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Hernandez-Suarez DF, Claudio-Campos K, Mirabal-Arroyo JE, Torres-Hernández BA, López-Candales A, Melin K, Duconge J. Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient: Role of a Novel NQO1*2 Polymorphism. J Investig Med High Impact Case Rep 2016; 4:2324709616682049. [PMID: 28210634 PMCID: PMC5298566 DOI: 10.1177/2324709616682049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/05/2016] [Accepted: 11/08/2016] [Indexed: 01/16/2023] Open
Abstract
Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results-including coagulation parameters-were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient's warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient's international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S) polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.
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Affiliation(s)
| | | | | | - Bianca A Torres-Hernández
- University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA; University of Puerto Rico Humacao Campus, Humacao, PR, USA
| | | | - Kyle Melin
- University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| | - Jorge Duconge
- University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
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202
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An SH, Chang BC, Lee KE, Gwak HS. Influence of UDP-Glucuronosyltransferase Polymorphisms on Stable Warfarin Doses in Patients with Mechanical Cardiac Valves. Cardiovasc Ther 2016. [PMID: 26223945 DOI: 10.1111/1755-5922.12147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM This study aimed to evaluate the effect of uridine diphosphate (UDP)-glucuronosyltransferase (UGT) polymorphisms on warfarin dosing requirements in patients with mechanical cardiac valves. METHODS A total of 191 patients with stable warfarin doses from the EAST Group of Warfarin were included in this study. The influence of genetic polymorphisms on stable warfarin doses was investigated by genotyping 6 single nucleotide polymorphisms (SNPs): vitamin K epoxide reductase complex 1 (VKORC1) rs9934438, cytochrome P450 (CYP) 2C9 rs1057910, CYP4F2 rs2108622, and UGT1A1 (rs887829, rs4148323, and rs4124874). An additional subgroup analysis was carried out using patients with wild-type homozygote carriers of CYP2C9. RESULTS One UGT1A1 SNP of rs887829 (C>T) exhibited significant association with stable warfarin doses in the study population and subgroup. Patients with the T allele in UGT1A1 rs887829 (CT or TT) required higher doses than those with the CC genotype in the study population (6.3 ± 2.4 mg vs. 5.2 ± 1.6 mg, P = 0.003). Similarly, in the subpopulation of AA carriers in the CYP2C9 gene, patients with the T allele required significantly higher doses of warfarin than those with other genotypes of rs887829 (6.5 ± 2.4 vs. 5.3 ± 1.5 mg, P = 0.002). Approximately 45.1% of overall interindividual variability in warfarin dose requirement was explained by the multivariate regression model. VKORC1, CYP2C9, UGT1A1 rs887829, age, and CYP4F2 accounted for 28.2%, 6.6%, 5.5%, 3.0%, and 1.8% of the variability, respectively. CONCLUSION Our results suggest that UGT1A1 could be a determinant of stable warfarin doses.
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Affiliation(s)
- Sook Hee An
- College of Pharmacy, Wonkwang University, Iksan, Jeonbuk, Korea
| | - Byung Chul Chang
- Department of Thoracic & Cardiovascular Surgery, Yonsei University Medical Center, Seodaemun-gu, Seoul, Korea
| | - Kyung Eun Lee
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seodaemun-gu, Seoul, Korea.,College of Pharmacy, Chungbuk National University, Cheongju, Chungbuk, Korea
| | - Hye Sun Gwak
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seodaemun-gu, Seoul, Korea
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203
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Johnsen JM. All too common: bleeding and genetic variation. J Thromb Haemost 2016; 14:2227-2229. [PMID: 27606572 DOI: 10.1111/jth.13499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/02/2016] [Indexed: 11/28/2022]
Affiliation(s)
- J M Johnsen
- Research Institute, Bloodworks Northwest, Seattle, WA, USA
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
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204
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Abstract
Warfarin is an oral anticoagulant agent with a narrow therapeutic index. There is a marked inter- and intra-patient variability in warfarin dose requirement. All factors influencing warfarin response are not known and this study aims to evaluate if regular physical activity (RPA) is a determining factor. RPA level was collected with the Stanford Brief Activity Survey in 1064 incident warfarin users, as part of the Quebec Warfarin Cohort (QWC), and with the Global Physical Activity Questionnaire in 618 patients from the Montreal Heart Institute (MHI) Biobank. Linear regression was performed to model relationship of warfarin dose after 3 months of therapy in the QWC with RPA, while controlling for height, weight, age, CYP2C9 (*2 and *3 alleles) and VKORC1 (*2 allele) genotype. Warfarin dose of prevalent users was modeled in the MHI Biobank for replication. A higher level of physical activity was associated with higher doses of warfarin in both cohorts. In the QWC, physical activity could explain 5.4 % (P < 0.001) and 0.9 % (P = 3.23 × 10−5) of variance in dose, in univariate and multivariable models, respectively. Similarly, RPA was found to be associated with 1.7 % (P = 0.0012) and 0.5 % (P = 0.0391) of inter-individual variability in warfarin dose requirement before and after adjustment for other covariables, respectively. RPA is associated with higher warfarin dose requirement. The relevance of clinical recommendations on RPA to maintain a steady response to warfarin should be assessed in further studies.
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205
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Sivadas A, Sharma P, Scaria V. Landscape of warfarin and clopidogrel pharmacogenetic variants in Qatari population from whole exome datasets. Pharmacogenomics 2016; 17:1891-1901. [PMID: 27767380 DOI: 10.2217/pgs-2016-0130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
AIM Pharmacogenetic landscapes of commonly used antiplatelet drugs, warfarin and clopidogrel have been studied in-depth in many countries. However, there is a paucity of data to understand their patterns in the Arab populations. MATERIALS & METHODS We analyzed the whole exome sequencing datasets of 100 Qatar individuals available in public domain with this perspective. RESULTS We characterized the allelic distribution of variants routinely tested for warfarin and clopidogrel. We additionally evaluated the population stratification and its effect on allele frequency distribution. Our analysis points to ethnic differences in the frequency distribution even for the small population studied. CONCLUSION This is one of the first and most comprehensive pharmacogenetic maps of variants associated with warfarin and clopidogrel for an Arab population, which can help tailor the drug dosage to the population.
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Affiliation(s)
- Ambily Sivadas
- GN Ramachandran Knowledge Center for Genome Informatics, CSIR Institute of Genomics & Integrative Biology, Mathura Road, New Delhi 110025, India.,Academy of Scientific & Innovative Research (AcSIR), New Delhi 110025, India
| | - Parul Sharma
- Center for Computational Biology, Indraprastha Institute of Information Technology Delhi (IIIT-Delhi), Okhla Industrial Estate, Phase III, New Delhi 110020, India
| | - Vinod Scaria
- GN Ramachandran Knowledge Center for Genome Informatics, CSIR Institute of Genomics & Integrative Biology, Mathura Road, New Delhi 110025, India.,Academy of Scientific & Innovative Research (AcSIR), New Delhi 110025, India.,Center for Computational Biology, Indraprastha Institute of Information Technology Delhi (IIIT-Delhi), Okhla Industrial Estate, Phase III, New Delhi 110020, India
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206
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Samwald M, Xu H, Blagec K, Empey PE, Malone DC, Ahmed SM, Ryan P, Hofer S, Boyce RD. Incidence of Exposure of Patients in the United States to Multiple Drugs for Which Pharmacogenomic Guidelines Are Available. PLoS One 2016; 11:e0164972. [PMID: 27764192 PMCID: PMC5072717 DOI: 10.1371/journal.pone.0164972] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/04/2016] [Indexed: 01/12/2023] Open
Abstract
Pre-emptive pharmacogenomic (PGx) testing of a panel of genes may be easier to implement and more cost-effective than reactive pharmacogenomic testing if a sufficient number of medications are covered by a single test and future medication exposure can be anticipated. We analysed the incidence of exposure of individual patients in the United States to multiple drugs for which pharmacogenomic guidelines are available (PGx drugs) within a selected four-year period (2009-2012) in order to identify and quantify the incidence of pharmacotherapy in a nation-wide patient population that could be impacted by pre-emptive PGx testing based on currently available clinical guidelines. In total, 73 024 095 patient records from private insurance, Medicare Supplemental and Medicaid were included. Patients enrolled in Medicare Supplemental age > = 65 or Medicaid age 40-64 had the highest incidence of PGx drug use, with approximately half of the patients receiving at least one PGx drug during the 4 year period and one fourth to one third of patients receiving two or more PGx drugs. These data suggest that exposure to multiple PGx drugs is common and that it may be beneficial to implement wide-scale pre-emptive genomic testing. Future work should therefore concentrate on investigating the cost-effectiveness of multiplexed pre-emptive testing strategies.
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Affiliation(s)
- Matthias Samwald
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Hong Xu
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Kathrin Blagec
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Daniel C. Malone
- College of Pharmacy, University of Arizona, Tucson, Arizona, United States of America
| | - Seid Mussa Ahmed
- Department of Pharmacy, College of public health and medical sciences, Jimma University, Jimma, Ethiopia
| | - Patrick Ryan
- Janssen Research and Development, Titusville, New Jersey, United States of America
- Observational Health Data Sciences and Informatics, New York, New York, United States of America
| | - Sebastian Hofer
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Richard D. Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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207
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Lauschke VM, Ingelman-Sundberg M. The Importance of Patient-Specific Factors for Hepatic Drug Response and Toxicity. Int J Mol Sci 2016; 17:E1714. [PMID: 27754327 PMCID: PMC5085745 DOI: 10.3390/ijms17101714] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 09/23/2016] [Accepted: 09/27/2016] [Indexed: 02/07/2023] Open
Abstract
Responses to drugs and pharmacological treatments differ considerably between individuals. Importantly, only 50%-75% of patients have been shown to react adequately to pharmacological interventions, whereas the others experience either a lack of efficacy or suffer from adverse events. The liver is of central importance in the metabolism of most drugs. Because of this exposed status, hepatotoxicity is amongst the most common adverse drug reactions and hepatic liabilities are the most prevalent reason for the termination of development programs of novel drug candidates. In recent years, more and more factors were unveiled that shape hepatic drug responses and thus underlie the observed inter-individual variability. In this review, we provide a comprehensive overview of different principle mechanisms of drug hepatotoxicity and illustrate how patient-specific factors, such as genetic, physiological and environmental factors, can shape drug responses. Furthermore, we highlight other parameters, such as concomitantly prescribed medications or liver diseases and how they modulate drug toxicity, pharmacokinetics and dynamics. Finally, we discuss recent progress in the field of in vitro toxicity models and evaluate their utility in reflecting patient-specific factors to study inter-individual differences in drug response and toxicity, as this understanding is necessary to pave the way for a patient-adjusted medicine.
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Affiliation(s)
- Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, SE-17177 Stockholm, Sweden.
| | - Magnus Ingelman-Sundberg
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, SE-17177 Stockholm, Sweden.
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208
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Genetic diversity of variants involved in drug response and metabolism in Sri Lankan populations: implications for clinical implementation of pharmacogenomics. Pharmacogenet Genomics 2016; 26:28-39. [PMID: 26444257 PMCID: PMC4890825 DOI: 10.1097/fpc.0000000000000182] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text. Background Interpopulation differences in drug responses are well documented, and in some cases they correspond to differences in the frequency of associated genetic markers. Understanding the diversity of genetic markers associated with drug response across different global populations is essential to infer population rates of drug response or risk for adverse drug reactions, and to guide implementation of pharmacogenomic testing. Sri Lanka is a culturally and linguistically diverse nation, but little is known about the population genetics of the major Sri Lankan ethnic groups. The objective of this study was to investigate the diversity of pharmacogenomic variants in the major Sri Lankan ethnic groups. Methods We examined the allelic diversity of more than 7000 variants in genes involved in drug biotransformation and response in the three major ethnic populations of Sri Lanka (Sinhalese, Sri Lankan Tamils, and Moors), and compared them with other South Asian, South East Asian, and European populations using Wright’s Fixation Index, principal component analysis, and STRUCTURE analysis. Results We observed overall high levels of similarity within the Sri Lankan populations (median FST=0.0034), and between Sri Lankan and other South Asian populations (median FST=0.0064). Notably, we observed substantial differentiation between Sri Lankan and European populations for important pharmacogenomic variants related to warfarin (VKORC1 rs9923231) and clopidogrel (CYP2C19 rs4986893) response. Conclusion These data expand our understanding of the population structure of Sri Lanka, provide a resource for pharmacogenomic research, and have implications for the clinical use of genetic testing of pharmacogenomic variants in these populations.
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209
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Warfarin resistance associated with genetic polymorphism of VKORC1: linking clinical response to molecular mechanism using computational modeling. Pharmacogenet Genomics 2016; 26:44-50. [PMID: 26513304 DOI: 10.1097/fpc.0000000000000184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The variable response to warfarin treatment often has a genetic basis. A protein homology model of human vitamin K epoxide reductase, subunit 1 (VKORC1), was generated to elucidate the mechanism of warfarin resistance observed in a patient with the Val66Met mutation. The VKORC1 homology model comprises four transmembrane (TM) helical domains and a half helical lid domain. Cys132 and Cys135, located in the N-terminal end of TM-4, are linked through a disulfide bond. Two distinct binding sites for warfarin were identified. Site-1, which binds vitamin K epoxide (KO) in a catalytically favorable orientation, shows higher affinity for S-warfarin compared with R-warfarin. Site-2, positioned in the domain occupied by the hydrophobic tail of KO, binds both warfarin enantiomers with similar affinity. Displacement of Arg37 occurs in the Val66Met mutant, blocking access of warfarin (but not KO) to Site-1, consistent with clinical observation of warfarin resistance.
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210
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Manolio TA. Implementing genomics and pharmacogenomics in the clinic: The National Human Genome Research Institute's genomic medicine portfolio. Atherosclerosis 2016; 253:225-236. [PMID: 27612677 PMCID: PMC5064852 DOI: 10.1016/j.atherosclerosis.2016.08.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 01/08/2023]
Abstract
Increasing knowledge about the influence of genetic variation on human health and growing availability of reliable, cost-effective genetic testing have spurred the implementation of genomic medicine in the clinic. As defined by the National Human Genome Research Institute (NHGRI), genomic medicine uses an individual's genetic information in his or her clinical care, and has begun to be applied effectively in areas such as cancer genomics, pharmacogenomics, and rare and undiagnosed diseases. In 2011 NHGRI published its strategic vision for the future of genomic research, including an ambitious research agenda to facilitate and promote the implementation of genomic medicine. To realize this agenda, NHGRI is consulting and facilitating collaborations with the external research community through a series of "Genomic Medicine Meetings," under the guidance and leadership of the National Advisory Council on Human Genome Research. These meetings have identified and begun to address significant obstacles to implementation, such as lack of evidence of efficacy, limited availability of genomics expertise and testing, lack of standards, and difficulties in integrating genomic results into electronic medical records. The six research and dissemination initiatives comprising NHGRI's genomic research portfolio are designed to speed the evaluation and incorporation, where appropriate, of genomic technologies and findings into routine clinical care. Actual adoption of successful approaches in clinical care will depend upon the willingness, interest, and energy of professional societies, practitioners, patients, and payers to promote their responsible use and share their experiences in doing so.
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Affiliation(s)
- Teri A Manolio
- Division of Genomic Medicine, National Human Genome Research Institute, 5635 Fishers Lane, Room 4113, MSC 9305, Bethesda MD, USA.
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211
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Alessandrini M, Chaudhry M, Dodgen TM, Pepper MS. Pharmacogenomics and Global Precision Medicine in the Context of Adverse Drug Reactions: Top 10 Opportunities and Challenges for the Next Decade. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2016; 20:593-603. [PMID: 27643672 PMCID: PMC5072285 DOI: 10.1089/omi.2016.0122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In a move indicative of the enthusiastic support of precision medicine, the U.S. President Barack Obama announced the Precision Medicine Initiative in January 2015. The global precision medicine ecosystem is, thus, receiving generous support from the United States ($215 million), and numerous other governments have followed suit. In the context of precision medicine, drug treatment and prediction of its outcomes have been important for nearly six decades in the field of pharmacogenomics. The field offers an elegant solution for minimizing the effects and occurrence of adverse drug reactions (ADRs). The Clinical Pharmacogenetics Implementation Consortium (CPIC) plays an important role in this context, and it aims at specifically guiding the translation of clinically relevant and evidence-based pharmacogenomics research. In this forward-looking analysis, we make particular reference to several of the CPIC guidelines and their role in guiding the treatment of highly relevant diseases, namely cardiovascular disease, major depressive disorder, cancer, and human immunodeficiency virus, with a view to predicting and managing ADRs. In addition, we provide a list of the top 10 crosscutting opportunities and challenges facing the fields of precision medicine and pharmacogenomics, which have broad applicability independent of the drug class involved. Many of these opportunities and challenges pertain to infrastructure, study design, policy, and science culture in the early 21st century. Ultimately, rational pharmacogenomics study design and the acquisition of comprehensive phenotypic data that proportionately match the genomics data should be an imperative as we move forward toward global precision medicine.
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Affiliation(s)
- Marco Alessandrini
- Department of Immunology, Faculty of Health Sciences, and Institute for Cellular and Molecular Medicine, South African Medical Research Council Extramural Unit for Stem Cell Research and Therapy, University of Pretoria , Pretoria, South Africa
| | - Mamoonah Chaudhry
- Department of Immunology, Faculty of Health Sciences, and Institute for Cellular and Molecular Medicine, South African Medical Research Council Extramural Unit for Stem Cell Research and Therapy, University of Pretoria , Pretoria, South Africa
| | - Tyren M Dodgen
- Department of Immunology, Faculty of Health Sciences, and Institute for Cellular and Molecular Medicine, South African Medical Research Council Extramural Unit for Stem Cell Research and Therapy, University of Pretoria , Pretoria, South Africa
| | - Michael S Pepper
- Department of Immunology, Faculty of Health Sciences, and Institute for Cellular and Molecular Medicine, South African Medical Research Council Extramural Unit for Stem Cell Research and Therapy, University of Pretoria , Pretoria, South Africa
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212
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The Active Metabolite of Warfarin (3'-Hydroxywarfarin) and Correlation with INR, Warfarin and Drug Weekly Dosage in Patients under Oral Anticoagulant Therapy: A Pharmacogenetics Study. PLoS One 2016; 11:e0162084. [PMID: 27606428 PMCID: PMC5015920 DOI: 10.1371/journal.pone.0162084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 08/17/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Warfarin oral anticoagulant therapy (OAT) requires regular and frequent drug adjustment monitored by INR. Interindividual variability, drug and diet interferences, and genetics (VKORC1 and CYP2C9) make the maintenance/reaching of stable INR a not so easy task. HPLC assessment of warfarin/enantiomers was suggested as a valid monitoring-tool along with INR, but definite results are still lacking. We evaluated possible correlations between INR, warfarin/3’-hydroxywarfarin, and drug weekly dosage aimed at searching novel alternatives to OAT monitoring. VKORC1/CYP2C9 pharmacogenetics investigation was performed to account for the known influence on warfarin homeostasis. Methods 133 OAT patients were recruited and assessed for warfarin/3’-hydroxywarfarin serum levels (HPLC), INR, and VKORC1 and CYP2C9 genotypes. A subgroup of 52 patients were monitored in detail (5 consecutive controls; c0-c4) till the target INR was reached. Correlation analyses were performed in both groups Results In the whole OAT group both warfarin and 3’-hydroxywarfarin correlate with INR at comparable degree (r2 = 0.0388 and 0.0362 respectively). Conversely, warfarin weekly dosage better correlates with warfarin than with 3’-hydroxywarfarin (r2 = 0.0975 and r2 = 0.0381 respectively), but considering together warfarin plus 3’-hydroxywarfarin the correlation strongly increased (r2 = 0.1114; p<0.0001). Interestingly, 3’-hydroxywarfarin reached a strong correlation at c4 respect to warfarin (r2 = 0.2157 and r2 = 0.0549; p = 0.0005 and p = 0.0944 respectively) seeming less affected by drug adjustments in the subgroup of 52 patients who started OAT. The multivariate analyses aimed at estimating the true contribution of 3’-hydroxywarfarin on INR value ascribed it the unique significant value (p = 0.0021) in spite of warfarin who lost association. The pharmacogenetics studies confirmed that patients carrying the VKORC1 variant-allele required lower warfarin maintenance dosage and that the combination of VKORC1 and CYP2C9 yielded a warfarin responsive index (WRI) inversely related to the number variant alleles Conclusion Our results overall suggest that 3’-hydroxywarfarin monitoring could be of great advantage in INR monitoring respect to classical warfarin assessment showing significant contribution also in multivariate analysis. Therefore, additional active metabolites should be recognized and investigated as novel useful indicators.
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Badreldin H, Nichols H, Rimsans J, Carter D. Evaluation of anticoagulation selection for acute venous thromboembolism. J Thromb Thrombolysis 2016; 43:74-78. [DOI: 10.1007/s11239-016-1417-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVES Single nucleotide variations (SNVs) in the cytochrome P450 (CYP) gene family are a primary cause of interindividual differences in therapeutic effects and adverse reactions to drugs. However, we still lack important information on the extent of CYP polymorphisms at the population level. Here, we developed a comprehensive data set of SNVs in all 57 human CYP genes by integrating data from two extensive population sequencing projects and analyzed the distribution of SNVs in different subpopulations. MATERIALS AND METHODS CYP genetic variants derived from the NHLBI and 1000 Genomes project were classified by variant type, frequency, and ethnic origins. The genetic variability of CYP genes was normalized on the basis of nonlinear regression and the total number of genetic variations was estimated by the derived formulas. RESULTS In total, we detected 6165 SNVs, of which many were novel. The vast majority (83.2%) of all SNVs in coding regions were very rare (minor allele frequency <0.1%). On the basis of the regression analysis, the total number of genetic variations in human CYP genes was calculated to be 3.4 × 10 and 4.8 × 10 for a population size of one million in Europeans and Africans, respectively. CONCLUSION Our results suggest that the variant spectrum of human CYP genes is extensive and only a fraction of SNVs has been characterized to date. Moreover, the multitude of very rare novel sequence variants indicates that the commonly used SNV platforms are not satisfactory for determining the true genotype, which is critical information for personalized treatment with drugs influenced by CYP polymorphisms.
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215
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Obeng AO, Kaszemacher T, Abul-Husn NS, Gottesman O, Vega A, Waite E, Myers K, Cho J, Bottinger EP, Ellis SB, Scott SA. Implementing Algorithm-Guided Warfarin Dosing in an Ethnically Diverse Patient Population Using Electronic Health Records and Preemptive CYP2C9 and VKORC1 Genetic Testing. Clin Pharmacol Ther 2016; 100:427-430. [PMID: 27393744 DOI: 10.1002/cpt.425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/01/2016] [Accepted: 07/06/2016] [Indexed: 11/11/2022]
Abstract
Implementation of pharmacogenetic-guided warfarin dosing has been hindered by inconsistent results from reported clinical trials and a lack of available algorithms that include alleles prevalent in non-white populations. However, current evidence indicates that algorithm-guided dosing is more accurate than empirical dosing. To facilitate multiethnic algorithm-guided warfarin dosing using preemptive genetic testing, we developed a strategy that accounts for the complexity of race and leverages electronic health records for algorithm variables and deploying point-of-care dose recommendations.
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Affiliation(s)
- A Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA. .,Department of Pharmacy, Mount Sinai Medical Center, New York, New York, USA.
| | - T Kaszemacher
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - N S Abul-Husn
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - O Gottesman
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - A Vega
- Mount Sinai Faculty Practice Associates Primary Care Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - E Waite
- Mount Sinai Faculty Practice Associates Primary Care Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - K Myers
- Information Technology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Cho
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - E P Bottinger
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Berlin Institute of Health, Berlin, Germany
| | - S B Ellis
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - S A Scott
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA. .,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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216
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Yang W, Wu G, Broeckel U, Smith CA, Turner V, Haidar CE, Wang S, Carter R, Karol SE, Neale G, Crews KR, Yang JJ, Mullighan CG, Downing JR, Evans WE, Relling MV. Comparison of genome sequencing and clinical genotyping for pharmacogenes. Clin Pharmacol Ther 2016; 100:380-8. [PMID: 27311679 DOI: 10.1002/cpt.411] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/23/2016] [Accepted: 06/13/2016] [Indexed: 12/28/2022]
Abstract
We compared whole exome sequencing (WES, n = 176 patients) and whole genome sequencing (WGS, n = 68) and clinical genotyping (DMET array-based approach) for interrogating 13 genes with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. We focused on 127 CPIC important variants: 103 single nucleotide variations (SNV), 21 insertion/deletions (Indel), HLA-B alleles, and two CYP2D6 structural variations. WES and WGS provided interrogation of nonoverlapping sets of 115 SNV/Indels with call rate >98%. Among 68 loci interrogated by both WES and DMET, 64 loci (94.1%, confidence interval [CI]: 85.6-98.4%) showed no discrepant genotyping calls. Among 66 loci interrogated by both WGS and DMET, 63 loci (95.5%, CI: 87.2-99.0%) showed no discrepant genotyping calls. In conclusion, even without optimization to interrogate pharmacogenetic variants, WES and WGS displayed potential to provide reliable interrogation of most pharmacogenes and further validation of genome sequencing in a clinical lab setting is warranted.
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Affiliation(s)
- W Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - G Wu
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - U Broeckel
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - C A Smith
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - V Turner
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - S Wang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - R Carter
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - S E Karol
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - G Neale
- Hartwell Center, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - K R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - J J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - J R Downing
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - W E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
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217
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Zhao S, Zhao H, Wang X, Gao C, Qin Y, Cai H, Chen B, Cao J. A prospective study investigating the causes of warfarin under-utilization in Chinese patients. Int J Clin Pharm 2016; 38:1286-93. [PMID: 27488309 DOI: 10.1007/s11096-016-0367-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
Background Warfarin is efficacious for ischemic stroke prevention in intermediate- to high-risk patients with atrial fibrillation; thus, warfarin is the recommended treatment according to evidence-based guidelines. Objective This prospective study evaluated the reasons for under-utilization of warfarin in Chinese patients with non-valvular atrial fibrillation (NVAF). Setting The People's Hospital of Henan Province of Zhengzhou City, which is a 3900-bed tertiary-care teaching institution. Methods We extracted data from an existing patient database. Patients at risk for thromboembolism were categorized based on CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 (doubled), diabetes, prior stroke (doubled), vascular disease, age 65-74 years, and sex category (female)] scores. Main outcome measure The percent of warfarin utilization was estimated in recruited patients. Any demographic and clinical factors associated with warfarin under-utilization were identified using a logistic regression model. Results Among the patient sample (n = 612), 569 patients had a CHA2DS2-VASc score of ≥1. At presentation, warfarin under-utilization was estimated to be 27.1 %. Only 120 patients (25.1 %) considered to be at the highest risk were prescribed warfarin. Binary logistic regression analysis indicated that previous stroke, age ≥75 years, and anti-platelet therapy were associated with warfarin under-utilization. Conclusion Patients with CHA2DS2-VASc scores ≥1 who were admitted with NVAF were under prescribed warfarin, and 138 patients were not treated with either warfarin or other antithrombotic therapies. In conclusion, a more aggressive approach for stroke prevention in NVAF patients is required.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Hongwei Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Xianpei Wang
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Chuanyu Gao
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Yuhua Qin
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China.
| | - Haixia Cai
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Boya Chen
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jingjing Cao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
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218
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Shahabi P, Scheinfeldt LB, Lynch DE, Schmidlen TJ, Perreault S, Keller MA, Kasper R, Wawak L, Jarvis JP, Gerry NP, Gordon ES, Christman MF, Dubé MP, Gharani N. An expanded pharmacogenomics warfarin dosing table with utility in generalised dosing guidance. Thromb Haemost 2016; 116:337-48. [PMID: 27121899 PMCID: PMC6375065 DOI: 10.1160/th15-12-0955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/19/2016] [Indexed: 12/14/2022]
Abstract
Pharmacogenomics (PGx) guided warfarin dosing, using a comprehensive dosing algorithm, is expected to improve dose optimisation and lower the risk of adverse drug reactions. As a complementary tool, a simple genotype-dosing table, such as in the US Food and Drug Administration (FDA) Coumadin drug label, may be utilised for general risk assessment of likely over- or under-anticoagulation on a standard dose of warfarin. This tool may be used as part of the clinical decision support for the interpretation of genetic data, serving as a first step in the anticoagulation therapy decision making process. Here we used a publicly available warfarin dosing calculator (www.warfarindosing.org) to create an expanded gene-based warfarin dosing table, the CPMC-WD table that includes nine genetic variants in CYP2C9, VKORC1, and CYP4F2. Using two datasets, a European American cohort (EUA, n=73) and the Quebec Warfarin Cohort (QWC, n=769), we show that the CPMC-WD table more accurately predicts therapeutic dose than the FDA table (51 % vs 33 %, respectively, in the EUA, McNemar's two-sided p=0.02; 52 % vs 37 % in the QWC, p<1×10(-6)). It also outperforms both the standard of care 5 mg/day dosing (51 % vs 34 % in the EUA, p=0.04; 52 % vs 31 % in the QWC, p<1×10(-6)) as well as a clinical-only algorithm (51 % vs 38 % in the EUA, trend p=0.11; 52 % vs 45 % in the QWC, p=0.003). This table offers a valuable update to the PGx dosing guideline in the drug label.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Neda Gharani
- Neda Gharani, PhD, 1 Templemere, Weybridge, Surrey KT13 9PA, UK, Tel.: +44 7984005796, Fax:+44 1932976519, E-mail:
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219
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Marek E, Momper JD, Hines RN, Takao CM, Gill JC, Pravica V, Gaedigk A, Burckart GJ, Neville KA. Prediction of Warfarin Dose in Pediatric Patients: An Evaluation of the Predictive Performance of Several Models. J Pediatr Pharmacol Ther 2016; 21:224-32. [PMID: 27453700 DOI: 10.5863/1551-6776-21.3.224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the performance of pediatric pharmacogenetic-based dose prediction models by using an independent cohort of pediatric patients from a multicenter trial. METHODS Clinical and genetic data (CYP2C9 [cytochrome P450 2C9] and VKORC1 [vitamin K epoxide reductase]) were collected from pediatric patients aged 3 months to 17 years who were receiving warfarin as part of standard care at 3 separate clinical sites. The accuracy of 8 previously published pediatric pharmacogenetic-based dose models was evaluated in the validation cohort by comparing predicted maintenance doses to actual stable warfarin doses. The predictive ability was assessed by using the proportion of variance (R(2)), mean prediction error (MPE), and the percentage of predictions that fell within 20% of the actual maintenance dose. RESULTS Thirty-two children reached a stable international normalized ratio and were included in the validation cohort. The pharmacogenetic-based warfarin dose models showed a proportion of variance ranging from 35% to 78% and an MPE ranging from -2.67 to 0.85 mg/day in the validation cohort. Overall, the model developed by Hamberg et al showed the best performance in the validation cohort (R(2) = 78%; MPE = 0.15 mg/day) with 38% of the predictions falling within 20% of observed doses. CONCLUSIONS Pharmacogenetic-based algorithms provide better predictions than a fixed-dose approach, although an optimal dose algorithm has not yet been developed.
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Affiliation(s)
- Elizabeth Marek
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Ronald N Hines
- Department of Pediatrics, Medical College of Wisconsin, City, Milwaukee, Wisconsin
| | - Cheryl M Takao
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, California
| | - Joan C Gill
- Department of Pediatrics, Medical College of Wisconsin, City, Milwaukee, Wisconsin
| | - Vera Pravica
- Institute of Microbiology and Immunology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Gilbert J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Kathleen A Neville
- Section of Pharmacology & Toxicology, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, Arkansas
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220
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Li H, Wang Y, Fan R, Lv H, Sun H, Xie H, Tang T, Luo J, Xia Z. The effects of ferulic acid on the pharmacokinetics of warfarin in rats after biliary drainage. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:2173-80. [PMID: 27462142 PMCID: PMC4940002 DOI: 10.2147/dddt.s107917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
According to previous research studies, warfarin can be detected in human bile after oral administration. Ferulic acid (FA) is the main bioactive component of many Chinese herbs for the treatment of cardiovascular disease. To elucidate the effects of FA on the pharmacokinetics of warfarin in rats after biliary drainage is necessary. Twenty rats were randomly divided into four groups: Group 1 (WN): healthy rats after the administration of warfarin sodium, Group 2 (WO): a rat model of biliary drainage after the administration of warfarin sodium, Group 3 (WFN): healthy rats after the administration of warfarin sodium and FA, and Group 4 (WFO): a rat model of biliary drainage after the administration of warfarin sodium and FA. Blood samples were collected at different time points after administration. The concentrations of blood samples were determined by ultraperformance liquid chromatography–tandem mass spectrometry. Comparisons between groups were performed according to the main pharmacokinetic parameters calculated by the DAS 2.1.1 software. The pharmacokinetic parameters showed a significant difference between the WN and WO groups, the WO group showed a decrease of 51% and 41.6% in area under the curve from 0 to time (AUC0–t) and peak plasma concentration (Cmax), respectively, whereas time to Cmax (Tmax) was delayed 3.27 folds. There were significant differences between the WFO and WFN groups, the WFO group showed a decrease of 63.8% and 70% in AUC0–t and Cmax, respectively; the delay in Tmax between the WN and WFN groups (mean, from 132–432 minutes) was significantly different; the mean retention time from 0 to time (MRT0–t) between the WO and WFO groups (mean, from 718.31–606.13 minutes) also showed a significant difference. Enterohepatic circulation markedly influences the disposition of warfarin in rats, and FA significantly affected the warfarin disposition in rat plasma.
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Affiliation(s)
- Haigang Li
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University; Department of Pharmacy, Changsha Medical University
| | - Yang Wang
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University
| | - Rong Fan
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University
| | - Huiying Lv
- Hunan Agricultural Product Processing Institute, Hunan Academy of Agricultural Sciences, Changsha
| | - Hua Sun
- Anhui Provincial Centre for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, People's Republic of China
| | - Haitang Xie
- Anhui Provincial Centre for Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, People's Republic of China
| | - Tao Tang
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University
| | - Jiekun Luo
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University
| | - Zian Xia
- Department of Integrated Traditional Chinese and Western Medicine, Laboratory of Ethnopharmacology, Xiangya Hospital, Central South University
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221
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Hohl RJ. Anticoagulants: Major Advances Without Clear Consensus. Clin Pharmacol Ther 2016; 100:116-8. [DOI: 10.1002/cpt.399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 12/24/2022]
Affiliation(s)
- RJ Hohl
- Penn State University; University Park; Pennsylvania USA
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222
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Takeuchi M, Kobayashi T, Brandão LR, Ito S. Effect of CYP2C9, VKORC1, and CYP4F2 polymorphisms on warfarin maintenance dose in children aged less than 18 years: a protocol for systematic review and meta-analysis. Syst Rev 2016; 5:105. [PMID: 27334984 PMCID: PMC4917995 DOI: 10.1186/s13643-016-0280-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/07/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite its shortcomings, warfarin is still the most commonly prescribed anticoagulant to prevent thromboembolism in children. In adults, numerous studies confirmed the robust relationship between warfarin maintenance doses and single nucleotide polymorphisms of cytochrome P450 2C9 (CYP2C9), vitamin K epoxide reductase (VKORC1), and cytochrome P450 4F2 (CYP4F2). However, their effect in children still remains to be determined. The primary objective of the present systematic review and meta-analysis is to assess the effect of genotypes of CYP2C9, VKORC1, and CYP4F2 on warfarin maintenance dose in children. METHODS/DESIGN A comprehensive literature review search using the OVID platform will be conducted by a specialized librarian, without language restrictions (i.e., MEDLINE/EMBASE/Cochrane Central Register of Controlled Trials), and all abstracts will be reviewed by two authors. Data abstraction from each eligible study will be extracted individually by two authors (MT and TK), and disagreements will be resolved through discussion with a third person (SI). Critical appraisal of the included analysis of the primary objective will follow the Newcastle-Ottawa Scale, in addition to the Strengthening the Reporting of Genetic Association study (STREGA) statement, and data reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. For the meta-analysis, the presence vs. absence of each genetic polymorphism will be pursued, respectively, using a random effect model with effect size expressed as a mean difference plus 95 % confidence interval. DISCUSSION Our study will provide a comprehensive systematic review and meta-analysis on the potential effects of CYP2C9, VKORC1, or CYP4F2 on the warfarin maintenance dose in children, exploring the feasibility of the development of pharmacogenetic-guided warfarin dosing algorithm for children on oral vitamin K antagonists. SYSTEMATIC REVIEW REGISTRATION The review has been registered with PROSPERO (registration number CRD42015016172 ).
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Affiliation(s)
- Masanobu Takeuchi
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Tohru Kobayashi
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Leonardo R Brandão
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada.
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223
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Lentz SR. Genetic testing to guide warfarin dosing: Impact of direct oral anticoagulants. Clin Pharmacol Ther 2016; 100:128-30. [DOI: 10.1002/cpt.395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/09/2016] [Accepted: 05/11/2016] [Indexed: 11/09/2022]
Affiliation(s)
- SR Lentz
- Department of Internal Medicine; University of Iowa Carver College of Medicine; Iowa City Iowa USA
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224
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Percutaneous closure of the left atrial appendage for stroke prevention in atrial fibrillation: an alternative to lifelong anticoagulation? Crit Care Nurs Q 2016; 38:371-84. [PMID: 26335216 DOI: 10.1097/cnq.0000000000000081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Atrial fibrillation is an important risk factor for thromboembolic stroke and it significantly increases the risk of stroke. The left atrial appendage (LAA) is the most common site of thrombus formation in nonvalvular atrial fibrillation, and the recent applications of percutaneous LAA closure devices offer a promising alternative for patients who are unable to tolerate lifelong anticoagulation. Critical care nurses who understand the procedures and are familiar with the various devices used for LAA closure will be well prepared to provide optimum care and appropriate education for these patients.
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225
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Arwood MJ, Chumnumwat S, Cavallari LH, Nutescu EA, Duarte JD. Implementing Pharmacogenomics at Your Institution: Establishment and Overcoming Implementation Challenges. Clin Transl Sci 2016; 9:233-245. [PMID: 27214750 PMCID: PMC5121089 DOI: 10.1111/cts.12404] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/12/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- M J Arwood
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - S Chumnumwat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Rajathevi, Bangkok, Thailand
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - E A Nutescu
- Personalized Medicine Program, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois College of Pharmacy, Chicago, Illinois, USA.,Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois College of Pharmacy, Chicago, Illinois, USA
| | - J D Duarte
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Center for Pharmacogenomics, University of Florida College of Pharmacy, Gainesville, Florida, USA
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226
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Manzi SF, Fusaro VA, Chadwick L, Brownstein C, Clinton C, Mandl KD, Wolf WA, Hawkins JB. Creating a scalable clinical pharmacogenomics service with automated interpretation and medical record result integration - experience from a pediatric tertiary care facility. J Am Med Inform Assoc 2016; 24:74-80. [PMID: 27301749 DOI: 10.1093/jamia/ocw052] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/01/2016] [Accepted: 03/12/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This paper outlines the implementation of a comprehensive clinical pharmacogenomics (PGx) service within a pediatric teaching hospital and the integration of clinical decision support in the electronic health record (EHR). MATERIALS AND METHODS An approach to clinical decision support for medication ordering and dispensing driven by documented PGx variant status in an EHR is described. A web-based platform was created to automatically generate a clinical report from either raw assay results or specified diplotypes, able to parse and combine haplotypes into an interpretation for each individual and compared to the reference lab call for accuracy. RESULTS Clinical decision support rules built within an EHR provided guidance to providers for 31 patients (100%) who had actionable PGx variants and were written for interacting medications. A breakdown of the PGx alerts by practitioner service, and alert response for the initial cohort of patients tested is described. In 90% (355/394) of the cases, thiopurine methyltranferase genotyping was ordered pre-emptively. DISCUSSION This paper outlines one approach to implementing a clinical PGx service in a pediatric teaching hospital that cares for a heterogeneous patient population. There is a focus on incorporation of PGx clinical decision support rules and a program to standardize report text within the electronic health record with subsequent exploration of clinician behavior in response to the alerts. CONCLUSION The incorporation of PGx data at the time of prescribing and dispensing, if done correctly, has the potential to impact the incidence of adverse drug events, a significant cause of morbidity and mortality.
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Affiliation(s)
- Shannon F Manzi
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA
| | - Vincent A Fusaro
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA.,Comptational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
| | - Laura Chadwick
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA.,Massachusetts College of Pharmacy and Allied Health Sciences University, Boston, MA, USA
| | | | - Catherine Clinton
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth D Mandl
- Comptational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA.,Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Wendy A Wolf
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA
| | - Jared B Hawkins
- Clinical Pharmacogenomics Service, Boston Children's Hospital, Boston, MA, USA.,Comptational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
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227
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Alolga RN, Fan Y, Chen Z, Liu LW, Zhao YJ, Li J, Chen Y, Lai MD, Li P, Qi LW. Significant pharmacokinetic differences of berberine are attributable to variations in gut microbiota between Africans and Chinese. Sci Rep 2016; 6:27671. [PMID: 27283523 PMCID: PMC4901288 DOI: 10.1038/srep27671] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 01/04/2023] Open
Abstract
We investigated the influence of gut microbiotal metabolism on the pharmacokinetics of berberine in healthy male Africans and Chinese. The Cmax and AUC in the Africans were 2.67-fold and 2.0-fold higher than the Chinese, respectively. Microbiotal compositions by 16S rRNA pyrosequencing showed higher abundance of the genera Prevotella, Bacteroides, and Megamonas (34.22, 13.88, and 10.68%, respectively) in the Chinese than the Africans (30.08, 9.43, and 0.48%, respectively). Scatter plot showed a strong negative correlation between the microbiotal abundance and the berberine AUC, especially for the genus Prevotella (r = -0.813) and its species. A more extensive metabolism was observed in Chinese with 1.83-fold higher metabolites, possibly contributing to the lower AUC than the Africans. In conclusion, significant PK differences of berberine were observed between Africans and Chinese, which is partly attributable to variations in gut microbiota and its corresponding metabolic capacity.
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Affiliation(s)
- Raphael N Alolga
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yong Fan
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Zhuo Chen
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Li-Wei Liu
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Jin Li
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yan Chen
- Department of Emergency Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mao-De Lai
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Ping Li
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Lian-Wen Qi
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, Jiangsu, China
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Lauschke VM, Ingelman-Sundberg M. Requirements for comprehensive pharmacogenetic genotyping platforms. Pharmacogenomics 2016; 17:917-24. [PMID: 27248710 DOI: 10.2217/pgs-2016-0023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Recent research highlighted the large extent of rare variants in pharmacogenes and, on this basis, it was estimated that rare variants account for 30-40% of the functional variability in pharmacogenes. It has been proposed that comprehensive next-generation sequencing (NGS)-based sequencing of pharmacogenes could soon be a cost-effective methodology for clinical routine genotyping. Yet, multiple challenges on technical, interpretative and ethical levels need to be overcome to enable the reasonable dissemination of comprehensive pharmacogenetic genotyping, that includes rare genetic variation, into clinical practice. We argue that current pre-emptive pharmacogenetic testing cannot be based on comprehensive approaches but needs to be restricted to validated variants. Rather, comprehensive strategies should only be used for retrospective analyses of patients exhibiting unanticipated drug responses. Thereby, subsequent to computational analyses and functional validations, emerging variants with confirmed functional relevance can be incorporated into candidate genotyping strategies, thus refining and enhancing future pre-emptive genetic testing.
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Affiliation(s)
- Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology & Pharmacology, Karolinska Institutet, SE-17177 Stockholm, Sweden
| | - Magnus Ingelman-Sundberg
- Section of Pharmacogenetics, Department of Physiology & Pharmacology, Karolinska Institutet, SE-17177 Stockholm, Sweden
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229
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Advantages of Array-Based Technologies for Pre-Emptive Pharmacogenomics Testing. MICROARRAYS 2016; 5:microarrays5020012. [PMID: 27600079 PMCID: PMC5003488 DOI: 10.3390/microarrays5020012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/04/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022]
Abstract
As recognised by the National Institutes of Health (NIH) Precision Medicine Initiative (PMI), microarray technology currently provides a rapid, inexpensive means of identifying large numbers of known genomic variants or gene transcripts in experimental and clinical settings. However new generation sequencing techniques are now being introduced in many clinical genetic contexts, particularly where novel mutations are involved. While these methods can be valuable for screening a restricted set of genes for known or novel mutations, implementation of whole genome sequencing in clinical practice continues to present challenges. Even very accurate high-throughput methods with small error rates can generate large numbers of false negative or false positive errors due to the high numbers of simultaneous readings. Additional validation is likely to be required for safe use of any such methods in clinical settings. Custom-designed arrays can offer advantages for screening for common, known mutations and, in this context, may currently be better suited for accredited, quality-controlled clinical genetic screening services, as illustrated by their successful application in several large-scale pre-emptive pharmacogenomics programs now underway. Excessive, inappropriate use of next-generation sequencing may waste scarce research funds and other resources. Microarrays presently remain the technology of choice in applications that require fast, cost-effective genome-wide screening of variants of known importance, particularly for large sample sizes. This commentary considers some of the applications where microarrays continue to offer advantages over next-generation sequencing technologies.
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230
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Improvements in CYP2C9 Genotyping Accuracy Are Needed: A Report of the First Proficiency Testing for Warfarin-related CYP2C9 and VKORC1 Genotyping in China. J Cardiovasc Pharmacol 2016; 66:129-34. [PMID: 25815675 DOI: 10.1097/fjc.0000000000000254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Warfarin is the most commonly used oral anticoagulant in clinical practice. The cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase complex 1 (VKORC1) genotypes have been confirmed to be associated with warfarin dose requirements. Accurate genotyping results are of particular importance for obtaining reliable genotype-guided warfarin dosing information. This study aims to determine analytic performance of laboratories offering CYP2C9 and VKORC1 testing in China. A proficiency panel of 15 validated cell samples covering common CYP2C9 and VKORC1 genetic polymorphisms was provided to 31 participating laboratories, and their genotyping results were evaluated. Fourteen data sets (45.2%) performed well with the entire panel of samples, and 17 data sets (54.8%) reported at least one genotyping error. For VKORC1 (-1639G>A), participating laboratories were 100% successful in detecting genotypes of GG, GA, and AA. For CYP2C9, participants were greater than 90% successful in detecting genotypes of *1/*1, *1/*2, *1/*3, *2/*3, and *3/*3. However, 15 laboratories failed to detect rarely encountered variant genotype *2/*2. The poor performance of CYP2C9 genotyping may be because of the limitation of methodologies used for detecting CYP2C9*2 allele. The proficiency testing survey highlighted the need for improving genotyping accuracy for some laboratories in this field.
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231
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Pharmacogenomics. JOURNAL OF INFUSION NURSING 2016; 39:139-48. [DOI: 10.1097/nan.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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232
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Ruff CT, Ansell JE, Becker RC, Benjamin EJ, Deicicchi DJ, Mark Estes NA, Ezekowitz MD, Fanikos J, Fareed J, Garcia D, Giugliano RP, Goldhaber SZ, Granger C, Healey JS, Hull R, Hylek EM, Libby P, Lopes RD, Mahaffey KW, Mega J, Piazza G, Sasahara AA, Sorond FA, Spyropoulos AC, Walenga JM, Weitz JI. North American Thrombosis Forum, AF Action Initiative Consensus Document. Am J Med 2016; 129:S1-S29. [PMID: 27126598 DOI: 10.1016/j.amjmed.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The North American Thrombosis Forum Atrial Fibrillation Action Initiative consensus document is a comprehensive yet practical briefing document focusing on stroke and bleeding risk assessment in patients with atrial fibrillation, as well as recommendations regarding anticoagulation options and management. Despite the breadth of clinical trial data and guideline recommendation updates, many clinicians continue to struggle to synthesize the disparate information available. This problem slows the uptake and utilization of updated risk prediction tools and adoption of new oral anticoagulants. This document serves as a practical and educational reference for the entire medical community involved in the care of patients with atrial fibrillation.
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Affiliation(s)
- Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Jack E Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, NY
| | - Richard C Becker
- University of Cincinnati College of Medicine, University of Cincinnati Medical Center, Ohio
| | - Emelia J Benjamin
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | | | - N A Mark Estes
- Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | - Michael D Ezekowitz
- Lankenau Medical Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - John Fanikos
- Massachusetts College of Pharmacy, Brigham and Women's Hospital, Northeastern University School of Pharmacy, Boston, Mass
| | - Jawed Fareed
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - David Garcia
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, Wash
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Granger
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Russell Hull
- Foothills Medical Center, University of Calgary, Alberta, Canada
| | - Elaine M Hylek
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Renato D Lopes
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford University Medical Center, Stanford University School of Medicine, Calif
| | - Jessica Mega
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Arthur A Sasahara
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Farzaneh A Sorond
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Jeanine M Walenga
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Brian W, Tremaine LM, Arefayene M, de Kanter R, Evers R, Guo Y, Kalabus J, Lin W, Loi CM, Xiao G. Assessment of drug metabolism enzyme and transporter pharmacogenetics in drug discovery and early development: perspectives of the I-PWG. Pharmacogenomics 2016; 17:615-31. [PMID: 27045656 DOI: 10.2217/pgs.16.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Genetic variants of drug metabolism enzymes and transporters can result in high pharmacokinetic and pharmacodynamic variability, unwanted characteristics of efficacious and safe drugs. Ideally, the contributions of these enzymes and transporters to drug disposition can be predicted from in vitro experiments and in silico modeling in discovery or early development, and then be utilized during clinical development. Recently, regulatory agencies have provided guidance on the preclinical investigation of pharmacogenetics, for application to clinical drug development. This white paper summarizes the results of an industry survey conducted by the Industry Pharmacogenomics Working Group on current practice and challenges with using in vitro systems and in silico models to understand pharmacogenetic causes of variability in drug disposition.
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Affiliation(s)
- William Brian
- Sanofi, Translational Medicine and Early Development, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Larry M Tremaine
- Pfizer Inc., Worldwide Research and Development, Department of Pharmacokinetics, Dynamics and Metabolism, Eastern Point Road, Groton, CT 06340, USA
| | - Million Arefayene
- Biogen, Early Development Sciences, 14 Cambridge Center, Cambridge, MA 02142, USA
| | - Ruben de Kanter
- Preclinical Pharmacokinetics and Metabolism, Actelion Pharmaceuticals Ltd., Gewerbestrasse 16, CH-4123 Allschwil, Switzerland
| | - Raymond Evers
- Merck & Co, Pharmacodynamics, Pharmacokinetics and Drug Metabolism, 2000 Galloping Hill Road, Kenilworth, NJ07033, USA
| | - Yingying Guo
- Eli Lilly and Company, Drug Disposition, LillyCorporate Center, Indianapolis, IN 46285, USA
| | - James Kalabus
- Novartis Pharmaceuticals, 1 Health Plaza, EastHanover, NJ 07936, USA
| | - Wen Lin
- Novartis Institutes for Biomedical Research, Drug Metabolism and Pharmacokinetics, One Health Plaza, East Hanover, NJ07936-1080, USA
| | - Cho-Ming Loi
- Pfizer Inc., Worldwide Research and Development, Department of Pharmacokinetics, Dynamics and Metabolism,10646 Science Center Drive, San Diego, CA 92121, USA
| | - Guangqing Xiao
- Biogen, Preclinical PK and In vitro ADME, 14 Cambridge Center, Cambridge, MA 02142, USA
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234
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PGRNseq: a targeted capture sequencing panel for pharmacogenetic research and implementation. Pharmacogenet Genomics 2016; 26:161-168. [PMID: 26736087 DOI: 10.1097/fpc.0000000000000202] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Although the costs associated with whole-genome and whole-exome next-generation sequencing continue to decline, they remain prohibitively expensive for large-scale studies of genetic variation. As an alternative, custom-target sequencing has become a common methodology on the basis of its favorable balance between cost, throughput, and deep coverage. METHODS We have developed PGRNseq, a custom-capture panel of 84 genes with associations to pharmacogenetic phenotypes, as a tool to explore the relationship between drug response and genetic variation, both common and rare. We utilized a set of 32 diverse HapMap trios and two clinical cohorts to assess platform performance, accuracy, and ability to discover novel variation. RESULTS We found that PGRNseq generates ultra-deep coverage data (mean=496x) that are over 99.8% concordant with orthogonal datasets. In addition, in our testing sets, PGRNseq identified many novel, rare variants of interest, underscoring its value in both research and clinical settings. CONCLUSION PGRNseq is an ideal platform for carrying out sequencing-based analyses of pharmacogenetic variation in large cohorts. In addition, the high accuracy associated with genotypes from PGRNseq highlight its utility as a clinical test.
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235
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Baker WL, Johnson SG. Pharmacogenetics and oral antithrombotic drugs. Curr Opin Pharmacol 2016; 27:38-42. [DOI: 10.1016/j.coph.2016.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/21/2016] [Accepted: 01/29/2016] [Indexed: 01/12/2023]
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236
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Kasner SE, Wang L, French B, Messé SR, Ellenberg J, Kimmel SE. Warfarin Dosing Algorithms and the Need for Human Intervention. Am J Med 2016; 129:431-7. [PMID: 26642907 PMCID: PMC4792751 DOI: 10.1016/j.amjmed.2015.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Dosing algorithms for warfarin incorporate clinical and genetic factors, but human intervention to overrule algorithm-based dosing may occasionally be required. The frequency and reasons for varying from algorithmic warfarin management have not been well studied. METHODS We analyzed a prospective cohort of 1015 participants from the Clarification of Optimal Anticoagulation through Genetics trial who were randomized to either pharmacogenetic- or clinically-guided warfarin dosing algorithms. Clinicians and participants were blinded to dose but not international normalized ratio (INR) during the first 28 days. If an issue arose that raised concern for clinicians but might not be adequately accounted for by the protocol, then clinicians contacted the unblinded medical monitor who could approve exceptions if clinically justified. All granted exceptions were logged and categorized. We analyzed the relationships between dosing exceptions and both baseline characteristics and the outcome of percentage of time in the therapeutic INR range during the first 4 weeks. RESULTS Sixteen percent of participants required at least one exception to the protocol-defined warfarin dose (15% in the genotype arm and 17% in the clinical arm). Ninety percent of dose exceptions occurred after the first 5 days of dosing. The only baseline characteristic associated with dose exceptions was congestive heart failure (odds ratio 2.12, 95% confidence interval, 1.49-3.02, P <.001). Neither study arm nor genotype was associated with dose exceptions. CONCLUSION Despite rigorous algorithms, human intervention is frequently employed in the early management of warfarin dosing. Congestive heart failure at baseline appears to predict early exceptions to standardized protocol management.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia.
| | - Le Wang
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Benjamin French
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Steven R Messé
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Jonas Ellenberg
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Stephen E Kimmel
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
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237
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Liao Z, Feng S, Ling P, Zhang G. Meta-analysis of randomized controlled trials reveals an improved clinical outcome of using genotype plus clinical algorithm for warfarin dosing. J Thromb Thrombolysis 2016; 39:228-34. [PMID: 24962733 DOI: 10.1007/s11239-014-1099-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Previous studies have raised interest in using the genotyping of CYP2C9 and VKORC1 to guide warfarin dosing. However, there is lack of solid evidence to prove that genotype plus clinical algorithm provides improved clinical outcomes than the single clinical algorithm. The results of recent reported clinical trials are paradoxical and needs to be systematically evaluated. In this study, we aim to assess whether genotype plus clinical algorithm of warfarin is superior to the single clinical algorithm through a meta-analysis of randomized controlled trials (RCTs). All relevant studies from PubMed and reference lists from Jan 1, 1995 to Jan 13, 2014 were extracted and screened. Eligible studies included randomized trials that compared clinical plus pharmacogenetic algorithms group to single clinical algorithm group using adult (≥ 18 years) patients with disease conditions that require warfarin use. We further used fix-effect models to calculate the mean difference or the risk ratios (RRs) and 95% CIs to analyze the extracted data. The statistical heterogeneity was calculated using I(2). The percentage of time within the therapeutic INR range was considered to be the primary clinical outcome. The initial search strategy identified 50 citations and 7 trials were eligible. These seven trials included 1,910 participants, including 960 patients who received genotype plus clinical algorithm of warfarin dosing and 950 patients who received clinical algorithm only. We discovered that the percentage of time within the therapeutic INR range of the genotype-guided group was improved compared with the standard group in the RCTs when the initial standard dose was fixed (95% CI 0.09-0.40; I(2) = 47.8%). However, for the studies using non-fixed initial doses, the genotype-guided group failed to exhibit statistically significant outcome compared to the standard group. No significant difference was observed in the incidences of adverse events (RR 0.94, 95% CI 0.84-1.04; I(2) = 0%, p = 0.647) and death rates (RR 1.36, 95% CI 0.46-4.05; I(2) = 10.4%, p = 0.328) between the two groups. Allocation to genotype plus clinical algorithm may be associated with a significant improvement of the percentage of time within the therapeutic INR range for patients adopting fixed dose of warfarin. The incidence of total adverse events and death rates did not differ between these two groups. Further experiments need to be conducted to confirm these findings.
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Affiliation(s)
- Zhenqi Liao
- Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, 215000, Jiangsu, China
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238
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Tong HY, Dávila-Fajardo CL, Borobia AM, Martínez-González LJ, Lubomirov R, Perea León LM, Blanco Bañares MJ, Díaz-Villamarín X, Fernández-Capitán C, Cabeza Barrera J, Carcas AJ. A New Pharmacogenetic Algorithm to Predict the Most Appropriate Dosage of Acenocoumarol for Stable Anticoagulation in a Mixed Spanish Population. PLoS One 2016; 11:e0150456. [PMID: 26977927 PMCID: PMC4792430 DOI: 10.1371/journal.pone.0150456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022] Open
Abstract
There is a strong association between genetic polymorphisms and the acenocoumarol dosage requirements. Genotyping the polymorphisms involved in the pharmacokinetics and pharmacodynamics of acenocoumarol before starting anticoagulant therapy would result in a better quality of life and a more efficient use of healthcare resources. The objective of this study is to develop a new algorithm that includes clinical and genetic variables to predict the most appropriate acenocoumarol dosage for stable anticoagulation in a wide range of patients. We recruited 685 patients from 2 Spanish hospitals and 1 primary healthcare center. We randomly chose 80% of the patients (n = 556), considering an equitable distribution of genotypes to form the generation cohort. The remaining 20% (n = 129) formed the validation cohort. Multiple linear regression was used to generate the algorithm using the acenocoumarol stable dosage as the dependent variable and the clinical and genotypic variables as the independent variables. The variables included in the algorithm were age, weight, amiodarone use, enzyme inducer status, international normalized ratio target range and the presence of CYP2C9*2 (rs1799853), CYP2C9*3 (rs1057910), VKORC1 (rs9923231) and CYP4F2 (rs2108622). The coefficient of determination (R2) explained by the algorithm was 52.8% in the generation cohort and 64% in the validation cohort. The following R2 values were evaluated by pathology: atrial fibrillation, 57.4%; valve replacement, 56.3%; and venous thromboembolic disease, 51.5%. When the patients were classified into 3 dosage groups according to the stable dosage (<11 mg/week, 11-21 mg/week, >21 mg/week), the percentage of correctly classified patients was higher in the intermediate group, whereas differences between pharmacogenetic and clinical algorithms increased in the extreme dosage groups. Our algorithm could improve acenocoumarol dosage selection for patients who will begin treatment with this drug, especially in extreme-dosage patients. The predictability of the pharmacogenetic algorithm did not vary significantly between diseases.
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Affiliation(s)
- Hoi Y. Tong
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Alberto M. Borobia
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
| | - Luis Javier Martínez-González
- Genomics Unit, Centre for Genomics and Oncological Research (GENYO), Pfizer-University of Granada-Andalusian Regional Government, Health Sciences Technology Park, PTS, Granada, Spain
| | - Rubin Lubomirov
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Laura María Perea León
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Antonio J. Carcas
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
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Shendre A, Brown TM, Liu N, Hill CE, Beasley TM, Nickerson DA, Limdi NA. Race-Specific Influence of CYP4F2 on Dose and Risk of Hemorrhage Among Warfarin Users. Pharmacotherapy 2016; 36:263-72. [PMID: 26877068 DOI: 10.1002/phar.1717] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The p.V433M in cytochrome P450 4F2 (rs2108622, CYP4F2*3) is associated with a higher warfarin dose and lower risk of hemorrhage among European Americans. We evaluate the influence of CYP4F2*3 on warfarin dose, time to target international normalized ratio (INR), and stable dose, proportion of time spent in target range (PTTR), as well as the risk of overanticoagulation and hemorrhage among European and African Americans. DESIGN CYP4F2*3 was genotyped in 1238 patients initiated on warfarin in a prospective inception cohort. Multivariable linear regression was used to assess warfarin dose and PTTR; proportional hazards analysis was performed to evaluate time to target INR and stable dose, overanticoagulation, and hemorrhage. SETTING Two outpatient anticoagulation clinics. PARTICIPANTS A total of 1238 anticoagulated patients. OUTCOMES Warfarin dose (mg/day), time to target INR and stable dose, PTTR, overanticoagulation (INR more than 4), and major hemorrhage. RESULTS Minor allele frequency for the CYP4F2*3 variant was 30.3% among European Americans and 8.4% among African Americans. CYP4F2*3 was associated with higher dose among European Americans but not African Americans. Compared to CYP4F2*1/*1, *1/*3 was associated with a statistically nonsignificant increase in dose (4.5%, p=0.22) and *3/*3 was associated with a statistically significant increase in dose (13.2%, p=0.02). CYP4F2 genotype did not influence time to target INR, time to stable dose, or PTTR in either race group. CYP4F2*3/*3 was associated with a 31% lower risk of over anticoagulation (p=0.06). Incidence of hemorrhage was lower among participants with CYP4F2 *3/*3 compared with *1/*3 or *1/*1 (incidence rate ratio = 0.45, 95% confidence interval 0.14-1.11, p=0.09). After controlling for covariates, CYP4F2 *3/*3 was associated with a 52% lower risk of hemorrhage, although this was not statistically significant (p=0.24). CONCLUSION Possession of CYP4F2*3 variant influences warfarin dose among European Americans but not African Americans. The CYP4F2-dose, CYP4F2-overanticoagulation, and CYP4F2-hemorrhage association follows a recessive pattern with possession of CYP4F2*3/*3 genotype likely demonstrating a protective effect. These findings need further confirmation.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Todd M Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nianjun Liu
- Biostatistics, Section on Statistical Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles E Hill
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - T Mark Beasley
- Biostatistics, Section on Statistical Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Deborah A Nickerson
- Genome Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Hall JL, Ryan JJ, Bray BE, Brown C, Lanfear D, Newby LK, Relling MV, Risch NJ, Roden DM, Shaw SY, Tcheng JE, Tenenbaum J, Wang TN, Weintraub WS. Merging Electronic Health Record Data and Genomics for Cardiovascular Research: A Science Advisory From the American Heart Association. ACTA ACUST UNITED AC 2016; 9:193-202. [PMID: 26976545 DOI: 10.1161/hcg.0000000000000029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The process of scientific discovery is rapidly evolving. The funding climate has influenced a favorable shift in scientific discovery toward the use of existing resources such as the electronic health record. The electronic health record enables long-term outlooks on human health and disease, in conjunction with multidimensional phenotypes that include laboratory data, images, vital signs, and other clinical information. Initial work has confirmed the utility of the electronic health record for understanding mechanisms and patterns of variability in disease susceptibility, disease evolution, and drug responses. The addition of biobanks and genomic data to the information contained in the electronic health record has been demonstrated. The purpose of this statement is to discuss the current challenges in and the potential for merging electronic health record data and genomics for cardiovascular research.
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241
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Alrashid MH, Al-Serri A, Alshemmari SH, Koshi P, Al-Bustan SA. Association of Genetic Polymorphisms in the VKORC1 and CYP2C9 Genes with Warfarin Dosage in a Group of Kuwaiti Individuals. Mol Diagn Ther 2016; 20:183-90. [DOI: 10.1007/s40291-016-0190-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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242
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Cifuentes RA, Murillo-Rojas J, Avella-Vargas E. Prediction of sensitivity to warfarin based on VKORC1 and CYP2C9 polymorphisms in patients from different places in Colombia. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2016; 36:91-100. [PMID: 27622442 DOI: 10.7705/biomedica.v36i1.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/14/2015] [Indexed: 06/06/2023]
Abstract
INTRODUCTION In the search to prevent hemorrhages associated with anticoagulant therapy, a major goal is to validate predictors of sensitivity to warfarin. However, previous studies in Colombia that included polymorphisms in the VKORC1 and CYP2C9 genes as predictors reported different algorithm performances to explain dose variations, and did not evaluate the prediction of sensitivity to warfarin. OBJECTIVE To determine the accuracy of the pharmacogenetic analysis, which includes the CYP2C9 *2 and *3 and VKORC1 1639G>A polymorphisms in predicting patients' sensitivity to warfarin at the Hospital Militar Central, a reference center for patients born in different parts of Colombia. MATERIALS AND METHODS Demographic and clinical data were obtained from 130 patients with stable doses of warfarin for more than two months. Next, their genotypes were obtained through a melting curve analysis. After verifying the Hardy-Weinberg equilibrium of the genotypes from the polymorphisms, a statistical analysis was done, which included multivariate and predictive approaches. RESULTS A pharmacogenetic model that explained 52.8% of dose variation (p<0.001) was built, which was only 4% above the performance resulting from the same data using the International Warfarin Pharmacogenetics Consortium algorithm. The model predicting the sensitivity achieved an accuracy of 77.8% and included age (p=0.003), polymorphisms *2 and *3 (p=0.002) and polymorphism 1639G>A (p<0.001) as predictors. CONCLUSIONS These results in a mixed population support the prediction of sensitivity to warfarin based on polymorphisms in VKORC1 and CYP2C9 as a valid approach in Colombian patients.
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Affiliation(s)
- Ricardo A Cifuentes
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, D.C., Colombia Grupo Insight, Universidad Militar Nueva Granada, Bogotá, D.C., Colombia.
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Ji Y, Skierka JM, Blommel JH, Moore BE, VanCuyk DL, Bruflat JK, Peterson LM, Veldhuizen TL, Fadra N, Peterson SE, Lagerstedt SA, Train LJ, Baudhuin LM, Klee EW, Ferber MJ, Bielinski SJ, Caraballo PJ, Weinshilboum RM, Black JL. Preemptive Pharmacogenomic Testing for Precision Medicine: A Comprehensive Analysis of Five Actionable Pharmacogenomic Genes Using Next-Generation DNA Sequencing and a Customized CYP2D6 Genotyping Cascade. J Mol Diagn 2016; 18:438-445. [PMID: 26947514 DOI: 10.1016/j.jmoldx.2016.01.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/24/2015] [Accepted: 01/11/2016] [Indexed: 01/08/2023] Open
Abstract
Significant barriers, such as lack of professional guidelines, specialized training for interpretation of pharmacogenomics (PGx) data, and insufficient evidence to support clinical utility, prevent preemptive PGx testing from being widely clinically implemented. The current study, as a pilot project for the Right Drug, Right Dose, Right Time-Using Genomic Data to Individualize Treatment Protocol, was designed to evaluate the impact of preemptive PGx and to optimize the workflow in the clinic setting. We used an 84-gene next-generation sequencing panel that included SLCO1B1, CYP2C19, CYP2C9, and VKORC1 together with a custom-designed CYP2D6 testing cascade to genotype the 1013 subjects in laboratories approved by the Clinical Laboratory Improvement Act. Actionable PGx variants were placed in patient's electronic medical records where integrated clinical decision support rules alert providers when a relevant medication is ordered. The fraction of this cohort carrying actionable PGx variant(s) in individual genes ranged from 30% (SLCO1B1) to 79% (CYP2D6). When considering all five genes together, 99% of the subjects carried an actionable PGx variant(s) in at least one gene. Our study provides evidence in favor of preemptive PGx testing by identifying the risk of a variant being present in the population we studied.
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Affiliation(s)
- Yuan Ji
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jennifer M Skierka
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joseph H Blommel
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Brenda E Moore
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Douglas L VanCuyk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jamie K Bruflat
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lisa M Peterson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Numrah Fadra
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Sandra E Peterson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Susan A Lagerstedt
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Laura J Train
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Linnea M Baudhuin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Eric W Klee
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Ferber
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Pedro J Caraballo
- Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Richard M Weinshilboum
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - John L Black
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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244
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Luzum JA, Luzum MJ. Physicians' attitudes toward pharmacogenetic testing before and after pharmacogenetic education. Per Med 2016; 13:119-127. [PMID: 29749904 DOI: 10.2217/pme.15.57] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIM Our aim was to evaluate physicians' attitudes toward pharmacogenetic testing before and after pharmacogenetic education. METHODS In total, 12 physicians (˜40% response rate) completed a survey with eight questions on 10-point scales on their attitudes toward pharmacogenetic testing before and after a 1-h grand rounds presentation on pharmacogenetics. Differences in question scores overall, among training levels (resident/fellow/attending), and specific drugs (clopidogrel/simvastatin/warfarin) were assessed using Wilcoxon signed-rank and exact Kruskal-Wallis tests. RESULTS & CONCLUSION The scores for all eight questions increased, with statistically significant (p < 0.05) increases for four out of eight questions. The scores were similar among training levels, but the postscores for clopidogrel were significantly higher than for simvastatin and warfarin. In conclusion, brief pharmacogenetic education can significantly affect physicians' attitudes toward pharmacogenetic testing.
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Affiliation(s)
- Jasmine A Luzum
- Center for Pharmacogenomics, The Ohio State University Wexner Medical Center, 5084 Graves Hall, 333 W 10th Ave., Columbus, OH 43210, USA
| | - Matthew J Luzum
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.,Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, Columbus, OH 43205, USA
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Cavallari LH, Mason DL. Cardiovascular Pharmacogenomics--Implications for Patients With CKD. Adv Chronic Kidney Dis 2016; 23:82-90. [PMID: 26979147 DOI: 10.1053/j.ackd.2015.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 01/20/2023]
Abstract
CKD is an independent risk factor for cardiovascular disease (CVD). Thus, patients with CKD often require treatment with cardiovascular drugs, such as antiplatelet, antihypertensive, anticoagulant, and lipid-lowering agents. There is significant interpatient variability in response to cardiovascular therapies, which contributes to risk for treatment failure or adverse drug effects. Pharmacogenomics offers the potential to optimize cardiovascular pharmacotherapy and improve outcomes in patients with CVD, although data in patients with concomitant CKD are limited. The drugs with the most pharmacogenomic evidence are warfarin, clopidogrel, and statins. There are also accumulating data for genetic contributions to β-blocker response. Guidelines are now available to assist with applying pharmacogenetic test results to optimize warfarin dosing, selection of antiplatelet therapy after percutaneous coronary intervention, and prediction of risk for statin-induced myopathy. Clinical data, such as age, body size, and kidney function have long been used to optimize drug prescribing. An increasing number of institutions are also implementing genetic testing to be considered in the context of important clinical factors to further personalize drug therapy for patients with CVD.
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246
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Ladda MA, Goralski KB. The Effects of CKD on Cytochrome P450-Mediated Drug Metabolism. Adv Chronic Kidney Dis 2016; 23:67-75. [PMID: 26979145 DOI: 10.1053/j.ackd.2015.10.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 12/20/2022]
Abstract
CKD affects a significant proportion of the world's population, and the prevalence of CKD is increasing. Standard practice currently is to adjust the dose of renally eliminated medications as kidney function declines in effort to prevent adverse drug reactions. It is increasingly becoming recognized that CKD also impacts nonrenal clearance mechanisms such as hepatic and intestinal cytochrome P450 (CYP) enzymes and drug transport proteins, the latter of which is beyond the scope of this review. CYPs are responsible for the metabolism of many clinically used drugs. Genetics, patient factors (eg, age and disease) and drug interactions are well known to affect CYP metabolism resulting in variable pharmacokinetics and responses to medications. There now exists an abundance of evidence demonstrating that CKD can impact the activity of many CYP isoforms either through direct inhibition by circulating uremic toxins and/or by reducing CYP gene expression. Evidence suggests that reductions in CYP metabolism in ESRD are reversed by kidney transplantation and temporarily restored via hemodialysis. This review summarizes the current understanding of the effects that CKD can have on CYP metabolism and also discusses the impact that CYP metabolism phenotypes can have on the development of kidney injury.
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247
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Cavallari LH, Weitzel K. Pharmacogenomics in cardiology--genetics and drug response: 10 years of progress. Future Cardiol 2016; 11:281-6. [PMID: 26021633 DOI: 10.2217/fca.15.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Claudio-Campos K, Duconge J, Cadilla CL, Ruaño G. Pharmacogenetics of drug-metabolizing enzymes in US Hispanics. Drug Metab Pers Ther 2016; 30:87-105. [PMID: 25431893 DOI: 10.1515/dmdi-2014-0023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/02/2014] [Indexed: 12/19/2022]
Abstract
Although the Hispanic population is continuously growing in the United States, they are underrepresented in pharmacogenetic studies. This review addresses the need for compiling available pharmacogenetic data in US Hispanics, discussing the prevalence of clinically relevant polymorphisms in pharmacogenes encoding for drug-metabolizing enzymes. CYP3A5*3 (0.245-0.867) showed the largest frequency in a US Hispanic population. A higher prevalence of CYP2C9*3, CYP2C19*4, and UGT2B7 IVS1+985 A>G was observed in US Hispanic vs. non-Hispanic populations. We found interethnic and intraethnic variability in frequencies of genetic polymorphisms for metabolizing enzymes, which highlights the need to define the ancestries of participants in pharmacogenetic studies. New approaches should be integrated in experimental designs to gain knowledge about the clinical relevance of the unique combination of genetic variants occurring in this admixed population. Ethnic subgroups in the US Hispanic population may harbor variants that might be part of multiple causative loci or in linkage-disequilibrium with functional variants. Pharmacogenetic studies in Hispanics should not be limited to ascertain commonly studied polymorphisms that were originally identified in their parental populations. The success of the Personalized Medicine paradigm will depend on recognizing genetic diversity between and within US Hispanics and the uniqueness of their genetic backgrounds.
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Abstract
In this review, we lay out 3 areas currently being evaluated for incorporation of genetic information into clinical practice related to atherosclerosis. The first, familial hypercholesterolemia, is the clearest case for utility of genetic testing in diagnosis and potentially guiding treatment. Already in use for confirmatory testing of familial hypercholesterolemia and for cascade screening of relatives, genetic testing is likely to expand to help establish diagnoses and facilitate research related to most effective therapies, including new agents, such as PCSK9 inhibitors. The second area, adding genetic information to cardiovascular risk prediction for primary prevention, is not currently recommended. Although identification of additional variants may add substantially to prediction in the future, combining known variants has not yet demonstrated sufficient improvement in prediction for incorporation into commonly used risk scores. The third area, pharmacogenetics, has utility for some therapies today. Future utility for pharmacogenetics will wax or wane depending on the nature of available drugs and therapeutic strategies.
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Affiliation(s)
- Nina P. Paynter
- From the Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Paul M Ridker
- From the Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Daniel I. Chasman
- From the Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Pai SA, Kshirsagar N. A Critical Evaluation of Pharmacogenetic Information in Package Inserts for Selected Drugs Marketed in India and Its Comparison With US FDA-Approved Package Inserts. J Clin Pharmacol 2016; 56:1232-42. [PMID: 26873003 DOI: 10.1002/jcph.720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/08/2016] [Indexed: 02/06/2023]
Abstract
Our objective was to compare the pharmacogenetic information provided in the package inserts (PIs) of 7 drugs marketed in the United States and India, namely, abacavir, capecitabine, carbamazepine, clopidogrel, irinotecan, valproic acid, and warfarin. We evaluated the pharmacogenetic information provided in Indian PIs for the highest level where it was included, robustness and completeness, clinical validity, and clinical utility and compared it with corresponding data of US PIs. Pharmacogenetic studies carried out in India were identified using PubMed. Pharmacogenetic information was provided in Indian PIs of all the drugs except irinotecan. It appeared in the same section as in US PIs for abacavir, capecitabine, carbamazepine (HLA-*3101), valproic acid (urea cycle disorders), and warfarin (protein C and protein S), whereas it appeared at lower levels for other drug-gene combinations. The robustness of pharmacogenetic testing was graded convincing for abacavir, adequate for carbamazepine and clopidogrel, and incomplete for the remaining drugs, and only abacavir and clopidogrel PIs provided full details of supporting studies. These details, when provided in the Indian PIs were identical to those in the US PIs. The Indian PIs did not provide data on Indian patients, although published studies are available. Both US and Indian PIs lacked critical information on the clinical validity and utility of pharmacogenetic testing. The pharmacogenetic information should provide country/ethnicity-specific data so that they are useful to clinicians. Where data are not available, the prevalence of genetic variation in the population of a country needs to be determined and should then be translated to the PIs.
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Affiliation(s)
- Sarayu Arvind Pai
- Institute of Chemical Technology, Formerly, Indian Council of Medical Research, Mumbai, India
| | - Nilima Kshirsagar
- National Chair in Clinical Pharmacology, South Asian Chapter of American College of Clinical Pharmacology (SAC-ACCP), Mumbai, India.
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