101
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Fawzy AM, Lip GYH. Pharmacokinetics and pharmacodynamics of oral anticoagulants used in atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:381-398. [PMID: 30951640 DOI: 10.1080/17425255.2019.1604686] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The availability of non-vitamin K antagonist oral anti-coagulants alongside vitamin K antagonists has offered a variety of options for anti-coagulation, but has also necessitated a good understanding of the pharmacological properties of each of these drugs prior to their use, to maximise the therapeutic benefit and minimise patient harm Areas covered: This review article outlines the pharmacokinetic and pharmacodynamic profiles of the currently licensed VKAs and NOACs that are most commonly used in clinical practice, with the aim of demonstrating how variations in these characteristics influence their use in clinical practice. A literature search was conducted on PubMed using keywords and relevant articles published by the 31st of December 2018 were included. Expert opinion: The effect of a drug is determined by a combination of elements which include patient characteristics and external factors, in addition to its pharmacokinetic and pharmacodynamic properties. A good understanding of these is essential. Despite the wealth of information available, particularly on VKAs, our knowledge on the pharmacology responsible for certain drug effects and inter-individual variations is still limited. Increasing efforts are being made to understand these and include focus on pharmacogenomics and drug transporter proteins.
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Affiliation(s)
| | - Gregory Y H Lip
- b Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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102
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Al-Mahayri ZN, Al Jaibeji HS, Saab Y, Soliman K, Al-Gazali L, Patrinos GP, Ali BR. VKORC1 variants as significant predictors of warfarin dose in Emiratis. Pharmgenomics Pers Med 2019; 12:47-57. [PMID: 31114289 PMCID: PMC6489578 DOI: 10.2147/pgpm.s187350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/22/2018] [Indexed: 02/05/2023] Open
Abstract
Purpose: Variability in response to warfarin is one of the main obstacles challenging its use in clinical practice. Vitamin K epoxide reductase complex (VKORC) is the target enzyme of warfarin, and variations in the form of single nucleotide polymorphisms (SNPs) in VKORC1, coding for this enzyme, are known to cause resistance to warfarin treatment. This study aimed to explore VKORC1 variants in Emirati patients receiving warfarin treatment and to correlate their genotypes at the studied SNPs to their maintenance warfarin dose. Patients and methods: Sanger sequencing of the majority of the VKORC1 gene was applied to samples from 90 patients and 117 normal individuals recruited from Tawam Hospital, Al-Ain, UAE. Genotypes at the following variants were determined (rs9923231, rs188009042, rs61742245, rs17708472, rs9934438, rs8050894, rs2359612, rs7294). Statistical analysis was applied, including ANOVA, cross-tabulation, and multiple linear regression analysis, to determine the ability of nongenetic factors (age and gender) and genetic factors (VKORC1 genotypes) to explain variability in warfarin dose in patients. Results: Different frequencies of minor alleles were detected in the selected SNPs. Significant variation among genotypes at six VKORC1 variants were identified (rs9923231, rs9934438, rs8050894, rs2359612, rs7294). The main predictors for warfarin dose were rs9923231, age, and rs61742245 with 50.7% of the average warfarin dose in our sample could be explained by a regression model built on these three factors. Conclusion: This is the first report of the explanatory power of VKORC1 genotypes and nongenetic factors (age and gender) on warfarin dose among Emiratis. Also, this study highlighted the positive effect of considering rare pharmacogenomic variants on explaining warfarin dose variability.
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Affiliation(s)
- Zeina N Al-Mahayri
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Hayat S Al Jaibeji
- Sharjah Institute for Medical Research, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Yolande Saab
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Karem Soliman
- INR Clinic, Tawam Hospital, Al-Ain, United Arab Emirates
| | - Lihadh Al-Gazali
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - George P Patrinos
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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103
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Jorgensen AL, Prince C, Fitzgerald G, Hanson A, Downing J, Reynolds J, Zhang JE, Alfirevic A, Pirmohamed M. Implementation of genotype-guided dosing of warfarin with point-of-care genetic testing in three UK clinics: a matched cohort study. BMC Med 2019; 17:76. [PMID: 30961588 PMCID: PMC6454722 DOI: 10.1186/s12916-019-1308-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/15/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Warfarin is a widely used oral anticoagulant. Determining the correct dose required to maintain the international normalised ratio (INR) within a therapeutic range can be challenging. In a previous trial, we showed that a dosing algorithm incorporating point-of-care genotyping information ('POCT-GGD' approach) led to improved anticoagulation control. To determine whether this approach could translate into clinical practice, we undertook an implementation project using a matched cohort design. METHODS At three clinics (implementation group; n = 119), initial doses were calculated using the POCT-GGD approach; at another three matched clinics (control group; n = 93), patients were dosed according to the clinic's routine practice. We also utilised data on 640 patients obtained from routinely collected data at comparable clinics. Primary outcome was percentage time in target INR range. Patients and staff from the implementation group also provided questionnaire feedback on POCT-GGD. RESULTS Mean percentage time in INR target range was 55.25% in the control group and 62.74% in the implementation group; therefore, 7.49% (95% CI 3.41-11.57%) higher in the implementation group (p = 0.0004). Overall, patients and staff viewed POCT-GGD positively, suggesting minor adjustments to allow smooth implementation into practice. CONCLUSIONS In the first demonstration of the implementation of genotype-guided dosing, we show that warfarin dosing determined using an algorithm incorporating genetic and clinical factors can be implemented smoothly into clinic, to ensure target INR range is reached sooner and maintained. The findings are like our previous randomised controlled trial, providing an alternative method for improving the risk-benefit of warfarin use in daily practice.
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Affiliation(s)
- Andrea L Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK.
| | - Clare Prince
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Gail Fitzgerald
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anita Hanson
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jennifer Downing
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK.,NIHR Collaboration for Leadership in Applied Health Research and Care, North West Coast, UK
| | - Julia Reynolds
- Innovation Agency, Academic Health Science Network for the North West Coast, Daresbury, Warrington, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK
| | - Ana Alfirevic
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals NHS Trust, members of Liverpool Health Partners, Liverpool, UK
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104
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Choi J, Tantisira KG, Duan QL. Whole genome sequencing identifies high-impact variants in well-known pharmacogenomic genes. THE PHARMACOGENOMICS JOURNAL 2019; 19:127-135. [PMID: 30214008 PMCID: PMC6417988 DOI: 10.1038/s41397-018-0048-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/10/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
Abstract
More than 1100 genetic loci have been correlated with drug response outcomes but disproportionately few have been translated into clinical practice. One explanation for the low rate of clinical implementation is that the majority of associated variants may be in linkage disequilibrium (LD) with the causal variants, which are often elusive. This study aims to identify and characterize likely causal variants within well-established pharmacogenomic genes using next-generation sequencing data from the 1000 Genomes Project. We identified 69,319 genetic variations within 160 pharmacogenomic genes, of which 8207 variants are in strong LD (r2>0.8) with known pharmacogenomic variants. Of the latter, eight are coding or structural variants predicted to have high impact, with 19 additional missense variants that are predicted to have moderate impact. In conclusion, we identified putatively functional variants within known pharmacogenomics loci that could account for the association signals and represent the missing causative variants underlying drug response phenotypes.
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Affiliation(s)
- Jihoon Choi
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
- School of Computing, Queen's University, Kingston, ON, Canada
| | - Kelan G Tantisira
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Qing Ling Duan
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.
- School of Computing, Queen's University, Kingston, ON, Canada.
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105
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Dávila-Fajardo CL, Díaz-Villamarín X, Antúnez-Rodríguez A, Fernández-Gómez AE, García-Navas P, Martínez-González LJ, Dávila-Fajardo JA, Barrera JC. Pharmacogenetics in the Treatment of Cardiovascular Diseases and Its Current Progress Regarding Implementation in the Clinical Routine. Genes (Basel) 2019; 10:genes10040261. [PMID: 30939847 PMCID: PMC6523655 DOI: 10.3390/genes10040261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
There is a special interest in the implementation of pharmacogenetics in clinical practice, although there are some barriers that are preventing this integration. A large part of these pharmacogenetic tests are focused on drugs used in oncology and psychiatry fields and for antiviral drugs. However, the scientific evidence is also high for other drugs used in other medical areas, for example, in cardiology. In this article, we discuss the evidence and guidelines currently available on pharmacogenetics for clopidogrel, warfarin, acenocoumarol, and simvastatin and its implementation in daily clinical practice.
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Affiliation(s)
- Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Alba Antúnez-Rodríguez
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | - Ana Estefanía Fernández-Gómez
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Paloma García-Navas
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Luis Javier Martínez-González
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
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106
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Nagar SD, Moreno AM, Norris ET, Rishishwar L, Conley AB, O'Neal KL, Vélez-Gómez S, Montes-Rodríguez C, Jaraba-Álvarez WV, Torres I, Medina-Rivas MA, Valderrama-Aguirre A, Jordan IK, Gallo JE. Population Pharmacogenomics for Precision Public Health in Colombia. Front Genet 2019; 10:241. [PMID: 30967898 PMCID: PMC6439339 DOI: 10.3389/fgene.2019.00241] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
While genomic approaches to precision medicine hold great promise, they remain prohibitively expensive for developing countries. The precision public health paradigm, whereby healthcare decisions are made at the level of populations as opposed to individuals, provides one way for the genomics revolution to directly impact health outcomes in the developing world. Genomic approaches to precision public health require a deep understanding of local population genomics, which is still missing for many developing countries. We are investigating the population genomics of genetic variants that mediate drug response in an effort to inform healthcare decisions in Colombia. Our work focuses on two neighboring populations with distinct ancestry profiles: Antioquia and Chocó. Antioquia has primarily European genetic ancestry followed by Native American and African components, whereas Chocó shows mainly African ancestry with lower levels of Native American and European admixture. We performed a survey of the global distribution of pharmacogenomic variants followed by a more focused study of pharmacogenomic allele frequency differences between the two Colombian populations. Worldwide, we found pharmacogenomic variants to have both unusually high minor allele frequencies and high levels of population differentiation. A number of these pharmacogenomic variants also show anomalous effect allele frequencies within and between the two Colombian populations, and these differences were found to be associated with their distinct genetic ancestry profiles. For example, the C allele of the single nucleotide polymorphism (SNP) rs4149056 [Solute Carrier Organic Anion Transporter Family Member 1B1 (SLCO1B1)∗5], which is associated with an increased risk of toxicity to a commonly prescribed statin, is found at relatively high frequency in Antioquia and is associated with European ancestry. In addition to pharmacogenomic alleles related to increased toxicity risk, we also have evidence that alleles related to dosage and metabolism have large frequency differences between the two populations, which are associated with their specific ancestries. Using these findings, we have developed and validated an inexpensive allele-specific PCR assay to test for the presence of such population-enriched pharmacogenomic SNPs in Colombia. These results serve as an example of how population-centered approaches to pharmacogenomics can help to realize the promise of precision medicine in resource-limited settings.
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Affiliation(s)
- Shashwat Deepali Nagar
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, United States.,IHRC-Georgia Tech Applied Bioinformatics Laboratory, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia
| | | | - Emily T Norris
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, United States.,IHRC-Georgia Tech Applied Bioinformatics Laboratory, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia
| | - Lavanya Rishishwar
- IHRC-Georgia Tech Applied Bioinformatics Laboratory, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia
| | - Andrew B Conley
- IHRC-Georgia Tech Applied Bioinformatics Laboratory, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia
| | - Kelly L O'Neal
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, United States
| | | | | | | | | | - Miguel A Medina-Rivas
- PanAmerican Bioinformatics Institute, Cali, Colombia.,Centro de Investigación en Biodiversidad y Hábitat, Universidad Tecnológica del Chocó, Quibdó, Colombia
| | - Augusto Valderrama-Aguirre
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia.,Biomedical Research Institute, Cali, Colombia
| | - I King Jordan
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, United States.,IHRC-Georgia Tech Applied Bioinformatics Laboratory, Atlanta, GA, United States.,PanAmerican Bioinformatics Institute, Cali, Colombia
| | - Juan Esteban Gallo
- PanAmerican Bioinformatics Institute, Cali, Colombia.,GenomaCES, Universidad CES, Medellín, Colombia
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107
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Li X, Li D, Wu JC, Liu ZQ, Zhou HH, Yin JY. Precision dosing of warfarin: open questions and strategies. THE PHARMACOGENOMICS JOURNAL 2019; 19:219-229. [PMID: 30745565 DOI: 10.1038/s41397-019-0083-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/17/2018] [Accepted: 12/21/2018] [Indexed: 12/30/2022]
Abstract
Warfarin has a very narrow therapeutic window and obvious interindividual variability in its effects, with many factors contributing to the body's response. Algorithms incorporating multiple genetic, environment and clinical factors have been established to select a precision dose for each patient. A number of randomized controlled trials (RCTs) were conducted to explore whether patients could benefit from these algorithms; however, the results were inconsistent. Some questions remain to be resolved. Recently, new genetic and non-genetic factors have been discovered to contribute to variability in optimal warfarin doses. The results of further RCTs have been unveiled, and guidelines for pharmacogenetically guided warfarin dosing have been updated. Based on these most recent advancements, we summarize some open questions in this field and try to propose possible strategies to resolve them.
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Affiliation(s)
- Xi Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Dan Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Chu Wu
- Department of Cardiovascular, Central Hospital of Shaoyang, Shaoyang, 422000, P. R. China
| | - Zhao-Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Ye Yin
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China. .,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China. .,Hunan Provincial Gynecological Cancer Diagnosis and Treatment Engineering Research Center, Changsha, 410078, P. R. China.
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108
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Schwarz UI, Gulilat M, Kim RB. The Role of Next-Generation Sequencing in Pharmacogenetics and Pharmacogenomics. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a033027. [PMID: 29844222 DOI: 10.1101/cshperspect.a033027] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Inherited genetic variations in pharmacogenetic loci are widely acknowledged as important determinants of phenotypic differences in drug response, and may be actionable in the clinic. However, recent studies suggest that a considerable number of novel rare variants in pharmacogenes likely contribute to a still unexplained fraction of the observed interindividual variability. Next-generation sequencing (NGS) represents a rapid, relatively inexpensive, large-scale DNA sequencing technology with potential relevance as a comprehensive pharmacogenetic genotyping platform to identify genetic variation related to drug therapy. However, many obstacles remain before the clinical use of NGS-based test results, including technical challenges, functional interpretation, and strict requirements for diagnostic tests. Advanced computational analyses, high-throughput screening methodologies, and generation of shared resources with cell-based and clinical information will facilitate the integration of NGS data into candidate genotyping approaches, likely enhancing future drug phenotype predictions in patients.
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Affiliation(s)
- Ute I Schwarz
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario N6A 5A5, Canada.,Department of Physiology and Pharmacology, Western University, London, Ontario N6A 5A5, Canada
| | - Markus Gulilat
- Department of Physiology and Pharmacology, Western University, London, Ontario N6A 5A5, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario N6A 5A5, Canada.,Department of Physiology and Pharmacology, Western University, London, Ontario N6A 5A5, Canada
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109
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Dong J, Shi GH, Lu M, Huang S, Liu YH, Yao JC, Li WY, Li LX. Evaluation of the predictive performance of Bayesian dosing for warfarin in Chinese patients. Pharmacogenomics 2019; 20:167-177. [PMID: 30777785 DOI: 10.2217/pgs-2018-0127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the accuracy and predictive performance of Bayesian dosing for warfarin in Chinese patients. Materials & methods: Six multiple linear regression algorithms (Wei, Lou, Miao, Huang, Gage and IWPC) and a Bayesian method implemented in Warfarin Dose Calculator were compared with each other. Results: Six multiple linear regression warfarin dosing algorithms had similar predictive ability, except Miao and Lou. The mean prediction error of Bayesian priori and posteriori method were 0.01 mg/day (95% CI: -0.18 to 0.19) and 0.17 mg/day (95% CI: -0.05 to 0.29), respectively, and Bayesian posteriori method demonstrated better performance in all dose ranges. Conclusion: The Bayesian method showed a good potential for warfarin maintenance dose prediction in Chinese patients requiring less than 6 mg/day.
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Affiliation(s)
- Jing Dong
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Guo-Hua Shi
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Man Lu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Shu Huang
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Yan-Hui Liu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jia-Chen Yao
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Wen-Yan Li
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Long-Xuan Li
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
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110
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McLaughlin MJ, Wagner J, Shakhnovich V, Carleton B, Leeder JS. Considerations for Implementing Precision Therapeutics for Children. Clin Transl Sci 2019; 12:140-150. [PMID: 30516322 PMCID: PMC6440566 DOI: 10.1111/cts.12607] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/13/2018] [Indexed: 12/12/2022] Open
Abstract
Improving the utilization of pharmacologic agents in the pediatric population yields significant, perhaps life‐long, benefits. Genetic factors related to the disposition of a medication or an alteration at the target receptor site contributes to the observed variability of exposure and response between individuals. An additional source of this variability specific to the pediatric population is ontogeny, where age‐specific changes during development may require dose adjustments to obtain the same levels of drug exposure and response. With significant improvements in characterizing both the ontogeny and genetic contributions of drug metabolizing enzymes, the time is right to begin placing more emphasis on response rather than only the dose‐exposure relationship. The amount of drug target receptors and the relative affinity for binding at that target site may require different levels of systemic exposure to achieve a desired response. Concentration‐controlled studies can identify the needed exposure for a response at the drug target, the level of expression of the target site in an individual patient, and the tools required to individualize response. Although pediatrics represents a large spectrum of growth and development, developing tools to improve drug delivery for each individual patient across the spectrum of the ages treated by clinicians remains valuable.
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Affiliation(s)
| | | | | | - Bruce Carleton
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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111
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Rodrigues-Soares F, Suarez-Kurtz G. Pharmacogenomics research and clinical implementation in Brazil. Basic Clin Pharmacol Toxicol 2019; 124:538-549. [PMID: 30589990 DOI: 10.1111/bcpt.13196] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/17/2018] [Indexed: 12/23/2022]
Abstract
We searched PubMed entries and the Lattes database of Brazilian Pharmacogenetics Network investigators, for pharmacogenetic/genomic (PGx) studies in the Brazilian population, focusing on the drugs and genes included in the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. Warfarin was the most extensively studied drug in a PGx context: a genomewide association study targeting warfarin stable dose identified significant signals in VKORC1 and CYP2C9, several PGx dosing algorithms were developed based on these and other genes, and the implications of population admixture on extrapolation of dosing recommendations in the CPIC guidelines were examined. A study in renal transplanted patients disclosed association of CYP3A5*6 and CYP3A5*7 with tacrolimus dosing, which led to addition of these variants to CYP3A5*3 in the CPIC tacrolimus guideline. Studies verified predisposition of HIV-positive carriers of UGT1A1*28 to severe atazanavir-induced hyperbilirubinaemia, intolerance to 5-fluorouracyl in gastrointestinal cancer patients with deleterious DPYD variants, failure of HCV-infected carriers of IFNL3 rs12979860 to obtain a sustained viral response to PEG-IFN-α, and hypersensitivity reactions to abacavir in HIV-positive carriers of HLA-B*57:01. No prospective analyses of drug therapy outcomes or cost-effectiveness assessments of PGx-guided therapy were found. In conclusion, the limited adoption of PGx-informed drug prescription in Brazil reflects combination of recognized barriers to PGx implementation worldwide plus factors specific to the Brazilian population. The latter include rarity/absence of genetic variants on which international PGx guidelines are based (eg HLA-B*15.02 for phenytoin and carbamazepine) and the caveat of extrapolating to the admixed Brazilian population, guidelines based on categorical variables, such as continental ancestry (eg warfarin guidelines), "race" or ethnicity.
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112
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Suarez-Kurtz G, Aklillu E, Saito Y, Somogyi AA. Conference report: pharmacogenomics in special populations at WCP2018. Br J Clin Pharmacol 2019; 85:467-475. [PMID: 30537134 DOI: 10.1111/bcp.13828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 12/12/2022] Open
Abstract
The 18th World Congress of Basic and Clinical Pharmacology (WCP2018), coordinated by IUPHAR and hosted by the Japanese Pharmacological Society and the Japanese Society of Clinical Pharmacology and Therapeutics, was held in July 2018 at the Kyoto International Conference Center, in Kyoto, Japan. Having as its main theme 'Pharmacology for the Future: Science, Drug Development and Therapeutics', WCP2018 was attended by over 4500 delegates, representing 78 countries. The present report is an overview of a symposium at WCP2018, entitled Pharmacogenomics in Special Populations, organized by IUPHAR´s Pharmacogenetics/Genomics (PGx) section. The PGx section congregates distinguished scientists from different continents, covering expertise from basic research, to clinical implementation and ethical aspects of PGx, and one of its major activities is the coordination of symposia and workshops to foster exchange of PGx knowledge (https://iuphar.org/sections-subcoms/pharmacogenetics-genomics/). The symposium attracted a large audience to listen to presentations covering various areas of research and clinical adoption of PGx in Oceania, Africa, Latin America and Asia.
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Affiliation(s)
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yoshiro Saito
- Division of Medical Safety Science, National Institute of Health Sciences, Kawasaki, Japan
| | - Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
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113
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Li H, Jiang Y, Wang Y, Lv H, Xie H, Yang G, Guo C, Tang J, Tang T. The Effects of Warfarin on the Pharmacokinetics of Senkyunolide I in a Rat Model of Biliary Drainage After Administration of Chuanxiong. Front Pharmacol 2019; 9:1461. [PMID: 30631279 PMCID: PMC6315196 DOI: 10.3389/fphar.2018.01461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/29/2018] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to elucidate the effects of warfarin on senkyunolide I in a rat model of biliary drainage after oral administration Chuanxiong extract based on pharmacokinetics. Thirty-two rats were randomly divided into four groups: CN, healthy rats after a single administration of Chuanxiong; CO, rats with biliary drainage after a single administration of Chuanxiong; WCN, healthy rats after the administration of Chuanxiong and warfarin; WCO, rats with biliary drainage after the administration of Chuanxiong and warfarin. A series of blood samples were collected at different time points before and after oral administration. An ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS) method for quantification of the main components of Chuanxiong and methyclothiazide (internal standard) have been established. The validated method was successfully applied to a comparative pharmacokinetics study. After calculated by the DAS 2.1.1 software, the pharmacokinetics parameters of senkyunolide I showed a significant difference between the CN and CO groups, the AUC0-t, and Cmax of CO group increased by 5.45, 4.02 folds, respectively. There was a significant difference between the WCO and WCN groups, the Tmax of WCO group prolonged 67%; compared to the CN group, the AUC0-t, and Cmax of WCN group raised 4.84, 3.49 folds, respectively; the Tmax and Cmax between the CO and WCO groups also showed a significant difference. The drug warfarin significantly affected the senkyunolide I disposition, which partly due to its enterohepatic circulation process in rat plasma after oral administration of Chuanxiong. The present study highlights an urgent evidence for drug-herb interactions.
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Affiliation(s)
- Haigang Li
- Department of Pharmacy, Changsha Medical University, Changsha, China.,Institute of Integrative Chinese Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yu Jiang
- Department of Gerontology, Affiliated Hospital of T.C.M. of Xinjiang Medical University, Urumqi, China
| | - Yang Wang
- Institute of Integrative Chinese Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Huiying Lv
- Hunan Agricultural Product Processing Institute, Hunan Academy of Agricultural Sciences, Changsha, China
| | - Haitang Xie
- Anhui Provincial Centre for Drug Clinical Evaluation, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jing Tang
- Department of Pharmacy, Changsha Medical University, Changsha, China
| | - Tao Tang
- Institute of Integrative Chinese Medicine, Xiangya Hospital, Central South University, Changsha, China
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114
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Lam YWF. Translating Pharmacogenomic Research to Therapeutic Potentials. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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115
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Sivadas A, Scaria V. Population-scale genomics-Enabling precision public health. ADVANCES IN GENETICS 2018; 103:119-161. [PMID: 30904093 DOI: 10.1016/bs.adgen.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The current excitement for affordable genomics technologies and national precision medicine initiatives marks a turning point in worldwide healthcare practices. The last decade of global population sequencing efforts has defined the enormous extent of genetic variation in the human population resulting in insights into differential disease burden and response to therapy within and between populations. Population-scale pharmacogenomics helps to provide insights into the choice of optimal therapies and an opportunity to estimate, predict and minimize adverse events. Such an approach can potentially empower countries to formulate national selection and dosing policies for therapeutic agents thereby promoting public health with precision. We review the breadth and depth of worldwide population-scale sequencing efforts and its implications for the implementation of clinical pharmacogenetics toward making precision medicine a reality.
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Affiliation(s)
- Ambily Sivadas
- GN Ramachandran Knowledge Center for Genome Informatics, CSIR Institute of Genomics and Integrative Biology (CSIR-IGIB), New Delhi, India; Academy of Scientific and Innovative Research (AcSIR), New Delhi, India
| | - Vinod Scaria
- GN Ramachandran Knowledge Center for Genome Informatics, CSIR Institute of Genomics and Integrative Biology (CSIR-IGIB), New Delhi, India; Academy of Scientific and Innovative Research (AcSIR), New Delhi, India.
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116
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Fereidouni M, Moossavi M, Kazemi T, Nouranihassankiade S, Asghari A. Association between polymorphisms of VKORC1 and CYP2C9 genes with warfarin maintenance dose in a group of warfarin users in Birjand city, Iran. J Cell Biochem 2018; 120:9588-9593. [PMID: 30525241 DOI: 10.1002/jcb.28235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/15/2018] [Indexed: 01/05/2023]
Abstract
Warfarin is the cardinal anticoagulant drug prescribed around the world. Due to stochastic bleeding in patients, it is essential to adjust the dose for every individual. The aim of the present study was to evaluate the frequency of CYP2C9 and VKORC1 gene polymorphisms and their association with warfarin maintenance dose in a sample of cardiovascular patients in Birjand, South-Khorasan province of Iran. Patients with a history of cardiovascular disorders who take warfarin daily were selected. CYP2C9 and VKORC1 gene polymorphisms were detected by polymerase chain reaction-restriction fragment length polymorphism in all participants. A total of 114 patients (mean age: 52.7 ± 14.9 years, M/F ratio: 0.76) participated in this study. Regarding CYP2C9 gene polymorphisms, the most frequent genotype was 1*/1* (80.4% in females and 62.5% in males). The frequency of 1*/2* and 2*/2* variants was 13% and 6.5% in females and 25% and 12.5% in males, respectively. The frequency of VKORC1 gene (1639 G > A), was 31.5%, 39.5%, and 29% for GG, GA, and AA in males, respectively. Besides, the mentioned genotype frequencies for females were 50%, 40.5%, and 9.5%, respectively. Moreover, there was a statistically significant correlation between VKORC1 gene -1639 G > A variant and warfarin maintenance dose (P < 0.001) but not for CYP2C9 variants. The results of the current study confirmed that the mutant variants of CYP2C9 are not frequent and do not have any impact on warfarin dose. In the case of VKORC1, the mutant allele (A) showed a positive correlation with warfarin dose adjustment.
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Affiliation(s)
- Mohammad Fereidouni
- Cellular and Molecular Research Center, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Maryam Moossavi
- Student Research Committee, Birjand University of Medical Science, Birjand, Iran
| | - Touba Kazemi
- Cardiovascular Diseases Research Center, Professor of cardiology, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Arghavan Asghari
- Student Research Committee, Birjand University of Medical Science, Birjand, Iran.,Asthma, Allergy, and Immunology Research Center, Faculty of Medicine, Birjand University of Medical Science, Birjand, Iran
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117
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Vélez Gómez S, Torres I, Manrique RD, Duque M, Gallo JE. Aplicación farmacogenómica de los genes CYP2C19, CYP2C9 y VKORC1 implicados en el metabolismo de los fármacos clopidogrel y warfarina. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2018.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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118
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Sanghera DK, Bejar C, Sapkota B, Wander GS, Ralhan S. Frequencies of poor metabolizer alleles of 12 pharmacogenomic actionable genes in Punjabi Sikhs of Indian Origin. Sci Rep 2018; 8:15742. [PMID: 30356105 PMCID: PMC6200732 DOI: 10.1038/s41598-018-33981-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 09/28/2018] [Indexed: 12/28/2022] Open
Abstract
Diversity in drug response is attributed to both genetic and non-genetic factors. However, there is paucity of pharmacogenetics information across ethnically and genetically diverse populations of India. Here, we have analyzed 21 SNPs from 12 pharmacogenomics genes in Punjabi Sikhs of Indian origin (N = 1,616), as part of the Sikh Diabetes Study (SDS). We compared the allele frequency of poor metabolism (PM) phenotype among Sikhs across other major global populations from the Exome Aggregation Consortium and 1000 Genomes. The PM phenotype of CYP1A2*1 F for slow metabolism of caffeine and carcinogens was significantly higher in Indians (SDS 42%, GIH [Gujarati] 51%, SAS [Pakistani] 45%) compared to Europeans 29% (pgenotype = 5.3E-05). Similarly, South Asians had a significantly higher frequency of CYP2C9*3 (12% SDS, 13% GIH, 11% SAS) vs. 7% in Europeans (pgenotype = <1.0E-05) and ‘T’ allele of CYP4F2 (36%) SDS, (43%) GIH, 40% (SAS) vs. (29%) in Europeans (pgenotype = <1.0E-05); both associated with a higher risk of bleeding with warfarin. All South Asians –the Sikhs (0.36), GIH (0.34), and SAS (0.36) had a higher frequency of the NAT2*6 allele (linked with slow acetylation of isoniazid) compared to Europeans (0.29). Additionally, the prevalence of the low activity ‘C’ allele of MTHFR (rs1801131) was highest in Sikhs compared to all other ethnic groups [SDS (44%), GIH (39%), SAS (42%) and European (32%) (pgenotype = <1.0E-05)]. SNPs in MTHFR affect metabolism of statins, 5-fluorouracil and methotrexate-based cancer drugs. These findings underscore the need for evaluation of other endogamous ethnic groups of India and beyond for establishing a global benchmark for pre-emptive genotyping in drug metabolizing genes before beginning therapeutic intervention.
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Affiliation(s)
- Dharambir K Sanghera
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA. .,Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA. .,Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA. .,Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Cynthia Bejar
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Bishwa Sapkota
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | - Sarju Ralhan
- Hero DMC Heart Institute, Ludhiana, Punjab, India
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119
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Shendre A, Dillon C, Limdi NA. Pharmacogenetics of warfarin dosing in patients of African and European ancestry. Pharmacogenomics 2018; 19:1357-1371. [PMID: 30345882 DOI: 10.2217/pgs-2018-0146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Despite the introduction of direct acting oral anticoagulants, warfarin remains the most commonly prescribed oral anticoagulant. However, warfarin therapy is plagued by the large inter- and intrapatient variability. The variability in dosing fueled research to identify clinical and genetic predictors and develop more accurate dosing algorithms. Observational studies have demonstrated the significant impact of single nucleotide polymorphisms in CYP2C9 and VKORC1 on warfarin dose in patients of European ancestry and African-Americans. This evidence supported the design and conduct of clinical trials to assess whether genotype-guided dosing results in improved anticoagulation control and outcomes. The trial results have shown discordance by race, with pharmacogenetic algorithms improving dose and anticoagulation control among European ancestry patients compared with African-American patients. Herein, we review the evidence from observational and interventional studies, highlight the need for inclusion of minority race groups and propose the need to develop race specific dosing algorithms.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M Fairbanks School of Public Health, Indiana University Purdue University Indianapolis, IN 46202, USA
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
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120
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Tian P, Yang F, Xu Y, Lin MM, Yu LP, Lin W, Lin QF, Lv ZF, Huang SY, Chen YZ. Oral disintegrating patient-tailored tablets of warfarin sodium produced by 3D printing. Drug Dev Ind Pharm 2018; 44:1918-1923. [DOI: 10.1080/03639045.2018.1503291] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Pan Tian
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
| | - Fan Yang
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
- College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yuan Xu
- College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Min-Mei Lin
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
| | - Li-Ping Yu
- College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Wei Lin
- College of Pharmacy, Guangdong Pharmaceutical University, Guangzhou, China
| | - Qi-Feng Lin
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
| | - Zhu-Fen Lv
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
| | - Si-Yu Huang
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yan-Zhong Chen
- Guangdong Key Laboratory of New Dosage Forms of Drugs, Guangdong Pharmaceutical University, Guangzhou, China
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121
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FREQUENCIES OF POLYMORPHISMS IN THE CYTOCHROME’S P450 GENES OF WARFARIN TRANSFORMATION IN A EUROPEAN POPULATION OF EASTERN SIBERIA. ACTA BIOMEDICA SCIENTIFICA 2018. [DOI: 10.29413/abs.2018-3.5.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. Genotypes of the cytochrome p450 isoform (CYP2C9 and CYP4F2) determine warfarin dose requirements. Frequencies of risk alleles and genotypes of CYP2C9 and CYP4F2 gene vary in different races and ethnic groups.Aim. This study analyzed the frequencies of *2, *3 alleles of CYP2C9 gene and the 1347 C>T allele of CYP4F2 gene in the Caucasians of Eastern Siberia, and compare with other populations.Materials and methods. Participants were 147 patients (Caucasians): 67 (45.58 %) man and 80 (54.42 %) women), taking warfarin for the prevention of thrombosis with a mean age of 64.74 ± 14.29 years. There were patients with atrial fibrillation – 77 (52.38 %) persons, coronary artery disease – 10 (6.80 %), pulmonary embolism – 5 (3.40 %), 15 (10.20 %) patients after implantation of an mechanical heart valve, etc. The subjects were genotyped for CYP2C9 (*1,*2,*3), and CYP4F2 (1347 C>T) by real-time polymerase chain reaction (RT-PCR) using “Pharmacogenetics Warfarin” reagent kits (DNA technology, Russia).Results. 69.4 % of Caucasians of Eastern Siberia (Russians), have two functional alleles (*1/*1) of CYP2C9 (they’re extensive/normal metabolizers), the number of intermediate metabolizers (*1/*2, *1/*3) was 29.8 % and 0.68 % of slow metabolizers (*3/*3). Homozygous carriers of two non-functional alleles *2 and *3 (*2/*2, *2/*3) were absent. Carriers of one coumarin-resistant Т-allele of CYP4F2 were 57 (38.7 %) respondents, two coumarin-resistant alleles – 10 (6.8 %) respondents.Conclusions. Frequencies of polymorphisms in the Cytochrome’s p450 genes of warfarin transformation in a European population of Eastern Siberia have no differences with other European populations of the world
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122
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An analysis of allele, genotype and phenotype frequencies, actionable pharmacogenomic (PGx) variants and phenoconversion in 5408 Australian patients genotyped for CYP2D6, CYP2C19, CYP2C9 and VKORC1 genes. J Neural Transm (Vienna) 2018; 126:5-18. [DOI: 10.1007/s00702-018-1922-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022]
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123
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Abstract
Pharmacogenetics is an emerging area of medicine, and more work is needed to fully integrate it into a clinical setting for the benefit of patients. Genetic markers can influence the action of many drugs, including those that prevent and treat cardiovascular conditions. Genotyping is not yet commonplace, but guidelines are being put in place to help practitioners determine the effect a genetic marker may have on certain drugs. With advancements in genetic technology and falling costs, genotyping could be available to all patients via a simple saliva test. This would be a cost-effective way for practitioners to determine the most effective treatment for individuals, reducing "trial and error," adverse effects, and rehospitalization rates and increasing patient compliance. Cardiovascular diseases are the leading causes of death worldwide, so using the most effective medication to treat or prevent them is of utmost importance in reducing incidence and mortality.
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124
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Warfarin Dosing According to the Genotype-guided Algorithm is Most Beneficial in Patients With Atrial Fibrillation: A Randomized Parallel Group Trial. Ther Drug Monit 2018; 40:362-368. [DOI: 10.1097/ftd.0000000000000501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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125
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Abstract
Considerable interindividual variability in response to cardiovascular pharmacotherapy exists with drug responses varying from being efficacious to inadequate to induce severe adverse events. Fueled by advancements and multidisciplinary collaboration across disciplines such as genetics, bioinformatics, and basic research, the vision of personalized medicine, rather than a one-size-fits-all approach, may be within reach. Pharmacogenetics offers the potential to optimize the benefit-risk profile of drugs by tailoring diagnostic and treatment strategies according to the individual patient. To date, a multitude of studies has tried to delineate the effects of gene-drug interactions for drugs commonly used to treat cardiovascular-related disease. The focus of this review is on how genetic variability may modify drug responsiveness and patient outcomes following therapy with commonly used cardiovascular drugs including clopidogrel, warfarin, statins, and β-blockers. Also included are examples of how genetic studies can be used to guide drug discovery and examples of how genetic information may be deployed in clinical decision making.
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Affiliation(s)
- Peter E Weeke
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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126
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Gu ZC, Ma XW, Zheng XY, Shen L, Shi FH, Li H. Left Atrial Appendage Thrombus Formation in a Patient on Dabigatran Therapy Associated With ABCB1 and CES-1 Genetic Defect. Front Pharmacol 2018; 9:491. [PMID: 29867495 PMCID: PMC5962821 DOI: 10.3389/fphar.2018.00491] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023] Open
Abstract
Dabigatran, directly targeting thrombin, is widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF). We reported a rare case of left atrial appendage thrombus formation in a persistent NVAF patient despite the 31 months uninterrupted treatment with dabigatran 110 mg twice daily. The patient is a carrier of ABCB1 variant alleles with 7 heterozygote single nucleotide polymorphisms (SNPs: rs4148738, rs2235046, rs1128503, rs10276036, rs1202169, rs1202168, rs1202167) as well as CES-1 variant alleles with 2 homozygote SNPs (rs2244613 and rs4122238) and 2 heterozygote SNPs (rs8192935 and rs4580160), which may contribute to the changes of dabigatran plasma concentration. In addition, Drug-drug interaction with atorvastatin may also play a role to decrease dabigatran plasma concentration. There are only four such cases till date, of which had thrombus in the left atrium, reported in the literature. We firstly reported the documented case in a Chinese patient carrying multiple alleles of ABCB1 and CES-1, who suffered from thrombus in the left atrial appendage despite long-term anticoagulation with dabigatran. More clinical data are required to elucidate the impact of CES-1 and ABCB1 polymorphism on dabigatran pharmacokinetics, especially for Asian.
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Affiliation(s)
- Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Wei Ma
- Department of Clinical Laboratory, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Yuan Zheng
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Fang-Hong Shi
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hao Li
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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127
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Sharabiani A, Nutescu EA, Galanter WL, Darabi H. A New Approach towards Minimizing the Risk of Misdosing Warfarin Initiation Doses. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2018; 2018:5340845. [PMID: 29861781 PMCID: PMC5971298 DOI: 10.1155/2018/5340845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
It is a challenge to be able to prescribe the optimal initial dose of warfarin. There have been many studies focused on an efficient strategy to determine the optimal initial dose. Numerous clinical, genetic, and environmental factors affect the warfarin dose response. In practice, it is common that the initial warfarin dose is substantially different from the stable maintenance dose, which may increase the risk of bleeding or thrombosis prior to achieving the stable maintenance dose. In order to minimize the risk of misdosing, despite popular warfarin dose prediction models in the literature which create dose predictions solely based on patients' attributes, we have taken physicians' opinions towards the initial dose into consideration. The initial doses selected by clinicians, along with other standard clinical factors, are used to determine an estimate of the difference between the initial dose and estimated maintenance dose using shrinkage methods. The selected shrinkage method was LASSO (Least Absolute Shrinkage and Selection Operator). The estimated maintenance dose was more accurate than the original initial dose, the dose predicted by a linear model without involving the clinicians initial dose, and the values predicted by the most commonly used model in the literature, the Gage clinical model.
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Affiliation(s)
- Ashkan Sharabiani
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A. Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L. Galanter
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Houshang Darabi
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
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128
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Mills RA, Eichmeyer JN, Williams LM, Muskett JA, Schmidlen TJ, Maloney KA, Lemke AA. Patient Care Situations Benefiting from Pharmacogenomic Testing. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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129
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Zanger UM, Klein K, Kugler N, Petrikat T, Ryu CS. Epigenetics and MicroRNAs in Pharmacogenetics. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:33-64. [PMID: 29801581 DOI: 10.1016/bs.apha.2018.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Germline pharmacogenetics has so far mainly studied common variants in "pharmacogenes," i.e., genes encoding drug metabolizing enzymes and transporters (DMET genes), certain auxiliary and regulatory genes, and drug target genes. Despite remarkable progress in understanding genetically determined differences in pharmacokinetics and pharmacodynamics of drugs, currently known common variants even in important pharmacogenes explain genetic variability only partially. This suggests "missing heritability" that may in part be due to rare variants in the classical pharmacogenes, but current evidence suggests that largely unexplored resources with potential for pharmacogenetics exist, both within already known pharmacogenes and in entirely new areas. In particular, recent studies suggest that epigenetic processes and noncoding RNAs, including mostly microRNAs (miRNAs), represent important and largely unexplored layers of DMET gene regulation that may fill some of the gaps in understanding interindividual variability and lead to new biomarkers. In this chapter we summarize recent advances in the understanding of genetic variability in epigenetic and miRNA-mediated processes with focus on their significance for DMET regulation and pharmacokinetic or pharmacological endpoints.
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Affiliation(s)
- Ulrich M Zanger
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany; University Hospital Tübingen, Tübingen, Germany.
| | - Kathrin Klein
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Nicole Kugler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Tamara Petrikat
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Chang S Ryu
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
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Mayet AY, Alsaqer AI, Alhammad AM, Al-Omar HA. Rivaroxaban prescribing in a Saudi tertiary care teaching hospital. Saudi Pharm J 2018; 26:775-779. [PMID: 30202216 PMCID: PMC6128799 DOI: 10.1016/j.jsps.2018.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/11/2018] [Indexed: 01/21/2023] Open
Abstract
Purpose This drug utilization review (DUR) aimed to describe the use of rivaroxaban in a tertiary care teaching hospital and to audit the hospital physicians’ prescribing practice. Methods This study reviewed rivaroxaban prescriptions for patients admitted to a tertiary care teaching hospital in Riyadh, Saudi Arabia, between October 1, 2016 and January 15, 2017. It included all in-patients who received at least one dose of rivaroxaban, using data from the hospital’s health information system (HIS). Appropriateness of prescribing was evaluated based on documented indication, dosing according to the patient’s renal function for each approved indication, and restriction policy as per hospital department. Results During the study period, a total of 343 rivaroxaban prescriptions for 322 patients were identified. Overall, more than 56% of rivaroxaban prescriptions met at least one inappropriate criterion. Inappropriate dosing per patient’s creatinine clearance (CrCl) was recognized in 42% of rivaroxaban prescriptions with the majority of these prescriptions issued for lower doses in 82.9% of prescriptions and non-approved indications identified in 14% of rivaroxaban prescriptions. Conclusions The introduction of oral rivaroxaban represents a paradigm shift in anticoagulation management. Future longer, larger multi-center research is needed to identify the most effective interventions to enhance rivaroxaban knowledge translation and reduce the likelihood of inappropriate rivaroxaban prescribing and associated economic and side effects sequelae.
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Affiliation(s)
- Ahmed Yacoob Mayet
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia.,King Khalid University Hospital, Riyadh 11451, Saudi Arabia
| | | | - Abdullah Musa Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
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131
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Bedewy AML, Sheweita SA, Mostafa MH, Kandil LS. The Influence of CYP2C9 and VKORC1 Gene Polymorphisms on the Response to Warfarin in Egyptians. Indian J Hematol Blood Transfus 2018; 34:328-336. [PMID: 29622878 DOI: 10.1007/s12288-016-0725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022] Open
Abstract
Warfarin is the most commonly used drug for chronic prevention of thromboembolic events, it also ranks high among drugs that cause serious adverse events. The variability in dose requirements has been attributed to inter-individual differences in medical, personal, and genetic factor. Cytochrome P-450 2C9 is the principle enzyme that terminates the anticoagulant effect of warfarin by catalyzing the conversion of the pharmacologically more potent S-enantiomer to its inactive metabolites. Warfarin exerts its effect by inhibition of vitamin K epoxide reductase. This protein is encoded by vitamin K epoxide reductase complex subunit 1 gene (VKORC1). The current study aimed to investigate the pharmacogenetic effect of CYP2C9 and VKORC1 gene polymorphisms on the patients response to warfarin. One hundred cases starting warfarin treatment and 20 healthy controls were enrolled. The mean daily dose of warfarin was calculated from patient's medical records. For each patient, less than 10 % variability in warfarin dose and a target international normalized ratio (INR) within the therapeutic target range were required for at least 3 months for one of the following indications (deep vein thrombosis, pulmonary embolism, cerebrovascular stroke and myocardial infarction) prior to inclusion in the study. Tetraprimer amplification refractory mutation system PCR was performed to determine CYP2C9*2, CYP2C9*3, and the VKORC1 1639 G > A genetic polymorphisms. Plasma warfarin determination was performed using rapid fluorometric assay. Plasma warfarin concentration ranged from 2.19 to 10.98 μg/ml with a median 3.52 μg/ml. Supratherpeutic INR was observed in 11 % of the cases. Thromboembolic complications occurred in 7 % of the cases and 8 % of cases experienced major bleeding. High maintenance dose (>7 mg/day) was associated with the combined non VKORC1*2 and homozygous wild type CYP2C9 (CYP2C9*1*1) alleles, while low maintenance dose was associated with the Variant (AG + AA)/Wild (*1/*1). (p value <0.001). CYP2C9 variant was a risk factor for supratherapeutic INR in the multivariate logistic regression model. Thromboembolic complication and incidence of supratherapeutic INR were observed in patients carrying combined VKORC1 Variant (AG + AA) and CYP2C9 Variant (*2/*3). Data from our study suggest that together with clinical factors, VKORC1 and CYP2C9 polymorphisms are important contributors to warfarin dosing and may help predict adverse effects in Egyptian patients.
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Affiliation(s)
- Ahmed M L Bedewy
- 1Hematology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt.,Abraj Al-Shaker, Zaky Ragab Street, Smouha, Alexandria, 21615 Egypt
| | - Salah A Sheweita
- 2Biotechnology Department, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt
| | - Mostafa Hasan Mostafa
- 2Biotechnology Department, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt
| | - Lamia Saeed Kandil
- 3Biochemistry Department, Pharos University in Alexandria, Alexandria, Egypt
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Biswas M, Bendkhale SR, Deshpande SP, Thaker SJ, Kulkarni DV, Bhatia SJ, Rajadhyaksha AG, Gogtay NJ, Thatte UM. Association between genetic polymorphisms of CYP2C9 and VKORC1 and safety and efficacy of warfarin: Results of a 5 years audit. Indian Heart J 2018; 70 Suppl 3:S13-S19. [PMID: 30595245 PMCID: PMC6309143 DOI: 10.1016/j.ihj.2018.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/02/2018] [Accepted: 02/13/2018] [Indexed: 11/30/2022] Open
Abstract
Objective Genetic polymorphisms of CYP2C9 and VKORC1 play major role in pharmacokinetics and pharmacodynamics of warfarin, respectively. Purpose of our study was to assess the utility of pretesting patients for the above mutations in predicting tendency for bleeding and achieving target INR. Methods This was an audit of data collected between July 2011 and December 2016. For safety and efficacy, patients were divided into two subgroups: those with or without bleeding and those who achieved target INR or not. Chi square test was applied to compare the between group differences and crude Odds Ratio (cOR) calculated. Results Among 521 patients evaluated, most common indication for warfarin therapy was valvular heart disease (210/521 = 40%); 36% (187/521) had at least one bleeding episode; 56% (269/479) had below target INR. 26% (136/521) had polymorphic alleles of CYP2C9 and 69% (358/521) had the GG haplotype of VKORC1. Polymorphic alleles of CYP2C9 or AG/AA haplotype had twice the odds of bleeding (cOR = 2.14 and 2.44 respectively) relative to those with wild CYP2C9 allele or GG haplotype. Combined CYP2C9 mutant alleles and/or AG/AA haplotypes had thrice the odds of bleeding (cOR = 3.12) relative to those with wild CYP2C9 alleles and GG haplotype. Those with GG haplotype had twice the odds (cOR = 1.81) and those with GG haplotype along with wild CYP2C9 allele had four times the odds (cOR = 4.27) of not achieving the target INR relative to those with other haplotype/alleles. All these associations were statistically significant (p < 0.05). Conclusions Pretesting patients for genetic polymorphisms could aid in individualizing warfarin therapy.
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Affiliation(s)
- Mansij Biswas
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shital R Bendkhale
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Saket J Thaker
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Dwarkanath V Kulkarni
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shobna J Bhatia
- Department of Gastroenterology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Anjali G Rajadhyaksha
- Department of Medicine, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
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Abstract
Adverse drug reactions can be caused by a wide range of therapeutics. Adverse drug reactions affect many bodily organ systems and vary widely in severity. Milder adverse drug reactions often resolve quickly following withdrawal of the casual drug or sometimes after dose reduction. Some adverse drug reactions are severe and lead to significant organ/tissue injury which can be fatal. Adverse drug reactions also represent a financial burden to both healthcare providers and the pharmaceutical industry. Thus, a number of stakeholders would benefit from development of new, robust biomarkers for the prediction, diagnosis, and prognostication of adverse drug reactions. There has been significant recent progress in identifying predictive genomic biomarkers with the potential to be used in clinical settings to reduce the burden of adverse drug reactions. These have included biomarkers that can be used to alter drug dose (for example, Thiopurine methyltransferase (TPMT) and azathioprine dose) and drug choice. The latter have in particular included human leukocyte antigen (HLA) biomarkers which identify susceptibility to immune-mediated injuries to major organs such as skin, liver, and bone marrow from a variety of drugs. This review covers both the current state of the art with regard to genomic adverse drug reaction biomarkers. We also review circulating biomarkers that have the potential to be used for both diagnosis and prognosis, and have the added advantage of providing mechanistic information. In the future, we will not be relying on single biomarkers (genomic/non-genomic), but on multiple biomarker panels, integrated through the application of different omics technologies, which will provide information on predisposition, early diagnosis, prognosis, and mechanisms. Impact statement • Genetic and circulating biomarkers present significant opportunities to personalize patient therapy to minimize the risk of adverse drug reactions. ADRs are a significant heath issue and represent a significant burden to patients, healthcare providers, and the pharmaceutical industry. • This review details the current state of the art in biomarkers of ADRs (both genetic and circulating). There is still significant variability in patient response which cannot be explained by current knowledge of genetic risk factors for ADRs; however, we discussed how specific advances in genomics have the potential to yield better and more predictive models. • Many current clinically utilized circulating biomarkers of tissue injury are valid biomarkers for a number of ADRs. However, they often give little insight into the specific cell or tissue subtype which may be affected. Emerging circulating biomarkers with potential to provide greater information on the etiology/pathophysiology of ADRs are described.
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Affiliation(s)
- Daniel F Carr
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, Institute of Translational Medicine, University of Liverpool, Liverpool L69 3GL, UK
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Hicks JK, Dunnenberger HM, Gumpper KF, Haidar CE, Hoffman JM. Integrating pharmacogenomics into electronic health records with clinical decision support. Am J Health Syst Pharm 2018; 73:1967-1976. [PMID: 27864204 DOI: 10.2146/ajhp160030] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Existing pharmacogenomic informatics models, key implementation steps, and emerging resources to facilitate the development of pharmacogenomic clinical decision support (CDS) are described. SUMMARY Pharmacogenomics is an important component of precision medicine. Informatics, especially CDS in the electronic health record (EHR), is a critical tool for the integration of pharmacogenomics into routine patient care. Effective integration of pharmacogenomic CDS into the EHR can address implementation challenges, including the increasing volume of pharmacogenomic clinical knowledge, the enduring nature of pharmacogenomic test results, and the complexity of interpreting results. Both passive and active CDS provide point-of-care information to clinicians that can guide the systematic use of pharmacogenomics to proactively optimize pharmacotherapy. Key considerations for a successful implementation have been identified; these include clinical workflows, identification of alert triggers, and tools to guide interpretation of results. These considerations, along with emerging resources from the Clinical Pharmacogenetics Implementation Consortium and the National Academy of Medicine, are described. CONCLUSION The EHR with CDS is essential to curate pharmacogenomic data and disseminate patient-specific information at the point of care. As part of the successful implementation of pharmacogenomics into clinical settings, all relevant clinical recommendations pertaining to gene-drug pairs must be summarized and presented to clinicians in a manner that is seamlessly integrated into the clinical workflow of the EHR. In some situations, ancillary systems and applications outside the EHR may be integrated to augment the capabilities of the EHR.
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Affiliation(s)
- J Kevin Hicks
- DeBartolo Family Personalized Medicine Institute and Department of Population Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Karl F Gumpper
- Department of Pharmacy, Boston Children's Hospital, Boston, MA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN.
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135
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Dunnenberger HM, Biszewski M, Bell GC, Sereika A, May H, Johnson SG, Hulick PJ, Khandekar J. Implementation of a multidisciplinary pharmacogenomics clinic in a community health system. Am J Health Syst Pharm 2018; 73:1956-1966. [PMID: 27864203 DOI: 10.2146/ajhp160072] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The development and implementation of a multidisciplinary pharmacogenomics clinic within the framework of an established community-based medical genetics program are described. SUMMARY Pharmacogenomics is an important component of precision medicine that holds considerable promise for pharmacotherapy optimization. As part of the development of a health system-wide integrated pharmacogenomics program, in early 2015 Northshore University Health-System established a pharmacogenomics clinic run by a multidisciplinary team including a medical geneticist, a pharmacist, a nurse practitioner, and genetic counselors. The team identified five key program elements: (1) a billable-service provider, (2) a process for documentation of relevant medication and family histories, (3) personnel with the knowledge required to interpret pharmacogenomic results, (4) personnel to discuss risks, benefits, and limitations of pharmacogenomic testing, and (5) a mechanism for reporting results. The most important program component is expert interpretation of genetic test results to provide clinically useful information; pharmacists are well positioned to provide that expertise. At the Northshore University HealthSystem pharmacogenomics clinic, patient encounters typically entail two one-hour visits and follow a standardized workflow. At the first visit, pharmacogenomics-focused medication and family histories are obtained, risks and benefits of genetic testing are explained, and a test sample is collected; at the second visit, test results are provided along with evidence-based pharmacotherapy recommendations. CONCLUSION A multidisciplinary clinic providing genotyping and related services can facilitate the integration of pharmacogenomics into clinical care and meet the needs of early adopters of precision medicine.
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Affiliation(s)
- Henry M Dunnenberger
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL.
| | - Matthew Biszewski
- Thrombosis and Anticoagulation Unit, NorthShore University HealthSystem, Glenview, IL
| | | | - Annette Sereika
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Holley May
- Center for Medical Genetics, NorthShore University HealthSystem, Evanston, IL
| | | | - Peter J Hulick
- Center for Medical Genetics, NorthShore University HealthSystem, Evanston, IL
| | - Janardan Khandekar
- Center for Molecular Medicine, NorthShore University HealthSystem, Evanston, IL
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Cavallari LH, Lee CR, Duarte JD, Nutescu EA, Weitzel KW, Stouffer GA, Johnson JA. Implementation of inpatient models of pharmacogenetics programs. Am J Health Syst Pharm 2018; 73:1944-1954. [PMID: 27864202 DOI: 10.2146/ajhp150946] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The operational elements essential for establishing an inpatient pharmacogenetic service are reviewed, and the role of the pharmacist in the provision of genotype-guided drug therapy in pharmacogenetics programs at three institutions is highlighted. SUMMARY Pharmacists are well positioned to assume important roles in facilitating the clinical use of genetic information to optimize drug therapy given their expertise in clinical pharmacology and therapeutics. Pharmacists have assumed important roles in implementing inpatient pharmacogenetics programs. This includes programs designed to incorporate genetic test results to optimize antiplatelet drug selection after percutaneous coronary intervention and personalize warfarin dosing. Pharmacist involvement occurs on many levels, including championing and leading pharmacogenetics implementation efforts, establishing clinical processes to support genotype-guided therapy, assisting the clinical staff with interpreting genetic test results and applying them to prescribing decisions, and educating other healthcare providers and patients on genomic medicine. The three inpatient pharmacogenetics programs described use reactive versus preemptive genotyping, the most feasible approach under the current third-party payment structure. All three sites also follow Clinical Pharmacogenetics Implementation Consortium guidelines for drug therapy recommendations based on genetic test results. CONCLUSION With the clinical emergence of pharmacogenetics into the inpatient setting, it is important that pharmacists caring for hospitalized patients are well prepared to serve as experts in interpreting and applying genetic test results to guide drug therapy decisions. Since genetic test results may not be available until after patient discharge, pharmacists practicing in the ambulatory care setting should also be prepared to assist with genotype-guided drug therapy as part of transitions in care.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC.,Center for Pharmacogenomics and Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL.,Personalized Medicine Program, University of Illinois Hospital and Health Science System, Chicago, IL
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL.,Personalized Medicine Program, University of Illinois Hospital and Health Science System, Chicago, IL
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - George A Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
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137
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Angelbello AJ, Chen JL, Childs-Disney JL, Zhang P, Wang ZF, Disney MD. Using Genome Sequence to Enable the Design of Medicines and Chemical Probes. Chem Rev 2018; 118:1599-1663. [PMID: 29322778 DOI: 10.1021/acs.chemrev.7b00504] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Rapid progress in genome sequencing technology has put us firmly into a postgenomic era. A key challenge in biomedical research is harnessing genome sequence to fulfill the promise of personalized medicine. This Review describes how genome sequencing has enabled the identification of disease-causing biomolecules and how these data have been converted into chemical probes of function, preclinical lead modalities, and ultimately U.S. Food and Drug Administration (FDA)-approved drugs. In particular, we focus on the use of oligonucleotide-based modalities to target disease-causing RNAs; small molecules that target DNA, RNA, or protein; the rational repurposing of known therapeutic modalities; and the advantages of pharmacogenetics. Lastly, we discuss the remaining challenges and opportunities in the direct utilization of genome sequence to enable design of medicines.
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Affiliation(s)
- Alicia J Angelbello
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Jonathan L Chen
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Jessica L Childs-Disney
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Peiyuan Zhang
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Zi-Fu Wang
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
| | - Matthew D Disney
- Departments of Chemistry and Neuroscience, The Scripps Research Institute , 130 Scripps Way, Jupiter, Florida 33458, United States
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138
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Evaluation of CYP2C9- and VKORC1-based pharmacogenetic algorithm for warfarin dose in Gaza-Palestine. Future Sci OA 2018; 4:FSO276. [PMID: 29568565 PMCID: PMC5859345 DOI: 10.4155/fsoa-2017-0112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/22/2017] [Indexed: 12/13/2022] Open
Abstract
Aim To evaluate applicability of CYP2C9*2, *3 and VKORC1-1639G > A based algorithm to predict warfarin stable dose (WSD) in a group of Palestinian patients. Patients & methods Warfarin doses were retrospectively calculated for 101 Palestinian patients under warfarin therapy using three models. Performance of the three models was assessed in 47 patients found to take WSD. Results Frequency of CYP2C9*2, *3 and VKORC1-1639G > A alleles is 13.6, 0.0 and 46.5% respectively. The international warfarin pharmacogenetics consortium algorithm was more reliable (MAE = 8.9 ± 1.4; R2 = 0.350) than both the clinical algorithm (MAE = 10.4 ± 1.4; R2 = 0.128;) and the fixed-dose algorithm (MAE = 11.1 ± 1.7). Conclusion The international warfarin pharmacogenetics consortium algorithm can be reliably applied for predicting the WSD in Palestinian population.
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Nuclear receptor gene polymorphisms and warfarin dose requirements in the Quebec Warfarin Cohort. THE PHARMACOGENOMICS JOURNAL 2018; 19:147-156. [PMID: 29298995 PMCID: PMC6462825 DOI: 10.1038/s41397-017-0005-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 08/24/2017] [Accepted: 09/18/2017] [Indexed: 01/02/2023]
Abstract
Warfarin is primarily metabolized by cytochrome 2C9, encoded by gene CYP2C9. Here, we investigated whether variants in nuclear receptor genes which regulate the expression of CYP2C9 are associated with warfarin response. We used data from 906 warfarin users from the Quebec Warfarin Cohort (QWC) and tested the association of warfarin dose requirement at 3 months following the initiation of therapy in nine nuclear receptor genes: NR1I3, NR1I2, NR3C1, ESR1, GATA4, RXRA, VDR, CEBPA, and HNF4A. Three correlated SNPs in the VDR gene (rs4760658, rs11168292, and rs11168293) were associated with dose requirements of warfarin (P = 2.68 × 10-5, P = 5.81 × 10-4, and P = 5.94 × 10-4, respectively). Required doses of warfarin were the highest for homozygotes of the minor allele at the VDR variants (P < 0.0026). Variants in the VDR gene were associated with the variability in response to warfarin, emphasizing the possible clinical relevance of nuclear receptor gene variants on the inter-individual variability in drug metabolism.
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140
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Zhuang B. Fully Integrated Genetic Analysis System. DEVELOPMENT OF A FULLY INTEGRATED “SAMPLE-IN-ANSWER-OUT” SYSTEM FOR AUTOMATIC GENETIC ANALYSIS 2018:89-109. [DOI: 10.1007/978-981-10-4753-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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141
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Osanlou O, Pirmohamed M, Daly AK. Pharmacogenetics of Adverse Drug Reactions. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2018; 83:155-190. [PMID: 29801574 DOI: 10.1016/bs.apha.2018.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Adverse drug reactions (ADRs) are an important cause of morbidity and mortality. Genetic factors predispose to many ADRs, affecting susceptibility to both type A and type B reactions. The overall contribution of genetics will vary according to drug and ADR, and should be considered when attempting to predict and prevent ADRs. Genetic risk factors are considered in detail for a number of type A ADRs, especially those relating to warfarin and thiopurines, and type B ADRs affecting skin, the liver, and the heart. As the availability of whole genome sequencing increases, it is likely that prospective genotype for particular ADRs prior to drug prescription will become more common in the future. Current examples of genetic testing to prevent ADRs which have already been implemented and future prospects for developments in the field are discussed in detail.
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Affiliation(s)
- Orod Osanlou
- Department of Molecular and Clinical Pharmacology, The University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, The University of Liverpool, Liverpool, United Kingdom
| | - Ann K Daly
- Institute of Cellular Medicine, Newcastle University, Medical School, Newcastle upon Tyne, United Kingdom.
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142
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Abstract
Pharmacogenetics is the study of how genetics influences drug treatment outcomes. Much research has been conducted to identify and characterize gene variants that impact the pharmacokinetic and pharmacodynamic aspects of medications used to treat neurologic and psychiatric disorders. This chapter reviews the current state of pharmacogenetic aspects of these treatments. Medications with supporting pharmacogenetic information in product labeling, clinical guidelines, or important mechanistic implications are discussed. At this time, clinically relevant genetic variation in drug metabolizing enzymes may inform drug dosing for a number of medications metabolized in the liver. Additionally, genetic variation in immunological genes may be tested to assess risk for severe hypersensitivity reactions to some anticonvulsant drugs. Finally, a growing body of research highlights that genetic polymorphisms in drug targets may influence symptom response or tolerability to some treatments.
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Affiliation(s)
- Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, United States.
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143
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Daly AK, Rettie AE, Fowler DM, Miners JO. Pharmacogenomics of CYP2C9: Functional and Clinical Considerations. J Pers Med 2017; 8:E1. [PMID: 29283396 PMCID: PMC5872075 DOI: 10.3390/jpm8010001] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023] Open
Abstract
CYP2C9 is the most abundant CYP2C subfamily enzyme in human liver and the most important contributor from this subfamily to drug metabolism. Polymorphisms resulting in decreased enzyme activity are common in the CYP2C9 gene and this, combined with narrow therapeutic indices for several key drug substrates, results in some important issues relating to drug safety and efficacy. CYP2C9 substrate selectivity is detailed and, based on crystal structures for the enzyme, we describe how CYP2C9 catalyzes these reactions. Factors relevant to clinical response to CYP2C9 substrates including inhibition, induction and genetic polymorphism are discussed in detail. In particular, we consider the issue of ethnic variation in pattern and frequency of genetic polymorphisms and clinical implications. Warfarin is the most well studied CYP2C9 substrate; recent work on use of dosing algorithms that include CYP2C9 genotype to improve patient safety during initiation of warfarin dosing are reviewed and prospects for their clinical implementation considered. Finally, we discuss a novel approach to cataloging the functional capabilities of rare 'variants of uncertain significance', which are increasingly detected as more exome and genome sequencing of diverse populations is conducted.
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Affiliation(s)
- Ann K Daly
- Institute of Cellular Medicine, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK.
| | - Allan E Rettie
- Department of Medicinal Chemistry, University of Washington, Seattle, WA 98195, USA.
| | - Douglas M Fowler
- Department of Genome Sciences and Department of Bioengineering, University of Washington, Seattle, WA 98195, USA.
| | - John O Miners
- Department of Clinical Pharmacology, Flinders University School of Medicine, Adelaide 5042, Australia.
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144
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CYP2B6*6 or Not CYP2B6*6-That Remains a Question for Precision Medicine and Ketamine! Anesthesiology 2017; 125:1085-1087. [PMID: 27763886 DOI: 10.1097/aln.0000000000001399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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145
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Cai LL, Huang WQ, Su ZY, Ye HM, Wang LS, Wu Y, Zhang ZY, Zhang W, Tzeng CM. Identification of two novel genes SLC15A2 and SLCO1B3 associated with maintenance dose variability of warfarin in a Chinese population. Sci Rep 2017; 7:17379. [PMID: 29234073 PMCID: PMC5727167 DOI: 10.1038/s41598-017-17731-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/29/2017] [Indexed: 01/12/2023] Open
Abstract
Warfarin is a commonly prescribed and effective oral anticoagulant. Genetic polymorphisms associated with warfarin metabolism and sensitivity have been implicated in the wide inter-individual dose variation that is observed. Several algorithms integrating patients’ clinical characteristics and genetic polymorphism information have been explored to predict warfarin dose. However, most of these algorithms could explain only over half of the variation in a warfarin maintenance dose, suggesting that additional genetic factors may exist and need to be identified. Here, a drug absorption, distribution, metabolism and excretion (ADME) Core Panel Kit-based pharmacogenetic study was performed to screen for warfarin dose-associated SNP sites in Han-Chinese population patients taking warfarin therapy, and the screen was followed by pyrosequencing-based validation. Finally, we confirmed that the common variant rs9923231 in VKORC1 and two novel genes, SLC15A2 (rs1143671 and rs1143672) and SLCO1B3 (rs4149117 and rs7311358), are associated with the warfarin maintenance dose. As has been shown for those carriers with the variant rs9923231 in VKORC1, it was suggested that those subjects with homozygous minor alleles in those four SNPs should take a lower warfarin dose than those carrying the wild type alleles. Together with the established predictor rs9923231 in VKORC1, those four novel variants on SLC15A2 and SLCO1B3 should be considered as useful biomarkers for warfarin dose adjustment in clinical practice in Han-Chinese populations.
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Affiliation(s)
- Liang-Liang Cai
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China
| | - Wen-Qing Huang
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China
| | - Zhi-Ying Su
- Clinical Research Laboratory, Xiamen's Maternal and Child Health Hospital, Teaching Hospital of Xiamen University, Xiamen, Fujian Sheng, China
| | - Hui-Ming Ye
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China.,Clinical Research Laboratory, Xiamen's Maternal and Child Health Hospital, Teaching Hospital of Xiamen University, Xiamen, Fujian Sheng, China
| | - Lian-Sheng Wang
- Department of Clinical Pharmacology, Xiangya Hospital, Institute of Clinical Pharmacology, Central South University, Changsha, Hunan Sheng, China
| | - Yuan Wu
- Department of cardiac surgery, Xiamen Cardiovascular Hospital, School of Medicine, Xiamen University, Xiamen, Fujian Sheng, China
| | - Zhong-Ying Zhang
- Department of Clinical laboratory, Zhongshan Hospital, Xiamen University, Xiamen, Fujian Sheng, China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Institute of Clinical Pharmacology, Central South University, Changsha, Hunan Sheng, China.
| | - Chi-Meng Tzeng
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China.
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146
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Mili FD, Allen T, Wadell PW, Hooper WC, Staercke CD, Bean CJ, Lally C, Austin H, Wenger NK. VKORC1-1639A allele influences warfarin maintenance dosage among Blacks receiving warfarin anticoagulation: a retrospective cohort study. Future Cardiol 2017; 14:15-26. [PMID: 29218998 DOI: 10.2217/fca-2017-0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM The study objectives were to investigate the association between selected CYP2C9 and VKORC1 single nucleotide polymorphisms with serious bleeding or thrombotic risk, and to estimate mean daily maintenance dose of warfarin and international normalized ratio measurements among Blacks receiving warfarin anticoagulation. METHODS We conducted a retrospective cohort study among 230 Black adults receiving warfarin for a minimum of three consecutive months with a confirmed date of first dosage. RESULTS A lower mean daily maintenance dosage of warfarin was required to maintain an international normalized ratio measurement within the therapeutic range among Blacks with the VKORC1-1639G>A variant alleles ([G/A vs G/G, p = 0.02], [A/A vs G/A, p = 0.008] and [A/A vs G/G, p = 0.001]). CONCLUSION Data indicated that VKORC1-1639A variant allele influenced warfarin daily maintenance dosage among our small, likely admixed Black patient population.
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Affiliation(s)
- Fatima Donia Mili
- Hemostasis Laboratory Branch, Division of Blood Disorders, Centers for Disease Control & Prevention, Atlanta, GA 30329, USA
| | - Tenecia Allen
- Emory Heart & Vascular Center, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Paula Weinstein Wadell
- Hemostasis Laboratory Branch, Division of Blood Disorders, Centers for Disease Control & Prevention, Atlanta, GA 30329, USA
| | - W Craig Hooper
- Hemostasis Laboratory Branch, Division of Blood Disorders, Centers for Disease Control & Prevention, Atlanta, GA 30329, USA
| | - Christine De Staercke
- Hemostasis Laboratory Branch, Division of Blood Disorders, Centers for Disease Control & Prevention, Atlanta, GA 30329, USA
| | - Christopher J Bean
- Hemostasis Laboratory Branch, Division of Blood Disorders, Centers for Disease Control & Prevention, Atlanta, GA 30329, USA
| | - Cathy Lally
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA
| | - Harland Austin
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA
| | - Nanette K Wenger
- Emory Heart & Vascular Center, Emory University School of Medicine, Atlanta, GA 30322, USA
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147
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Okumura LM, Negretto GW, Carvalho CG. UNUSUAL WARFARIN DOSE TO ACHIEVE THERAPEUTIC INR IN A 4-MONTH OLD CHILD: NON-GENETICS RISK FACTORS ARE STILL A CHALLENGE. REVISTA PAULISTA DE PEDIATRIA 2017; 35:472-475. [PMID: 29185625 PMCID: PMC5737273 DOI: 10.1590/1984-0462/;2017;35;4;00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/12/2017] [Indexed: 12/05/2022]
Abstract
Objective: To report a case of a 4-month old girl that required 0.7 mg/kg/day (5 mg) of warfarin and discuss relevant risk factors for requiring higher doses. Case Description: In November 2015, a 5 kg female infant (36-week preterm) was admitted to the hospital due to status epilepticus and fever. Diazepam, phenytoin and ceftriaxone were prescribed. Cerebrospinal fluid contained 7 leukocytes, 150 mg/dL proteins, 1 mg/dL glucose and gram positive cocci were observed. Cranial tomography suggested hypodense signs in the cerebellum, right temporal lobe and left basal nuclei, which was consistent with pneumococcal meningitis-induced infectious vasculitis. She required low molecular weight heparin and warfarin for post-encephalitis thrombosis. About 10 days were required to achieve therapeutic INR, and warfarin was adjusted five times since the initial prescription. Comments: The risk factors for higher warfarin doses were age and enteral tube feeding. Phenobarbital and prednisone might also have contributed with one of the highest warfarin dose ever reported. Despite current importance given to genetics testing, clinicians should attempt to identify common contributing factors for prolonged non-therapeutic INR, to minimize the risk of coagulation, and to reduce costs of hospital stay and laboratory exams.
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148
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Yang J, Gao L, Zhang Y, Wang H, Lu C, Zhao Y, Xu Q, Xu B, Zhang Y, Yin T. Estimation of the warfarin dose with a pharmacogenetic refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Thromb Haemost 2017; 108:1132-40. [DOI: 10.1160/th12-05-0362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/14/2012] [Indexed: 12/28/2022]
Abstract
SummaryPharmacogenetic (PG) dosing algorithms have been confirmed to predict warfarin therapeutic dose more accurately;however, most of them are based on standard intensity of warfarin anticoagulation, and their utility outside this range is limited. This study was designed to develop and validate a PG refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Consented Chinese-Han patients (n=310) under stable warfarin treatment were randomly divided into a derivation (n=207) and a validation cohort (n=103), with 83% and 80% of the patients under low-intensity anticoagulation, respectively. In the derivation cohort, a PG algorithm was constructed on the basis of genotypes (CYP2C9*3 and VKORC1–1639A/G) and clinical data. After integrating additional covariates of international normalised ratio (INR) values (INR on day 4 of therapy and target INR) and genotype of CYP4F2 (rs2108622), a PG refinement algorithm was established and explained 54% of warfarin dose variability. In the validation cohort, warfarin dose prediction was more accurate (p <0.01) with the PG refinement algorithm than with the PG algorithm and the fixed dose approach (3 mg/day). In the entire cohort, the PG refinement algorithm could accurately identify larger proportions of patients with lower dose requirement (≤2 mg/day) and higher dose requirement (≥4 mg/day) than did the PG algorithm. In conclusion, PG refinement algorithm integrating early INR response and three genotypes CYP2C9*3, VKORC1–1639A/G, CYP4F2 rs2108622) improves the accuracy of warfarin dose prediction in Chinese patients mainly under low-intensity anticoagulation.
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149
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Influence of Shenxiong Glucose Injection on the Activities of Six CYP Isozymes and Metabolism of Warfarin in Rats Assessed Using Probe Cocktail and Pharmacokinetic Approaches. Molecules 2017; 22:molecules22111994. [PMID: 29156621 PMCID: PMC6150296 DOI: 10.3390/molecules22111994] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 01/21/2023] Open
Abstract
Shenxiong glucose injection (SGI), a traditional Chinese medicine (TCM) preparation, has been widely used for the treatment of various cardiovascular and cerebrovascular diseases for many years. We assessed the potential influences of SGI on the activities of six CYP enzymes (CYP1A2, CYP2C11, CYP2C19, CYP2D4, CYP2E1, and CYP3A2) and on the pharmacokinetics of warfarin in rats. We compared plasma pharmacokinetics of six probe drugs (caffeine/CYP1A2, tolbutamide/CYP2C11, omeprazole/CYP2C19, metoprolol/CYP2D4, chlorzoxazone/CYP2E1, and midazolam/CYP3A2) and of warfarin between control and SGI-pretreated groups, to estimate the effect on the relative activities of the six isozymes and warfarin metabolism. There were no significant differences in the pharmacokinetic parameters of caffeine, omeprazole, metoprolol, chlorzoxazone, and midazolam between the SGI-pretreated and control groups. However, many pharmacokinetic parameters of tolbutamide in SGI-pretreated rats were affected significantly (p < 0.05), and indicated tolbutamide metabolism in the former group was markedly slower. Moreover, SGI reduced the clearance of warfarin. These results suggested SGI showed no effects on the enzyme activities of rat CYP1A2, CYP2C19, CYP2D4, CYP2E1, and CYP3A2, but inhibited the enzyme activity of CYP2C11, and improved the blood concentration of warfarin. This suggests that the dose of warfarin may need be adjusted when co-administrated with SGI.
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150
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Fricke-Galindo I, Jung-Cook H, LLerena A, López-López M. Interethnic variability of pharmacogenetic biomarkers in Mexican healthy volunteers: a report from the RIBEF (Ibero-American Network of Pharmacogenetics and Pharmacogenomics). Drug Metab Pers Ther 2017; 31:61-81. [PMID: 26812836 DOI: 10.1515/dmpt-2015-0030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/04/2015] [Indexed: 01/01/2023]
Abstract
Mexico presents a complex population diversity integrated by Mexican indigenous (MI) (7% of Mexico's population) and Mexican mestizos (MMs). This composition highlights the importance of pharmacogenetic studies in Mexican populations. The aims of this study were to analyze the reported frequencies of the most relevant pharmacogenetic biomarkers and metabolic phenotypes in healthy volunteers from Mexican populations and to assess its interethnic variability across MI and MM populations. After a literature search in PubMed, and according to previously defined inclusion criteria, 63 pharmacogenetic studies performed in Mexican healthy volunteers up to date were selected. These reports comprised 56,292 healthy volunteers (71.58% MM). Allele frequencies in 31 pharmacogenetic biomarkers, from 121 searched, are described. Nine of these biomarkers presented variation within MM and MI groups. The frequencies of CYP2D6*3, *4, *5, *10, *17, *35 and *41 alleles in the MM group were different from those reported in the MI group. CYP2C9*2 and *3 alleles were more frequent in MM than in MI populations (χ2 test, p<0.05). CYP2C19*3 allele was not found in the MM or MI populations reported. For UGT1A1*28, only one study was found. HLA-A*31:01 and HLA-B*15:02 were present in some MM and MI populations. Poor metabolizers for CYP2D6 and CYP2C9 were more frequent in MM than in MI groups (χ2 test, p<0.05). Only 26% of the relevant pharmacogenetic biomarkers searched have been studied in Mexican healthy volunteers; therefore, further studies are warranted. The frequency variation of biomarkers in MM and MI populations could be important for the clinical implementation of pharmacogenetics in Mexico.
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