151
|
Zhu Y, Swanson KM, Rojas RL, Wang Z, St Sauver JL, Visscher SL, Prokop LJ, Bielinski SJ, Wang L, Weinshilboum R, Borah BJ. Systematic review of the evidence on the cost-effectiveness of pharmacogenomics-guided treatment for cardiovascular diseases. Genet Med 2019; 22:475-486. [PMID: 31591509 PMCID: PMC7056639 DOI: 10.1038/s41436-019-0667-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To examine the evidence on the cost-effectiveness of implementing pharmacogenomics (PGx) in cardiovascular disease (CVD) care. METHODS We conducted a systematic review using multiple databases from inception to 2018. The titles and abstracts of cost-effectiveness studies on PGx-guided treatment in CVD care were screened, and full texts were extracted. RESULTS We screened 909 studies and included 46 to synthesize. Acute coronary syndrome and atrial fibrillation were the predominantly studied conditions (59%). Most studies (78%) examined warfarin-CYP2C9/VKORC1 or clopidogrel-CYP2C19. A payer's perspective was commonly used (39%) for cost calculations, and most studies (46%) were US-based. The majority (67%) of the studies found PGx testing to be cost-effective in CVD care, but cost-effectiveness varied across drugs and conditions. Two studies examined PGx panel testing, of which one examined pre-emptive testing strategies. CONCLUSION We found mixed evidence on the cost-effectiveness of PGx in CVD care. Supportive evidence exists for clopidogrel-CYP2C19 and warfarin-CYP2C9/VKORC1, but evidence is limited in other drug-gene combinations. Gaps persist, including unclear explanation of perspective and cost inputs, underreporting of study design elements critical to economic evaluations, and limited examination of PGx panel and pre-emptive testing for their cost-effectiveness. This review identifies the need for further research on economic evaluations of PGx implementation.
Collapse
Affiliation(s)
- Ye Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kristi M Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ricardo L Rojas
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L St Sauver
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Liewei Wang
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. .,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
152
|
Abstract
Precision medicine was conceptualized on the strength of genomic sequence analysis. High-throughput functional metrics have enhanced sequence interpretation and clinical precision. These technologies include metabolomics, magnetic resonance imaging, and I rhythm (cardiac monitoring), among others. These technologies are discussed and placed in clinical context for the medical specialties of internal medicine, pediatrics, obstetrics, and gynecology. Publications in these fields support the concept of a higher level of precision in identifying disease risk. Precise disease risk identification has the potential to enable intervention with greater specificity, resulting in disease prevention-an important goal of precision medicine.
Collapse
Affiliation(s)
- Thomas Caskey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas 77030;
| |
Collapse
|
153
|
Affiliation(s)
- Stephanie Ross
- From the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.R., G.P.).,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (G.P.).,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (G.P.).,Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences and McMaster University, Canada (G.P.)
| | - Guillaume Paré
- From the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.R., G.P.).,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (G.P.).,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (G.P.).,Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences and McMaster University, Canada (G.P.)
| |
Collapse
|
154
|
Roden DM, Van Driest SL, Wells QS, Mosley JD, Denny JC, Peterson JF. Opportunities and Challenges in Cardiovascular Pharmacogenomics: From Discovery to Implementation. Circ Res 2019; 122:1176-1190. [PMID: 29700066 DOI: 10.1161/circresaha.117.310965] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This review will provide an overview of the principles of pharmacogenomics from basic discovery to implementation, encompassing application of tools of contemporary genome science to the field (including areas of apparent divergence from disease-based genomics), a summary of lessons learned from the extensively studied drugs clopidogrel and warfarin, the current status of implementing pharmacogenetic testing in practice, the role of genomics and related tools in the drug development process, and a summary of future opportunities and challenges.
Collapse
Affiliation(s)
- Dan M Roden
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.) .,Department of Pharmacology (D.M.R., Q.S.W.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Sara L Van Driest
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pediatrics (S.L.V.D.), Vanderbilt University Medical Center, Nashville, TN
| | - Quinn S Wells
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pharmacology (D.M.R., Q.S.W.)
| | - Jonathan D Mosley
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.)
| | - Joshua C Denny
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Josh F Peterson
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| |
Collapse
|
155
|
Gage BF, Bass AR, Lin H, Woller SC, Stevens SM, Al-Hammadi N, Anderson JL, Li J, Rodriguez T, Miller JP, McMillin GA, Pendleton RC, Jaffer AK, King CR, Whipple B, Porche-Sorbet R, Napoli L, Merritt K, Thompson AM, Hyun G, Hollomon W, Barrack RL, Nunley RM, Moskowitz G, Dávila-Román V, Eby CS. Effect of Low-Intensity vs Standard-Intensity Warfarin Prophylaxis on Venous Thromboembolism or Death Among Patients Undergoing Hip or Knee Arthroplasty: A Randomized Clinical Trial. JAMA 2019; 322:834-842. [PMID: 31479138 PMCID: PMC6724181 DOI: 10.1001/jama.2019.12085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The optimal international normalized ratio (INR) to prevent venous thromboembolism (VTE) in warfarin-treated patients with recent arthroplasty is unknown. OBJECTIVE To determine the safety and efficacy of a target INR of 1.8 vs 2.5 for VTE prophylaxis after orthopedic surgery. DESIGN, SETTING, AND PARTICIPANTS The randomized Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis enrolled 1650 patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. INTERVENTIONS In a 2 × 2 factorial design, participants were randomized to a target INR of 1.8 (n = 823) or 2.5 (n = 827) and to either genotype-guided or clinically guided warfarin dosing. For the first 11 days of therapy, open-label warfarin dosing was guided by a web application. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of VTE (within 60 days) or death (within 30 days). Participants underwent screening duplex ultrasound postoperatively. The hypothesis was that an INR target of 1.8 would be noninferior to an INR target of 2.5, using a noninferiority margin of 3% for the absolute risk of VTE. Secondary end points were bleeding and INR values of 4 or more. RESULTS Among 1650 patients who were randomized (mean age, 72.1 years; 1049 women [63.6%]; 1502 white [91.0%]), 1597 (96.8%) received at least 1 dose of warfarin and were included in the primary analysis. The rate of the primary composite outcome of VTE or death was 5.1% (41 of 804) in the low-intensity-warfarin group (INR target, 1.8) vs 3.8% (30 of 793) in the standard-treatment-warfarin group (INR target, 2.5), for a difference of 1.3% (1-sided 95% CI, -∞ to 3.05%, P = .06 for noninferiority). Major bleeding occurred in 0.4% of patients in the low-intensity group and 0.9% of patients in the standard-intensity group, for a difference of -0.5% (95% CI, -1.6% to 0.4%). The INR values of 4 or more occurred in 4.5% of patients in the low-intensity group and 12.2% of the standard-intensity group, for a difference of -7.8% (95% CI, -10.5% to -5.1%). CONCLUSIONS AND RELEVANCE Among older patients undergoing hip or knee arthroplasty and receiving warfarin prophylaxis, an international normalized ratio goal of 1.8 compared with 2.5 did not meet the criterion for noninferiority for risk of the composite outcome of VTE or death. However, the trial may have been underpowered to meet this criterion and further research may be warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01006733.
Collapse
Affiliation(s)
- Brian F. Gage
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Anne R. Bass
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Hannah Lin
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Massachusetts, Worcester
| | - Scott C. Woller
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Scott M. Stevens
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Noor Al-Hammadi
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Jeffrey L. Anderson
- Department of Medicine, University of Utah, Salt Lake City
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah
| | - Juan Li
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Tomás Rodriguez
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | | | - Amir K. Jaffer
- Department of Medicine, New York Presbyterian Queens Hospital, New York
| | - Cristi R. King
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Brandi Whipple
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Lynnae Napoli
- Department of Medicine, University of Utah, Salt Lake City
| | - Kerri Merritt
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Anna M. Thompson
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Central Florida College of Medicine, Orlando
| | - Gina Hyun
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Wesley Hollomon
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert L. Barrack
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ryan M. Nunley
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Gerard Moskowitz
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Victor Dávila-Román
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles S. Eby
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Pathology and Immunology, Washington University in St Louis, St Louis, Missouri
| |
Collapse
|
156
|
Johnson D, Hughes D, Pirmohamed M, Jorgensen A. Evidence to Support Inclusion of Pharmacogenetic Biomarkers in Randomised Controlled Trials. J Pers Med 2019; 9:E42. [PMID: 31480618 PMCID: PMC6789450 DOI: 10.3390/jpm9030042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 01/01/2023] Open
Abstract
Pharmacogenetics and biomarkers are becoming normalised as important technologies to improve drug efficacy rates, reduce the incidence of adverse drug reactions, and make informed choices for targeted therapies. However, their wider clinical implementation has been limited by a lack of robust evidence. Suitable evidence is required before a biomarker's clinical use, and also before its use in a clinical trial. We have undertaken a review of five pharmacogenetic biomarker-guided randomised controlled trials (RCTs) and evaluated the evidence used by these trials to justify biomarker inclusion. We assessed and quantified the evidence cited in published rationale papers, or where these were not available, obtained protocols from trial authors. Very different levels of evidence were provided by the trials. We used these observations to write recommendations for future justifications of biomarker use in RCTs and encourage regulatory authorities to write clear guidelines.
Collapse
Affiliation(s)
- Danielle Johnson
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK.
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Ardudwy, Normal Site, Bangor LL57 2PZ, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Andrea Jorgensen
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| |
Collapse
|
157
|
Bush WS, Cooke Bailey JN, Beno MF, Crawford DC. Bridging the Gaps in Personalized Medicine Value Assessment: A Review of the Need for Outcome Metrics across Stakeholders and Scientific Disciplines. Public Health Genomics 2019; 22:16-24. [PMID: 31454805 PMCID: PMC6752968 DOI: 10.1159/000501974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/07/2019] [Indexed: 12/14/2022] Open
Abstract
Despite monumental advances in genomics, relatively few health care provider organizations in the United States offer personalized or precision medicine as part of the routine clinical workflow. The gaps between research and applied genomic medicine may be a result of a cultural gap across various stakeholders representing scientists, clinicians, patients, policy makers, and third party payers. Scientists are trained to assess the health care value of genomics by either quantifying population-scale effects, or through the narrow lens of clinical trials where the standard of care is compared with the predictive power of a single or handful of genetic variants. While these metrics are an essential first step in assessing and documenting the clinical utility of genomics, they are rarely followed up with other assessments of health care value that are critical to stakeholders who use different measures to define value. The limited value assessment in both the research and implementation science of precision medicine is likely due to necessary logistical constraints of these teams; engaging bioethicists, health care economists, and individual patient belief systems is incredibly daunting for geneticists and informaticians conducting research. In this narrative review, we concisely describe several definitions of value through various stakeholder viewpoints. We highlight the existing gaps that prevent clinical translation of scientific findings generally as well as more specifically using two present-day, extreme scenarios: (1) genetically guided warfarin dosing representing a handful of genetic markers and more than 10 years of basic and translational research, and (2) next-generation sequencing representing genome-dense data lacking substantial evidence for implementation. These contemporary scenarios highlight the need for various stakeholders to broadly adopt frameworks designed to define and collect multiple value measures across different disciplines to ultimately impact more universal acceptance of and reimbursement for genomic medicine.
Collapse
Affiliation(s)
- William S Bush
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jessica N Cooke Bailey
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark F Beno
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dana C Crawford
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA,
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA,
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, USA,
| |
Collapse
|
158
|
Krebs K, Milani L. Translating pharmacogenomics into clinical decisions: do not let the perfect be the enemy of the good. Hum Genomics 2019; 13:39. [PMID: 31455423 PMCID: PMC6712791 DOI: 10.1186/s40246-019-0229-z] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/31/2019] [Indexed: 12/14/2022] Open
Abstract
The field of pharmacogenomics (PGx) is gradually shifting from the reactive testing of single genes toward the proactive testing of multiple genes to improve treatment outcomes, reduce adverse events, and decrease the burden of unnecessary costs for healthcare systems. Despite the progress in the field of pharmacogenomics, its implementation into routine care has been slow due to several barriers. However, in recent years, the number of studies on the implementation of PGx has increased, all providing a wealth of knowledge on different solutions for overcoming the obstacles that have been emphasized over the past years. This review focuses on some of the challenges faced by these initiatives, the solutions and different approaches for testing that they suggest, and the evidence that they provide regarding the benefits of preemptive PGx testing.
Collapse
Affiliation(s)
- Kristi Krebs
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
- Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
| | - Lili Milani
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| |
Collapse
|
159
|
Shi Y, Graves JA, Garbett SP, Zhou Z, Marathi R, Wang X, Harrell FE, Lasko TA, Denny JC, Roden DM, Peterson JF, Schildcrout JS. A Decision-Theoretic Approach to Panel-Based, Preemptive Genotyping. MDM Policy Pract 2019; 4:2381468319864337. [PMID: 31453360 PMCID: PMC6699004 DOI: 10.1177/2381468319864337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/01/2019] [Indexed: 12/22/2022] Open
Abstract
We discuss a decision-theoretic approach to building a panel-based, preemptive
genotyping program. The method is based on findings that a large percentage of
patients are prescribed medications that are known to have pharmacogenetic
associations, and over time, a substantial proportion are prescribed additional
such medication. Preemptive genotyping facilitates genotype-guided therapy at
the time medications are prescribed; panel-based testing allows providers to
reuse previously collected genetic data when a new indication arises. Because it
is cost-prohibitive to conduct panel-based genotyping on all patients, we
describe a three-step approach to identify patients with the highest anticipated
benefit. First, we construct prediction models to estimate the risk of being
prescribed one of the target medications using readily available clinical data.
Second, we use literature-based estimates of adverse event rates, variant allele
frequencies, secular death rates, and costs to construct a discrete event
simulation that estimates the expected benefit of having an individual’s genetic
data in the electronic health record after an indication has occurred. Finally,
we combine medication prescription risk with expected benefit of genotyping once
a medication is indicated to calculate the expected benefit of preemptive
genotyping. For each patient-clinic visit, we calculate this expected benefit
across a range of medications and select patients with the highest expected
benefit overall. We build a proof of concept implementation using a cohort of
patients from a single academic medical center observed from July 2010 through
December 2012. We then apply the results of our modeling strategy to show the
extent to which we can improve clinical and economic outcomes in a cohort
observed from January 2013 through December 2015.
Collapse
Affiliation(s)
- Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A Graves
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shawn P Garbett
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zilu Zhou
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ramya Marathi
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiaoming Wang
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas A Lasko
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | |
Collapse
|
160
|
Roden DM, McLeod HL, Relling MV, Williams MS, Mensah GA, Peterson JF, Van Driest SL. Pharmacogenomics. Lancet 2019; 394:521-532. [PMID: 31395440 PMCID: PMC6707519 DOI: 10.1016/s0140-6736(19)31276-0] [Citation(s) in RCA: 211] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/04/2019] [Accepted: 05/16/2019] [Indexed: 02/08/2023]
Abstract
Genomic medicine, which uses DNA variation to individualise and improve human health, is the subject of this Series of papers. The idea that genetic variation can be used to individualise drug therapy-the topic addressed here-is often viewed as within reach for genomic medicine. We have reviewed general mechanisms underlying variability in drug action, the role of genetic variation in mediating beneficial and adverse effects through variable drug concentrations (pharmacokinetics) and drug actions (pharmacodynamics), available data from clinical trials, and ongoing efforts to implement pharmacogenetics in clinical practice.
Collapse
Affiliation(s)
- Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL, USA
| | - Mary V Relling
- Pharmaceutical Department, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Josh F Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
161
|
da Silveira MMBM, Melo LDA, Gomes FMF, Andrade LJDCBDR, Serur IP, Piscoya ICDV, Gueiros RM, Palmeira do Ó K, de Lima RE, Brasileiro VAE, Vasconcelos LRS, Sobral Filho DC. Polymorphisms of CYP2C9*2, CYP2C9*3 and VKORC1 genes related to time in therapeutic range in patients with atrial fibrillation using warfarin. Appl Clin Genet 2019; 12:151-159. [PMID: 31447576 PMCID: PMC6684853 DOI: 10.2147/tacg.s197316] [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: 12/06/2018] [Accepted: 04/10/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Warfarin continues to be the most widely used anticoagulant in clinical practice around the world for the prevention of thromboembolic events in patients with atrial fibrillation (AF). The evaluation of the quality of anticoagulation control, estimated by time in therapeutic range (TTR), is accepted as a good method to evaluate the quality of anticoagulation. The variability of TTR can be explained by the presence of variants of the CYP2C9 and VKORC1 genes. METHODS This study examined the association between polymorphisms of the CYP2C9 and VKORC1 genes and control of oral anticoagulation, through TTR, in patients with AF. A cross-sectional study was conducted within a cohort follow-up. The study comprised of 317 patients with AF, using warfarin, who were followed up for one year. The genotyping of genes CYP2C9 (rs1057910), (rs1799853) and VKORC1 (rs923231) was performed by PCR in real time, using TaqMan probes. RESULTS Patients who had variant genotypes for the CYP2C9*3 gene (rs1057910) presented higher TTR (TTR 81-100%) when compared to when compared to the <45% and 46-60% TTR groups (p=0.005 and p=0.002, respectively). Regarding VKORC1 (rs923231), patients who had the variant genotype for the VKORC1 (rs923231) gene also presented a higher TTR (TTR 81-100%), when when compared to the <45% and 46-60% TTR groups (p=0.005 and p=0.004, respectively). In a multivariate model, VKORC1 (rs923231) remained associated for comparisons with the TTR groups (<45% vs 81-100% groups, p=0.01; and 46-60% vs 81-100% groups, p=0.01). CONCLUSION The genotypes of the CYP2C9*3 (AA) and VKORC1 -1639 (GG) genes were associated with the worst quality of anticoagulation control (TTR) in patients with AF using warfarin in the northeast of Brazil.
Collapse
Affiliation(s)
- Maria Mariana Barros Melo da Silveira
- Faculdade de Ciências Médicas, Universidade de Pernambuco - FCM/UPE, Recife, Brazil
- Pronto Socorro Cardiológico Professor Luiz Tavares - PROCAPE/UPE
, Recife, Brazil
| | - Leiliandry de Araújo Melo
- Faculdade de Ciências Médicas, Universidade de Pernambuco - FCM/UPE, Recife, Brazil
- Pronto Socorro Cardiológico Professor Luiz Tavares - PROCAPE/UPE
, Recife, Brazil
| | | | | | | | | | | | | | | | - Victor Arthur Eulálio Brasileiro
- Faculdade de Ciências Médicas, Universidade de Pernambuco - FCM/UPE, Recife, Brazil
- Pronto Socorro Cardiológico Professor Luiz Tavares - PROCAPE/UPE
, Recife, Brazil
| | | | | |
Collapse
|
162
|
Musunuru K, Arora P, Cooke JP, Ferguson JF, Hershberger RE, Hickey KT, Lee JM, Lima JAC, Loscalzo J, Pereira NL, Russell MW, Shah SH, Sheikh F, Wang TJ, MacRae CA. Interdisciplinary Models for Research and Clinical Endeavors in Genomic Medicine: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 11:e000046. [PMID: 29844141 DOI: 10.1161/hcg.0000000000000046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The completion of the Human Genome Project has unleashed a wealth of human genomics information, but it remains unclear how best to implement this information for the benefit of patients. The standard approach of biomedical research, with researchers pursuing advances in knowledge in the laboratory and, separately, clinicians translating research findings into the clinic as much as decades later, will need to give way to new interdisciplinary models for research in genomic medicine. These models should include scientists and clinicians actively working as teams to study patients and populations recruited in clinical settings and communities to make genomics discoveries-through the combined efforts of data scientists, clinical researchers, epidemiologists, and basic scientists-and to rapidly apply these discoveries in the clinic for the prediction, prevention, diagnosis, prognosis, and treatment of cardiovascular diseases and stroke. The highly publicized US Precision Medicine Initiative, also known as All of Us, is a large-scale program funded by the US National Institutes of Health that will energize these efforts, but several ongoing studies such as the UK Biobank Initiative; the Million Veteran Program; the Electronic Medical Records and Genomics Network; the Kaiser Permanente Research Program on Genes, Environment and Health; and the DiscovEHR collaboration are already providing exemplary models of this kind of interdisciplinary work. In this statement, we outline the opportunities and challenges in broadly implementing new interdisciplinary models in academic medical centers and community settings and bringing the promise of genomics to fruition.
Collapse
|
163
|
Knijnik L, Rivera M, Blumer V, Cardoso R, Fernandes A, Fernandes G, Ferreira T, Romano JG, Lambrakos LK, Cohen MG. Prevention of Stroke in Atrial Fibrillation After Coronary Stenting. Stroke 2019; 50:2125-2132. [PMID: 31303150 DOI: 10.1161/strokeaha.119.026078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.
Collapse
Affiliation(s)
- Leonardo Knijnik
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Manuel Rivera
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.R.)
| | - Vanessa Blumer
- Cardiovascular Division, Duke University Hospital, Durham, NC (V.B.)
| | - Rhanderson Cardoso
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD (R.C.)
| | - Amanda Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Gilson Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Tanira Ferreira
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Jose G Romano
- Department of Neurology (J.G.R.), University of Miami Miller School of Medicine, FL
| | - Litsa K Lambrakos
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
| |
Collapse
|
164
|
Chinese Patients With Heart Valve Replacement Do Not Benefit From Warfarin Pharmacogenetic Testing on Anticoagulation Outcomes. Ther Drug Monit 2019; 41:748-754. [PMID: 31259883 DOI: 10.1097/ftd.0000000000000664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Genotype-guided warfarin dosing has been shown in some randomized trials to improve anticoagulation outcomes in individuals of European ancestry; yet, its utility in Chinese patients with heart valve replacement remains unresolved. METHODS A total of 2264 patients who underwent heart valve replacement at Wuhan Asia Heart Hospital were enrolled in this study. Patients were randomly divided into 2 groups, namely, a genotype-guided and a traditional clinically guided warfarin dosing group. In the genotype-guided group (n = 1134), genotyping for CYP2C9 and VKORC1 (-1639 G→A) was performed using TaqMan genotyping assay. Warfarin doses were predicted with the International Warfarin Pharmacogenetics Consortium algorithm. Patients in the control group (n = 1130) were clinically guided. The primary outcome was to compare the incidence of adverse events (major bleeding and thrombotic) during a 90-day follow-up period between 2 groups. Secondary objectives were to describe effects of the pharmacogenetic intervention on the first therapeutic-target-achieving time, the stable maintenance dose, and the hospitalization days. RESULTS A total of 2245 patients were included in the analysis. Forty-nine events occurred during follow-up. Genotype-guided dosing strategy did not result in a reduction in major bleeding (0.26% versus 0.63%; hazard ratio, 0.44; 95% confidence interval, 0.13-1.53; P = 0.20) and thrombotic events (0.89% versus 1.61%; hazard ratio, 0.56; 95% confidence interval, 0.27-1.17; P = 0.12) compared with clinical dosing group. Compared with traditional dosing, patients in the genotype-guided group reached their therapeutic international normalized ratio in a shorter time (3.8 ± 2.0 versus 4.4 ± 2.0 days, P < 0.001). There was no difference in hospitalization days (P = 0.28). CONCLUSIONS Warfarin pharmacogenetic testing according to the International Warfarin Pharmacogenetics Consortium algorithm cannot improve anticoagulation outcomes in Chinese patients with heart valve replacement.
Collapse
|
165
|
Onundarson PT, Flygenring B. Oral anticoagulant monitoring: Are we on the right track? Int J Lab Hematol 2019; 41 Suppl 1:40-48. [PMID: 31069986 DOI: 10.1111/ijlh.13008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 12/21/2022]
Abstract
Vitamin K antagonists (VKAs) cannot be administered without regular monitoring in order to assure their efficacy and safety. Indeed, if well managed, the VKAs appear to be no less efficacious or safe than the newer direct oral anticoagulants (DOACs). Although it is claimed that no regular monitoring of the DOACs is needed, their levels are increasingly being measured under a variety of circumstances, for example, prior to surgery, in suspected overdose, to confirm effective reversal, in patients with malabsorption and to assess patient compliance. Although no therapeutic range has been identified for the DOACs, it has been demonstrated for dabigatran and edoxaban that their antithrombotic effect increases gradually with increasing concentrations and that the risk of major bleeding also gradually increases. Furthermore, it has been determined that almost all dabigatran-related thrombotic events occur in patients with the lowest quartile concentration of the drug. This suggests that to assure an ideal effect of DOACs in all patients taking them, some form of regular monitoring and dose tailoring should be performed. For the vitamin K antagonists, the best outcome is obtained using formal algorithms and centralized management. Furthermore, data suggest that replacing the standard prothrombin time as a monitoring test may increase the stability of VKA anticoagulation with consequent reduction in thromboembolism without an increase in bleeding. Thus, it is likely that the outcome of all current oral anticoagulants can be improved in the coming years by improving monitoring and tailoring their effect.
Collapse
Affiliation(s)
- Pall T Onundarson
- Landspitali/The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bjorn Flygenring
- Landspitali/The National University Hospital of Iceland, Reykjavik, Iceland
| |
Collapse
|
166
|
Helin TA, Joutsi-Korhonen L, Asmundela H, Niemi M, Orpana A, Lassila R. Warfarin dose requirement in patients having severe thrombosis or thrombophilia. Br J Clin Pharmacol 2019; 85:1684-1691. [PMID: 30933373 DOI: 10.1111/bcp.13948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 03/12/2019] [Accepted: 03/23/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS Warfarin dose requirement varies significantly. We compared the clinically established doses based on international normalized ratio (INR) among patients with severe thrombosis and/or thrombophilia with estimates from genetic dosing algorithms. METHODS Fifty patients with severe thrombosis and/or thrombophilia requiring permanent anticoagulation, referred to the Helsinki University Hospital Coagulation Center, were screened for thrombophilias and genotyped for CYP2C9*2 (c.430C>T, rs1799853), CYP2C9*3 (c.1075A>C, rs1057910) and VKORC1 c.-1639G>A (rs9923231) variants. The warfarin maintenance doses (target INR 2.0-3.0 in 94%, 2.5-3.5 in 6%) were estimated by the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) algorithms. The individual warfarin maintenance dose was tailored, supplementing estimates with comprehensive clinical evaluation and INR data. RESULTS Mean patient age was 47 years (range 20-76), and BMI 27 (SD 6), 68% being women. Forty-six (92%) had previous venous or arterial thrombosis, and 26 (52%) had a thrombophilia, with 22% having concurrent aspirin. A total of 40% carried the CYP2C9*2 or *3 allele and 54% carried the VKORC1-1639A allele. The daily mean maintenance dose of warfarin estimated by the Gage algorithm was 5.4 mg (95% CI 4.9-5.9 mg), and by the IWPC algorithm was 5.2 mg (95% CI 4.7-5.7 mg). The daily warfarin maintenance dose after clinical visits and follow-up was higher than the estimates, mean 6.9 mg (95% CI 5.6-8.2 mg, P < 0.006), with highest dose in patients having multiple thrombophilic factors (P < 0.03). CONCLUSIONS In severe thrombosis and/or thrombophilia, variation in thrombin generation and pharmacodynamics influences warfarin response. Pharmacogenetic dosing algorithms seem to underestimate dose requirement.
Collapse
Affiliation(s)
- Tuukka A Helin
- Coagulation Disorders Unit, Clinical Chemistry, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Lotta Joutsi-Korhonen
- Coagulation Disorders Unit, Clinical Chemistry, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Heidi Asmundela
- Coagulation Disorders Unit, Hematology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Arto Orpana
- Genetics and Clinical Chemistry, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Riitta Lassila
- Coagulation Disorders Unit, Clinical Chemistry, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland.,Coagulation Disorders Unit, Hematology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
167
|
van der Wouden CH, van Rhenen MH, Jama WOM, Ingelman-Sundberg M, Lauschke VM, Konta L, Schwab M, Swen JJ, Guchelaar HJ. Development of the PGx-Passport: A Panel of Actionable Germline Genetic Variants for Pre-Emptive Pharmacogenetic Testing. Clin Pharmacol Ther 2019; 106:866-873. [PMID: 31038729 PMCID: PMC6771671 DOI: 10.1002/cpt.1489] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/21/2019] [Indexed: 12/19/2022]
Abstract
Pre-emptive pharmacogenetics (PGx) testing of a panel of germline genetic variants represents a new model for personalized medicine. Clinical impact of PGx testing is maximized when all variant alleles for which actionable clinical guidelines are available are included in the test panel. However, no such standardized panel has been presented to date, impeding adoption, exchange, and continuity of PGx testing. We, therefore, developed such a panel, hereafter called the PGx-Passport, based on the actionable Dutch Pharmacogenetics Working Group (DPWG) guidelines. Germline-variant alleles were systematically selected using predefined criteria regarding allele population frequencies, effect on protein functionality, and association with drug response. A PGx-Passport of 58 germline variant alleles, located within 14 genes (CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A5, DPYD, F5, HLA-A, HLA-B, NUDT15, SLCO1B1, TPMT, UGT1A1, and VKORC1) was composed. This PGx-Passport can be used in combination with the DPWG guidelines to optimize drug prescribing for 49 commonly prescribed drugs.
Collapse
Affiliation(s)
- Cathelijne H van der Wouden
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden, The Netherlands
| | | | - Wafa O M Jama
- Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | - Magnus Ingelman-Sundberg
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Biomedicum 5B Karolinska Institutet, Stockholm, Sweden
| | - Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Biomedicum 5B Karolinska Institutet, Stockholm, Sweden
| | - Lidija Konta
- bio.logis Center for Human Genetics, Frankfurt am Main, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Clinical Pharmacology and Departments of Biochemistry and Pharmacy,, University Tuebingen, Tuebingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Leiden Network for Personalised Therapeutics, Leiden, The Netherlands
| |
Collapse
|
168
|
Chanfreau-Coffinier C, Hull LE, Lynch JA, DuVall SL, Damrauer SM, Cunningham FE, Voight BF, Matheny ME, Oslin DW, Icardi MS, Tuteja S. Projected Prevalence of Actionable Pharmacogenetic Variants and Level A Drugs Prescribed Among US Veterans Health Administration Pharmacy Users. JAMA Netw Open 2019; 2:e195345. [PMID: 31173123 PMCID: PMC6563578 DOI: 10.1001/jamanetworkopen.2019.5345] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Implementation of pharmacogenetic testing to guide drug prescribing has potential to improve drug response and prevent adverse events. Robust data exist for more than 30 gene-drug pairs linking genotype to drug response phenotypes; however, it is unclear which pharmacogenetic tests, if implemented, would provide the greatest utility for a given patient population. OBJECTIVES To project the proportion of veterans in the US Veterans Health Administration (VHA) with actionable pharmacogenetic variants and evaluate how testing might be associated with prescribing decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included veterans who used national VHA pharmacy services from October 1, 2011, to September 30, 2017. Data analyses began April 26, 2018, and were completed February 6, 2019. EXPOSURES Receipt of level A drugs based on VHA pharmacy dispensing records. MAIN OUTCOMES AND MEASURES Projected prevalence of actionable pharmacogenetic variants among VHA pharmacy users based on variant frequencies from the 1000 Genomes Project and veteran demographic characteristics; incident number of level A prescriptions, and proportion of new level A drug recipients projected to carry an actionable pharmacogenetic variant. RESULTS During the study, 7 769 359 veterans (mean [SD] age, 58.1 [17.8] years; 7 021 504 [90.4%] men) used VHA pharmacy services. It was projected that 99% of VHA pharmacy users would carry at least 1 actionable pharmacogenetic variant. Among VHA pharmacy users, 4 259 153 (54.8%) received at least 1 level A drug with 1 188 124 (15.3%) receiving 2 drugs, and 912 189 (11.7%) receiving 3 or more drugs. The most common incident prescriptions during the study were tramadol (923 671 new recipients), simvastatin (533 928 new recipients), citalopram (266 952 new recipients), and warfarin (205 177 new recipients). Gene-drug interactions projected to have substantial clinical impacts in the VHA population include the interaction of SLCO1B1 with simvastatin (1 988 956 veterans [25.6%]), CYP2D6 with tramadol (318 544 veterans [4.1%]), and CYP2C9 or VKORC1 with warfarin (7 163 349 veterans [92.2%]). CONCLUSIONS AND RELEVANCE Clinically important pharmacogenetic variants are highly prevalent in the VHA population. Almost all veterans would carry an actionable variant, and more than half of the population had been exposed to a drug affected by these variants. These results suggest that pharmacogenetic testing has the potential to affect pharmacotherapy decisions for commonly prescribed outpatient medications for many veterans.
Collapse
Affiliation(s)
- Catherine Chanfreau-Coffinier
- US Department of Veterans Affairs, VA Informatics and Computing Infrastructure, Salt Lake City Health Care System, Salt Lake City, Utah
| | - Leland E. Hull
- Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Boston Healthcare System, Boston, Massachusetts
- US Department of Veterans Affairs, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Julie A. Lynch
- US Department of Veterans Affairs, VA Informatics and Computing Infrastructure, Salt Lake City Health Care System, Salt Lake City, Utah
- US Department of Veterans Affairs, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
- College of Nursing and Health Sciences, University of Massachusetts, Boston
| | - Scott L. DuVall
- US Department of Veterans Affairs, VA Informatics and Computing Infrastructure, Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Scott M. Damrauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Francesca E. Cunningham
- US Department of Veterans Affairs Center for Medication Safety, Pharmacy Benefits Management Services, Hines, Illinois
| | | | - Michael E. Matheny
- Geriatrics Research Education and Clinical Care Center, US Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David W. Oslin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Michael S. Icardi
- US Department of Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- US Department of Veterans Affairs National Office of Pathology and Laboratory Medicine, Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City
| | - Sony Tuteja
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| |
Collapse
|
169
|
Lin B, Chung WK. Cases in Precision Medicine: The Role of Pharmacogenetics in Precision Prescribing. Ann Intern Med 2019; 170:796-804. [PMID: 31108507 PMCID: PMC7458588 DOI: 10.7326/m18-2357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pharmacogenetics may help physicians deliver individualized treatments based on how a person's genes affect a drug's effects and metabolism. This information can help prevent adverse events or improve drug efficacy by enabling the physician to optimize dosage or to avoid a medication with adverse reactions and to prescribe an alternative therapy. This article discusses the current clinical utility of pharmacogenetic testing in the context of a patient who requires anticoagulation with warfarin.
Collapse
Affiliation(s)
- Bohan Lin
- Columbia University, New York, New York (B.L., W.K.C.)
| | - Wendy K Chung
- Columbia University, New York, New York (B.L., W.K.C.)
| |
Collapse
|
170
|
Fitzgerald G, Prince C, Downing J, Reynolds J, Zhang JE, Hanson A, Alfirevic A, Pirmohamed M. Processes and barriers to implementation of point-of-care genotype-guided dosing of warfarin into UK outpatient anticoagulation clinics. Pharmacogenomics 2019; 20:599-608. [DOI: 10.2217/pgs-2019-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Gail Fitzgerald
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Clare Prince
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Jennifer Downing
- Research Manager, NIHR CLAHRC NWC, University of Liverpool, Liverpool, UK
| | - Julia Reynolds
- Associate Director, Innovation Agency, Academic Health Science Network for the North West Coast, Warrington, UK
| | - Jieying Eunice Zhang
- Post-doctoral Research Associate, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Anita Hanson
- Research Nurse, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Ana Alfirevic
- Professor of Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- David Weatherall Chair of Medicine, University of Liverpool & Royal Liverpool & Broadgreen University Hospitals NHS Trust, Liverpool, UK
| |
Collapse
|
171
|
Lv C, Liu C, Liu J, Li Z, Du X, Li Y, Sun J, Sun L, Fan R, Huang Y. The Effect of Compound Danshen Dripping Pills on the Dose and Concentration of Warfarin in Patients with Various Genetic Polymorphisms. Clin Ther 2019; 41:1097-1109. [DOI: 10.1016/j.clinthera.2019.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
|
172
|
Danese E, Raimondi S, Montagnana M, Tagetti A, Langaee T, Borgiani P, Ciccacci C, Carcas AJ, Borobia AM, Tong HY, Dávila-Fajardo C, Botton MR, Bourgeois S, Deloukas P, Caldwell MD, Burmester JK, Berg RL, Cavallari LH, Drozda K, Huang M, Zhao LZ, Cen HJ, Gonzalez-Conejero R, Roldan V, Nakamura Y, Mushiroda T, Gong IY, Kim RB, Hirai K, Itoh K, Isaza C, Beltrán L, Jiménez-Varo E, Cañadas-Garre M, Giontella A, Kringen MK, Foss Haug KB, Gwak HS, Lee KE, Minuz P, Lee MTM, Lubitz SA, Scott S, Mazzaccara C, Sacchetti L, Genç E, Özer M, Pathare A, Krishnamoorthy R, Paldi A, Siguret V, Loriot MA, Kutala VK, Suarez-Kurtz G, Perini J, Denny JC, Ramirez AH, Mittal B, Rathore SS, Sagreiya H, Altman R, Shahin MHA, Khalifa SI, Limdi NA, Rivers C, Shendre A, Dillon C, Suriapranata IM, Zhou HH, Tan SL, Tatarunas V, Lesauskaite V, Zhang Y, Maitland-van der Zee AH, Verhoef TI, de Boer A, Taljaard M, Zambon CF, Pengo V, Zhang JE, Pirmohamed M, Johnson JA, Fava C. Effect of CYP4F2, VKORC1, and CYP2C9 in Influencing Coumarin Dose: A Single-Patient Data Meta-Analysis in More Than 15,000 Individuals. Clin Pharmacol Ther 2019; 105:1477-1491. [PMID: 30506689 PMCID: PMC6542461 DOI: 10.1002/cpt.1323] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/18/2018] [Indexed: 11/06/2022]
Abstract
The cytochrome P450 (CYP)4F2 gene is known to influence mean coumarin dose. The aim of the present study was to undertake a meta-analysis at the individual patients level to capture the possible effect of ethnicity, gene-gene interaction, or other drugs on the association and to verify if inclusion of CYP4F2*3 variant into dosing algorithms improves the prediction of mean coumarin dose. We asked the authors of our previous meta-analysis (30 articles) and of 38 new articles retrieved by a systematic review to send us individual patients' data. The final collection consists of 15,754 patients split into a derivation and validation cohort. The CYP4F2*3 polymorphism was consistently associated with an increase in mean coumarin dose (+9% (95% confidence interval (CI) 7-10%), with a higher effect in women, in patients taking acenocoumarol, and in white patients. The inclusion of the CYP4F2*3 in dosing algorithms slightly improved the prediction of stable coumarin dose. New pharmacogenetic equations potentially useful for clinical practice were derived.
Collapse
Affiliation(s)
- Elisa Danese
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Raimondi
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Martina Montagnana
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Angela Tagetti
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Paola Borgiani
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Cinzia Ciccacci
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Antonio J. Carcas
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Hoi Y. Tong
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Cristina Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, IBS, Granada, Spain
| | | | - Stephane Bourgeois
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
| | - Panos Deloukas
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Michael D. Caldwell
- Center for Hyperbaric Medicine and Tissue Repair, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Jim K. Burmester
- Grants Office, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Richard L. Berg
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Katarzyna Drozda
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Li-Zi Zhao
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Han-Jing Cen
- Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Rocio Gonzalez-Conejero
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Vanessa Roldan
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Yusuke Nakamura
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Taisei Mushiroda
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Inna Y. Gong
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Richard B. Kim
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Keita Hirai
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Carlos Isaza
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Leonardo Beltrán
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
- Faculty of Heath Sciences, Unidad Central del Valle del Cauca, Valle del Cauca, Colombia
| | | | - Marisa Cañadas-Garre
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Alice Giontella
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Marianne K. Kringen
- Department of Pharmacology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Kari Bente Foss Haug
- Department of Medical Biochemistry, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Hye Sun Gwak
- Division of Life and Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, Korea
| | - Kyung Eun Lee
- College of Pharmacy, Chungbuk National University, Cheongju-si, Korea
| | - Pietro Minuz
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Ming Ta Michael Lee
- Genomic Medicine Institute, Geisinger Health System, Danville, Pennsylvania, USA
- National Center for Genome Medicine, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stuart Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Mazzaccara
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Lucia Sacchetti
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Ece Genç
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Mahmut Özer
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Anil Pathare
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | - Andras Paldi
- Ecole Pratique des Hautes Etudes, UMRS_951, Genethon, Evry, France
| | - Virginie Siguret
- Sorbonne Paris Cité, INSERM, UMR-S-1140, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière, Service d’Hématologie Biologique, Paris, France
| | - Marie-Anne Loriot
- Sorbonne Paris Cité, INSERM, UMR-S-1147, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Biochimie UF Pharmacogénétique et Oncologie Moléculaire, Paris, France
| | - Vijay Kumar Kutala
- Department of Clinical Pharmacology & Therapeutics, Nizam’s Institute of Medical Sciences, Hyderabad, India
| | | | - Jamila Perini
- Research Laboratory of Pharmaceutical Sciences, West Zone State University-UEZO, Rio de Janeiro, Brazil
| | - Josh C. Denny
- Department of Medicine and Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrea H. Ramirez
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Balraj Mittal
- Department of Biotechnology, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | | | - Hersh Sagreiya
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Russ Altman
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Mohamed Hossam A. Shahin
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sherief I. Khalifa
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Rivers
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aditi Shendre
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana, USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ivet M. Suriapranata
- Mochtar Riady Institute for Nanotechnology, Universitas Pelita Harapan, Lippo Karawaci, Tangerang, Banten, Indonesia
| | - Hong-Hao Zhou
- Institute of Clinical Pharmacology, Central South University, Hunan Sheng, China
| | - Sheng-Lan Tan
- Department of Pharmacy, Xiangya Second Hospital, Central South University, Hunan Sheng, China
| | - Vacis Tatarunas
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaiva Lesauskaite
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yumao Zhang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke H. Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Talitha I. Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Monica Taljaard
- Clinica Epidemiology Program and Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jieying Eunice Zhang
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Cristiano Fava
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| |
Collapse
|
173
|
Kampouraki E, Kamali F. Pharmacogenetics of anticoagulants used for stroke prevention in patients with atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:449-458. [PMID: 31120800 DOI: 10.1080/17425255.2019.1623878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: The inclusion of pharmacogenetics alongside clinical information in anticoagulant therapy offers the opportunity for a tailored approach to treatment according to individual patient characteristics. Areas covered: Literature was searched using PubMed database, focusing on pharmacogenetics of oral anticoagulants. Original research articles and review articles in English language were included in the literature reviewed. This article includes all information available for the genetic cause of inter-individual variability in anticoagulation response to oral anticoagulant drugs. The pharmacogenetics of VKAs and NOACs are described in detail. Expert opinion: There have been numerous studies focusing on the pharmacogenetics of VKAs, particularly warfarin. Current evidence suggests that known genetic and clinical factors explain a large proportion of the inter-individual variability in response to warfarin. Pharmacogenetic-based algorithms have been validated to determine their clinical utility with equivocal results. To date, only a limited number of mostly small studies on the pharmacogenetics of NOACs exists. The latter have highlighted genetic polymorphisms in specific genes that may affect clinical outcomes. Further evaluations of these polymorphisms are needed before firm conclusions can be drawn about the significance of pharmacogenetics on NOAC therapy.
Collapse
Affiliation(s)
- Emmanouela Kampouraki
- a Institute of Cellular Medicine within Faculty of Medical Sciences , Newcastle University , Newcastle upon Tyne , UK
| | - Farhad Kamali
- b Newcastle upon Tyne Hospitals, NHS Foundation Trust , Newcastle upon Tyne , UK
| |
Collapse
|
174
|
van der Wouden CH, Bank PCD, Özokcu K, Swen JJ, Guchelaar HJ. Pharmacist-Initiated Pre-Emptive Pharmacogenetic Panel Testing with Clinical Decision Support in Primary Care: Record of PGx Results and Real-World Impact. Genes (Basel) 2019; 10:E416. [PMID: 31146504 PMCID: PMC6628264 DOI: 10.3390/genes10060416] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 12/16/2022] Open
Abstract
Logistics and (cost-)effectiveness of pharmacogenetic (PGx)-testing may be optimized when delivered through a pre-emptive panel-based approach, within a clinical decision support system (CDSS). Here, clinical recommendations are automatically deployed by the CDSS when a drug-gene interaction (DGI) is encountered. However, this requires record of PGx-panel results in the electronic medical record (EMR). Several studies indicate promising clinical utility of panel-based PGx-testing in polypharmacy and psychiatry, but is undetermined in primary care. Therefore, we aim to quantify both the feasibility and the real-world impact of this approach in primary care. Within a prospective pilot study, community pharmacists were provided the opportunity to request a panel of eight pharmacogenes to guide drug dispensing within a CDSS for 200 primary care patients. In this side-study, this cohort was cross-sectionally followed-up after a mean of 2.5-years. PGx-panel results were successfully recorded in 96% and 68% of pharmacist and general practitioner (GP) EMRs, respectively. This enabled 97% of patients to (re)use PGx-panel results for at least one, and 33% for up to four newly initiated prescriptions with possible DGIs. A total of 24.2% of these prescriptions had actionable DGIs, requiring pharmacotherapy adjustment. Healthcare utilization seemed not to vary among those who did and did not encounter a DGI. Pre-emptive panel-based PGx-testing is feasible and real-world impact is substantial in primary care.
Collapse
Affiliation(s)
- Cathelijne H. van der Wouden
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Paul C. D. Bank
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Kübra Özokcu
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, 3584 CG Utrecht, The Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
175
|
Mak M, Lam C, Pineda SJ, Lou M, Xu LY, Meeks C, Lin C, Stone R, Rodgers K, Mitani G. Pharmacogenetics of Warfarin in a Diverse Patient Population. J Cardiovasc Pharmacol Ther 2019; 24:521-533. [PMID: 31064211 DOI: 10.1177/1074248419843530] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Many warfarin-related genotypes have shown to impact the average daily warfarin (ADW) dose requirements; however, information in non-Caucasian populations is limited. OBJECTIVES To identify the frequencies of 4 warfarin-related gene polymorphisms in an ethnically diverse patient population and to examine their impact with other clinical variables on ADW dose requirements. METHODS Patients were recruited from 2 anticoagulation clinics in the Los Angeles area. Blood samples were collected and genotyped for vitamin K epoxide reductase (VKORC1), CYP2C9*2, CYP2C9*3, and CYP4F2 after informed consent. Charts were reviewed to collect demographic, clinical, and warfarin dosing data. RESULTS A total of 291 patients were included (120 Caucasians, 127 Hispanics, and 44 Asians). In patients with wild-type genotypes for VKORC1, CYP2C9*2, CYP2C9*3, and CYP4F2, the highest warfarin requirement was found in Caucasians, lower in Hispanics, and lowest in Asians. Homozygous VKORC1 variant carriers were detected in 15%, 15%, and 79% in Caucasians, Hispanics, and Asians, respectively. Progressive lowering of ADW doses were associated with each VKORC1 variant in Caucasians and Hispanics, but the results in wild-type/ heterozygote Asians were unclear. CYP2C9 variants were associated with lower ADW doses; frequencies of CYP2C9*2 and CYP2C9*3 mutations were higher in Caucasians than in Hispanics but rare to none in Asians. The frequencies of CYP4F2 variant were similar across all ethnicities, but their impact on warfarin dose requirement were insignificant. Clinical factors such as age, body surface area, history of coronary artery disease, deep vein thrombosis or atrial fibrillation, and concomitant amiodarone or HMG-CoA reductase inhibitors had varying impact on the ADW requirements in the ethnicities studied. CONCLUSIONS Our study demonstrated differences among 3 ethnic groups in terms of ADW dose requirements and the impact of associated clinical variables. The results suggest that a single model for all ethnicities may not provide the best performance in predicting warfarin dose requirements.
Collapse
Affiliation(s)
- May Mak
- 1 Chapman University School of Pharmacy, Irvine, CA, USA
| | - Carol Lam
- 2 Medical Communications department, Los Angeles, CA, USA
| | - Sandra J Pineda
- 3 Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Mimi Lou
- 4 School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | | | | | - Cindy Lin
- 7 Los Angeles County Correctional Health Services, Los Angeles, CA, USA
| | - Roslynn Stone
- 4 School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Kathy Rodgers
- 8 Department of Pharmacology, University of Arizona, Tucson, AZ, USA
| | - Gladys Mitani
- 9 Department of Clinical Pharmacy, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
176
|
Lauschke VM, Zhou Y, Ingelman-Sundberg M. Novel genetic and epigenetic factors of importance for inter-individual differences in drug disposition, response and toxicity. Pharmacol Ther 2019; 197:122-152. [PMID: 30677473 PMCID: PMC6527860 DOI: 10.1016/j.pharmthera.2019.01.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Individuals differ substantially in their response to pharmacological treatment. Personalized medicine aspires to embrace these inter-individual differences and customize therapy by taking a wealth of patient-specific data into account. Pharmacogenomic constitutes a cornerstone of personalized medicine that provides therapeutic guidance based on the genomic profile of a given patient. Pharmacogenomics already has applications in the clinics, particularly in oncology, whereas future development in this area is needed in order to establish pharmacogenomic biomarkers as useful clinical tools. In this review we present an updated overview of current and emerging pharmacogenomic biomarkers in different therapeutic areas and critically discuss their potential to transform clinical care. Furthermore, we discuss opportunities of technological, methodological and institutional advances to improve biomarker discovery. We also summarize recent progress in our understanding of epigenetic effects on drug disposition and response, including a discussion of the only few pharmacogenomic biomarkers implemented into routine care. We anticipate, in part due to exciting rapid developments in Next Generation Sequencing technologies, machine learning methods and national biobanks, that the field will make great advances in the upcoming years towards unlocking the full potential of genomic data.
Collapse
Affiliation(s)
- Volker M Lauschke
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Magnus Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| |
Collapse
|
177
|
Benincasa G, Costa D, Infante T, Lucchese R, Donatelli F, Napoli C. Interplay between genetics and epigenetics in modulating the risk of venous thromboembolism: A new challenge for personalized therapy. Thromb Res 2019; 177:145-153. [DOI: 10.1016/j.thromres.2019.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/12/2019] [Accepted: 03/13/2019] [Indexed: 02/09/2023]
|
178
|
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.
Collapse
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
| |
Collapse
|
179
|
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.
Collapse
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
| |
Collapse
|
180
|
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.
Collapse
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.
| |
Collapse
|
181
|
Personal genome testing on physicians improves attitudes on pharmacogenomic approaches. PLoS One 2019; 14:e0213860. [PMID: 30921347 PMCID: PMC6438681 DOI: 10.1371/journal.pone.0213860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/01/2019] [Indexed: 01/17/2023] Open
Abstract
In this era of clinical genomics, the accumulation of knowledge of pharmacogenomics (PGx) is rising dramatically and attempts to utilize it in clinical practice are also increasing. However, this advanced knowledge and information have not yet been sufficiently utilized in the clinical field due to various barriers including physician factors. This study was conducted to evaluate the attitudes of physicians to PGx services by providing them their own genomic data analysis report focusing on PGx. We also tried to evaluate the clinical applicability of whole exome sequencing (WES)-based functional PGx test. In total 88 physicians participated in the study from September 2015 to August 2016. Physicians who agreed to participate in the study were asked to complete a pre-test survey evaluating their knowledge of and attitude toward clinical genomics including PGx. Only those who completed the pre-test survey proceeded to WES and were provided with a personal PGx analysis report in an offline group meeting. Physicians who received these PGx reports were asked to complete a follow-up survey within two weeks. We then analyzed changes in their knowledge and attitude after reviewing their own PGx analysis results through differences in their pre-test and post-test survey responses. In total, 70 physicians (79.5%) completed the pre-test and post-test surveys and attended an off-line seminar to review their personal PGx reports. After physicians reviewed the report, their perception of and attitude towards the PGx domain and genomics significantly changed. Physician’ awareness of the likelihood of occurrence of adverse drug reactions and genetic contribution was also changed significantly. Overall, physicians were very positive about the value and potential of the PGx test but maintained a conservative stance on its actual clinical use. Results revealed that physicians’ perception and attitude to the utility of PGx testing was significantly changed after reviewing their own WES results.
Collapse
|
182
|
Verification of pharmacogenomics-based algorithms to predict warfarin maintenance dose using registered data of Japanese patients. Eur J Clin Pharmacol 2019; 75:901-911. [DOI: 10.1007/s00228-019-02656-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
|
183
|
Scherman J, Manganyi R, Human P, Pennel T, Brooks A, Brink J, Zilla P. Isolated mechanical aortic valve replacement in rheumatic patients in a low- to middle-income country. J Thorac Cardiovasc Surg 2019; 157:886-893. [DOI: 10.1016/j.jtcvs.2018.06.083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/29/2018] [Accepted: 06/15/2018] [Indexed: 01/03/2023]
|
184
|
Differences in Warfarin Pharmacodynamics and Predictors of Response Among Three Racial Populations. Clin Pharmacokinet 2019; 58:1077-1089. [DOI: 10.1007/s40262-019-00745-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
185
|
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.
Collapse
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.
| |
Collapse
|
186
|
Abstract
Vascular dementia (VaD) is a common disorder that encompasses heterogeneous entities, which creates challenges in order to reach a global consensus for diagnostic criteria. While the genetic basis for sporadic VaD remains poorly understood, the identification of causal genes in monogenic forms of VaD sheds light on the pathophysiological mechanisms of VaD. This special report describes progress in genetic research on monogenic and sporadic VaD, as well as on associated phenotypes, such as cerebral small vessel disease, stroke and Alzheimer's disease. Methodological issues (e.g., small-size studies) and strategies to overcome these problems (e.g., collaborative consortiums, endophenotypes) are discussed. Lastly, future perspectives in the field and how such work could benefit patients and clinicians are mentioned.
Collapse
Affiliation(s)
- Raquel Manso-Calderón
- Department of Neurology, University Hospital of Salamanca, Salamanca 37007, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca, Salamanca 37007, Spain
| |
Collapse
|
187
|
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: 42] [Impact Index Per Article: 8.4] [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.
Collapse
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
| |
Collapse
|
188
|
Plumpton CO, Pirmohamed M, Hughes DA. Cost‐Effectiveness of Panel Tests for Multiple Pharmacogenes Associated With Adverse Drug Reactions: An Evaluation Framework. Clin Pharmacol Ther 2019; 105:1429-1438. [DOI: 10.1002/cpt.1312] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/08/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Catrin O. Plumpton
- Centre for Health Economics and Medicines EvaluationBangor University Wales UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical PharmacologyUniversity of Liverpool Liverpool UK
| | - Dyfrig A. Hughes
- Centre for Health Economics and Medicines EvaluationBangor University Wales UK
- Department of Molecular and Clinical PharmacologyUniversity of Liverpool Liverpool UK
| |
Collapse
|
189
|
Lauschke VM, Ingelman-Sundberg M. Prediction of drug response and adverse drug reactions: From twin studies to Next Generation Sequencing. Eur J Pharm Sci 2019; 130:65-77. [PMID: 30684656 DOI: 10.1016/j.ejps.2019.01.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 01/12/2023]
Abstract
Understanding and predicting inter-individual differences related to the success of drug therapy is of tremendous importance, both during drug development and for clinical applications. Importantly, while seminal twin studies indicate that the majority of inter-individual differences in drug disposition are driven by hereditary factors, common genetic polymorphisms explain only less than half of this genetically encoded variability. Recent progress in Next Generation Sequencing (NGS) technologies has for the first time allowed to comprehensively map the genetic landscape of human pharmacogenes. Importantly, these projects have unveiled vast numbers of rare genetic variants, which are estimated to contribute substantially to the missing heritability of drug metabolism phenotypes. However, functional interpretation of these rare variants remains challenging and constitutes one of the important frontiers of contemporary pharmacogenomics. Furthermore, NGS technologies face challenges in the interrogation of genes residing in complex genomic regions, such as CYP2D6 and HLA genes. We here provide an update of the implementation of pharmacogenomic variations in the clinical setting and present emerging strategies that facilitate the translation of NGS data into clinically useful information. Importantly, we anticipate that these developments will soon result in a paradigm shift of pre-emptive genotyping away from the interrogation to candidate variants and towards the comprehensive profiling of an individuals genotype, thus allowing for a true individualization of patient drug treatment regimens.
Collapse
Affiliation(s)
- Volker M Lauschke
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Magnus Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| |
Collapse
|
190
|
Haga SB, Kantor A. Horizon Scan Of Clinical Laboratories Offering Pharmacogenetic Testing. Health Aff (Millwood) 2019; 37:717-723. [PMID: 29733708 DOI: 10.1377/hlthaff.2017.1564] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pharmacogenetic (PGx) testing involves the analysis of genes known to affect response to medications. The field has been projected as a leading application of personalized or precision medicine, but the use of PGx tests has been stymied, in part, by the lack of clinical evidence of utility and reported low provider awareness. Another factor is the availability of testing. The range and types of PGx tests available have not been assessed to date. In the period September 2017-January 2018 we analyzed the numbers and types of PGx tests offered by clinical testing laboratories in the US. Of the 111 such labs that we identified, we confirmed that 76 offered PGx testing services. Of these, 31 offered only tests for single genes; 30 offered only tests for multiple genes; and 15 offered both types of tests. Collectively, 45 laboratories offered 114 multigene panel tests covering 295 genes. The majority of these tests did not have any clinical guidelines. PGx tests vary in type and makeup, which presents challenges in appropriate test evaluation and selection for providers, insurers, health systems, and patients alike.
Collapse
Affiliation(s)
- Susanne B Haga
- Susanne B. Haga ( ) is an associate professor of medicine at the Duke University School of Medicine, in Durham, North Carolina
| | - Ariel Kantor
- Ariel Kantor is an undergraduate research assistant at Duke University
| |
Collapse
|
191
|
Warfarin loading dose guided by pharmacogenetics is effective and safe in cardioembolic stroke patients – a randomized, prospective study. THE PHARMACOGENOMICS JOURNAL 2019; 19:446-454. [DOI: 10.1038/s41397-019-0066-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 10/18/2018] [Accepted: 12/21/2018] [Indexed: 11/08/2022]
|
192
|
Al-Eitan LN, Almasri AY, Al-Habahbeh SO. Effects of coagulation factor VII polymorphisms on warfarin sensitivity and responsiveness in Jordanian cardiovascular patients during the initiation and maintenance phases of warfarin therapy. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:1-8. [PMID: 30679919 PMCID: PMC6338106 DOI: 10.2147/pgpm.s189458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aims to investigate the relationships between genetic polymorphisms of the coagulation factor VII (FVII) gene and warfarin responsiveness and sensitivity. Patients and methods The study population consisted of 417 subjects (207 Jordanian cardiovascular patients and 210 healthy individuals). Cardiovascular patients were classified into two groups: those sensitive to warfarin dosage (sensitive, moderate, and resistant) and those responsive to warfarin based on International Normalized Ratios (INRs; poor, good, and extensive responders). The HVR4 polymorphism of the FVII gene was genotyped. Results Our results showed that there are significant differences between patients and controls according to both genotypic and allelic frequencies (P<0.0001) in the genetic susceptibility study. Moreover, the pharmacogenetics study reported that HVR4 had no association with warfarin sensitivity or responsiveness during the initiation and maintenance phases of therapy, the only significant differences were in the INR outcome measured during the maintenance phase of therapy (P=0.012). Conclusion Our data suggests lacking of association between the HVR4 polymorphism in the FVII gene and warfarin sensitivity and responsiveness during the initiation and maintenance phases of therapy. It is possible that these patients carry additional mutations in genes involved in the coagulation pathway.
Collapse
Affiliation(s)
- Laith N Al-Eitan
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan, .,Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid 22110, Jordan,
| | - Ayah Y Almasri
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan,
| | - Sahar O Al-Habahbeh
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan,
| |
Collapse
|
193
|
Shukla A, Jain A, Kahalekar V, Bendkhale S, Gogtay N, Thatte U, Bhatia S. Mutations in CYP2C9 and/or VKORC1 haplotype are associated with higher bleeding complications in patients with Budd-Chiari syndrome on warfarin. Hepatol Int 2019; 13:214-221. [PMID: 30617764 DOI: 10.1007/s12072-018-9922-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Anticoagulation is universally recommended in Budd-Chiari syndrome [BCS]. Vitamin K epoxide reductase complex 1 (VKORC1) and CYP2C9 are involved in the metabolism of warfarin. The present study was done to assess whether these mutations are associated with the risk of bleeding in patients with BCS receiving warfarin. PATIENTS AND METHODS Patients diagnosed with BCS underwent genotyping for three single nucleotide polymorphisms [SNPs]-two for the CYP2C9 and one for the VKORC1 haplotype. The patients were followed up for at least 12 months and all bleeding episodes were recorded. Patients with and without mutations were compared for bleeding complications and a crude odds ratio [crude OR] was derived for the association between bleeding and presence or absence of mutant alleles. RESULTS Eighty patients [mean (SD) age 27.47 (8.93) years, 35 male] with BCS underwent genetic testing. 37/80 (46.2%) patients had mutation of CYP2C9 and/or VKORC1; 22/80 (27.5%) had either of the mutant alleles of CYP2C9 and, similarly, 22/80 (27.5%) had the VKORC mutation. Over a median follow-up of 20 (range 12-96) months, 21/80 (26.3%) patients had bleeding complications. Patients with mutant SNPs had a higher risk of bleeding than those without [14/37 vs. 7/43, p = 0.04, crude OR (95% CI) 3.13 (1.1-8.9)]. CONCLUSION The presence of mutations in VKORC1 or CYP2C9 is associated with increased risk of bleeding in patients with BCS on warfarin. Such patients with SNPs of CY2C9 or VKORC1 haplotype should be monitored intensively while receiving warfarin.
Collapse
Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India.
| | - Abhinav Jain
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Vinit Kahalekar
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Sheetal Bendkhale
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Nithya Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Urmila Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| |
Collapse
|
194
|
Scott ER, Wallsten RL. A Look to the Future. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00010-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
195
|
|
196
|
Abstract
Warfarin dosing is challenging due to a multitude of factors affecting its pharmacokinetics (PK) and pharmacodynamics (PD). A novel personalised dosing algorithm predicated on a warfarin PK/PD model and incorporating CYP2C9 and VKORC1 genotype information has been developed for children. The present prospective, observational study aimed to compare the model with conventional weight-based dosing. The study involved two groups of children post-cardiac surgery: Group 1 were warfarin naïve, in whom loading and maintenance doses were estimated using the model over a 6-month duration and compared to historical case-matched controls. Group 2 were already established on maintenance therapy and randomised into a crossover study comparing the model with conventional maintenance dosing, over a 12-month period. Five patients enrolled in Group 1. Compared to the control group, the median time to achieve the first therapeutic INR was longer (5 vs. 2 days), to stable anticoagulation was shorter (29.0 vs. 96.5 days), to over-anticoagulation was longer (15.0 vs. 4.0 days). In addition, median percentage of INRs within the target range (%ITR) and percentage of time in therapeutic range (%TTR) was higher; 70% versus 47.4% and 83.4% versus 62.3%, respectively. Group 2 included 26 patients. No significant differences in INR control were found between model and conventional dosing phases; mean %ITR was 68.82% versus 67.9% (p = 0.84) and mean %TTR was 85.47% versus 80.2% (p = 0.09), respectively. The results suggest model-based dosing can improve anticoagulation control, particularly when initiating and stabilising warfarin dosing. Larger studies are needed to confirm these findings.
Collapse
|
197
|
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
|
198
|
Yang T, Zhou Y, Chen C, Lu M, Ma L, Cui Y. Genotype-guided dosing versus conventional dosing of warfarin: A meta-analysis of 15 randomized controlled trials. J Clin Pharm Ther 2018; 44:197-208. [PMID: 30593674 DOI: 10.1111/jcpt.12782] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/31/2018] [Accepted: 11/18/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Ting Yang
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Ying Zhou
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Chaoyang Chen
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Min Lu
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Lingyue Ma
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Yimin Cui
- Department of Pharmacy; Peking University First Hospital; Beijing China
| |
Collapse
|
199
|
Ndadza A, Cindi Z, Makambwa E, Chimusa E, Wonkam A, Kengne AP, Ntsekhe M, Dandara C. Warfarin Dose and CYP2C Gene Cluster: An African Ancestral-Specific Variant Is a Strong Predictor of Dose in Black South African Patients. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2018; 23:36-44. [PMID: 30566377 DOI: 10.1089/omi.2018.0174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Warfarin is a widely prescribed anticoagulant with a narrow therapeutic index. The rs12777823G>A single-nucleotide polymorphism (SNP) in the CYP2C gene cluster has been shown to influence optimal warfarin doses in African Americans. We report here effects of rs12777823G>A SNP on warfarin dose requirements in two South African population groups, black Africans (BA) and mixed ancestry (MA). A total of 425 participants on warfarin treatment were enrolled in the study. The age group of the studied population ranged between 44 and 66 years, with 69% females enrolled. Genetic characterization of the rs12777823G>A was done using the TaqMan SNP genotyping assay. To further compare effects of rs12777823G>A to those of other SNPs, VKORC1 g.-1639G>A and 4 SNPs in CYP2C9 gene (i.e., CYP2C9 c.430C>T, c.1075A>C, c.449G>A, and c.1003C>T) were analyzed. The rs12777823A variant allele frequencies were 0.28 and 0.25 in the BA and MA, respectively. The rs12777823A/A genotype was associated with significantly (p = 0.002) reduced mean warfarin dosage (27 ± 5.3 mg/week) compared with the G/G genotype (45 ± 16.1 mg/week) among BA, but not among the MA. The rs12777823G>A is located in a nongenomic region, suggesting that this SNP might be in linkage disequilibrium with another, likely causal SNP that is present in BA only. Given ongoing worldwide efforts to identify clinically relevant human genetic variation impacting on optimal warfarin dose selection, the African ancestry-specific genetic variant in the CYP2C cluster and others warrant further research and consideration in development of future warfarin dosing algorithms for precision medicine guidelines.
Collapse
Affiliation(s)
- Arinao Ndadza
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Zinhle Cindi
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Edson Makambwa
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Emile Chimusa
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Ambroise Wonkam
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Andre P Kengne
- 3 Non-Communicable Diseases Research Unit, South African Medical Research Council and University of Cape Town , Cape Town, South Africa
| | - Mpiko Ntsekhe
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Collet Dandara
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| |
Collapse
|
200
|
Zhou S, Skaar DJ, Jacobson PA, Huang RS. Pharmacogenomics of Medications Commonly Used in the Intensive Care Unit. Front Pharmacol 2018; 9:1436. [PMID: 30564130 PMCID: PMC6289166 DOI: 10.3389/fphar.2018.01436] [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: 08/03/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022] Open
Abstract
In the intensive care unit (ICU) setting, where highly variable and insufficient drug efficacies, as well as frequent and unpredictable adverse drug reactions (ADRs) occur, pharmacogenomics (PGx) offers an opportunity to improve health outcomes. However, PGx has not been fully evaluated in the ICU, partly due to lack of knowledge of how genetic markers may affect drug therapy. To fill in this gap, we conducted a review to summarize the PGx information for the medications commonly encountered in the ICU.
Collapse
Affiliation(s)
- Shuqin Zhou
- Department of Emergency and Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Debra J Skaar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - R Stephanie Huang
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| |
Collapse
|