bleeding after stenting due to dual antiplatelet therapy (DAPT). The other drugs that have been combined with Paclitaxel are either iopromide or urea.

Paclitaxel is a cytostatic agent that binds to tubulin inside cells, blocking normal cell division and chromosome separation. Iopromide is added as a carrier to transfer and release the paclitaxel into the arterial wall. Paclitaxel is lipophilic and may not dissolve or may stick to the balloon surface on its own. Iopromide, a water-soluble, low-osmolality contrast medium, helps paclitaxel rapidly absorb into the intima within seconds, inhibiting smooth muscle cell proliferation and preventing restenosis. Iopromide dissolves safely in blood and is well tolerated by vascular tissue without causing inflammation.

Few studies have used Urea instead of iopromide, as urea acts as a spacer that prevents paclitaxel molecules from clumping together, with a more even, reproducible, and uniform transfer and absorption of the drug into the targeted vascular tissue within 30 to 60 seconds of balloon inflation.

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References:

1. Gitto M, Tartaglia F, Leone PP, Calamita G, Gabrielli A, Gramss L, Rossi ML, Regazzoli D, Gasparini G, Cozzi O, Reimers B, Stefanini GG, Mangieri A, Latib A, Colombo A. Paclitaxel-coated balloon with urea or iopromide as the excipient for treatment of coronary artery disease. Clin Res Cardiol. 2026 Jan;115(1):89-98. doi: 10.1007/s00392-025-02758-6. Epub 2025 Oct 27. PMID: 41143901.

2. von Koch S, Frank E, Gabrysch K, James S, Götberg M, Mohammad MA, Erlinge D. Real-World Usage of a Paclitaxel-Coated Balloon With Urea Compared With Other Contemporary Drug-Coated Balloons: A 2-Year Analysis From SCAAR in Over 6000 Patients. J Am Heart Assoc. 2026 Jun 2;15(11):e045621. doi: 10.1161/JAHA.125.045621. Epub 2026 May 29. PMID: 42216271; PMCID: PMC13315143.

3. Rissanen TT, Uskela S, Eränen J, et al. Drug-coated balloon for treatment of de-novo coronary artery lesions in patients with high bleeding risk (DEBUT): a single-blind, randomised, non-inferiority trial. Lancet 2019; 394:230.

4. Jeger RV, Farah A, Ohlow MA, et al. Long-term efficacy and safety of drug-coated balloons versus drug-eluting stents for small coronary artery disease (BASKET-SMALL 2): 3-year follow-up of a randomised, non-inferiority trial. Lancet 2020; 396:1504.