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Ndadza A, Cindi Z, Makambwa E, Chimusa E, Wonkam A, Kengne AP, Ntsekhe M, Dandara C. Warfarin Dose and CYP2C Gene Cluster: An African Ancestral-Specific Variant Is a Strong Predictor of Dose in Black South African Patients. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2018; 23:36-44. [PMID: 30566377 DOI: 10.1089/omi.2018.0174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Warfarin is a widely prescribed anticoagulant with a narrow therapeutic index. The rs12777823G>A single-nucleotide polymorphism (SNP) in the CYP2C gene cluster has been shown to influence optimal warfarin doses in African Americans. We report here effects of rs12777823G>A SNP on warfarin dose requirements in two South African population groups, black Africans (BA) and mixed ancestry (MA). A total of 425 participants on warfarin treatment were enrolled in the study. The age group of the studied population ranged between 44 and 66 years, with 69% females enrolled. Genetic characterization of the rs12777823G>A was done using the TaqMan SNP genotyping assay. To further compare effects of rs12777823G>A to those of other SNPs, VKORC1 g.-1639G>A and 4 SNPs in CYP2C9 gene (i.e., CYP2C9 c.430C>T, c.1075A>C, c.449G>A, and c.1003C>T) were analyzed. The rs12777823A variant allele frequencies were 0.28 and 0.25 in the BA and MA, respectively. The rs12777823A/A genotype was associated with significantly (p = 0.002) reduced mean warfarin dosage (27 ± 5.3 mg/week) compared with the G/G genotype (45 ± 16.1 mg/week) among BA, but not among the MA. The rs12777823G>A is located in a nongenomic region, suggesting that this SNP might be in linkage disequilibrium with another, likely causal SNP that is present in BA only. Given ongoing worldwide efforts to identify clinically relevant human genetic variation impacting on optimal warfarin dose selection, the African ancestry-specific genetic variant in the CYP2C cluster and others warrant further research and consideration in development of future warfarin dosing algorithms for precision medicine guidelines.
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Affiliation(s)
- Arinao Ndadza
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Zinhle Cindi
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Edson Makambwa
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Emile Chimusa
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Ambroise Wonkam
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Andre P Kengne
- 3 Non-Communicable Diseases Research Unit, South African Medical Research Council and University of Cape Town , Cape Town, South Africa
| | - Mpiko Ntsekhe
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Collet Dandara
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
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202
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Zhou S, Skaar DJ, Jacobson PA, Huang RS. Pharmacogenomics of Medications Commonly Used in the Intensive Care Unit. Front Pharmacol 2018; 9:1436. [PMID: 30564130 PMCID: PMC6289166 DOI: 10.3389/fphar.2018.01436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022] Open
Abstract
In the intensive care unit (ICU) setting, where highly variable and insufficient drug efficacies, as well as frequent and unpredictable adverse drug reactions (ADRs) occur, pharmacogenomics (PGx) offers an opportunity to improve health outcomes. However, PGx has not been fully evaluated in the ICU, partly due to lack of knowledge of how genetic markers may affect drug therapy. To fill in this gap, we conducted a review to summarize the PGx information for the medications commonly encountered in the ICU.
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Affiliation(s)
- Shuqin Zhou
- Department of Emergency and Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Debra J Skaar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - R Stephanie Huang
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
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203
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Xu Z, Zhang SY, Huang M, Hu R, Li JL, Cen HJ, Wang ZP, Ou JS, Yin SL, Xu YQ, Wu ZK, Zhang X. Genotype-Guided Warfarin Dosing in Patients With Mechanical Valves: A Randomized Controlled Trial. Ann Thorac Surg 2018; 106:1774-1781. [DOI: 10.1016/j.athoracsur.2018.07.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 06/30/2018] [Accepted: 07/06/2018] [Indexed: 12/27/2022]
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204
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Pengo V, Denas G. Optimizing quality care for the oral vitamin K antagonists (VKAs). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:332-338. [PMID: 30504329 PMCID: PMC6245991 DOI: 10.1182/asheducation-2018.1.332] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Vitamin K antagonists (VKAs) have been the only oral anticoagulants for decades. The management of anticoagulant therapy with VKA is challenging because of the intricate pharmacological properties of these agents. The success of VKA therapy depends on the quality of treatment that is ensured through continuing comprehensive communication and education. The educational program should address important issues of the VKA therapy such as beginning of treatment, pharmacological, dietary, and drug-drug interactions, as well as treatment temporary suspension during surgical interventions or invasive maneuvers. In addition, the initial and continuing patient education is of imperative importance. A major role in the educational process may be addressed by patient associations. The quality of treatment is better reached if patients are followed in anticoagulation clinics. Moreover, a federation of anticoagulation clinics may improve patient care through regular meetings to update knowledge on VKA treatment. Learning objectives of this paper is to allow readers to correctly approach patients starting VKA treatment, recognize possible pitfalls of treatment, and provide adequate solutions.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
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205
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Shaul C, Blotnick S, Deutsch L, Rosenberg G, Caraco Y. The impact of R353Q genetic polymorphism in coagulation factor VII on the initial anticoagulant effect exerted by warfarin. Eur J Clin Pharmacol 2018; 75:343-350. [PMID: 30411147 DOI: 10.1007/s00228-018-2594-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The initial rise in INR following warfarin is attributed to rapid decline in coagulation factor VII (F7). The R353Q polymorphism in F7 accounts for approximately 1/3 of the variability in F7 activity (FVIIc). OBJECTIVE Evaluate the role of R353Q in the initial response to warfarin. METHODS Twenty-eight healthy, males, carrying CYP2C9*1/*1 (n = 14), CYP2C9*1/*2 (n = 4) or CYP2C9*1/*3 (n = 10) genotypes, received single 20 mg warfarin. S&R-warfarin concentrations, INR, and FVIIc were monitored periodically for 7 days. RESULTS Baseline and maximal INR were 5.6% and 33.5% higher among carriers of the RQ (n = 12) as compared with those carrying the RR (n = 16) genotype (p = 0.032, p = 0.003, respectively). Baseline and nadir FVIIc were 21.6% and 42.0% lower among subjects carrying the RQ as compared with carriers of the RR genotype (p = 0.001, p = 0.007 respectively). In multiple regression analysis, R353Q predicted 36.6% of the variability in peak INR whereas 20.2%, 9.9%, and 5.9% were attributed to VKORC1 genetic polymorphism, cholesterol concentration, and S Warfarin concentration after 24 h, respectively. CONCLUSIONS R353Q genetic polymorphism plays a key role in determining the initial response to warfarin. The incorporation of this genetic variant into warfarin loading algorithm should be further investigated.
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Affiliation(s)
- Chanan Shaul
- Clinical Pharmacology Unit, Division of Medicine, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.,Institute of Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Simcha Blotnick
- Clinical Pharmacology Unit, Division of Medicine, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Liat Deutsch
- Clinical Pharmacology Unit, Division of Medicine, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | | | - Yoseph Caraco
- Clinical Pharmacology Unit, Division of Medicine, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
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206
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Chen X, Jin DY, Stafford DW, Tie JK. Evaluation of oral anticoagulants with vitamin K epoxide reductase in its native milieu. Blood 2018; 132:1974-1984. [PMID: 30089628 PMCID: PMC6213321 DOI: 10.1182/blood-2018-05-846592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/05/2018] [Indexed: 12/14/2022] Open
Abstract
Warfarin, acenocoumarol, phenprocoumon, and fluindione are commonly prescribed oral anticoagulants for the prevention and treatment of thromboembolic disorders. These anticoagulants function by impairing the biosynthesis of active vitamin K-dependent coagulation factors through the inhibition of vitamin K epoxide reductase (VKOR). Genetic variations in VKOR have been closely associated with the resistant phenotype of oral anticoagulation therapy. However, the relative efficacy of these anticoagulants, their mechanisms of action, and their resistance variations among naturally occurring VKOR mutations remain elusive. Here, we explored these questions using our recently established cell-based VKOR activity assay with the endogenous VKOR function ablated. Our results show that the efficacy of these anticoagulants on VKOR inactivation, from most to least, is: acenocoumarol > phenprocoumon > warfarin > fluindione. This is consistent with their effective clinical dosages for stable anticoagulation control. Cell-based functional studies of how each of the 27 naturally occurring VKOR mutations responds to these 4 oral anticoagulants indicate that phenprocoumon has the largest resistance variation (up to 199-fold), whereas the resistance of acenocoumarol varies the least (<14-fold). Cell-based kinetics studies show that fluindione appears to be a competitive inhibitor of VKOR, whereas warfarin is likely to be a mixed-type inhibitor of VKOR. The anticoagulation effect of these oral anticoagulants can be reversed by the administration of a high dose of vitamin K, apparently due to the existence of a different enzyme that can directly reduce vitamin K. These findings provide new insights into the selection of oral anticoagulants, their effective dosage management, and their mechanisms of anticoagulation.
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Affiliation(s)
- Xuejie Chen
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Da-Yun Jin
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Darrel W Stafford
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jian-Ke Tie
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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207
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Effect of genetic and patient factors on warfarin pharmacodynamics following warfarin withdrawal: Implications for patients undergoing surgery. Thromb Res 2018; 171:167-170. [DOI: 10.1016/j.thromres.2018.09.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 01/18/2023]
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208
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Shendre A, Dillon C, Limdi NA. Pharmacogenetics of warfarin dosing in patients of African and European ancestry. Pharmacogenomics 2018; 19:1357-1371. [PMID: 30345882 PMCID: PMC6562764 DOI: 10.2217/pgs-2018-0146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/28/2018] [Indexed: 12/20/2022] Open
Abstract
Despite the introduction of direct acting oral anticoagulants, warfarin remains the most commonly prescribed oral anticoagulant. However, warfarin therapy is plagued by the large inter- and intrapatient variability. The variability in dosing fueled research to identify clinical and genetic predictors and develop more accurate dosing algorithms. Observational studies have demonstrated the significant impact of single nucleotide polymorphisms in CYP2C9 and VKORC1 on warfarin dose in patients of European ancestry and African-Americans. This evidence supported the design and conduct of clinical trials to assess whether genotype-guided dosing results in improved anticoagulation control and outcomes. The trial results have shown discordance by race, with pharmacogenetic algorithms improving dose and anticoagulation control among European ancestry patients compared with African-American patients. Herein, we review the evidence from observational and interventional studies, highlight the need for inclusion of minority race groups and propose the need to develop race specific dosing algorithms.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M Fairbanks School of Public Health, Indiana University Purdue University Indianapolis, IN 46202, USA
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
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209
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Fang Y, Gao J, Wang T, Tian X, Gao N, Zhou J, Zhang HF, Wen Q, Jin H, Xing YR, Qiao HL. Intraindividual Variation and Correlation of Cytochrome P450 Activities in Human Liver Microsomes. Mol Pharm 2018; 15:5312-5318. [PMID: 30346185 DOI: 10.1021/acs.molpharmaceut.8b00787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We systematically studied and explored intraindividual variation and correlation in the activities of cytochrome P450 (CYP) using 105 normal liver samples. The intraindividual percentage coefficients of variation of relative Km, Vmax, and CLint were 45.9% (18.3-140%), 44.0% (16.8-127%), and 52.0% (24.2-134%). Overall values of relative Km, Vmax, and CLint for 10 CYPs were sorted. The order, from highest to lowest, was CYP2D6, 3A4/5, 2C19, 2C9, 2B6, 1A2, 2A6, 2C8, and 2E1 for Km; CYP3A4/5, 2C19, 2D6, 2C8, 2E1, 2B6, 1A2, 2A6, and 2C9 for Vmax; and CYP2D6, 2B6, 3A4/5, 2C19, 2C9, 1A2, 2E1, 2C8, and 2A6 for CLint. CYP2A6*4, 2B6 785A>G, and 2D6 100C>T contributed to intraindividual variation of CYP activities. The correlations and similarities among 10 CYP activities were analyzed, and it was found that the highest correlation and similarity for Vmax, Km, and CLint occurred between CYP2C9 and 2C8, CYP2C9 and 1A2, and CYP2C9 and 2C8, respectively. In conclusion, CYP activities exhibit considerable intraindividual variation, with some notable correlations, which might be helpful to comprehensively understand the internal connection among CYP activities and to guide the rational use of drugs.
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Affiliation(s)
- Yan Fang
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Jie Gao
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Tong Wang
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Xin Tian
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Na Gao
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Jun Zhou
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Hai-Feng Zhang
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Qiang Wen
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Han Jin
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Yu-Rong Xing
- The First Affiliated Hospital of Zhengzhou University , Zhengzhou , 450052 Henan , China
| | - Hai-Ling Qiao
- Institute of Clinical Pharmacology , Zhengzhou University , Zhengzhou , 450052 Henan , China
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210
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Vassy JL, Chun S, Advani S, Ludin SA, Smith JG, Alligood EC. Impact of SLCO1B1 Pharmacogenetic Testing on Patient and Healthcare Outcomes: A Systematic Review. Clin Pharmacol Ther 2018; 106:360-373. [PMID: 30137643 DOI: 10.1002/cpt.1223] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
Demonstrated improvements in patient outcomes will facilitate the clinical implementation of pharmacogenetic testing. Using the association between solute carrier organic anion transporter family member 1B1 (SLCO1B1) and statin-associated muscle symptoms (SAMSs) as a model, we conducted a systematic review of patient outcomes after delivery of SLCO1B1 results. Using PubMed and Embase searches through December 19, 2017, we identified 37 eligible records reporting preliminary or final outcomes, including six studies delivering only SLCO1B1 results and five large healthcare system-based implementation projects of multipharmacogene panels. Two small trials have demonstrated at least short-term improvements in low-density lipoprotein cholesterol after SLCO1B1 testing among previously statin intolerant patients. Evidence from large implementation projects suggests that SLCO1B1 results may change prescribing patterns for some high-risk patients. No study has reported improvements in SAMSs or cardiovascular events or tracked the economic outcomes of SLCO1B1 testing. Ongoing studies should collect and report outcomes relevant to pharmacogenetics stakeholders.
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Affiliation(s)
- Jason L Vassy
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sojeong Chun
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts, USA
| | - Sanjay Advani
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Sophie A Ludin
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA.,Cornell University, Ithaca, New York, USA
| | - Jason G Smith
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Elaine C Alligood
- Veterans Affairs (VA) VA Boston Healthcare System, Boston, Massachusetts, USA
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211
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Galvez JM, Restrepo CM, Contreras NC, Alvarado C, Calderón-Ospina CA, Peña N, Cifuentes RA, Duarte D, Laissue P, Fonseca DJ. Creating and validating a warfarin pharmacogenetic dosing algorithm for Colombian patients. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:169-178. [PMID: 30410385 PMCID: PMC6198877 DOI: 10.2147/pgpm.s170515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose Warfarin is an oral anticoagulant associated with adverse reaction to drugs due to wide inter- and intra-individual dosage variability. Warfarin dosage has been related to non-genetic and genetic factors. CYP2C9 and VKORC1 gene polymorphisms affect warfarin metabolism and dosage. Due to the central role of populations’ ethnical and genetic origin on warfarin dosage variability, novel algorithms for Latin American subgroups are necessary to establish safe anticoagulation therapy. Patients and methods We genotyped CYP2C9*2 (c.430C > T), CYP2C9*3 (c.1075A > C), CYP4F2 (c.1297G > A), and VKORC1 (−1639 G > A) polymorphisms in 152 Colombian patients who received warfarin. We evaluated the impact on the variability of patients’ warfarin dose requirements. Multiple linear regression analysis, using genetic and non-genetic variables, was used for creating an algorithm for optimal warfarin maintenance dose. Results Median weekly prescribed warfarin dosage was significantly lower in patients having the VKORC1-1639 AA genotype and poor CYP2C9*2/*2,*2/*3 metabolizers than their wild-type counterparts. We found a 2.3-fold increase in mean dose for normal sensitivity patients (wild-type VKORC1/CYP2C9 genotypes) compared to the other groups (moderate and high sensitivity); 31.5% of the patients in our study group had warfarin sensitivity-related genotypes. The estimated regression equation accounted for 44.4% of overall variability in regard to warfarin maintenance dose. The algorithm was validated, giving 45.9% correlation (R2=0.459). Conclusion Our results describe and validate the first algorithm for predicting warfarin maintenance in a Colombian mestizo population and have contributed toward the understanding of pharmacogenetics in a Latin American population subgroup.
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Affiliation(s)
- Jubby Marcela Galvez
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos Martin Restrepo
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nora Constanza Contreras
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Clara Alvarado
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos-Alberto Calderón-Ospina
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nidia Peña
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Ricardo A Cifuentes
- Area of Basic Sciences, College of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Daniela Duarte
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Paul Laissue
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Dora Janeth Fonseca
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
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212
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Abstract
Pharmacogenomics is a tool for practitioners to provide precision pharmacotherapy using genomics. All providers are likely to encounter genomic data in practice with the expectation that they are able to successfully apply it to patient care. Pharmacogenomics tests for genetic variations in genes that are responsible for drug metabolism, transport, and targets of drug action. Variations can increase the risk for drug toxicity or poor efficacy. Pharmacogenomics can, therefore, be used to help select the best medication or aid in dosing. Nephrologists routinely treat cardiovascular disease and manage patients after kidney transplantation, two situations for which there are several high-evidence clinical recommendations for commonly used anticoagulants, antiplatelets, statins, and transplant medications. Successful use of pharmacogenomics in practice requires that providers are familiar with how to access and use pharmacogenomics resources. Similarly, clinical decision making related to whether to use existing data, whether to order testing, and if data should be used in practice is needed to deliver precision medicine. Pharmacogenomics is applicable to virtually every medical specialty, and nephrologists are well positioned to be implementation leaders.
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Affiliation(s)
| | | | - Philip E. Empey
- Department of Pharmacy and Therapeutics, School of Pharmacy, and
- Institute and of Precision Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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213
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De T, Park CS, Perera MA. Cardiovascular Pharmacogenomics: Does It Matter If You're Black or White? Annu Rev Pharmacol Toxicol 2018; 59:577-603. [PMID: 30296897 DOI: 10.1146/annurev-pharmtox-010818-021154] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Race and ancestry have long been associated with differential risk and outcomes to disease as well as responses to medications. These differences in drug response are multifactorial with some portion associated with genomic variation. The field of pharmacogenomics aims to predict drug response in patients prior to medication administration and to uncover the biological underpinnings of drug response. The field of human genetics has long recognized that genetic variation differs in frequency between ancestral populations, with some single nucleotide polymorphisms found solely in one population. Thus far, most pharmacogenomic studies have focused on individuals of European and East Asian ancestry, resulting in a substantial disparity in the clinical utility of genetic prediction for drug response in US minority populations. In this review, we discuss the genetic factors that underlie variability to drug response and known pharmacogenomic associations and how these differ between populations, with an emphasis on the current knowledge in cardiovascular pharmacogenomics.
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Affiliation(s)
- Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - C Sehwan Park
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
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214
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Perera M. Leaving some behind: the growing gap in precision medicine for minority populations. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018; 4:3-5. [PMID: 31681851 PMCID: PMC6824595 DOI: 10.1080/23808993.2019.1529541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/25/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Minoli Perera
- Department of Pharmacology, Center for Pharmacogenomics, Northwestern University, Chicago, IL
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215
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Interventions and Strategies to Improve Oral Anticoagulant Use in Patients with Atrial Fibrillation: A Systematic Review of Systematic Reviews. Clin Drug Investig 2018; 38:579-591. [PMID: 29569095 DOI: 10.1007/s40261-018-0641-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Anticoagulation therapy is the fundamental approach for stroke prevention in atrial fibrillation (AF) patients. Numerous systematic reviews comparing anticoagulation strategies have been published. We aim to summarize the efficacy and safety evidence of these strategies in AF patients from previously published systematic reviews. METHODS We searched PubMed, EMBASE and Cochrane library from inception to Feb 24th, 2017, to identify systematic reviews and meta-analyses of randomized controlled trials that assessed interventions or strategies to improve oral anticoagulant use in AF patients. RESULTS Thirty-four systematic reviews were eligible for inclusion but only 11 were included in the qualitative analyses, corresponding to 40 unique meta-analyses, as the remaining systematic reviews had overlapping primary studies. There was insufficient evidence to support the efficacy of genotype-guided dosing and pharmacist-managed anticoagulation clinics for stroke prevention in AF patients. Conversely, patient's self-management and novel oral anticoagulants (NOACs), in general were superior to warfarin for preventing stroke and reducing mortality. All interventions showed comparable risk of major bleeding with warfarin. CONCLUSION Findings from this overview support the superiority of NOACs and patient's self-management for preventing stroke in AF patients. However, uncertainties remain on the benefits of genotype-guided dosing and pharmacist-managed anticoagulation clinics due to poor quality evidence, and future research is warranted.
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216
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Luzum JA, Cheung JC. Does cardiology hold pharmacogenetics to an inconsistent standard? A comparison of evidence among recommendations. Pharmacogenomics 2018; 19:1203-1216. [PMID: 30196751 PMCID: PMC6219446 DOI: 10.2217/pgs-2018-0097] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/17/2018] [Indexed: 12/20/2022] Open
Abstract
Current guideline recommendations for pharmacogenetic testing for clopidogrel by the American Heart Association/American College of Cardiology (AHA/ACC) contradict the Clinical Pharmacogenetics Implementation Consortium and the US FDA. The AHA/ACC recommends against routine pharmacogenetic testing for clopidogrel because no randomized controlled trials have demonstrated that testing improves patients' outcomes. However the AHA/ACC and the National Comprehensive Cancer Network (NCCN) recommend other pharmacogenetic tests in the absence of randomized controlled trials evidence. Using clopidogrel as a case example, we compared the evidence for other pharmacogenetic tests recommended by the AHA/ACC and NCCN. In patients that received percutaneous coronary intervention, the evidence supporting pharmacogenetic testing for clopidogrel is stronger than other pharmacogenetic tests recommended by the AHA/ACC and NCCN.
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Affiliation(s)
- Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Jason C Cheung
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
- Department of Pharmacy, Baptist Health Floyd, New Albany, IN, USA
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217
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Franceschini N, Frick A, Kopp JB. Genetic Testing in Clinical Settings. Am J Kidney Dis 2018; 72:569-581. [PMID: 29655499 PMCID: PMC6153053 DOI: 10.1053/j.ajkd.2018.02.351] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/20/2018] [Indexed: 12/16/2022]
Abstract
Genetic testing is used for screening, diagnosis, and prognosis of diseases consistent with a genetic cause and to guide drug therapy to improve drug efficacy and avoid adverse effects (pharmacogenomics). This In Practice review aims to inform about DNA-related genetic test availability, interpretation, and recommended clinical actions based on results using evidence from clinical guidelines, when available. We discuss challenges that limit the widespread use of genetic information in the clinical care setting, including a small number of actionable genetic variants with strong evidence of clinical validity and utility, and the need for improving the health literacy of health care providers and the public, including for direct-to-consumer tests. Ethical, legal, and social issues and incidental findings also need to be addressed. Because our understanding of genetic factors associated with disease and drug response is rapidly increasing and new genetic tests are being developed that could be adopted by clinicians in the short term, we also provide extensive resources for information and education on genetic testing.
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Affiliation(s)
- Nora Franceschini
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC.
| | - Amber Frick
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Jeffrey B Kopp
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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218
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FREQUENCIES OF POLYMORPHISMS IN THE CYTOCHROME’S P450 GENES OF WARFARIN TRANSFORMATION IN A EUROPEAN POPULATION OF EASTERN SIBERIA. ACTA BIOMEDICA SCIENTIFICA 2018. [DOI: 10.29413/abs.2018-3.5.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. Genotypes of the cytochrome p450 isoform (CYP2C9 and CYP4F2) determine warfarin dose requirements. Frequencies of risk alleles and genotypes of CYP2C9 and CYP4F2 gene vary in different races and ethnic groups.Aim. This study analyzed the frequencies of *2, *3 alleles of CYP2C9 gene and the 1347 C>T allele of CYP4F2 gene in the Caucasians of Eastern Siberia, and compare with other populations.Materials and methods. Participants were 147 patients (Caucasians): 67 (45.58 %) man and 80 (54.42 %) women), taking warfarin for the prevention of thrombosis with a mean age of 64.74 ± 14.29 years. There were patients with atrial fibrillation – 77 (52.38 %) persons, coronary artery disease – 10 (6.80 %), pulmonary embolism – 5 (3.40 %), 15 (10.20 %) patients after implantation of an mechanical heart valve, etc. The subjects were genotyped for CYP2C9 (*1,*2,*3), and CYP4F2 (1347 C>T) by real-time polymerase chain reaction (RT-PCR) using “Pharmacogenetics Warfarin” reagent kits (DNA technology, Russia).Results. 69.4 % of Caucasians of Eastern Siberia (Russians), have two functional alleles (*1/*1) of CYP2C9 (they’re extensive/normal metabolizers), the number of intermediate metabolizers (*1/*2, *1/*3) was 29.8 % and 0.68 % of slow metabolizers (*3/*3). Homozygous carriers of two non-functional alleles *2 and *3 (*2/*2, *2/*3) were absent. Carriers of one coumarin-resistant Т-allele of CYP4F2 were 57 (38.7 %) respondents, two coumarin-resistant alleles – 10 (6.8 %) respondents.Conclusions. Frequencies of polymorphisms in the Cytochrome’s p450 genes of warfarin transformation in a European population of Eastern Siberia have no differences with other European populations of the world
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Mukerjee G, Huston A, Kabakchiev B, Piquette-Miller M, van Schaik R, Dorfman R. User considerations in assessing pharmacogenomic tests and their clinical support tools. NPJ Genom Med 2018; 3:26. [PMID: 30210808 PMCID: PMC6133969 DOI: 10.1038/s41525-018-0065-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/18/2022] Open
Abstract
Pharmacogenomic (PGx) testing is gaining recognition from physicians, pharmacists and patients as a tool for evidence-based medication management. However, seemingly similar PGx testing panels (and PGx-based decision support tools) can diverge in their technological specifications, as well as the genetic factors that determine test specificity and sensitivity, and hence offer different values for users. Reluctance to embrace PGx testing is often the result of unfamiliarity with PGx technology, a lack of knowledge about the availability of curated guidelines/evidence for drug dosing recommendations, and an absence of wide-spread institutional implementation efforts and educational support. Demystifying an often confusing and variable PGx marketplace can lead to greater acceptance of PGx as a standard-of-care practice that improves drug outcomes and provides a lifetime value for patients. Here, we highlight the key underlying factors of a PGx test that should be considered, and discuss the current progress of PGx implementation.
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Affiliation(s)
| | - Andrea Huston
- GeneYouIn Inc., 156 Front St. W., Toronto, ON Canada
| | - Boyko Kabakchiev
- GeneYouIn Inc., 156 Front St. W., Toronto, ON Canada.,2Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON Canada
| | | | - Ron van Schaik
- 4International Expert Center Pharmacogenetics, Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
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220
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Chung SC, Pujades-Rodriguez M, Duyx B, Denaxas SC, Pasea L, Hingorani A, Timmis A, Williams B, Hemingway H. Time spent at blood pressure target and the risk of death and cardiovascular diseases. PLoS One 2018; 13:e0202359. [PMID: 30183734 PMCID: PMC6124703 DOI: 10.1371/journal.pone.0202359] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The time a patient spends with blood pressure at target level is an intuitive measure of successful BP management, but population studies on its effectiveness are as yet unavailable. METHOD We identified a population-based cohort of 169,082 individuals with newly identified high blood pressure who were free of cardiovascular disease from January 1997 to March 2010. We used 1.64 million clinical blood pressure readings to calculate the TIme at TaRgEt (TITRE) based on current target blood pressure levels. RESULT The median (Inter-quartile range) TITRE among all patients was 2.8 (0.3, 5.6) months per year, only 1077 (0.6%) patients had a TITRE ≥11 months. Compared to people with a 0% TITRE, patients with a TITRE of 3-5.9 months, and 6-8.9 months had 75% and 78% lower odds of the composite of cardiovascular death, myocardial infarction and stroke (adjusted odds ratios, 0.25 (95% confidence interval: 0.21, 0.31) and 0.22 (0.17, 0.27), respectively). These associations were consistent for heart failure and any cardiovascular disease and death (comparing a 3-5.9 month to 0% TITRE, 63% and 60% lower in odds, respectively), among people who did or did not have blood pressure 'controlled' on a single occasion during the first year of follow-up, and across groups defined by number of follow-up BP measure categories. CONCLUSION Based on the current frequency of measurement of blood pressure this study suggests that few newly hypertensive patients sustained a complete, year-round on target blood pressure over time. The inverse associations between a higher TITRE and lower risk of incident cardiovascular diseases were independent of widely-used blood pressure 'control' indicators. Randomized trials are required to evaluate interventions to increase a person's time spent at blood pressure target.
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Affiliation(s)
- Sheng-Chia Chung
- Health Data Research UK London, University College London, London, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Mar Pujades-Rodriguez
- Health Data Research UK London, University College London, London, United Kingdom
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Bram Duyx
- Health Data Research UK London, University College London, London, United Kingdom
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Spiros C. Denaxas
- Health Data Research UK London, University College London, London, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Laura Pasea
- Health Data Research UK London, University College London, London, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Aroon Hingorani
- Health Data Research UK London, University College London, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- National Institute for Health Research (NIHR), University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Adam Timmis
- Health Data Research UK London, University College London, London, United Kingdom
- Barts Heart Centre, London, United Kingdom
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- National Institute for Health Research (NIHR), University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Harry Hemingway
- Health Data Research UK London, University College London, London, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
- National Institute for Health Research (NIHR), University College London Hospitals Biomedical Research Centre, London, United Kingdom
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221
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Tavares LC, Duarte NE, Marcatto LR, Soares RAG, Krieger JE, Pereira AC, Santos PCJL. Impact of incorporating ABCB1 and CYP4F2 polymorphisms in a pharmacogenetics-guided warfarin dosing algorithm for the Brazilian population. Eur J Clin Pharmacol 2018; 74:1555-1566. [PMID: 30051215 DOI: 10.1007/s00228-018-2528-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Interpatient variation of warfarin dose requirements may be explained by genetic variations and general and clinical factors. In this scenario, diverse population-calibrated dosing algorithms, which incorporate the main warfarin dosing influencers, have been widely proposed for predicting supposed warfarin maintenance dose, in order to prevent and reduce adverse events. The aim of the present study was to evaluate the impact of the inclusion of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms as additional covariates in a previously developed pharmacogenetic-based warfarin dosing algorithm calibrated for the Brazilian population. METHODS Two independent cohorts of patients treated with warfarin (n = 832 and n = 133) were included for derivation and replication of the algorithm, respectively. Genotyping of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms was performed by polymerase chain reaction followed by melting curve analysis and TaqMan® assay, respectively. A multiple linear regression was performed for the warfarin stable doses as a dependent variable, considering clinical, general, and genetic data as covariates. RESULTS The inclusion of ABCB1 and CYP4F2 polymorphisms was able to improve the algorithm's coefficient of determination (R2) by 2.6%. In addition, the partial determination coefficients of these variants revealed that they explained 3.6% of the warfarin dose variability. We also observed a marginal improvement of the linear correlation between observed and predicted doses (from 59.7 to 61.4%). CONCLUSION Although our study indicates that the contribution of the combined ABCB1 and CYP4F2 genotypes in explaining the overall variability in warfarin dose is not very large, we demonstrated that these pharmacogenomic data are statistically significant. However, the clinical relevance and cost-effective impact of incorporating additional variants in warfarin dosing algorithms should be carefully evaluated.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nubia E Duarte
- Department of Mathematic and Statistics, Universidad Nacional de Colombia, Manizales, Caldas, Colombia
| | - Leiliane R Marcatto
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Renata A G Soares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Jose E Krieger
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Paulo Caleb Junior Lima Santos
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil.
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo UNIFESP, São Paulo, SP, Brazil.
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Ravvaz K, Weissert JA, Ruff CT, Chi CL, Tonellato PJ. Personalized Anticoagulation: Optimizing Warfarin Management Using Genetics and Simulated Clinical Trials. ACTA ACUST UNITED AC 2018; 10:CIRCGENETICS.117.001804. [PMID: 29237680 DOI: 10.1161/circgenetics.117.001804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical trials testing pharmacogenomic-guided warfarin dosing for patients with atrial fibrillation have demonstrated conflicting results. Non-vitamin K antagonist oral anticoagulants are expensive and contraindicated for several conditions. A strategy optimizing anticoagulant selection remains an unmet clinical need. METHODS AND RESULTS Characteristics from 14 206 patients with atrial fibrillation were integrated into a validated warfarin clinical trial simulation framework using iterative Bayesian network modeling and a pharmacokinetic-pharmacodynamic model. Individual dose-response for patients was simulated for 5 warfarin protocols-a fixed-dose protocol, a clinically guided protocol, and 3 increasingly complex pharmacogenomic-guided protocols. For each protocol, a complexity score was calculated using the variables predicting warfarin dose and the number of predefined international normalized ratio (INR) thresholds for each adjusted dose. Study outcomes included optimal time in therapeutic range ≥65% and clinical events. A combination of age and genotype identified different optimal protocols for various subpopulations. A fixed-dose protocol provided well-controlled INR only in normal responders ≥65, whereas for normal responders <65 years old, a clinically guided protocol was necessary to achieve well-controlled INR. Sensitive responders ≥65 and <65 and highly sensitive responders ≥65 years old required pharmacogenomic-guided protocols to achieve well-controlled INR. However, highly sensitive responders <65 years old did not achieve well-controlled INR and had higher associated clinical events rates than other subpopulations. CONCLUSIONS Under the assumptions of this simulation, patients with atrial fibrillation can be triaged to an optimal warfarin therapy protocol by age and genotype. Clinicians should consider alternative anticoagulation therapy for patients with suboptimal outcomes under any warfarin protocol.
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Affiliation(s)
- Kourosh Ravvaz
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.).
| | - John A Weissert
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Christian T Ruff
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Chih-Lin Chi
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Peter J Tonellato
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
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Syn NL, Wong ALA, Lee SC, Teoh HL, Yip JWL, Seet RC, Yeo WT, Kristanto W, Bee PC, Poon LM, Marban P, Wu TS, Winther MD, Brunham LR, Soong R, Tai BC, Goh BC. Genotype-guided versus traditional clinical dosing of warfarin in patients of Asian ancestry: a randomized controlled trial. BMC Med 2018; 16:104. [PMID: 29986700 PMCID: PMC6038204 DOI: 10.1186/s12916-018-1093-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Genotype-guided warfarin dosing has been shown in some randomized trials to improve anticoagulation outcomes in individuals of European ancestry, yet its utility in Asian patients remains unresolved. METHODS An open-label, non-inferiority, 1:1 randomized trial was conducted at three academic hospitals in South East Asia, involving 322 ethnically diverse patients newly indicated for warfarin (NCT00700895). Clinical follow-up was 90 days. The primary efficacy measure was the number of dose titrations within the first 2 weeks of therapy, with a mean non-inferiority margin of 0.5 over the first 14 days of therapy. RESULTS Among 322 randomized patients, 269 were evaluable for the primary endpoint. Compared with traditional dosing, the genotype-guided group required fewer dose titrations during the first 2 weeks (1.77 vs. 2.93, difference -1.16, 90% CI -1.48 to -0.84, P < 0.001 for both non-inferiority and superiority). The percentage of time within the therapeutic range over 3 months and median time to stable international normalized ratio (INR) did not differ between the genotype-guided and traditional dosing groups. The frequency of dose titrations (incidence rate ratio 0.76, 95% CI 0.67 to 0.86, P = 0.001), but not frequency of INR measurements, was lower at 1, 2, and 3 months in the genotype-guided group. The proportions of patients who experienced minor or major bleeding, recurrent venous thromboembolism, or out-of-range INR did not differ between both arms. For predicting maintenance doses, the pharmacogenetic algorithm achieved an R2 = 42.4% (P < 0.001) and mean percentage error of -7.4%. CONCLUSIONS Among Asian adults commencing warfarin therapy, a pharmacogenetic algorithm meets criteria for both non-inferiority and superiority in reducing dose titrations compared with a traditional dosing approach, and performs well in prediction of actual maintenance doses. These findings imply that clinicians may consider applying a pharmacogenetic algorithm to personalize initial warfarin dosages in Asian patients. TRIAL REGISTRATION ClinicalTrials.gov NCT00700895 . Registered on June 19, 2008.
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Affiliation(s)
- Nicholas L Syn
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Andrea Li-Ann Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - James Wei Luen Yip
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Raymond Cs Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - William Kristanto
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ping-Chong Bee
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - L M Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Patrick Marban
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Tuck Seng Wu
- Department of Pharmacy, National University Hospital, Singapore, Singapore
| | - Michael D Winther
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore, Singapore
| | - Liam R Brunham
- Translational Laboratory in Genetic Medicine, Agency for Science, Technology and Research, Singapore, Singapore.,Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - Richie Soong
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Pathology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore
| | - Bee-Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Boon-Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore. .,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore. .,Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, 119228, Singapore.
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Schatz A, Guggenberger V, Fischer MD, Schommer K, Bartz-Schmidt KU, Gekeler F, Willmann G. Optic nerve oedema at high altitude occurs independent of acute mountain sickness. Br J Ophthalmol 2018; 103:bjophthalmol-2018-312224. [PMID: 29973364 DOI: 10.1136/bjophthalmol-2018-312224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS The study aims to investigate changes in the optic nerve sheath diameter (ONSD) at high altitude and to assess correlation to optic disc oedema (ODE) and acute mountain sickness (AMS). This investigation is part of the Tübingen High Altitude Ophthalmology study. METHODS Fourteen volunteers ascended to 4559 m for 4 days before returning to low altitude. Ultrasonography of ONSD, quantification of optic disc parameters using a scanning laser ophthalmoscope and fluorescein angiography were performed at 341 m and at high altitude. Pearson's coefficient was used to correlate changes in ONSD with the optic disc and AMS. Assessment of AMS was performed using the Lake Louise (LL) and AMS-cerebral (AMS-C) scores of the Environmental Symptom Questionnaire-III. All volunteers were clinically monitored for heart rate (HR) and oxygen saturation (SpO2). RESULTS The mean ONSD at high altitude (4.6±0.3 mm, p<0.05) was significantly increased compared with baseline (3.8±0.4 mm) and remained enlarged throughout high-altitude exposure. This change in ONSD did not correlate with AMS (AMS-C, r=0.26, p=0.37; LL, r=0.21, p=0.48) and high-altitude headache (r=0.54, p=0.046), or clinical parameters of SpO2 (r=0.11, p=0.72) and HR (r=0.22, p=0.44). Increased ONSD did not correlate with altered key stereometric parameters of the optic disc describing ODE at high altitude (r<0.1, p>0.5). CONCLUSION High-altitude exposure leads to marked oedema formation of the optic nerve independent of AMS. Increased ONSD and ODE reflect hypoxia-driven oedema formation of the optic nerve at high altitude, providing important pathophysiological insight into high-altitude illness development and for future research.
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Affiliation(s)
- Andreas Schatz
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
- Department of Ophthalmology, Katharinenhospital, Stuttgart, Germany
| | | | - M Dominik Fischer
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
| | - Kai Schommer
- Medizinischer Dienst der Krankenversicherungen, MDK Baden-Württemberg, Mannheim, Germany
| | | | - Florian Gekeler
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
- Department of Ophthalmology, Katharinenhospital, Stuttgart, Germany
| | - Gabriel Willmann
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
- Department of Ophthalmology, Katharinenhospital, Stuttgart, Germany
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Dong AN, Tan BH, Pan Y, Ong CE. Cytochrome P450 genotype-guided drug therapies: An update on current states. Clin Exp Pharmacol Physiol 2018; 45:991-1001. [PMID: 29858511 DOI: 10.1111/1440-1681.12978] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 01/07/2023]
Abstract
Over the past 2 decades, knowledge of the role and clinical value of pharmacogenetic markers has expanded so that individualized pre-emptive therapy based on genetic background of patients could be within reach for clinical implementation. This is evidenced from the frequent updating of drug labels that incorporates pharmacogenetic information (where compelling data become available) by the regulatory agencies (such as the US FDA), and the periodical publication of guidelines of specific therapeutic recommendations based on the results of pharmacogenetic tests by the pharmacogenetics working groups or consortiums of professional bodies. Clinical relevance of the cytochrome P450 (CYP) polymorphism related to dose, effectiveness and/or toxicity of key drugs are presented in this review, including that of warfarin, clopidogrel, tricyclic antidepressants, and proton pump inhibitors. Prospect for routine clinical application of CYP genotyping before prescribing drugs is still currently unclear due to challenges and barriers associated with availability of well-defined and validated pharmacogenetic studies, the interpretation, result reporting and potential error of genotype testing, involvement of non-genetic factors, and other patient's demographic and disease conditions. Further studies to provide additional supporting clinical data and acceleration of pharmacogenetic testing standards and techniques should help improve the evidence base needed for clinical utility and hence move the implementation of genotype-guided therapy in clinical practice a step closer to reality.
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Affiliation(s)
- Amelia Nathania Dong
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Boon Hooi Tan
- Division of Applied Biomedical Sciences and Biotechnology, International Medical University, Kuala Lumpur, Malaysia
| | - Yan Pan
- Department of Biomedical Science, University of Nottingham Malaysia Campus, Semenyih, Selangor, Malaysia
| | - Chin Eng Ong
- School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
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226
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Blagec K, Koopmann R, Crommentuijn – van Rhenen M, Holsappel I, van der Wouden CH, Konta L, Xu H, Steinberger D, Just E, Swen JJ, Guchelaar HJ, Samwald M. Implementing pharmacogenomics decision support across seven European countries: The Ubiquitous Pharmacogenomics (U-PGx) project. J Am Med Inform Assoc 2018; 25:893-898. [PMID: 29444243 PMCID: PMC6016647 DOI: 10.1093/jamia/ocy005] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/23/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
Clinical pharmacogenomics (PGx) has the potential to make pharmacotherapy safer and more effective by utilizing genetic patient data for drug dosing and selection. However, widespread adoption of PGx depends on its successful integration into routine clinical care through clinical decision support tools, which is often hampered by insufficient or fragmented infrastructures. This paper describes the setup and implementation of a unique multimodal, multilingual clinical decision support intervention consisting of digital, paper-, and mobile-based tools that are deployed across implementation sites in seven European countries participating in the Ubiquitous PGx (U-PGx) project.
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Affiliation(s)
- Kathrin Blagec
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
| | - Rudolf Koopmann
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
| | | | - Inge Holsappel
- Medicines Information Centre; Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | | | - Lidija Konta
- bio.logis Center for Human Genetics, Frankfurt am Main, Germany
| | - Hong Xu
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
| | - Daniela Steinberger
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
- bio.logis Center for Human Genetics, Frankfurt am Main, Germany
- Institute for Human Genetics, Justus Liebig University, Giessen, Germany
| | - Enrico Just
- bio.logis Genetic Information Management GmbH, Frankfurt am Main, Germany
| | - Jesse J Swen
- Deptartment of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Deptartment of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Samwald
- Section for Artificial Intelligence and Decision Support; Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna, Vienna, Austria
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227
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Pirmohamed M. Warfarin: The End or the End of One Size Fits All Therapy? J Pers Med 2018; 8:jpm8030022. [PMID: 29958440 PMCID: PMC6163581 DOI: 10.3390/jpm8030022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
Oral anticoagulants are required for both treatment and prophylaxis in many different diseases. Clinicians and patients now have a choice of oral anticoagulants, including the vitamin K antagonists (of which warfarin is the most widely used and is used as the exemplar in this paper), and direct oral anticoagulants (DOACs: dabigatran, apixaban, rivaroxaban, and edoxaban). This paper explores the recent advances and controversies in oral anticoagulation. While some commentators may favour a complete switchover to DOACs, this paper argues that warfarin still has a place in therapy, and a stratified approach that enables the correct choice of both drug and dose would improve both patient outcomes and affordability.
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Affiliation(s)
- Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool L69 3GL, UK.
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228
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Ruff CT. Pharmacogenetics of Warfarin Therapy. Clin Chem 2018; 64:1558-1559. [PMID: 29941467 DOI: 10.1373/clinchem.2017.284927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/23/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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229
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Tse G, Gong M, Li G, Wong SH, Wu WKK, Wong WT, Roever L, Lee APW, Lip GYH, Wong MCS, Liu T. Genotype-guided warfarin dosing vs. conventional dosing strategies: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2018; 84:1868-1882. [PMID: 29704269 DOI: 10.1111/bcp.13621] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/03/2018] [Accepted: 04/17/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS Previous trials on the effectiveness of genotype-guided warfarin dosing vs. conventional dosing have been inconclusive. We conducted a systematic review and meta-analysis of randomized trials comparing genotype-guided to conventional dosing strategies. METHODS PubMed and the Cochrane Library were searched up to 23 October 2017. RESULTS A total of 76 and 94 entries were retrieved were retrieved from PubMed and the Cochrane Library, respectively. A total of 2626 subjects in the genotype-guided dosing (mean age 63.3 ± 5.8 years; 46% male) and 2604 subjects in the conventional dosing (mean age 64.7 ± 6.1 years; 46% male) groups (mean follow-up duration 64 days) from 18 trials were included. Compared with conventional dosing, genotype-guided dosing significantly shortened the time to first therapeutic international normalized ratio (INR) (mean difference 2.6 days, standard error 0.3 days; P < 0.0001; I2 0%) and time to first stable INR (mean difference 5.9 days, standard error 2.0 days; P < 0.01; I2 94%). Genotype-guided dosing also increased the time in therapeutic range (mean difference 3.1%, standard error 1.2%; P < 0.01; I2 80%) and reduced the risks of both excessive anticoagulation, defined as INR ≥4 [risk ratio (RR) 0.87; 95% confidence interval (CI) 0.78, 0.98; P < 0.05; I2 : 0%), and bleeding (RR 0.82; 95% CI 0.69, 0.98; P < 0.05; I2 31%). No difference in thromboembolism (RR 0.84; 95% CI 0.56, 1.26; P = 0.40; I2 0%) or mortality (RR 1.16; 95% CI 0.46, 2.91; P = 0.76; I2 0%) was observed between the two groups. CONCLUSIONS Genotype-guided warfarin dosing offers better safety with less bleeding compared with conventional dosing strategies. No significant benefit on thromboembolism or mortality was evident.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, MG, Brazil
| | - Alex Pui Wai Lee
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martin C S Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
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230
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Duconge J, Ruaño G. Preventing the exacerbation of health disparities by iatrogenic pharmacogenomic applications: lessons from warfarin. Pharmacogenomics 2018; 19:875-881. [PMID: 29898627 DOI: 10.2217/pgs-2018-0055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Jorge Duconge
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936, USA
| | - Gualberto Ruaño
- Institute of Living at Hartford Hospital, Hartford, CT 06102, USA
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231
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Warfarin Dosing According to the Genotype-guided Algorithm is Most Beneficial in Patients With Atrial Fibrillation: A Randomized Parallel Group Trial. Ther Drug Monit 2018; 40:362-368. [DOI: 10.1097/ftd.0000000000000501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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232
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Serna MJ, Rivera-Caravaca JM, Gonzalez-Conejero R, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Roldán V, Marín F. Pharmacogenetics of vitamin K antagonists and bleeding risk prediction in atrial fibrillation. Eur J Clin Invest 2018; 48:e12929. [PMID: 29577257 DOI: 10.1111/eci.12929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Polymorphisms in the vitamin K epoxide reductase complex 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) genes increase the bleeding risk in anticoagulated atrial fibrillation (AF) patients. Here, we aimed to investigate whether VKORC1 and CYP2C9 polymorphisms improved the predictive performance for major bleeding using the HAS-BLED score. MATERIAL AND METHODS We recruited 652 consecutive AF patients stable on vitamin K antagonist (INR 2.0-3.0) during at least the previous 6 months. A baseline venous blood sample was obtained for DNA extraction. We gave an extra point to the HAS-BLED score if the patient was a simultaneous carrier of the VKORC1 and CYP2C9 polymorphisms related to bleeding, and we called this modified score "GEN|HAS-BLED." During a median follow-up of 7.6 years (IQR 5.6-8.0), all major bleeding events were recorded. RESULTS During follow-up, 106 (16.2%) patients experienced a major bleeding (2.81%/y; 42 intracranial haemorrhages and 44 gastrointestinal bleeding) and 24 (3.7%) died from major bleeding (0.48%/y). Cox regression analyses demonstrated a significant association between HAS-BLED or GEN|HAS-BLED and major bleeds, both as continuous or categorical scores. Comparison of receiver operating characteristic (ROC) curves shows that original HAS-BLED clinical score had better predictive ability than GEN|HAS-BLED (0.660, 95% CI 0.622-0.696 vs 0.645, 95% CI 0.607-0.682; P = .030). Discrimination and reclassification analyses showed that GEN|HAS-BLED did not improve sensitivity compared with the original score and even showed significant negative reclassification. CONCLUSION Adding pharmacogenetic factors (ie polymorphisms of the VKORC1 and CYP2C9 genes) to the HAS-BLED score does not improve the prediction or discrimination performance for major bleeding.
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Affiliation(s)
- María José Serna
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Rocío Gonzalez-Conejero
- Centro Regional de Hemodonación, Universidad de Murcia, CIBERER, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Centro Regional de Hemodonación, Universidad de Murcia, CIBERER, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
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233
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Thomford NE, Dzobo K, Chimusa E, Andrae-Marobela K, Chirikure S, Wonkam A, Dandara C. Personalized Herbal Medicine? A Roadmap for Convergence of Herbal and Precision Medicine Biomarker Innovations. ACTA ACUST UNITED AC 2018; 22:375-391. [DOI: 10.1089/omi.2018.0074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nicholas Ekow Thomford
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Medical Sciences, University of Cape Coast, Cape Coast, PMB, Ghana
| | - Kevin Dzobo
- International Centre for Genetic Engineering and Biotechnology, Cape Town component, University of Cape Town, Cape Town, South Africa
- Department of Integrative Biomedical Science, Division of Medical Biochemistry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emile Chimusa
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kerstin Andrae-Marobela
- Molecular Cell Biology, Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Shadreck Chirikure
- Department of Archaeology, University of Cape Town, Cape Town, South Africa
| | - Ambroise Wonkam
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Collet Dandara
- Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology and Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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234
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Billings J, Racsa PN, Bordenave K, Long CL, Ellis JJ. The impact of real-world cardiovascular-related pharmacogenetic testing in an insured population. Int J Clin Pract 2018; 72:e13088. [PMID: 29767472 DOI: 10.1111/ijcp.13088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pharmacogenomics is intended to help clinicians provide the right drug to the right patient at an appropriate dose. However, limited evidence of clinical utility has slowed uptake of pharmacogenomic testing (PGT). OBJECTIVE To evaluate the impact of real-world cardiovascular (CV)-related PGT on clinical outcomes, healthcare resource utilisation (HCRU) and cost in a large, heterogeneous population. METHODS Individuals with Medicare Advantage Prescription Drug, Medicaid, or commercial coverage between 1/1/2011 and 9/30/2015 and ≥1 atherosclerotic CV-related diagnosis were identified. Those with ≥1 claim for CV-related PGT were included in the test group (index date = 1st PGT claim) and matched 1:2 to controls without PGT. Individuals aged <22 or ≥90 years old on the index date, with <12 months continuous enrollment before and after the index date, or without an ASCVD-related diagnosis in the 12-month pre-index period were excluded. The primary outcome was occurrence of a major CV event during the 12-month post-index period. RESULTS After adjustment, the PGT group was significantly more likely to experience ischaemic stroke, pulmonary embolism, deep vein thrombosis or a composite event compared with controls. Adjusting for baseline characteristics, HCRU was significantly higher for the test group across all measured outcomes except all-cause and ASCVD-related inpatient admissions. Median all-cause and ASCVD-related healthcare costs were significantly higher for the test group. CONCLUSIONS Real world PGT in a large population did not improve outcomes. Tailoring medication therapy to each patient holds great promise for providing quality care but a deeper understanding of how widespread utilisation of PGT might impact objective health outcomes is needed.
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Affiliation(s)
| | - Patrick N Racsa
- Comprehensive Health Insights, Humana Inc., Louisville, KY, USA
| | | | - Charron L Long
- Research and Publications, Humana Inc., Louisville, KY, USA
| | - Jeffrey J Ellis
- Comprehensive Health Insights, Humana Inc., Louisville, KY, USA
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235
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Lorés-Motta L, de Jong EK, den Hollander AI. Exploring the Use of Molecular Biomarkers for Precision Medicine in Age-Related Macular Degeneration. Mol Diagn Ther 2018; 22:315-343. [PMID: 29700787 PMCID: PMC5954014 DOI: 10.1007/s40291-018-0332-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Precision medicine aims to improve patient care by adjusting medication to each patient's individual needs. Age-related macular degeneration (AMD) is a heterogeneous eye disease in which several pathways are involved, and the risk factors driving the disease differ per patient. As a consequence, precision medicine holds promise for improved management of this disease, which is nowadays a main cause of vision loss in the elderly. In this review, we provide an overview of the studies that have evaluated the use of molecular biomarkers to predict response to treatment in AMD. We predominantly focus on genetic biomarkers, but also include studies that examined circulating or eye fluid biomarkers in treatment response. This involves studies on treatment response to dietary supplements, response to anti-vascular endothelial growth factor, and response to complement inhibitors. In addition, we highlight promising new therapies that have been or are currently being tested in clinical trials and discuss the molecular studies that can help identify the most suitable patients for these upcoming therapeutic approaches.
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Affiliation(s)
- Laura Lorés-Motta
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Philips van Leydenlaan 15, 6525 EX, Nijmegen, The Netherlands
| | - Eiko K de Jong
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Philips van Leydenlaan 15, 6525 EX, Nijmegen, The Netherlands
| | - Anneke I den Hollander
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Philips van Leydenlaan 15, 6525 EX, Nijmegen, The Netherlands.
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
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236
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Abstract
Considerable interindividual variability in response to cardiovascular pharmacotherapy exists with drug responses varying from being efficacious to inadequate to induce severe adverse events. Fueled by advancements and multidisciplinary collaboration across disciplines such as genetics, bioinformatics, and basic research, the vision of personalized medicine, rather than a one-size-fits-all approach, may be within reach. Pharmacogenetics offers the potential to optimize the benefit-risk profile of drugs by tailoring diagnostic and treatment strategies according to the individual patient. To date, a multitude of studies has tried to delineate the effects of gene-drug interactions for drugs commonly used to treat cardiovascular-related disease. The focus of this review is on how genetic variability may modify drug responsiveness and patient outcomes following therapy with commonly used cardiovascular drugs including clopidogrel, warfarin, statins, and β-blockers. Also included are examples of how genetic studies can be used to guide drug discovery and examples of how genetic information may be deployed in clinical decision making.
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Affiliation(s)
- Peter E Weeke
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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237
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Gu ZC, Ma XW, Zheng XY, Shen L, Shi FH, Li H. Left Atrial Appendage Thrombus Formation in a Patient on Dabigatran Therapy Associated With ABCB1 and CES-1 Genetic Defect. Front Pharmacol 2018; 9:491. [PMID: 29867495 PMCID: PMC5962821 DOI: 10.3389/fphar.2018.00491] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023] Open
Abstract
Dabigatran, directly targeting thrombin, is widely used for the prevention of stroke in nonvalvular atrial fibrillation (NVAF). We reported a rare case of left atrial appendage thrombus formation in a persistent NVAF patient despite the 31 months uninterrupted treatment with dabigatran 110 mg twice daily. The patient is a carrier of ABCB1 variant alleles with 7 heterozygote single nucleotide polymorphisms (SNPs: rs4148738, rs2235046, rs1128503, rs10276036, rs1202169, rs1202168, rs1202167) as well as CES-1 variant alleles with 2 homozygote SNPs (rs2244613 and rs4122238) and 2 heterozygote SNPs (rs8192935 and rs4580160), which may contribute to the changes of dabigatran plasma concentration. In addition, Drug-drug interaction with atorvastatin may also play a role to decrease dabigatran plasma concentration. There are only four such cases till date, of which had thrombus in the left atrium, reported in the literature. We firstly reported the documented case in a Chinese patient carrying multiple alleles of ABCB1 and CES-1, who suffered from thrombus in the left atrial appendage despite long-term anticoagulation with dabigatran. More clinical data are required to elucidate the impact of CES-1 and ABCB1 polymorphism on dabigatran pharmacokinetics, especially for Asian.
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Affiliation(s)
- Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Wei Ma
- Department of Clinical Laboratory, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Yuan Zheng
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Long Shen
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Fang-Hong Shi
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hao Li
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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238
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Hasan SS, Kow CS, Curley LE, Baines DL, Babar ZUD. Economic evaluation of prescribing conventional and newer oral anticoagulants in older adults. Expert Rev Pharmacoecon Outcomes Res 2018; 18:371-377. [PMID: 29741099 DOI: 10.1080/14737167.2018.1474101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Anticoagulants refer to a variety of agents that inhibit one or more steps in the coagulation cascade. Generally, clinical conditions that require the prescribing of an oral anticoagulant increase in frequency with age. However, a major challenge of anticoagulation use among older patients is that this group of patients also experience the highest bleeding risk. To date, economic evaluation of prescribing of anticoagulants that includes the novel or newer oral anticoagulants (NOACs) in older adults has not been conducted and is warranted. AREAS COVERED A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults. EXPERT COMMENTARY While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin.
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Affiliation(s)
- Syed Shahzad Hasan
- a Department of Pharmacy , University of Huddersfield , Huddersfield , United Kingdom.,e School of Biomedical Sciences and Pharmacy, The University of Newcastle , Newcastle , Australia
| | - Chia Siang Kow
- b Department of Pharmacy , Health Clinic Bukit Kuda , Klang , Malaysia
| | - Louise E Curley
- c School of Pharmacy, The University of Auckland , Auckland , New Zealand
| | - Darrin L Baines
- d Department of Accounting , Finance & Economics, Bournemouth University , Bournemouth , United Kingdom
| | - Zaheer-Ud-Din Babar
- a Department of Pharmacy , University of Huddersfield , Huddersfield , United Kingdom.,c School of Pharmacy, The University of Auckland , Auckland , New Zealand
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Roden DM, Van Driest SL, Mosley JD, Wells QS, Robinson JR, Denny JC, Peterson JF. Benefit of Preemptive Pharmacogenetic Information on Clinical Outcome. Clin Pharmacol Ther 2018; 103:787-794. [PMID: 29377064 PMCID: PMC6134843 DOI: 10.1002/cpt.1035] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 12/13/2022]
Abstract
The development of new knowledge around the genetic determinants of variable drug action has naturally raised the question of how this new knowledge can be used to improve the outcome of drug therapy. Two broad approaches have been taken: a point-of-care approach in which genotyping for specific variant(s) is undertaken at the time of drug prescription, and a preemptive approach in which multiple genetic variants are typed in an individual patient and the information archived for later use when a drug with a "pharmacogenetic story" is prescribed. This review addresses the current state of implementation, the rationale for these approaches, and barriers that must be overcome. Benefits to pharmacogenetic testing are only now being defined and will be discussed.
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Affiliation(s)
- Dan M. Roden
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Pharmacology, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Sara L. Van Driest
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center Nashville, TN
| | - Jonathan D. Mosley
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Quinn S. Wells
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
| | - Jamie R. Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center Nashville, TN
| | - Joshua C. Denny
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
| | - Josh F. Peterson
- Department of Medicine, Vanderbilt University Medical Center Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center Nashville, TN
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Mills RA, Eichmeyer JN, Williams LM, Muskett JA, Schmidlen TJ, Maloney KA, Lemke AA. Patient Care Situations Benefiting from Pharmacogenomic Testing. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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241
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Tavares LC, Marcatto LR, Santos PCJL. Genotype-guided warfarin therapy: current status. Pharmacogenomics 2018; 19:667-685. [PMID: 29701078 DOI: 10.2217/pgs-2017-0207] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Warfarin pharmacogenomics has been an extensively studied field in the last decades as it is focused on personalized therapy to overcome the wide interpatient warfarin response variability and decrease the risk of side effects. In this expert review, besides briefly summarizing the current knowledge about warfarin pharmacogenetics, we also present an overview of recent studies that aimed to assess the efficacy, safety and economic issues related to genotype-based dosing algorithms used to guide warfarin therapy, including randomized and controlled clinical trials, meta-analyses and cost-effectiveness studies. To date, the findings still present disparities, mostly because of standard limitations. Thus, further studies should be encouraged to try to demonstrate the benefits of the application of warfarin pharmacogenomic dosing algorithms in clinical practice.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics & Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP 05403-900, Brazil
| | - Leiliane R Marcatto
- Laboratory of Genetics & Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP 05403-900, Brazil
| | - Paulo C J L Santos
- Department of Pharmacology, Universidade Federal de Sao Paulo UNIFESP, SP 04044-020, Brazil
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242
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Abstract
Precision medicine is an integrative approach to cardiovascular disease prevention and treatment that considers an individual's genetics, lifestyle, and exposures as determinants of their cardiovascular health and disease phenotypes. This focus overcomes the limitations of reductionism in medicine, which presumes that all patients with the same signs of disease share a common pathophenotype and, therefore, should be treated similarly. Precision medicine incorporates standard clinical and health record data with advanced panomics (ie, transcriptomics, epigenomics, proteomics, metabolomics, and microbiomics) for deep phenotyping. These phenotypic data can then be analyzed within the framework of molecular interaction (interactome) networks to uncover previously unrecognized disease phenotypes and relationships between diseases, and to select pharmacotherapeutics or identify potential protein-drug or drug-drug interactions. In this review, we discuss the current spectrum of cardiovascular health and disease, population averages and the response of extreme phenotypes to interventions, and population-based versus high-risk treatment strategies as a pretext to understanding a precision medicine approach to cardiovascular disease prevention and therapeutic interventions. We also consider the search for resilience and Mendelian disease genes and argue against the theory of a single causal gene/gene product as a mediator of the cardiovascular disease phenotype, as well as an Erlichian magic bullet to solve cardiovascular disease. Finally, we detail the importance of deep phenotyping and interactome networks and the use of this information for rational polypharmacy. These topics highlight the urgent need for precise phenotyping to advance precision medicine as a strategy to improve cardiovascular health and prevent disease.
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Affiliation(s)
- Jane A Leopold
- From the Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Joseph Loscalzo
- From the Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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243
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Ueshima S, Hira D, Kimura Y, Fujii R, Tomitsuka C, Yamane T, Tabuchi Y, Ozawa T, Itoh H, Ohno S, Horie M, Terada T, Katsura T. Population pharmacokinetics and pharmacogenomics of apixaban in Japanese adult patients with atrial fibrillation. Br J Clin Pharmacol 2018; 84:1301-1312. [PMID: 29457840 DOI: 10.1111/bcp.13561] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 12/16/2022] Open
Abstract
AIMS This study aimed to analyse the effects of genetic polymorphisms in drug transporters and metabolizing enzymes, and clinical laboratory data on the pharmacokinetic parameters of apixaban. METHODS Data were collected from 81 Japanese patients with atrial fibrillation. Pharmacogenomic data were stratified by ABCB1, ABCG2 and CYP3A5 polymorphisms. The pharmacokinetic profile of apixaban was described by a one-compartment model with first-order absorption. Population pharmacokinetic analysis was conducted using a nonlinear mixed effect modelling (NONMEM™) program. RESULTS The nonlinear relationship between oral clearance (CL/F) of apixaban and creatinine clearance (Ccr) was observed. The population mean of CL/F for a typical patient (Ccr value of 70 ml min-1 ) with the CYP3A5*1/*1 and ABCG2 421C/C or C/A genotypes was estimated to be 3.06 l h-1 . When Ccr values were set to the typical value, the population mean of CL/F was 1.52 times higher in patients with the CYP3A5*1/*1 genotype compared with patients with the CYP3A5*1/*3 or *3/*3 genotype, while the population mean of CL/F was 1.49 times higher in patients with the ABCG2 421C/C or C/A genotype compared with patients with the ABCG2 421A/A genotype. However, no covariates affected the population mean of the apparent volume of distribution (Vd/F) of apixaban. The population mean of Vd/F was estimated to be 24.7 l. CONCLUSION The present study suggests that the ABCG2 421A/A and CYP3A5*3 genotypes and renal function are intrinsic factors affecting apixaban pharmacokinetics. These findings may provide useful information for precision medicine using apixaban, to avoid the risk of adverse reactions.
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Affiliation(s)
- Satoshi Ueshima
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Yuuma Kimura
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Ryo Fujii
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Chiho Tomitsuka
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Takuya Yamane
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
| | - Yohei Tabuchi
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Tomoya Ozawa
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Hideki Itoh
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Seiko Ohno
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Toshiya Katsura
- Laboratory of Clinical Pharmaceutics and Therapeutics, College of Pharmaceutical Sciences, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525-8577, Japan
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244
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Kheiri B, Abdalla A, Haykal T, Osman M, Ahmed S, Hassan M, Bachuwa G. Meta-Analysis of Genotype-Guided Versus Standard Dosing of Vitamin K Antagonists. Am J Cardiol 2018; 121:879-887. [PMID: 29402419 DOI: 10.1016/j.amjcard.2017.12.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/14/2017] [Accepted: 12/27/2017] [Indexed: 12/24/2022]
Abstract
Vitamin K antagonist (VKA) is a commonly prescribed anticoagulant with a narrow therapeutic window. Genetic polymorphisms account for high VKA dosage variability. Hence, we performed an updated meta-analysis of all randomized clinical trials (RCTs) comparing genotype-guided VKA versus standard dosing algorithms. We conducted a systematic search of electronic databases from inception to October 2017 for all RCTs. The primary outcome was the percentage of time in therapeutic range (TTR). Secondary outcomes were international normalized ratio >4, major and all bleeding events, thromboembolism, adverse and serious adverse events, and all-cause mortality. We calculated the weighted mean difference for the primary outcome and risk ratio (RR) for secondary outcomes using a random-effect model. We included 20 RCTs and analyzed a total of 5,980 adult patients. Our pooled analysis showed greater improvement in TTR for the genotype-guided group in comparison with the standard group (mean difference 3.41%, 95% confidence interval [CI] 0.71 to 6.10, p = 0.01). In addition, there were significant reductions in major and all bleeding events ((RR 0.35, 95% CI 0.20 to 0.63, p = 0.0004) and (RR 0.79, 95% CI 0.66 to 0.95, p = 0.01), respectively). However, there were no significant differences between the groups for international normalized ratio >4 (RR 0.89, 95% CI 0.80 to 1.00, p = 0.06), thromboembolism (RR 0.81, 95% CI 0.56 to 1.17, p = 0.25), serious adverse events (RR 0.79, 95% CI 0.61 to 1.03, p = 0.08), any adverse events (RR 0.94, 95% CI 0.88 to 1.01, p = 0.07), or all-cause mortality (RR 0.73, 95% CI 0.32 to 1.66, p = 0.46). In conclusion, genotype-guided VKA dosing can improve the TTR and reduce the risk for bleeding episodes, in comparison with standard dosing algorithms.
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Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan.
| | - Ahmed Abdalla
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Tarek Haykal
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Mohammed Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Sahar Ahmed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, Michigan
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245
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Wiltshire T, Dong OM. Clinical pharmacogenetics: how do we ensure a favorable future for patients? Pharmacogenomics 2018; 19:553-562. [DOI: 10.2217/pgs-2017-0192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Currently, there is sufficient evidence for the use of pharmacogenetic information to optimize medication prescribing, but why has this information not been integrated into the drug prescribing process to improve patient care? A discussion about the major contributing factors that have limited the use of pharmacogenetic information in the drug prescribing process, the solutions to ensure widespread uptake, and a vision for the future of the pharmacogenetic field will be explored.
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Affiliation(s)
- Tim Wiltshire
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for Pharmacogenomics & Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Olivia M Dong
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Center for Pharmacogenomics & Individualized Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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246
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Dainis AM, Ashley EA. Cardiovascular Precision Medicine in the Genomics Era. JACC Basic Transl Sci 2018; 3:313-326. [PMID: 30062216 PMCID: PMC6059349 DOI: 10.1016/j.jacbts.2018.01.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/31/2017] [Accepted: 01/02/2018] [Indexed: 12/20/2022]
Abstract
Precision medicine strives to delineate disease using multiple data sources-from genomics to digital health metrics-in order to be more precise and accurate in our diagnoses, definitions, and treatments of disease subtypes. By defining disease at a deeper level, we can treat patients based on an understanding of the molecular underpinnings of their presentations, rather than grouping patients into broad categories with one-size-fits-all treatments. In this review, the authors examine how precision medicine, specifically that surrounding genetic testing and genetic therapeutics, has begun to make strides in both common and rare cardiovascular diseases in the clinic and the laboratory, and how these advances are beginning to enable us to more effectively define risk, diagnose disease, and deliver therapeutics for each individual patient.
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Key Words
- CAD, coronary artery disease
- CF, cystic fibrosis
- CHD, coronary heart disease
- CML, chronic myelogenous leukemia
- CRS, conventional risk score
- CVD, cardiovascular disease
- CaM, calmodulin
- DCM, dilated cardiomyopathy
- DMD, Duchenne muscular dystrophy
- FH, familial hypercholesterolemia
- GRS, genomic risk score
- HCM, hypertrophic cardiomyopathy
- HDR, homology directed repair
- IVF, in vitro fertilization
- LDL-C, low-density lipoprotein cholesterol
- LQTS, long QT syndrome
- NGS, next-generation sequencing
- PGD, preimplantation genetic diagnosis
- SNP, single nucleotide polymorphism
- genome sequencing
- genomics
- iPSC, induced pluripotent stem cells
- precision medicine
- ssODN, single-stranded oligodeoxynucleotide
- targeted therapeutics
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Affiliation(s)
| | - Euan A. Ashley
- Department of Genetics, Stanford University, Stanford, California
- Department of Medicine, Stanford University, Stanford, California
- Stanford Center for Inherited Cardiovascular Disease, Stanford University, Stanford, California
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Allyn-Feuer A, Ade A, Luzum JA, Higgins GA, Athey BD. The pharmacoepigenomics informatics pipeline defines a pathway of novel and known warfarin pharmacogenomics variants. Pharmacogenomics 2018; 19:413-434. [PMID: 29400612 PMCID: PMC6021929 DOI: 10.2217/pgs-2017-0186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/16/2018] [Indexed: 12/21/2022] Open
Abstract
AIM 'Pharmacoepigenomics' methods informed by omics datasets and pre-existing knowledge have yielded discoveries in neuropsychiatric pharmacogenomics. Now we evaluate the generality of these methods by discovering an extended warfarin pharmacogenomics pathway. MATERIALS & METHODS We developed the pharmacoepigenomics informatics pipeline, a scalable multi-omics variant screening pipeline for pharmacogenomics, and conducted an experiment in the genomics of warfarin. RESULTS We discovered known and novel pharmacogenomics variants and genes, both coding and regulatory, for warfarin response, including adverse events. Such genes and variants cluster in a warfarin response pathway consolidating known and novel warfarin response variants and genes. CONCLUSION These results can inform a new warfarin test. The pharmacoepigenomics informatics pipeline may be able to discover new pharmacogenomics markers in other drug-disease systems.
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Affiliation(s)
- Ari Allyn-Feuer
- Department of Computational Medicine & Bioinformatics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Alex Ade
- Department of Computational Medicine & Bioinformatics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Gerald A Higgins
- Department of Computational Medicine & Bioinformatics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Brian D Athey
- Department of Computational Medicine & Bioinformatics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Michigan Institute for Data Science, University of Michigan Office of Research, Ann Arbor, MI 48109, USA
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248
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Limdi NA, Brown TM, Shendre A, Liu N, Hill CE, Beasley TM. Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users. Pharmacogenet Genomics 2018; 27:347-355. [PMID: 28806200 DOI: 10.1097/fpc.0000000000000298] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We evaluated whether percent time in target range (PTTR), risk of over-anticoagulation [international normalized ratio (INR)>4], and risk of hemorrhage differ by race. As PTTR is a strong predictor of hemorrhage risk, we also determined the influence of PTTR on the risk of hemorrhage by race. PARTICIPANTS AND METHODS Among 1326 warfarin users, PTTR was calculated as the percentage of interpolated INR values within the target range of 2.0-3.0. PTTR was also categorized as poor (PTTR<60%), good (60≤PTTR<70%), or excellent (PTTR≥70%) anticoagulation control. Over-anticoagulation was defined as INR more than 4 and major hemorrhages included serious, life-threatening, and fatal bleeding episodes. Logistic regression and survival analyses were carried out to evaluate the association of race with PTTR (≥60 vs. <60) and major hemorrhages, respectively. RESULTS Compared with African Americans, European Americans had higher PTTR (57.6 vs. 49.1%; P<0.0001) and were more likely to attain 60≤PTTR<70% (22.9 vs. 13.1%; P<0.001) or PTTR of at least 70% (26.9 vs. 18.2%; P=0.001). Older (>65 years) patients without venous thromboembolism indication and chronic kidney disease were more likely to attain PTTR of at least 60%. After accounting for clinical and genetic factors, and PTTR, African Americans had a higher risk of hemorrhage [hazard ratio (HR)=1.58; 95% confidence interval (CI): 1.04-2.41; P=0.034]. Patients with 60≤PTTR<70% (HR=0.62; 95% CI: 0.38-1.02; P=0.058) and PTTR of at least 70% (HR=0.27; 95% CI: 0.15-0.49; P<0.001) had a lower risk of hemorrhage compared with those with PTTR less than 60%. CONCLUSION Despite the provision of warfarin management through anticoagulation clinics, African Americans achieve a lower overall PTTR and have a significantly higher risk of hemorrhage. Personalized medicine interventions tailored to African American warfarin users need to be developed.
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Affiliation(s)
- Nita A Limdi
- aDepartment of Neurology bDepartment of Medicine, Division of Cardiovascular Diseases cDepartment of Epidemiology dDepartment of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA eDepartment of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
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Biswas M, Bendkhale SR, Deshpande SP, Thaker SJ, Kulkarni DV, Bhatia SJ, Rajadhyaksha AG, Gogtay NJ, Thatte UM. Association between genetic polymorphisms of CYP2C9 and VKORC1 and safety and efficacy of warfarin: Results of a 5 years audit. Indian Heart J 2018; 70 Suppl 3:S13-S19. [PMID: 30595245 PMCID: PMC6309143 DOI: 10.1016/j.ihj.2018.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/02/2018] [Accepted: 02/13/2018] [Indexed: 11/30/2022] Open
Abstract
Objective Genetic polymorphisms of CYP2C9 and VKORC1 play major role in pharmacokinetics and pharmacodynamics of warfarin, respectively. Purpose of our study was to assess the utility of pretesting patients for the above mutations in predicting tendency for bleeding and achieving target INR. Methods This was an audit of data collected between July 2011 and December 2016. For safety and efficacy, patients were divided into two subgroups: those with or without bleeding and those who achieved target INR or not. Chi square test was applied to compare the between group differences and crude Odds Ratio (cOR) calculated. Results Among 521 patients evaluated, most common indication for warfarin therapy was valvular heart disease (210/521 = 40%); 36% (187/521) had at least one bleeding episode; 56% (269/479) had below target INR. 26% (136/521) had polymorphic alleles of CYP2C9 and 69% (358/521) had the GG haplotype of VKORC1. Polymorphic alleles of CYP2C9 or AG/AA haplotype had twice the odds of bleeding (cOR = 2.14 and 2.44 respectively) relative to those with wild CYP2C9 allele or GG haplotype. Combined CYP2C9 mutant alleles and/or AG/AA haplotypes had thrice the odds of bleeding (cOR = 3.12) relative to those with wild CYP2C9 alleles and GG haplotype. Those with GG haplotype had twice the odds (cOR = 1.81) and those with GG haplotype along with wild CYP2C9 allele had four times the odds (cOR = 4.27) of not achieving the target INR relative to those with other haplotype/alleles. All these associations were statistically significant (p < 0.05). Conclusions Pretesting patients for genetic polymorphisms could aid in individualizing warfarin therapy.
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Affiliation(s)
- Mansij Biswas
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shital R Bendkhale
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Saket J Thaker
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Dwarkanath V Kulkarni
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shobna J Bhatia
- Department of Gastroenterology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Anjali G Rajadhyaksha
- Department of Medicine, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
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