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Cavalli M, Pan G, Nord H, Eriksson N, Wadelius C, Wadelius M. Novel regulatory variant detected on the VKORC1 haplotype that is associated with warfarin dose. Pharmacogenomics 2016; 17:1305-14. [PMID: 26847243 DOI: 10.2217/pgs-2015-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM Warfarin dose requirement is associated with VKORC1 rs9923231, and we studied whether it is a functional variant. MATERIALS & METHODS We selected variants in linkage disequilibrium with rs9923231 that bind transcription factors in an allele-specific way. Representative haplotypes were cloned or constructed, nuclear protein binding and transcriptional activity were evaluated. RESULTS rs56314408C>T and rs2032915C>T were detected in a liver enhancer in linkage disequilibrium with rs9923231. The rs56314408-rs2032915 C-C haplotype preferentially bound nuclear proteins and had higher transcriptional activity than T-T and the African-specific T-C. A motif for TFAP2A/C was disrupted by rs56314408T. No difference in transcriptional activity was detected for rs9923231G>A. CONCLUSION Our results supported an activating role for rs56314408C, while rs9923231G>A had no evidence of being functional.
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Affiliation(s)
- Marco Cavalli
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Gang Pan
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Helena Nord
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Niclas Eriksson
- Uppsala Clinical Research Center & Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Claes Wadelius
- Department of Immunology, Genetics & Pathology, & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Mia Wadelius
- Department of Medical Sciences & Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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Cooper-DeHoff RM, Johnson JA. Hypertension pharmacogenomics: in search of personalized treatment approaches. Nat Rev Nephrol 2016; 12:110-22. [PMID: 26592190 PMCID: PMC4778736 DOI: 10.1038/nrneph.2015.176] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiovascular and renal diseases are associated with many risk factors, of which hypertension is one of the most prevalent. Worldwide, blood pressure control is only achieved in ∼50% of those treated for hypertension, despite the availability of a considerable number of antihypertensive drugs from different pharmacological classes. Although many reasons exist for poor blood pressure control, a likely contributor is the inability to predict to which antihypertensive drug an individual is most likely to respond. Hypertension pharmacogenomics and other 'omics' technologies have the potential to identify genetic signals that are predictive of response or adverse outcome to particular drugs, and guide selection of hypertension treatment for a given individual. Continued research in this field will enhance our understanding of how to maximally deploy the various antihypertensive drug classes to optimize blood pressure response at the individual level. This Review summarizes the available literature on the most convincing genetic signals associated with antihypertensive drug responses and adverse cardiovascular outcomes. Future research in this area will be facilitated by enhancing collaboration between research groups through consortia such as the International Consortium for Antihypertensives Pharmacogenomics Studies, with the goal of translating replicated findings into clinical implementation.
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Affiliation(s)
- Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Division of Cardiovascular Medicine, Colleges of Pharmacy and Medicine, University of Florida, PO Box 100484, 1600 SW Archer Road, Gainesville, Florida 32610-0484, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Division of Cardiovascular Medicine, Colleges of Pharmacy and Medicine, University of Florida, PO Box 100484, 1600 SW Archer Road, Gainesville, Florida 32610-0484, USA
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Vizirianakis IS, Mystridis GA, Avgoustakis K, Fatouros DG, Spanakis M. Enabling personalized cancer medicine decisions: The challenging pharmacological approach of PBPK models for nanomedicine and pharmacogenomics (Review). Oncol Rep 2016; 35:1891-904. [PMID: 26781205 DOI: 10.3892/or.2016.4575] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/27/2015] [Indexed: 11/05/2022] Open
Abstract
The existing tumor heterogeneity and the complexity of cancer cell biology critically demand powerful translational tools with which to support interdisciplinary efforts aiming to advance personalized cancer medicine decisions in drug development and clinical practice. The development of physiologically based pharmacokinetic (PBPK) models to predict the effects of drugs in the body facilitates the clinical translation of genomic knowledge and the implementation of in vivo pharmacology experience with pharmacogenomics. Such a direction unequivocally empowers our capacity to also make personalized drug dosage scheme decisions for drugs, including molecularly targeted agents and innovative nanoformulations, i.e. in establishing pharmacotyping in prescription. In this way, the applicability of PBPK models to guide individualized cancer therapeutic decisions of broad clinical utility in nanomedicine in real-time and in a cost-affordable manner will be discussed. The latter will be presented by emphasizing the need for combined efforts within the scientific borderlines of genomics with nanotechnology to ensure major benefits and productivity for nanomedicine and personalized medicine interventions.
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Affiliation(s)
- Ioannis S Vizirianakis
- Laboratory of Pharmacology, Department of Pharmaceutical Sciences, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki GR‑54124, Greece
| | - George A Mystridis
- Laboratory of Pharmacology, Department of Pharmaceutical Sciences, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki GR‑54124, Greece
| | - Konstantinos Avgoustakis
- Laboratory of Pharmaceutical Technology, Department of Pharmaceutical Sciences, University of Patras, Patras GR-26504, Greece
| | - Dimitrios G Fatouros
- Laboratory of Pharmaceutical Technology, Department of Pharmaceutical Sciences, Aristotle University of Thessaloniki, Thessaloniki GR-54124, Greece
| | - Marios Spanakis
- Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology-Hellas, Heraklion GR-71110, Crete, Greece
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Mitropoulou C, Fragoulakis V, Bozina N, Vozikis A, Supe S, Bozina T, Poljakovic Z, van Schaik RH, Patrinos GP. Economic evaluation of pharmacogenomic-guided warfarin treatment for elderly Croatian atrial fibrillation patients with ischemic stroke. Pharmacogenomics 2016; 16:137-48. [PMID: 25616100 DOI: 10.2217/pgs.14.167] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND & METHODS Economic evaluation in genomic medicine is an emerging discipline to assess the cost-effectiveness of genome-guided treatment. Here, we developed a pharmaco-economic model to assess whether pharmacogenomic (PGx)-guided warfarin treatment of elderly ischemic stroke patients with atrial fibrillation in Croatia is cost effective compared with non-PGx therapy. The time horizon of the model was set at 1 year. RESULTS Our primary analysis indicates that 97.07% (95% CI: 94.08-99.34%) of patients belonging to the PGx-guided group have not had any major complications, compared with the control group (89.12%; 95% CI: 84.00-93.87%, p < 0.05). The total cost per patient was estimated at €538.7 (95% CI: €526.3-551.2) for the PGx-guided group versus €219.7 (95% CI: €137.9-304.2) for the control group. In terms of quality-adjusted life-years (QALYs) gained, total QALYs was estimated at 0.954 (95% CI: 0.943-0.964) and 0.944 (95% CI: 0.931-0.956) for the PGx-guided and the control groups, respectively. The true difference in QALYs was estimated at 0.01 (95% CI: 0.005-0.015) in favor of the PGx-guided group. The incremental cost-effectiveness ratio of the PGx-guided versus the control groups was estimated at €31,225/QALY. CONCLUSION Overall, our data indicate that PGx-guided warfarin treatment may represent a cost-effective therapy option for the management of elderly patients with atrial fibrillation who developed ischemic stroke in Croatia.
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Affiliation(s)
- Christina Mitropoulou
- Department of Clinical Chemistry, Faculty of Medicine & Health Sciences, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Duconge J, Ramos AS, Claudio-Campos K, Rivera-Miranda G, Bermúdez-Bosch L, Renta JY, Cadilla CL, Cruz I, Feliu JF, Vergara C, Ruaño G. A Novel Admixture-Based Pharmacogenetic Approach to Refine Warfarin Dosing in Caribbean Hispanics. PLoS One 2016; 11:e0145480. [PMID: 26745506 PMCID: PMC4706412 DOI: 10.1371/journal.pone.0145480] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 12/03/2015] [Indexed: 12/13/2022] Open
Abstract
AIM This study is aimed at developing a novel admixture-adjusted pharmacogenomic approach to individually refine warfarin dosing in Caribbean Hispanic patients. PATIENTS & METHODS A multiple linear regression analysis of effective warfarin doses versus relevant genotypes, admixture, clinical and demographic factors was performed in 255 patients and further validated externally in another cohort of 55 individuals. RESULTS The admixture-adjusted, genotype-guided warfarin dosing refinement algorithm developed in Caribbean Hispanics showed better predictability (R2 = 0.70, MAE = 0.72mg/day) than a clinical algorithm that excluded genotypes and admixture (R2 = 0.60, MAE = 0.99mg/day), and outperformed two prior pharmacogenetic algorithms in predicting effective dose in this population. For patients at the highest risk of adverse events, 45.5% of the dose predictions using the developed pharmacogenetic model resulted in ideal dose as compared with only 29% when using the clinical non-genetic algorithm (p<0.001). The admixture-driven pharmacogenetic algorithm predicted 58% of warfarin dose variance when externally validated in 55 individuals from an independent validation cohort (MAE = 0.89 mg/day, 24% mean bias). CONCLUSIONS Results supported our rationale to incorporate individual's genotypes and unique admixture metrics into pharmacogenetic refinement models in order to increase predictability when expanding them to admixed populations like Caribbean Hispanics. TRIAL REGISTRATION ClinicalTrials.gov NCT01318057.
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Affiliation(s)
- Jorge Duconge
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Alga S. Ramos
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Karla Claudio-Campos
- Department of Pharmacology and Toxicology, School of Medicine, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Giselle Rivera-Miranda
- Pharmacy Service, VA Caribbean Healthcare Systems (VACHS), San Juan, Puerto Rico, United States of America
| | - Luis Bermúdez-Bosch
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Jessicca Y. Renta
- Molecular Genetics Lab, Department of Biochemistry, School of Medicine, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Carmen L. Cadilla
- Molecular Genetics Lab, Department of Biochemistry, School of Medicine, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Iadelisse Cruz
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus (UPR-MSC), San Juan, Puerto Rico, United States of America
| | - Juan F. Feliu
- Pharmacy Service, VA Caribbean Healthcare Systems (VACHS), San Juan, Puerto Rico, United States of America
| | - Cunegundo Vergara
- Brownstone Outpatient Clinic, Hartford Hospital, Hartford, CT, United States of America
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Zhuang B, Han J, Xiang G, Gan W, Wang S, Wang D, Wang L, Sun J, Li CX, Liu P. A fully integrated and automated microsystem for rapid pharmacogenetic typing of multiple warfarin-related single-nucleotide polymorphisms. LAB ON A CHIP 2016; 16:86-95. [PMID: 26568290 DOI: 10.1039/c5lc01094b] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A fully integrated and automated microsystem consisting of low-cost, disposable plastic chips for DNA extraction and PCR amplification combined with a reusable glass capillary array electrophoresis chip in a modular-based format was successfully developed for warfarin pharmacogenetic testing. DNA extraction was performed by adopting a filter paper-based method, followed by "in situ" PCR that was carried out directly in the same reaction chamber of the chip without elution. PCR products were then co-injected with sizing standards into separation channels for detection using a novel injection electrode. The entire process was automatically conducted on a custom-made compact control and detection instrument. The limit of detection of the microsystem for the singleplex amplification of amelogenin was determined to be 0.625 ng of standard K562 DNA and 0.3 μL of human whole blood. A two-color multiplex allele-specific PCR assay for detecting the warfarin-related single-nucleotide polymorphisms (SNPs) 6853 (-1639G>A) and 6484 (1173C>T) in the VKORC1 gene and the *3 SNP (1075A>C) in the CYP2C9 gene was developed and used for validation studies. The fully automated genetic analysis was completed in two hours with a minimum requirement of 0.5 μL of input blood. Samples from patients with different genotypes were all accurately analyzed. In addition, both dried bloodstains and oral swabs were successfully processed by the microsystem with a simple modification to the DNA extraction and amplification chip. The successful development and operation of this microsystem establish the feasibility of rapid warfarin pharmacogenetic testing in routine clinical practice.
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Affiliation(s)
- Bin Zhuang
- Department of Biomedical Engineering, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, Tsinghua University, Beijing, 100084, China. and CapitalBio Corporation, Beijing, 102206, China
| | - Junping Han
- Chinese People's Public Security University, Beijing, 100038, China
| | - Guangxin Xiang
- Department of Biomedical Engineering, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, Tsinghua University, Beijing, 100084, China. and CapitalBio Corporation, Beijing, 102206, China
| | - Wupeng Gan
- Department of Biomedical Engineering, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, Tsinghua University, Beijing, 100084, China. and CapitalBio Corporation, Beijing, 102206, China
| | - Shuaiqin Wang
- Department of Biomedical Engineering, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, Tsinghua University, Beijing, 100084, China.
| | - Dong Wang
- CapitalBio Corporation, Beijing, 102206, China and National Engineering Research Center for Beijing Biochip Technology, Beijing, 102206, China
| | - Lei Wang
- CapitalBio Corporation, Beijing, 102206, China and National Engineering Research Center for Beijing Biochip Technology, Beijing, 102206, China
| | - Jing Sun
- Key Laboratory of Forensic Genetics, Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Cai-Xia Li
- Key Laboratory of Forensic Genetics, Institute of Forensic Science, Ministry of Public Security, Beijing, 100038, China
| | - Peng Liu
- Department of Biomedical Engineering, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, Tsinghua University, Beijing, 100084, China.
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257
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Lee K, Woo HI, Bang OY, On YK, Kim JS, Lee SY. How to use warfarin assays in patient management: analysis of 437 warfarin measurements in a clinical setting. Clin Pharmacokinet 2016; 54:517-25. [PMID: 25466603 DOI: 10.1007/s40262-014-0219-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Approximately 50% of inter-individual variation in warfarin dose requirements is attributed to the polymorphisms of cytochrome P450 (CYP) 2C9 (CYP2C9) and vitamin K epoxide reductase complex, subunit 1 (VKORC1) genotypes. What contributes to the remaining 50% of variation remains unclear. The aim of this study is to assess the clinical usefulness of monitoring plasma warfarin concentrations. We examined genotypic and clinical factors influencing high and low warfarin concentrations. METHODS We included 325 Korean patients who received warfarin therapy for more than 7 days whose plasma warfarin concentrations were measured and whose genotypes for VKORC1 and CYP2C9 were determined. The plasma concentrations of total warfarin and 7-hydroxywarfarin were determined by high-performance liquid chromatography-tandem mass spectrometry. RESULTS Using 437 warfarin measurements obtained from 325 patients, we found a correlation between plasma warfarin concentration and warfarin dose (r (2) = 0.356; P < 0.001) and a significant difference in the warfarin/7-hydroxywarfarin ratios of the CYP2C9*1/*1 and CYP2C9*1/*3 genotypes combined with drugs that inhibited warfarin (P = 0.003). Insufficient warfarin dose and patient noncompliance were the most common causes of low warfarin concentrations (<0.54 µg/mL, <5th percentile). Genetic factors that cause pharmacodynamic resistance (e.g., VKORC1 genotype) and thus require high warfarin doses were the most common causes of high warfarin concentrations (>1.85 µg/mL, >95th percentile). CONCLUSION Monitoring warfarin concentrations along with the prothrombin time-international normalized ratio may be clinically useful for managing patients with long-term warfarin therapy and identifying factors contributing to inter- or intra-individual variability such as genetic polymorphisms, underlying diseases, drug interactions with warfarin, and patient compliance.
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Affiliation(s)
- Kyunghoon Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Korea
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258
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Tomlinson B, Hu M, Waye MM, Chan P, Liu ZM. Current status of personalized medicine based on pharmacogenetics in cardiovascular medicine. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2016. [DOI: 10.1080/23808993.2016.1142826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Laper SM, Restrepo NA, Crawford DC. THE CHALLENGES IN USING ELECTRONIC HEALTH RECORDS FOR PHARMACOGENOMICS AND PRECISION MEDICINE RESEARCH. PACIFIC SYMPOSIUM ON BIOCOMPUTING. PACIFIC SYMPOSIUM ON BIOCOMPUTING 2016; 21:369-80. [PMID: 26776201 PMCID: PMC4720980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Access and utilization of electronic health records with extensive medication lists and genetic profiles is rapidly advancing discoveries in pharmacogenomics. In this study, we analyzed ~116,000 variants on the Illumina Metabochip for response to antihypertensive and lipid lowering medications in African American adults from BioVU, the Vanderbilt University Medical Center's biorepository linked to de-identified electronic health records. Our study population included individuals who were prescribed an antihypertensive or lipid lowering medication, and who had both pre- and post-medication blood pressure or low-density lipoprotein cholesterol (LDL-C) measurements, respectively. Among those with pre- and post-medication systolic and diastolic blood pressure measurements (n=2,268), the average change in systolic and diastolic blood pressure was -0.6 mg Hg and -0.8 mm Hg, respectively. Among those with pre- and post-medication LDL-C measurements (n=1,244), the average change in LDL-C was -26.3 mg/dL. SNPs were tested for an association with change and percent change in blood pressure or blood levels of LDL-C. After adjustment for multiple testing, we did not observe any significant associations, and we were not able to replicate previously reported associations, such as in APOE and LPA, from the literature. The present study illustrates the benefits and challenges with using electronic health records linked to biorepositories for pharmacogenomic studies.
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Affiliation(s)
- Sarah M. Laper
- Eastern Virginia Medical School, Norfolk, VA, 23507, USA
| | - Nicole A. Restrepo
- Center for Human Genetics Research, Vanderbilt University, 519 Light Hall, 2215 Garland Avenue, Nashville, TN 37232, USA
| | - Dana C. Crawford
- Institute for Computational Biology, Department of Epidemiology and Biostatistics, Case Western Reserve University, Wolstein Research Building, 2103 Cornell Road, Suite 2527, Cleveland, OH 44106, USA
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260
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Sing CW, Cheung CL, Wong ICK. Pharmacogenomics--how close/far are we to practising individualized medicine for children? Br J Clin Pharmacol 2015; 79:419-28. [PMID: 25855823 DOI: 10.1111/bcp.12338] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The translation of pharmacogenomics into clinical practice is a key approach for practising individualized medicine, which aims to maximize drug efficacy and minimize drug toxicity. Since the completion of both the Human Genome Project and the International HapMap project, the development of pharmacogenomics has been greatly facilitated. However, progress in translating pharmacogenomics into clinical practice, especially in paediatric medicine, is unexpectedly slow. Many challenges from different areas remain. This paper discusses the existing applications and the limitations to the implementation of paediatric pharmacogenomics, as well as possible solutions for overcoming these limitations and challenges.
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261
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262
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Ziegelstein RC. Who will deliver personalized medicine? J Eval Clin Pract 2015; 21:1038-9. [PMID: 26290319 DOI: 10.1111/jep.12440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Roy C Ziegelstein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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263
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Zhu Q, Liu H, Chute CG, Ferber M. EHR based Genetic Testing Knowledge Base (iGTKB) Development. BMC Med Inform Decis Mak 2015; 15 Suppl 4:S3. [PMID: 26606281 PMCID: PMC4660117 DOI: 10.1186/1472-6947-15-s4-s3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The gap between a large growing number of genetic tests and a suboptimal clinical workflow of incorporating these tests into regular clinical practice poses barriers to effective reliance on advanced genetic technologies to improve quality of healthcare. A promising solution to fill this gap is to develop an intelligent genetic test recommendation system that not only can provide a comprehensive view of genetic tests as education resources, but also can recommend the most appropriate genetic tests to patients based on clinical evidence. In this study, we developed an EHR based Genetic Testing Knowledge Base for Individualized Medicine (iGTKB). METHODS We extracted genetic testing information and patient medical records from EHR systems at Mayo Clinic. Clinical features have been semi-automatically annotated from the clinical notes by applying a Natural Language Processing (NLP) tool, MedTagger suite. To prioritize clinical features for each genetic test, we compared odds ratio across four population groups. Genetic tests, genetic disorders and clinical features with their odds ratios have been applied to establish iGTKB, which is to be integrated into the Genetic Testing Ontology (GTO). RESULTS Overall, there are five genetic tests operated with sample size greater than 100 in 2013 at Mayo Clinic. A total of 1,450 patients who was tested by one of the five genetic tests have been selected. We assembled 243 clinical features from the Human Phenotype Ontology (HPO) for these five genetic tests. There are 60 clinical features with at least one mention in clinical notes of patients taking the test. Twenty-eight clinical features with high odds ratio (greater than 1) have been selected as dominant features and deposited into iGTKB with their associated information about genetic tests and genetic disorders. CONCLUSIONS In this study, we developed an EHR based genetic testing knowledge base, iGTKB. iGTKB will be integrated into the GTO by providing relevant clinical evidence, and ultimately to support development of genetic testing recommendation system, iGenetics.
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Winner JG, Dechairo B. Combinatorial Versus Individual Gene Pharmacogenomic Testing in Mental Health: A Perspective on Context and Implications on Clinical Utility. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2015; 88:375-82. [PMID: 26604861 PMCID: PMC4654186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pharmacogenomic testing in mental health has not yet reached its full potential. An important reason for this involves differentiating individual gene testing (IGT) from a combinatorial pharmacogenomic (CPGx) approach. With IGT, any given gene reveals specific information that may, in turn, pertain to a smaller number of medications. CPGx approaches attempt to encompass more complete genomic information by combining moderate risk alleles and synergistically viewing the results from the perspective of the medication. This manuscript will discuss IGT and CPGx approaches to psychiatric pharmacogenomics and review the clinical validity, clinical utility, and economic parameters of both.
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Affiliation(s)
- Joel G. Winner
- To whom all correspondence should be addressed: Joel G. Winner, MD, 2595 Canyon Boulevard, Suite 100, Boulder, CO 80302; Tele: 720-920-9174; Fax: 720-920-9307;
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Abstract
Heart disease is a leading cause of death in the United States, and hypertension is a predominant risk factor. Thus, effective blood pressure control is important to prevent adverse sequelae of hypertension, including heart failure, coronary artery disease, atrial fibrillation, and ischemic stroke. Over half of Americans have uncontrolled blood pressure, which may in part be explained by interpatient variability in drug response secondary to genetic polymorphism. As such, pharmacogenetic testing may be a supplementary tool to guide treatment. This review highlights the pharmacogenetics of antihypertensive response and response to drugs that treat adverse hypertension-related sequelae, particularly coronary artery disease and atrial fibrillation. While pharmacogenetic evidence may be more robust for the latter with respect to clinical implementation, there is increasing evidence of genetic variants that may help predict antihypertensive response. However, additional research and validation are needed before clinical implementation guidelines for antihypertensive therapy can become a reality.
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Abstract
Nucleotide changes in gene regulatory elements can have a major effect on interindividual differences in drug response. For example, by reviewing all published pharmacogenomic genome-wide association studies, we show here that 96.4% of the associated single nucleotide polymorphisms reside in noncoding regions. We discuss how sequencing technologies are improving our ability to identify drug response-associated regulatory elements genome-wide and to annotate nucleotide variants within them. We highlight specific examples of how nucleotide changes in these elements can affect drug response and illustrate the techniques used to find them and functionally characterize them. Finally, we also discuss challenges in the field of drug-responsive regulatory elements that need to be considered in order to translate these findings into the clinic.
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Affiliation(s)
- Marcelo R Luizon
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94158, USA.,Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Nadav Ahituv
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA 94158, USA.,Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94158, USA
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Haga SB, Moaddeb J, Mills R, Patel M, Kraus W, Allen LaPointe NM. Incorporation of pharmacogenetic testing into medication therapy management. Pharmacogenomics 2015; 16:1931-41. [PMID: 26555559 DOI: 10.2217/pgs.15.124] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIM To assess feasibility and patient satisfaction with a pharmacist-delivered medication therapy management (MTM) plus pharmacogenetic (PGx) testing service. METHODS Thirty patients from a cardiology outpatient clinic were enrolled to attend two MTM sessions, undergo PGx testing and complete pre- and post-intervention surveys. Outcome measures included duration of MTM sessions, clinical application of test results, self-reported medication adherence, patient recall of results and perceived value of testing and MTM. RESULTS Overall, patients were very satisfied with the MTM plus PGx testing service. About half of participants (47%) were able to accurately recall their PGx test results. Comparable to MTM without PGx testing, the first MTM session averaged 40 min and the follow-up MTM session averaged 15 min. CONCLUSION PGx testing incorporated into a clinical MTM service offered by pharmacists may be a feasible delivery model and is satisfactory to patients.
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Affiliation(s)
- Susanne B Haga
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
| | - Jivan Moaddeb
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
| | - Rachel Mills
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
| | - Mahesh Patel
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
| | - William Kraus
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
| | - Nancy M Allen LaPointe
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 201 Trent Dr, Durham, NC 27710, USA
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268
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The influence of VKORC1 gene polymorphism on warfarin maintenance dosage in pediatric patients: A systematic review and meta-analysis. Thromb Res 2015; 136:955-61. [DOI: 10.1016/j.thromres.2015.09.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/12/2015] [Accepted: 09/22/2015] [Indexed: 11/18/2022]
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269
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Cheek DJ, Bashore L, Brazeau DA. Pharmacogenomics and Implications for Nursing Practice. J Nurs Scholarsh 2015; 47:496-504. [DOI: 10.1111/jnu.12168] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Dennis J. Cheek
- Beta Alpha , Abell-Hanger Professor, Texas Christian University; Harris College of Nursing and Health Sciences & School of Nurse Anesthesia; Fort Worth TX USA
| | - Lisa Bashore
- Beta Alpha , Assistant Professor, Texas Christian University; Harris College of Nursing and Health Sciences; Fort Worth TX USA
| | - Dan Alan Brazeau
- Director of Genomics, Analytics and Proteomics, Research Associate Professor, College of Pharmacy; University of New England; Portland ME USA
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270
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Duconge J, Ruaño G. Fixed-dose combination products and unintended drug interactions: urgent need for pharmacogenetic evaluation. Pharmacogenomics 2015; 16:1685-8. [DOI: 10.2217/pgs.15.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jorge Duconge
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936, USA
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271
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Pharmacogenetic versus clinical dosing of warfarin in individuals of Chinese and African-American ancestry. Pharmacogenet Genomics 2015; 25:491-500. [DOI: 10.1097/fpc.0000000000000165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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272
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Chang MT, McCarthy JJ, Shin J. Clinical application of pharmacogenetics: focusing on practical issues. Pharmacogenomics 2015; 16:1733-41. [PMID: 26411302 DOI: 10.2217/pgs.15.112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Recent large-scale genetic-based studies have transformed the field of pharmacogenetics to identify, characterize and leverage genetic information to inform patient care. Genetic testing can be used to alter drug selection, optimize drug dosing and prevent unnecessary adverse events. As precision medicine becomes the mainstay in the clinic, it becomes critical for clinicians to utilize pharmacogenetics to guide patient care. One primary challenge is identifying patients where genetic tests that can potentially impact patient care. To address this challenge, our review highlights many practical issues clinicians may encounter: identifying candidate patients and clinical laboratories for pharmacogenetic testing, selecting highly curated resources to help asses test validity, reimbursing costs of pharmacogenetic tests, and interpreting of pharmacogenetic test results.
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Affiliation(s)
- Matthew T Chang
- Departments of Bioengineering & Therapeutic Sciences, University of California, San Francisco, CA, USA
| | - Jeanette J McCarthy
- Division of Medical Genetics, University of California, San Francisco, CA, USA.,Department of Community & Family Medicine, Duke University, Durham, NC, USA
| | - Jaekyu Shin
- Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
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273
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Spizz G, Chen Z, Li P, McGuire IC, Klimkiewicz P, Zysling D, Yasmin R, Hungerford W, Thomas B, Wilding G, Mouchka G, Young L, Zhou P, Montagna RA. Determination of genotypes using a fully automated molecular detection system. Arch Pathol Lab Med 2015; 139:805-11. [PMID: 26030250 DOI: 10.5858/arpa.2014-0059-oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Although the value of pharmacogenomics to improve patient outcomes has become increasingly clear, adoption in medical practice has been slow, which can be attributed to several factors, including complicated and expensive testing procedures and required equipment, lack of training by private practice physicians, and reluctance of both private and commercial payers to reimburse for such testing. OBJECTIVES To evaluate a fully automated molecular detection system for human genotyping assays, starting with anticoagulated whole blood samples, and to perform all sample preparation, assay, and analysis steps automatically with actionable results reported by the system's software. DESIGN The genotypes of 254 random individuals were determined by performing bidirectional DNA sequencing, and that information was used to statistically train the imaging software of the automated molecular detection system to distinguish the 3 possible genotypes (ie, homozygous wild type, heterozygous, and homozygous mutant) at each of 3 different loci (CYP2C9*2, CYP2C9*3, and VKORC1). RESULTS The resulting software algorithm was able to correctly identify the genotypes of all 254 individuals (100%) evaluated without any further user analysis. CONCLUSIONS The EncompassMDx workstation (Rheonix, Inc, Ithaca, New York) is a molecular detection system that can automatically determine the genotypes of individuals in an unattended manner. Considerably less technical expertise was required to achieve results identical to those obtained using more complex, time-consuming, and expensive bidirectional DNA sequencing. This optimized system may dramatically simplify and reduce the costs of pharmacogenomics testing, thus leading to more-widespread use.
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Affiliation(s)
- Gwendolyn Spizz
- From Rheonix, Inc, Ithaca, New York (Drs Spizz, Chen, Li, McGuire, Zysling, Yasmin, Zhou, and Montagna; Mss Klimkiewicz and Hungerford; and Messrs Thomas, Mouchka, and Young); and the Department of Biostatistics, State University of New York, Buffalo (Dr Wilding). Dr Li is now with Thermo Fisher Scientific, San Francisco, California; Ms Klimkiewicz is now with the Rochester Institute of Technology, Rochester, New York; and Mr Young is now with INEng, LLC, Ithaca, New York
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274
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de Denus S, Dubé MP, Tardif JC. Will personalized drugs for cardiovascular disease become an option? - Defining 'Evidence-based personalized medicine' for its implementation and future use. Expert Opin Pharmacother 2015; 16:2549-52. [PMID: 26371722 DOI: 10.1517/14656566.2015.1088829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is generally accepted that the implementation of pharmacogenomics and, more broadly, personalized medicine will have to be 'evidence-based'. However, there is a lack of consensus on the level of evidence required to justify the use of pharmacogenomic testing in clinical practice. In the cardiovascular field, this lack of agreement has led to somewhat contradicting recommendations by different organizations regarding the clinical utility and use of pharmacogenomic tests or information. Here, we argue that randomized, controlled trials are paramount in order to enable and accelerate the widespread implementation of pharmacogenomics, not only to demonstrate the clinical efficacy and cost-effectiveness of such tests, but because such level of evidence is required to support the considerable changes associated with the implantation of pharmacogenomics in clinical practice.
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Affiliation(s)
- Simon de Denus
- a 1 Université de Montréal, Faculty of Pharmacy , Montreal, Canada.,b 2 Université de Montréal Beaulieu-Saucier Pharmacogenomics Center , Montreal, Canada.,c 3 Research Center, Montreal Heart Institute , Montreal, Canada
| | - Marie-Pierre Dubé
- b 2 Université de Montréal Beaulieu-Saucier Pharmacogenomics Center , Montreal, Canada.,c 3 Research Center, Montreal Heart Institute , Montreal, Canada.,d 4 Université de Montréal, Faculty of Medicine , Montreal, Canada , +1 514 376 3330 ; +1 514 593 2521 ;
| | - Jean-Claude Tardif
- b 2 Université de Montréal Beaulieu-Saucier Pharmacogenomics Center , Montreal, Canada.,c 3 Research Center, Montreal Heart Institute , Montreal, Canada.,d 4 Université de Montréal, Faculty of Medicine , Montreal, Canada , +1 514 376 3330 ; +1 514 593 2521 ;
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275
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Poor warfarin dose prediction with pharmacogenetic algorithms that exclude genotypes important for African Americans. Pharmacogenet Genomics 2015; 25:73-81. [PMID: 25461246 DOI: 10.1097/fpc.0000000000000108] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Recent clinical trial data cast doubt on the utility of genotype-guided warfarin dosing, specifically showing worse dosing with a pharmacogenetic versus clinical dosing algorithm in African Americans. However, many genotypes important in African Americans were not accounted for. We aimed to determine whether omission of the CYP2C9*5, CYP2C9*6, CYP2C9*8, CYP2C9*11 alleles and rs12777823 G > A genotype affects performance of dosing algorithms in African Americans. METHODS In a cohort of 274 warfarin-treated African Americans, we examined the association between the CYP2C9*5, CYP2C9*6, CYP2C9*8, CYP2C9*11 alleles and rs12777823 G > A genotype and warfarin dose prediction error with pharmacogenetic algorithms used in clinical trials. RESULTS The http://www.warfarindosing.org algorithm overestimated doses by a median (interquartile range) of 1.2 (0.02-2.6) mg/day in rs12777823 heterozygotes (P<0.001 for predicted vs. observed dose), 2.0 (0.6-2.8) mg/day in rs12777823 variant homozygotes (P = 0.004), and 2.2 (0.5-2.9) mg/day in carriers of a CYP2C9 variant (P < 0.001). The International Warfarin Pharmacogenetics Consortium (IWPC) algorithm underdosed warfarin by 0.8 (-2.3 to 0.4) mg/day for patients with the rs12777823 GG genotype (P < 0.001) and overdosed warfarin by 0.7 (-0.4 to 1.9) mg/day in carriers of a variant CYP2C9 allele (P = 0.04). Modifying the http://www.warfarindosing.org algorithm to adjust for variants important in African Americans led to better dose prediction than either the original http://www.warfarindosing.org (P < 0.01) or IWPC (P < 0.01) algorithm. CONCLUSION These data suggest that, when providing genotype-guided warfarin dosing, failure to account for variants important in African Americans leads to significant dosing error in this population.
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276
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Patel SR, Langaee TY, Wong SS, Cavallari LH. Pyrosequencing of the CYP2C9 -1766T>C polymorphism as a means of detecting the CYP2C9*8 allele. Pharmacogenomics 2015; 15:1717-22. [PMID: 25410896 DOI: 10.2217/pgs.14.130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The CYP2C9 c.449G>A (p.R150H, rs7900194) polymorphism, which confers the CYP2C9*8 allele, is common in persons of African descent and results in reduced clearance of the narrow therapeutic index drugs, warfarin and phenytoin. Because of significant homology in DNA sequence at the 449G>A locus among CYP2C genes, the 449G>A variant cannot be reliably detected via PCR-based genotyping assays that require a short PCR product, such as pyrosequencing. Herein, we propose genotyping for the CYP2C9 c.-1766T>C polymorphism via pyrosequencing as an alternative and accurate means of identifying the CYP2C9*8 allele.
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Affiliation(s)
- Shitalben R Patel
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
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277
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Duconge J, Cadilla CL, Seip RL, Ruaño G. Why admixture matters in genetically-guided therapy: missed targets in the COAG and EU-PACT trials. PUERTO RICO HEALTH SCIENCES JOURNAL 2015; 34:175-7. [PMID: 26454897 PMCID: PMC4770896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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278
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Kawai VK, Cunningham A, Vear SI, Van Driest SL, Oginni A, Xu H, Jiang M, Li C, Denny JC, Shaffer C, Bowton E, Gage BF, Ray WA, Roden DM, Stein CM. Genotype and risk of major bleeding during warfarin treatment. Pharmacogenomics 2015; 15:1973-83. [PMID: 25521356 DOI: 10.2217/pgs.14.153] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIM To determine whether genetic variants associated with warfarin dose variability were associated with increased risk of major bleeding during warfarin therapy. MATERIALS & METHODS Using Vanderbilt's DNA biobank we compared the prevalence of CYP2C9, VKORC1 and CYP4F2 variants in 250 cases with major bleeding and 259 controls during warfarin therapy. RESULTS CYP2C9*3 was the only allele that differed significantly among cases (14.2%) and controls (7.8%; p = 0.022). In the 214 (85.6%) cases with a major bleed 30 or more days after warfarin initiation, CYP2C9*3 was the only variant associated with bleeding (adjusted odds ratio: 2.05; 95% CI: 1.04, 4.04). CONCLUSION The CYP2C9*3 allele may double the risk of major bleeding among patients taking warfarin for 30 or more days.
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Affiliation(s)
- Vivian K Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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279
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Abstract
Consensus practice guidelines and the implementation of clinical therapeutic advances are usually based on the results of large, randomized clinical trials (RCTs). However, RCTs generally inform us on an average treatment effect for a presumably homogeneous population, but therapeutic interventions rarely benefit the entire population targeted. Indeed, multiple RCTs have demonstrated that interindividual variability exists both in drug response and in the development of adverse effects. The field of pharmacogenomics promises to deliver the right drug to the right patient. Substantial progress has been made in this field, with advances in technology, statistical and computational methods, and the use of cell and animal model systems. However, clinical implementation of pharmacogenetic principles has been difficult because RCTs demonstrating benefit are lacking. For patients, the potential benefits of performing such trials include the individualization of therapy to maximize efficacy and minimize adverse effects. These trials would also enable investigators to reduce sample size and hence contain costs for trial sponsors. Multiple ethical, legal, and practical issues need to be considered for the conduct of genotype-based RCTs. Whether pre-emptive genotyping embedded in electronic health records will preclude the need for performing genotype-based RCTs remains to be seen.
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Affiliation(s)
- Naveen L Pereira
- Division of Cardiovascular Diseases, Department of Internal Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Daniel J Sargent
- Department of Biomedical Statistics and Informatics, Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewer Centre, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Charanjit S Rihal
- Division of Cardiovascular Diseases, Department of Internal Medicine, 200 First Street SW, Rochester, MN 55905, USA
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280
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Elewa H, Alkhiyami D, Alsahan D, Abdel-Aziz A. A survey on the awareness and attitude of pharmacists and doctors towards the application of pharmacogenomics and its challenges in Qatar. J Eval Clin Pract 2015; 21:703-9. [PMID: 25929423 DOI: 10.1111/jep.12372] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2015] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Pharmacists are expected to play an important role in applying pharmacogenomics discoveries to patient care. Despite the increased attention to genetic research in Qatar, clinicians' attitudes towards the application of pharmacogenomics are not yet explored. The aim of this study was to assess the awareness and attitude of pharmacists compared with doctors towards pharmacogenomics and its implications by submitting an electronic-based survey to all pharmacists and doctors currently working in a large medical corporation in Qatar. METHODS A cross-sectional survey instrument was developed based on literature review. Eligible participants were pharmacists and doctors currently practicing in Hamad Medical Corporation hospitals in Qatar. The survey comprised questions on demographic and professional characteristics. It also evaluated the awareness, attitudes and challenges towards pharmacogenomics and its application. RESULTS We collected 202 surveys, 108 (53.2%) of which were pharmacists and the remaining 94 (46.5%) were doctors. The overall participants' mean total awareness score percentage was low (39% ± 22) and there were no difference between the mean score achieved by pharmacists and doctors. Pharmacists had significantly more positive attitudes than doctors towards: (i) taking the responsibility of applying pharmacogenomics to drug therapy selection, dosing and monitoring; (ii) perceiving a positive role of pharmacogenomics testing on the control of drug expenditure; and (iii) their willingness to participate in pharmacogenomics-related training sessions. Both pharmacists and doctors perceived lack of knowledge and guidelines as major challenges towards the application of pharmacogenomics in Qatar. CONCLUSION Despite doctors' and pharmacists' low level of awareness towards pharmacogenomics, they both have positive attitudes towards the clinical implications of pharmacogenomics. Pharmacists are more motivated to learn about pharmacogenomics and are more willing to take initiatives in its clinical application and patient education.
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Affiliation(s)
- Hazem Elewa
- Clinical Pharmacy and Practice Section, Qatar University, Doha, Qatar
| | | | - Dima Alsahan
- College of Pharmacy, Qatar University, Doha, Qatar
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281
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Kasner SE, Wang L, French B, Messe SR, Horenstein R, Mohler ER, Muldowney JAS, Ellenberg J, Kimmel SE. The Impact of Inpatient Versus Outpatient Initiation on Early Warfarin Dosing. Am J Cardiovasc Drugs 2015; 15:267-74. [PMID: 26037731 PMCID: PMC4508217 DOI: 10.1007/s40256-015-0126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Dosing algorithms for warfarin incorporate clinical and genetic factors but may not account for the numerous comorbidities affecting patients who start warfarin while hospitalized. We aimed to determine whether these algorithms perform differently when warfarin is initiated for inpatients compared with outpatients. PATIENTS AND METHODS We analyzed a prospective cohort of 1015 participants from the Clarification of Optimal Anticoagulation through Genetics (COAG) trial who were randomized to either pharmacogenetically or clinically guided warfarin dosing algorithms. Clinicians and participants were blinded to dose during the first 28 days. We compared groups, based on location at the time of the first warfarin dose request, in relation to the following outcomes: percentage of time in the therapeutic international normalized ratio (INR) range (PTTR) during the first 4 weeks, time to first therapeutic INR, time to maintenance dose, and the difference between predicted and observed maintenance doses. RESULTS A total of 527 participants started warfarin as inpatients and 488 as outpatients. There was no difference in PTTR based on location: 43.2 % for inpatient versus 47.4 % for outpatient initiation [mean adjusted difference -2.2 %; 95 % confidence interval (CI) -5.9 to 1.6]. Similarly, there were no differences in time to first therapeutic INR [hazard ratio (HR) 1.06; 95 % CI 0.91-1.24] or to maintenance dose (HR 0.96; 95 % CI 0.81-1.14). There was no evidence of interaction between study intervention (pharmacogenetically vs. clinically guided therapy) and location of initiation for these main outcomes. The difference between predicted and observed maintenance doses was similar for both locations. CONCLUSION The warfarin dosing algorithms performed similarly for subjects who initiated warfarin as inpatients and outpatients, regardless of whether dosing was pharmacogenetically or clinically guided.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania Medical Center, 3W Gates Bldg, 3400 Spruce Street, Philadelphia, PA, 19104, USA,
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282
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Goulding R, Dawes D, Price M, Wilkie S, Dawes M. Genotype-guided drug prescribing: a systematic review and meta-analysis of randomized control trials. Br J Clin Pharmacol 2015; 80:868-77. [PMID: 25060532 PMCID: PMC4594730 DOI: 10.1111/bcp.12475] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/21/2014] [Indexed: 01/11/2023] Open
Abstract
AIM Adverse drug events lead to increased morbidity, mortality and health care costs. Pharmacogenetic testing that guides drug prescribing has the potential to reduced adverse drug events and increase drug effectiveness. Our aim was to quantify the clinical effectiveness of genotype-guided prescribing. METHODS Three electronic databases were searched from January 1980 through December 2013. Studies were eligible if they were RCTs comparing genotype-guided prescribing with non-genetic informed prescribing, reported drug specific adverse drug events and clinical effectiveness outcomes. Two reviewers independently screened titles and abstracts, extracted data and assessed study quality. Meta-analyses of specific outcomes were conducted where data allowed. RESULTS Fifteen studies, involving 5688 patients and 19 drugs, met the inclusion and exclusion criteria. Eight studies had statistically significant results for their primary outcome in favour of genotype-guided prescribing. Nine studies evaluated genotype-guided warfarin dosing. Analysis of percentage of time in therapeutic international normalized ratio range (1952 individuals) showed a statistically significant benefit in favour of genotype-guided warfarin dosing (mean difference = 6.67; 95% CI 1.34, 12.0, I(2) = 80%). There was a statistically significant reduction in numbers of warfarin-related minor bleeding, major bleeding and thromboembolisms associated with genotype guided warfarin dosing, relative risk 0.57 (95% CI 0.33, 0.99; I(2) = 60%). It was not possible to meta-analyze genotype-guided dosing for other drugs. Of the six non-warfarin genotype-guided trials, two demonstrated a statistically significant benefit for their primary outcome, odds ratio 0.03 (95% CI 0.00, 0.62, P < 0.001) for abacavir. CONCLUSIONS There is evidence of improved clinical effectiveness associated with genotype-guided warfarin dosing.
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Affiliation(s)
- Rebecca Goulding
- Department of Family Practice, Faculty of Medicine, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Diana Dawes
- Department of Family Practice, Faculty of Medicine, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Morgan Price
- Department of Family Practice and Island Medical Program, University of Victoria, PO Box 1700 STN CSC, Victoria, British Columbia, V8W 2Y2, Canada
| | - Sabrina Wilkie
- Department of Family Practice, Faculty of Medicine, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Martin Dawes
- Department of Family Practice, Faculty of Medicine, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, British Columbia, V6T 1Z3, Canada
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283
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Abstract
Antithrombotic drugs, which include antiplatelet and anticoagulant therapies, prevent and treat many cardiovascular disorders and, as such, are some of the most commonly prescribed drugs worldwide. The first drugs designed to inhibit platelets or coagulation factors, such as the antiplatelet clopidogrel and the anticoagulant warfarin, significantly reduced the risk of thrombotic events at the cost of increased bleeding in patients. However, both clopidogrel and warfarin have some pharmacological limitations including interpatient variability in antithrombotic effects in part due to the metabolism, interactions (eg, drug, environment, and genetic), or targets of the drugs. Increased knowledge of the pharmacology of antithrombotic drugs and the mechanisms underlying thrombosis has led to the development of newer drugs with faster onset of action, fewer interactions, and less interpatient variability in their antithrombotic effects than previous antithrombotic drugs. Treatment options now include the next-generation antiplatelet drugs prasugrel and ticagrelor, and, in terms of anticoagulants, inhibitors that directly target factor IIa (dabigatran) or Xa (rivaroxaban, apixaban, edoxaban) are available. In this Series paper we review the pharmacological properties of these most commonly used oral antithrombotic drugs, and explore the development of antiplatelet and anticoagulant therapies.
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Affiliation(s)
- Jessica L Mega
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Tabassome Simon
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Department of Clinical Pharmacology and Unité de Recherche Clinique (URCEST), Paris, France; Université Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, National Institute of Health and Medical Research, U-698, Paris, France
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284
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Sipeky C, Weber A, Melegh BI, Matyas P, Janicsek I, Szalai R, Szabo I, Varnai R, Tarlos G, Ganczer A, Melegh B. Interethnic variability of CYP4F2 (V433M) in admixed population of Roma and Hungarians. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2015; 40:280-283. [PMID: 26176903 DOI: 10.1016/j.etap.2015.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/13/2015] [Accepted: 05/16/2015] [Indexed: 06/04/2023]
Abstract
AIMS Pharmacogenetic based dosing recommendations are provided in FDA-approved warfarin label for Caucasians. Evidence of notable difference in dosing algorithms of under-represented populations forced us to explore the genetic variability of CYP4F2 gene in Roma and Hungarian populations. PATIENTS AND METHODS 484 Roma, 493 Hungarian untreated subjects were genotyped for the CYP4F2*3 (rs2108622) variant by PCR-RFLP assay. RESULTS AND DISCUSSION We firstly report, that frequencies of the CYP4F2 rs2108622 GG, GA, AA genotypes and A allele in the Roma population were 46.5%, 42.6%, 10.9% and 32.2%; in Hungarians 50.1%, 42.2%, 7.7% and 22.8%, respectively. Bearing of two minor alleles of CYP4F2 missense variant (AA genotype) modestly explains inter-ethnic differences of studied populations (p<0.08). CYP4F2*3 (V433M) risk allele frequency of Roma (0.32) was in higher range, and of Hungarians (0.23) in lower range, as compared with other world populations. CONCLUSIONS Roma have an elevated chance for higher mean warfarin dose, besides a decreased risk of major bleeding events in long-term warfarin use.
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Affiliation(s)
- Csilla Sipeky
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary; Human Genetic and Pharmacogenetic Research Group, Janos Szentagothai Research Centre, Ifjusag 20, H-7624 Pecs, Hungary.
| | - Agnes Weber
- B.A.Z County Hospital and University Teaching Hospital, Szentpeteri Gate 72-76, H-3526 Miskolc, Hungary
| | - Bela I Melegh
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Petra Matyas
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Ingrid Janicsek
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Renata Szalai
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary; Human Genetic and Pharmacogenetic Research Group, Janos Szentagothai Research Centre, Ifjusag 20, H-7624 Pecs, Hungary
| | - Istvan Szabo
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Reka Varnai
- University of Pecs, Institute of Family Medicine, Akac str. 1, H-7632 Pecs, Hungary
| | - Greta Tarlos
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Alma Ganczer
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary
| | - Bela Melegh
- University of Pecs, Clinical Centre, Department of Medical Genetics, Szigeti 12, H-7624 Pecs, Hungary; Human Genetic and Pharmacogenetic Research Group, Janos Szentagothai Research Centre, Ifjusag 20, H-7624 Pecs, Hungary
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285
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Shabaruddin FH, Fleeman ND, Payne K. Economic evaluations of personalized medicine: existing challenges and current developments. Pharmgenomics Pers Med 2015; 8:115-26. [PMID: 26309416 PMCID: PMC4538689 DOI: 10.2147/pgpm.s35063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Personalized medicine, with the aim of safely, effectively, and cost-effectively targeting treatment to a prespecified patient population, has always been a long-time goal within health care. It is often argued that personalizing treatment will inevitably improve clinical outcomes for patients and help achieve more effective use of health care resources. Demand is increasing for demonstrable evidence of clinical and cost-effectiveness to support the use of personalized medicine in health care. This paper begins with an overview of the existing challenges in conducting economic evaluations of genetics- and genomics-targeted technologies, as an example of personalized medicine. Our paper illustrates the complexity of the challenges faced by these technologies by highlighting the variations in the issues faced by diagnostic tests for somatic variations, generally referring to genetic variation in a tumor, and germline variations, generally referring to inherited genetic variation in enzymes involved in drug metabolic pathways. These tests are typically aimed at stratifying patient populations into subgroups on the basis of clinical effectiveness (response) or safety (avoidance of adverse events). The paper summarizes the data requirements for economic evaluations of genetics and genomics-based technologies while outlining that the main challenges relating to data requirements revolve around the availability and quality of existing data. We conclude by discussing current developments aimed to address the challenges of assessing the cost-effectiveness of genetics and genomics-based technologies, which revolve around two central issues that are interlinked: the need to adapt available evaluation methods and identifying who is responsible for generating evidence for these technologies.
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Affiliation(s)
| | - Nigel D Fleeman
- Liverpool Reviews and Implementation Group (LRiG), University of Liverpool, Liverpool, UK
| | - Katherine Payne
- Institute of Population Health, The University of Manchester, Manchester, UK
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286
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Yu Z, Ding YL, Lu F, Miao LY, Shen ZY, Ye WX. Warfarin dosage adjustment strategy in Chinese population. Int J Clin Exp Med 2015; 8:9904-9910. [PMID: 26309674 PMCID: PMC4538110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/26/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Blood anticoagulation after heart valve replacement is a recognized difficulty all over the world. In this study, we identified the effect of amiodarone on the function of warfarin and confirmed the countermeasure by concluding the genotype distribution of vitamin K epoxide reductase complex 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) of the patient to predict the security dose of warfarin. METHODS Studying on the VKORC1 (-1639G>A) and CYP2C9 genotype of 271 cases on heart valve replacement in the First Affiliated Hospital of Soochow University from Jan. 2012 to Jan. 2014. Warfarin's multivariable regression equation was taken to calculate their warfarin dosage. In the study, 80 of them were selected and divided into 4 groups according to their different warfarin dosage and their usage of amiodaron. The differences of INR values at the 5(th), 8(th), 11(th), 14(th) days of operation were analyzed. RESULTS Among the 80 cases, VKORC1 (-1639G>A) AA types accounted for 90%, and AG types accounted for another 10%, while GG types were not found. In addition that, all of the patients (100%) had CYP2C9*1/*1 type, and CYP2C9*1/*3 had not appeared. There was significant difference in INR values between the groups who used amiodarone or not. The pharmacogenetic equation was accurate in the predicting of the warfarin dosage, so that satisfied anticoagulation efficacy had been achieved in 2 weeks after surgery. CONCLUSION It is necessary for the patients to do the warfarin pharmacogenetic test to get the suitable dose before heart valve replacement. Amiodarone can enhance the anticoagulant efficacy of warfarin, so the dosages of warfarin should be reduced properly because of the medicine combination, and INR values must be monitored more frequently to make the anticoagulant process secure and efficient.
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Affiliation(s)
- Zhe Yu
- Department of Cardiovascular Surgery of The First affiliated Hospital of Soochow University and Institute for Cardiovascular Science of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Ying-Long Ding
- Department of Cardiovascular Surgery of The First affiliated Hospital of Soochow University and Institute for Cardiovascular Science of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Fei Lu
- Department of Cardiovascular Surgery of The First affiliated Hospital of Soochow University and Institute for Cardiovascular Science of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Li-Yan Miao
- Department of Clinical Pharmacology Research Lab of The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Zhen-Ya Shen
- Department of Cardiovascular Surgery of The First affiliated Hospital of Soochow University and Institute for Cardiovascular Science of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Wen-Xue Ye
- Department of Cardiovascular Surgery of The First affiliated Hospital of Soochow University and Institute for Cardiovascular Science of Soochow UniversitySuzhou, Jiangsu Province, China
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287
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Mega JL, Walker JR, Ruff CT, Vandell AG, Nordio F, Deenadayalu N, Murphy SA, Lee J, Mercuri MF, Giugliano RP, Antman EM, Braunwald E, Sabatine MS. Genetics and the clinical response to warfarin and edoxaban: findings from the randomised, double-blind ENGAGE AF-TIMI 48 trial. Lancet 2015; 385:2280-7. [PMID: 25769357 DOI: 10.1016/s0140-6736(14)61994-2] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Warfarin is the most widely used oral anticoagulant worldwide, but serious bleeding complications are common. We tested whether genetic variants can identify patients who are at increased risk of bleeding with warfarin and, consequently, those who would derive a greater safety benefit with a direct oral anticoagulant rather than warfarin. METHODS ENGAGE AF-TIMI 48 was a randomised, double-blind trial in which patients with atrial fibrillation were assigned to warfarin to achieve a target international normalised ratio of 2·0-3·0, or to higher-dose (60 mg) or lower-dose (30 mg) edoxaban once daily. A subgroup of patients was included in a prespecified genetic analysis and genotyped for variants in CYP2C9 and VKORC1. The results were used to create three genotype functional bins (normal, sensitive, and highly sensitive responders to warfarin). This trial is registered with ClinicalTrials.gov, number NCT00781391. FINDINGS 14,348 patients were included in the genetic analysis. Of 4833 taking warfarin, 2982 (61·7%) were classified as normal responders, 1711 (35·4%) as sensitive responders, and 140 (2·9%) as highly sensitive responders. Compared with normal responders, sensitive and highly sensitive responders spent greater proportions of time over-anticoagulated in the first 90 days of treatment (median 2·2%, IQR 0-20·2; 8·4%, 0-25·8; and 18·3%, 0-32·6; ptrend<0·0001) and had increased risks of bleeding with warfarin (sensitive responders hazard ratio 1·31, 95% CI 1·05-1·64, p=0·0179; highly sensitive responders 2·66, 1·69-4·19, p<0·0001). Genotype added independent information beyond clinical risk scoring. During the first 90 days, when compared with warfarin, treatment with edoxaban reduced bleeding more so in sensitive and highly sensitive responders than in normal responders (higher-dose edoxaban pinteraction=0·0066; lower-dose edoxaban pinteraction=0·0036). After 90 days, the reduction in bleeding risk with edoxaban versus warfarin was similarly beneficial across genotypes. INTERPRETATION CYP2C9 and VKORC1 genotypes identify patients who are more likely to experience early bleeding with warfarin and who derive a greater early safety benefit from edoxaban compared with warfarin. FUNDING Daiichi Sankyo.
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Affiliation(s)
- Jessica L Mega
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Francesco Nordio
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Naveen Deenadayalu
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James Lee
- Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | | | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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288
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Revisiting Warfarin Dosing Using Machine Learning Techniques. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:560108. [PMID: 26146514 PMCID: PMC4471424 DOI: 10.1155/2015/560108] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/11/2015] [Accepted: 05/21/2015] [Indexed: 12/23/2022]
Abstract
Determining the appropriate dosage of warfarin is an important yet challenging task. Several prediction models have been proposed to estimate a therapeutic dose for patients. The models are either clinical models which contain clinical and demographic variables or pharmacogenetic models which additionally contain the genetic variables. In this paper, a new methodology for warfarin dosing is proposed. The patients are initially classified into two classes. The first class contains patients who require doses of >30 mg/wk and the second class contains patients who require doses of ≤30 mg/wk. This phase is performed using relevance vector machines. In the second phase, the optimal dose for each patient is predicted by two clinical regression models that are customized for each class of patients. The prediction accuracy of the model was 11.6 in terms of root mean squared error (RMSE) and 8.4 in terms of mean absolute error (MAE). This was 15% and 5% lower than IWPC and Gage models (which are the most widely used models in practice), respectively, in terms of RMSE. In addition, the proposed model was compared with fixed-dose approach of 35 mg/wk, and the model proposed by Sharabiani et al. and its outperformance were proved in terms of both MAE and RMSE.
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289
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Cheli S, Pietrantonio F, Clementi E, Falvella FS. LightSNiP assay is a good strategy for pharmacogenetics test. Front Pharmacol 2015; 6:114. [PMID: 26082719 PMCID: PMC4451335 DOI: 10.3389/fphar.2015.00114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/12/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stefania Cheli
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano Milan, Italy
| | - Filippo Pietrantonio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori Milan, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea Lecco, Italy ; Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, CNR Institute of Neuroscience, "Luigi Sacco" University Hospital, Università di Milano Milan, Italy
| | - Felicia S Falvella
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano Milan, Italy
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290
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Abstract
There is considerable interindividual variation in the response to antiplatelet and anticoagulant therapies. It has been proposed that this variability in drug response may be attributable to genetic variants. Thus, pharmacogenetics may help to accurately predict response to cardiovascular disease (CVD) therapies in order to maximize drug efficacy, minimize drug toxicity, and to tailor personalized care for these patients. Although the clinical utility of pharmacogenetics is promising, its adoption in clinical practice has been slow. This resistance may stem from sometimes conflicting findings among pharmacogenetic studies. Thus, this review focuses on the genetic determinants of commonly used platelet antagonists and anticoagulants including aspirin, clopidogrel, dabigatran, and warfarin. We also explore the clinical translation of pharmacogenetics in the management of patients with CVD.
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Affiliation(s)
- S Ross
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology & Biostatistics, Population Genomics Program, McMaster University, Hamilton, ON, Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
| | - S Nejat
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - G Paré
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology & Biostatistics, Population Genomics Program, McMaster University, Hamilton, ON, Canada
- Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis & Atherosclerosis Research Institute, Hamilton Health Sciences & McMaster University, Hamilton, ON, Canada
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291
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Šupe S, Poljaković Z, Božina T, Ljevak J, Macolić Šarinić V, Božina N. Clinical Application of Genotype-guided Dosing of Warfarin in Patients with Acute Stroke. Arch Med Res 2015; 46:265-73. [PMID: 25989350 DOI: 10.1016/j.arcmed.2015.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/12/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients with certain types of stroke need urgent anticoagulation and it is extremely important for them to achieve fast and stable anticoagulant effect and receive individualized treatment during the initiation of warfarin therapy. METHODS We conducted a prospective study among 210 acute stroke patients who had an indication for anticoagulation and compared the impact of CYP2C9 and VKORC1 genotype-guided warfarin dosing (PhG) with fixed dosing (NPhG) on anticoagulation control and clinical outcome between groups. RESULTS PhG achieved target INR values earlier, i.e., on average in 4.2 (4.1-4.7, 95% CI) days compared to NPhG (5.2 days [4.7-6.4, 95% CI]) (p = 0.0009), spent a higher percentage of time in the therapeutic INR range (76.3% [74.7-78.5, 95% CI] vs. 67.1% [64.5-69.6, 95% CI] in NPhG), and spent less time overdosed (INR > 3.1) (PhG 0.4 [0.1-0.7, 95% CI], NPhG 1.7 [1.1-2.3, 95% CI] days; p >0.000). PhG reached stable maintenance dose faster (10 [9.9-10.7, 95% CI] vs. 13.9 [13.3-14.7, 95% CI] days in controls; p = 0.0049) and had a better clinical outcome in relation to neurological deficit on admission as compared to NPhG. CONCLUSION We confirmed that warfarin therapy with genotype-guided dosing instead of fixed dosing reduces the time required for stabilization and improves anticoagulant control with better clinical outcome in early stages of warfarin therapy introduction among acute stroke patients, which is essential for clinical practice.
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Affiliation(s)
- Svjetlana Šupe
- Department of Neurology, Intensive Care Unit, University Hospital Center Zagreb, Zagreb, Croatia
| | - Zdravka Poljaković
- Department of Neurology, Intensive Care Unit, University Hospital Center Zagreb, Zagreb, Croatia
| | - Tamara Božina
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Josip Ljevak
- Department of Neurology, Intensive Care Unit, University Hospital Center Zagreb, Zagreb, Croatia
| | | | - Nada Božina
- Department of Laboratory Diagnostics, Zagreb University Hospital Center, Zagreb, Croatia; Department of Pharmacology, School of Medicine, University of Zagreb, Zagreb, Croatia.
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292
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Overby CL, Devine EB, Abernethy N, McCune JS, Tarczy-Hornoch P. Making pharmacogenomic-based prescribing alerts more effective: A scenario-based pilot study with physicians. J Biomed Inform 2015; 55:249-59. [PMID: 25957826 DOI: 10.1016/j.jbi.2015.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 04/27/2015] [Accepted: 04/28/2015] [Indexed: 01/06/2023]
Abstract
To facilitate personalized drug dosing (PDD), this pilot study explored the communication effectiveness and clinical impact of using a prototype clinical decision support (CDS) system embedded in an electronic health record (EHR) to deliver pharmacogenomic (PGx) information to physicians. We employed a conceptual framework and measurement model to access the impact of physician characteristics (previous experience, awareness, relative advantage, perceived usefulness), technology characteristics (methods of implementation-semi-active/active, actionability-low/high) and a task characteristic (drug prescribed) on communication effectiveness (usefulness, confidence in prescribing decision), and clinical impact (uptake, prescribing intent, change in drug dosing). Physicians performed prescribing tasks using five simulated clinical case scenarios, presented in random order within the prototype PGx-CDS system. Twenty-two physicians completed the study. The proportion of physicians that saw a relative advantage to using PGx-CDS was 83% at the start and 94% at the conclusion of our study. Physicians used semi-active alerts 74-88% of the time. There was no association between previous experience with, awareness of, and belief in a relative advantage of using PGx-CDS and improved uptake. The proportion of physicians reporting confidence in their prescribing decisions decreased significantly after using the prototype PGx-CDS system (p=0.02). Despite decreases in confidence, physicians perceived a relative advantage to using PGx-CDS, viewed semi-active alerts on most occasions, and more frequently changed doses toward doses supported by published evidence. Specifically, sixty-five percent of physicians reduced their dosing, significantly for capecitabine (p=0.002) and mercaptopurine/thioguanine (p=0.03). These findings suggest a need to improve our prototype such that PGx CDS content is more useful and delivered in a way that improves physician's confidence in their prescribing decisions. The greatest increases in communication effectiveness and clinical impact of PGx-CDS are likely to be realized through continued focus on content, content delivery, and tailoring to physician characteristics.
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Affiliation(s)
- Casey Lynnette Overby
- Program in Personalized & Genomic Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Emily Beth Devine
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Pharmacy, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Neil Abernethy
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Jeannine S McCune
- Department of Pharmacy, University of Washington, Seattle, WA, United States
| | - Peter Tarczy-Hornoch
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Computer Science & Engineering, University of Washington, Seattle, WA, United States
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293
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Wagner J, Abdel-Rahman SM. Oseltamivir-warfarin interaction in hypoplastic left heart syndrome: case report and review. Pediatrics 2015; 135:e1333-6. [PMID: 25917992 PMCID: PMC9923525 DOI: 10.1542/peds.2014-2578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
An 8-year-old boy with hypoplastic left heart syndrome with a previous history of thrombosis within the inferior vena cava receiving stable warfarin dosing for anticoagulation was diagnosed with influenza B. He was subsequently placed on oseltamivir therapy according to the Centers for Disease Control and Prevention clinical practice guidelines. During the hospitalization, his international normalized ratio steadily increased to supratherapeutic levels and returned to baseline after discontinuation of oseltamivir therapy. This case represents a drug-drug interaction that has not been previously reported in children or adolescents. An extensive review of the pharmacokinetic and pharmacodynamic literature did not uncover a definitive etiology for this interaction. However, several undefined aspects in each drug's disposition pathway need further elucidation. Until this interaction is understood, caution is warranted, and close monitoring of the international normalized ratio should be performed in all patients prescribed oseltamivir concomitantly with warfarin.
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Affiliation(s)
- Jonathan Wagner
- Section of Cardiology, and Division of Clinical Pharmacology, Medical Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri; and Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan M. Abdel-Rahman
- Division of Clinical Pharmacology, Medical Toxicology and Therapeutic Innovation, Children’s Mercy Hospital, Kansas City, Missouri; and,Department of Pediatrics, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
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294
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Fox CS, Hall JL, Arnett DK, Ashley EA, Delles C, Engler MB, Freeman MW, Johnson JA, Lanfear DE, Liggett SB, Lusis AJ, Loscalzo J, MacRae CA, Musunuru K, Newby LK, O'Donnell CJ, Rich SS, Terzic A. Future translational applications from the contemporary genomics era: a scientific statement from the American Heart Association. Circulation 2015; 131:1715-36. [PMID: 25882488 DOI: 10.1161/cir.0000000000000211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The field of genetics and genomics has advanced considerably with the achievement of recent milestones encompassing the identification of many loci for cardiovascular disease and variable drug responses. Despite this achievement, a gap exists in the understanding and advancement to meaningful translation that directly affects disease prevention and clinical care. The purpose of this scientific statement is to address the gap between genetic discoveries and their practical application to cardiovascular clinical care. In brief, this scientific statement assesses the current timeline for effective translation of basic discoveries to clinical advances, highlighting past successes. Current discoveries in the area of genetics and genomics are covered next, followed by future expectations, tools, and competencies for achieving the goal of improving clinical care.
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295
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Shahabi P, Dubé MP. Cardiovascular pharmacogenomics; state of current knowledge and implementation in practice. Int J Cardiol 2015; 184:772-795. [DOI: 10.1016/j.ijcard.2015.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/17/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
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296
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Li X, Yang J, Wang X, Xu Q, Zhang Y, Yin T. Clinical benefits of pharmacogenetic algorithm-based warfarin dosing: meta-analysis of randomized controlled trials. Thromb Res 2015; 135:621-9. [DOI: 10.1016/j.thromres.2015.01.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 01/13/2015] [Indexed: 11/16/2022]
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297
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Clarke JD, Cherrington NJ. Nonalcoholic steatohepatitis in precision medicine: Unraveling the factors that contribute to individual variability. Pharmacol Ther 2015; 151:99-106. [PMID: 25805597 DOI: 10.1016/j.pharmthera.2015.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/17/2015] [Indexed: 01/14/2023]
Abstract
There are numerous factors in individual variability that make the development and implementation of precision medicine a challenge in the clinic. One of the main goals of precision medicine is to identify the correct dose for each individual in order to maximize therapeutic effect and minimize the occurrence of adverse drug reactions. Many promising advances have been made in identifying and understanding how factors such as genetic polymorphisms can influence drug pharmacokinetics (PK) and contribute to variable drug response (VDR), but it is clear that there remain many unidentified variables. Underlying liver diseases such as nonalcoholic steatohepatitis (NASH) alter absorption, distribution, metabolism, and excretion (ADME) processes and must be considered in the implementation of precision medicine. There is still a profound need for clinical investigation into how NASH-associated changes in ADME mediators, such as metabolism enzymes and transporters, affect the pharmacokinetics of individual drugs known to rely on these pathways for elimination. This review summarizes the key PK factors in individual variability and VDR and highlights NASH as an essential underlying factor that must be considered as the development of precision medicine advances. A multifactorial approach to precision medicine that considers the combination of two or more risk factors (e.g. genetics and NASH) will be required in our effort to provide a new era of benefit for patients.
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Affiliation(s)
- John D Clarke
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, AZ 85721, United States
| | - Nathan J Cherrington
- Department of Pharmacology and Toxicology, University of Arizona, Tucson, AZ 85721, United States.
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298
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Affiliation(s)
- Sara L Van Driest
- From Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Steven A Webber
- From Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN.
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299
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Integrating dynamic mixed-effect modelling and penalized regression to explore genetic association with pharmacokinetics. Pharmacogenet Genomics 2015; 25:231-8. [PMID: 25751396 PMCID: PMC4387202 DOI: 10.1097/fpc.0000000000000127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT In a previous work, we have shown that penalized regression approaches can allow many genetic variants to be incorporated into sophisticated pharmacokinetic (PK) models in a way that is both computationally and statistically efficient. The phenotypes were the individual model parameter estimates, obtained a posteriori of the model fit and known to be sensitive to the study design. OBJECTIVE The aim of this study was to propose an integrated approach in which genetic effect sizes are estimated simultaneously with the PK model parameters, which should improve the estimate precision and reduce sensitivity to study design. METHODS A total of 200 data sets were simulated under the null and each of the following three alternative scenarios: (i) a phase II study with N=300 participants and n=6 sampling times, wherein six unobserved causal variants affect the drug elimination clearance; (ii) the addition of participants with a residual concentration collected in clinical routine (N=300, n=6 plus N=700, n=1); and (iii) a phase II study (N=300, n=6) in which four unobserved causal variants affect two different model parameters. RESULTS In all scenarios the integrated approach detected fewer false positives. In scenario (i), true-positive rates were low and the stepwise procedure outperformed the integrated approach. In scenario (ii), approaches performed similarly and rates were higher. In scenario (iii), the integrated approach outperformed the stepwise procedure. CONCLUSION A PK phase II study with N=300 lacks the power to detect genetic effects on PK using genetic arrays. Our approach can simultaneously analyse phase II and clinical routine data and identify when genetic variants affect multiple PK parameters.
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300
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Gaio V, Picanço I, Nunes B, Fernandes A, Mendonça F, Horta Correia F, Beleza Á, Gil AP, Bourbon M, Vicente A, Matias Dias C, Barreto da Silva M. Pharmacogenetic Profile of a South Portuguese Population: Results from the Pilot Study of the European Health Examination Survey in Portugal. Public Health Genomics 2015; 18:139-50. [DOI: 10.1159/000373920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/08/2015] [Indexed: 01/19/2023] Open
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