1
|
Farajzadeh-Dehkordi M, Samiee-Rad F, Farzam SS, Javadi A, Cheraghi S, Hamedi-Asl D, Rahmani B. Evaluation of a warfarin dosing algorithm including CYP2C9, VKORC1, and CYP4F2 polymorphisms and non-genetic determinants for the Iranian population. Pharmacol Rep 2023; 75:695-704. [PMID: 37039974 DOI: 10.1007/s43440-023-00476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The response to warfarin, as an oral anticoagulant agent, varies widely among patients from different ethnic groups. In this study, we tried to ascertain and determine the relationship between non-genetic factors and genetic polymorphisms with warfarin therapy; we then proposed a new warfarin dosing prediction algorithm for the estimation of drug sensitivity and resistance in the Iranian population. METHODS Overall, 200 warfarin-treated patients with stable doses were recruited, the demographic and clinical characteristics were documented, and genotyping was done using a sequencing assay. RESULTS The outcomes of our investigation showed that the genetic polymorphisms of VKORC1(-1639 G > A), CYP2C9*3, CYP2C9*2, amiodarone use, and increasing age were found to be related to a significantly lower mean daily warfarin dose. In contrast, the CYP4F2*3 variant and increased body surface area were linked with an increased dose of warfarin in the Iranians. Our descriptive model could describe 56.5% of the variability in response to warfarin. This population-specific dosing model performed slightly better than other previously published warfarin algorithms for our patient's series. Furthermore, our findings provided the suggestion that incorporating the CYP4F2*3 variant into the dosing algorithm could result in a more precise calculation of warfarin dose requirements in the Iranian population. CONCLUSIONS We proposed and validated a population-specific dosing algorithm based on genetic and non-genetic determinants for Iranian patients and evaluated its performance. Accordingly, by using this newly developed algorithm, prescribers could make more informed decisions regarding the treatment of Iranian patients with warfarin.
Collapse
Affiliation(s)
- Mahvash Farajzadeh-Dehkordi
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Samiee-Rad
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Pathology, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Seyed Saeed Farzam
- Department of Cardiovascular Surgery, Faculty of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amir Javadi
- Department of Social Sciences, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Sara Cheraghi
- Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Dariush Hamedi-Asl
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Babak Rahmani
- Cellular and Molecular Research Center, Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran.
- Department of Molecular Medicine, Faculty of Medical School, Qazvin University of Medical Sciences, Qazvin, Iran.
| |
Collapse
|
2
|
Demirci B, Coskun A. Efficacy of Prothrombin Complex Concentrate versus Fresh Frozen Plasma in Patients with Bleeding in the Emergency Department. HASEKI TIP BÜLTENI 2022. [DOI: 10.4274/haseki.galenos.2021.7639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
|
3
|
Xu Q, Zhang S, Wu C, Xiong Y, Niu J, Li F, Zhu J, Shen L, Zhu B, Xing Q, He L, Chen L, Li M, Li H, Ge J, Qin S. Genetic Associations With Stable Warfarin Dose Requirements in Han Chinese Patients. J Cardiovasc Pharmacol 2021; 78:e105-e111. [PMID: 33958549 DOI: 10.1097/fjc.0000000000001048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Warfarin is a commonly prescribed anticoagulant for valvular heart disease that plays an important role in clinical management to prevent thrombotic events. In this study, we aim to perform a comprehensive study to investigate the genetic biomarkers of stable warfarin dose in the Han Chinese population. We performed an integrative study on 211 Han Chinese patients with valvular heart disease. A total of 40 single nucleotide polymorphisms (SNPs) in 10 important genes (CYP2C9, VKORC1, ABCB1, CYP4F2, APOE, PROC, GGCX, EPHX1, CALU, and SETD1A) which are involved in the warfarin metabolic pathway and equilibrium of coagulation and anticoagulation were selected. We applied MassARRAY technology to genotype the 40 SNPs identified in these Han Chinese patients. Our results showed that 13 SNPs on 6 genes (CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A) were associated with the individual stable warfarin dose. Two VKORC1 SNPs (rs9934438 and rs2359612) were the strongest genetic factors determining warfarin dose requirements (P = 8 × 10-6 and 9 × 10-6, respectively). Rs4889599 in SETD1A was first reported to be associated with warfarin dose at a significant level of 0.001 in our study (Padjust = 0.040 after Bonferroni correction). We discovered that genetic variants in CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A may affect the stable warfarin dose requirement in Han Chinese patients with valvular disease. The discovery of these potential genetic markers will facilitate the development of advanced personalized anticoagulation therapy in Han Chinese patients.
Collapse
Affiliation(s)
- Qingqing Xu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Suli Zhang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Chaoneng Wu
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuyu Xiong
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Jiamin Niu
- Laiwu People's Hospital, Shandong, China
| | | | - Jinhang Zhu
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Lu Shen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Bin Zhu
- Shanghai Baio Technology Co, Ltd Shanghai, China
| | | | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Luan Chen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Mo Li
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Hua Li
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengying Qin
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
- The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
4
|
Lin X, Chen H, Ni L, Yu Y, Luo Z, Liao L. Effects of EPHX1 rs2260863 polymorphisms on warfarin maintenance dose in very elderly, frail Han-Chinese population. Pharmacogenomics 2020; 21:863-870. [PMID: 32559398 DOI: 10.2217/pgs-2020-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study was conducted to investigate the effects of VKORC1, CYP2C9, CYP4F2 and EPHX1 and nongenetic factors on warfarin maintenance dose in a very elderly, frail Han-Chinese population. Materials & methods: 16 variants of VKORC1, CYP2C9, CYP4F2 and EPHX1 were genotyped. Univariate analysis and multivariable regression model were performed for the associations of gene variants and warfarin maintenance dose. Results & conclusion: EPHX1 rs2260863 nonvariant CC homozygotes required significantly lower daily warfarin dose than GC heterozygotes. In the multivariable model, VKORC1 rs9923231, CYP2C9 rs1057910, EPHX1 rs2260863, CYP4F2 rs2189784 and body surface area altogether explained 26.9% of dosing variability. This study revealed the main impact of genetic factors on warfarin response in this special population.
Collapse
Affiliation(s)
- Xianliang Lin
- Department of Cardiovascular Disease, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| | - Hao Chen
- Department of Cardiovascular Disease, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| | - Le Ni
- Department of Cardiovascular Disease, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| | - Yunqiang Yu
- Department of Cardiovascular Disease, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| | - Zhurong Luo
- Department of Cardiovascular Disease, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| | - Lihong Liao
- Department of Electrocardiogram Room, 900 Hospital of The Joint Logistics Team, 156 North Road, West 2nd Ring Road, Fuzhou, Fujian, 350000, PR China
| |
Collapse
|
5
|
Polymorphisms of vitamin K-related genes (EPHX1 and VKORC1L1) and stable warfarin doses. Gene 2018; 641:68-73. [DOI: 10.1016/j.gene.2017.10.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/05/2017] [Accepted: 10/16/2017] [Indexed: 01/05/2023]
|
6
|
Yu WY, Sun X, Wadelius M, Huang L, Peng C, Ma WL, Yang GP. Influence of APOE Gene Polymorphism on Interindividual and Interethnic Warfarin Dosage Requirement: A Systematic Review and Meta-Analysis. Cardiovasc Ther 2017; 34:297-307. [PMID: 27062534 DOI: 10.1111/1755-5922.12186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Warfarin is the most extensively used coumarin anticoagulant. It has been shown that the anticoagulant effect of warfarin is associated with genetic variation. Apolipoprotein E (ApoE) is a possible candidate to influence the maintenance dose of warfarin. ApoE affects the vitamin K cycle by mediating the uptake of vitamin K into the liver. The vitamin K cycle is the drug target of warfarin. However, the association between genetic variants of the APOE gene and warfarin dose requirement is still controversial. METHODS Revman 5.3 software was used to analyze the relationship between APOE genotypes and warfarin dose requirements. RESULTS In our meta-analysis, the E2/E2 genotype was significantly associated with warfarin dose. E2/E2 patients required 12% (P = 0.0002) lower mean daily warfarin dose than E3/E3 carriers. In addition, subgroup analysis showed that Asians with the E4/E4 genotype tended to need lower warfarin maintenance doses, while the African American E4/E4 carriers needed slightly higher doses than E3/E3 carriers; however, these subgroups were very small. CONCLUSION This is the first meta-analysis of the association between APOE genotypes and warfarin dose. APOE E2/E2 might be one of the factors affecting warfarin dose requirements. The effect of APOE may vary between ethnicities.
Collapse
Affiliation(s)
- Wan-Ying Yu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xue Sun
- Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Lihua Huang
- Center for Medical Experiments, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chen Peng
- Institute of Pharmacy & Pharmacology, University of South China, Hengyang, Hunan, China
| | - Wan-le Ma
- Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guo-Ping Yang
- Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.
| |
Collapse
|
7
|
Mohammed S, Aljundi AHS, Kasem M, Alhashemi M, El-Menyar A. Anticoagulation control among patients with nonvalvular atrial fibrillation: A single tertiary cardiac center experience. J Adv Pharm Technol Res 2017; 8:14-18. [PMID: 28217549 PMCID: PMC5288964 DOI: 10.4103/2231-4040.197370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
There is a limited knowledge about the predictors of anticoagulation control in patients with nonvalvular atrial fibrillation (NVAF). Furthermore, few reports addressed the role of time in therapeutic range (TTR) that could reflect the safety and efficacy of anticoagulation therapy. We aimed to assess factors that affect the quality of anticoagulation therapy utilizing TTR in patients with NVAF. A retrospective observational study was conducted for patients with NVAF who were maintained on warfarin >6 months at a tertiary cardiac care hospital. Patients were categorized according to the TTR status (≥65% vs. <65%). A total of 241 eligible patients were identified. A high-quality anticoagulation based on TTR values ≥65% was found in 157 (65.1%) patients; the remaining (34.9%) patients represented the low-quality anticoagulation group (TTR <65%). Demographics and clinical characteristics were comparable in the two TTR groups. Both groups were comparable in terms of warfarin dose and medications use. When compared to patients with high-quality anticoagulation, patients in the low-quality anticoagulation group were more likely to seek outpatient warfarin clinic visits more frequently (22.3 ± 5.5 vs. 18 ± 4.4, P = 0.001) and to have higher rate of polypharmacy (57.1% vs. 42%, P = 0.03). Of note, patients in both groups had similar major bleeding events (P = 0.41). After adjusting for age and sex, polypharmacy use was a predictor of poor coagulation control (odds ratio = 1.89, 95% confidence interval: 1.03–3.33; P = 0.03). In NVAF patients, TTR is generally high in our cohort. Patients with polypharmacy and frequent clinic visits have lower TTR. High-quality oral anticoagulation could be achieved through optimizing TTR without a significant risk of major bleeding.
Collapse
Affiliation(s)
- Shaban Mohammed
- Department of Clinical Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Amer H S Aljundi
- Department of Clinical Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Kasem
- Department of Clinical Pharmacy, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Alhashemi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Clinical Medicine, Weill Cornel Medical College, Doha, Qatar; Department of Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| |
Collapse
|
8
|
The Impact of Genetic and Non-Genetic Factors on Warfarin Dose Prediction in MENA Region: A Systematic Review. PLoS One 2016; 11:e0168732. [PMID: 27992547 PMCID: PMC5167425 DOI: 10.1371/journal.pone.0168732] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/05/2016] [Indexed: 01/13/2023] Open
Abstract
Background Warfarin is the most commonly used oral anticoagulant for the treatment and prevention of thromboembolic disorders. Pharmacogenomics studies have shown that variants in CYP2C9 and VKORC1 genes are strongly and consistently associated with warfarin dose variability. Although different populations from the Middle East and North Africa (MENA) region may share the same ancestry, it is still unclear how they compare in the genetic and non-genetic factors affecting their warfarin dosing. Objective To explore the prevalence of CYP2C9 and VKORC1 variants in MENA, and the effect of these variants along with other non-genetic factors in predicting warfarin dose. Methods In this systematic review, we included observational cross sectional and cohort studies that enrolled patients on stable warfarin dose and had the genetics and non-genetics factors associated with mean warfarin dose as the primary outcome. We searched PubMed, Medline, Scopus, PharmGKB, PHGKB, Google scholar and reference lists of relevant reviews. Results We identified 17 studies in eight different populations: Iranian, Israeli, Egyptian, Lebanese, Omani, Kuwaiti, Sudanese and Turkish. Most common genetic variant in all populations was the VKORC1 (-1639G>A), with a minor allele frequency ranging from 30% in Egyptians and up to 52% and 56% in Lebanese and Iranian, respectively. Variants in the CYP2C9 were less common, with the highest MAF for CYP2C9*2 among Iranians (27%). Variants in the VKORC1 and CYP2C9 were the most significant predictors of warfarin dose in all populations. Along with other genetic and non-genetic factors, they explained up to 63% of the dose variability in Omani and Israeli patients. Conclusion Variants of VKORC1 and CYP2C9 are the strongest predictors of warfarin dose variability among the different populations from MENA. Although many of those populations share the same ancestry and are similar in their warfarin dose predictors, a population specific dosing algorithm is needed for the prospective estimation of warfarin dose.
Collapse
|
9
|
Ababneh MA, Al-Azzam SI, Alzoubi KH, Rababa'h AM. Adherence in outpatients taking warfarin and its effect on anticoagulation control in Jordan. Int J Clin Pharm 2016. [PMID: 27015937 DOI: 10.1007/s11096-016-0282-9.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Medication adherence is an important element for the success of any therapeutic plan. The picture is more complicated with warfarin, due to its small therapeutic window and patients' needs to have effective anticoagulation control. Objective To measure warfarin-adherence, warfarin-knowledge and to assess the relationship between adherence and anticoagulation control. Setting Adult outpatients (≥18 years) taking warfarin at two medical sites in north of Jordan were invited to participate. Method This was a cross sectional study in which survey questionnaire that included demographic, clinical, warfarin related questions and Morisky Medication Adherence Scale (MMAS-8) was administered to patients in Arabic language. International normalization ratio (INR) readings were retrieved from patients' medical records. Main outcome measure MMAS-8 adherence scores and time within therapeutic range were calculated. Results More than half of study participants (54 %) were adherent (MMAS-8 = 8). The MMAS-8 adherence scores were significantly associated with warfarin-knowledge scores (Spearman's ρ = 0.291, p = 0.000). Adherent patients were more likely to have good anticoagulation control compared to non-adherent patients (MMAS-8 ≤ 7). Conclusion Adherence to warfarin therapy can have a substantial effect on anticoagulation control. Thus, healthcare practitioners should consider strategies to improve patient adherence to warfarin.
Collapse
Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Sayer I Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Abeer M Rababa'h
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| |
Collapse
|
10
|
Ababneh MA, Al-Azzam SI, Alzoubi KH, Rababa'h AM. Adherence in outpatients taking warfarin and its effect on anticoagulation control in Jordan. Int J Clin Pharm 2016; 38:816-21. [PMID: 27015937 DOI: 10.1007/s11096-016-0282-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 03/07/2016] [Indexed: 01/13/2023]
Abstract
Background Medication adherence is an important element for the success of any therapeutic plan. The picture is more complicated with warfarin, due to its small therapeutic window and patients' needs to have effective anticoagulation control. Objective To measure warfarin-adherence, warfarin-knowledge and to assess the relationship between adherence and anticoagulation control. Setting Adult outpatients (≥18 years) taking warfarin at two medical sites in north of Jordan were invited to participate. Method This was a cross sectional study in which survey questionnaire that included demographic, clinical, warfarin related questions and Morisky Medication Adherence Scale (MMAS-8) was administered to patients in Arabic language. International normalization ratio (INR) readings were retrieved from patients' medical records. Main outcome measure MMAS-8 adherence scores and time within therapeutic range were calculated. Results More than half of study participants (54 %) were adherent (MMAS-8 = 8). The MMAS-8 adherence scores were significantly associated with warfarin-knowledge scores (Spearman's ρ = 0.291, p = 0.000). Adherent patients were more likely to have good anticoagulation control compared to non-adherent patients (MMAS-8 ≤ 7). Conclusion Adherence to warfarin therapy can have a substantial effect on anticoagulation control. Thus, healthcare practitioners should consider strategies to improve patient adherence to warfarin.
Collapse
Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Sayer I Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Abeer M Rababa'h
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| |
Collapse
|
11
|
Liu J, Jiang HH, Wu DK, Zhou YX, Ye HM, Li X, Luo ZY, Guo Z, Zhang YL, Wang YC, Zhang W, Zhou HH, Wang LS. Effect of gene polymorphims on the warfarin treatment at initial stage. THE PHARMACOGENOMICS JOURNAL 2015; 17:47-52. [PMID: 26644206 DOI: 10.1038/tpj.2015.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 07/13/2015] [Accepted: 10/16/2015] [Indexed: 11/09/2022]
Abstract
The adverse reactions of warfarin that were found mainly occurred in the first month. This study was carried out to observe the effect of gene polymorphisms on the warfarin therapy at the initial stage. Four-hundred and sixty Chinese patients began warfarin treatment with daily 2.5 mg after heart valve replacement operations were enrolled. The daily international normalized ratio (INR) for anticoagulation were recorded till the seventh day. Blood samples were collected and used to detect genotypes for VKORC1 rs7294, CYP2C9 rs1057910, CYP4F2 rs2108622 and ORM1 rs17650. INR and their changes were compared among genotypes. INR was partially correlated with the VKORC1 rs7294, CYP2C9 rs1057910, CYP4F2 rs2108622 and ORM1 rs17650 polymorphisms from the third, fourth and sixth day on, respectively. VKORC1 rs7294 and CYP4F2 rs2108622 carriers responded lower than the wild genotype, whereas CYP2C9 rs1057910 and ORM1 rs17650 carriers responded higher, respectively. Fifty percent of AA/*1*3/CC/*S*S patients and 16% of AA/*1*1/CC/*S*S patients were over anticoagulation treated with INR >4.0 at the third day. Ninety percent of VKORC1 rs7294 carrier patients have INR <1.63, a mark of the 25% of lower responders of the wild genotype. Our study provided another kind of evidence that VKORC1 rs7294, CYP2C9 rs1057910, CYP4F2 rs2108622 and ORM1 rs17650 affected the action of warfarin in different styles. Patients with AA/*1*1/CC/*S*S, AA/*1*3/CC/*S*S should use a less initial dosage to avoid over anticoagulation, and patients with VKORC1 rs7294 should use larger initial dose to proof an effective therapy.
Collapse
Affiliation(s)
- J Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - H H Jiang
- Department of Cardiothoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - D K Wu
- Department of Cardiothoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Y X Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - H M Ye
- Department of Clinical Laboratory, Zhongshan Hospital Xiamen University Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, China
| | - X Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - Z Y Luo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - Z Guo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - Y L Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - Y C Wang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - W Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - H H Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - L S Wang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacology, Central South University, Changsha, China
| |
Collapse
|
12
|
Li S, Zou Y, Wang X, Huang X, Sun Y, Wang Y, Dong L, Jiang H. Warfarin dosage response related pharmacogenetics in Chinese population. PLoS One 2015; 10:e0116463. [PMID: 25594941 PMCID: PMC4296935 DOI: 10.1371/journal.pone.0116463] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 12/10/2014] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES As the most frequently prescribed anticoagulant, warfarin has large inter-individual variability in dosage. Genetic polymorphisms could largely explain the differences in dosage requirement. rs9923231 (VKORC1), rs7294 (VKORC1), rs1057910 (CYP2C9), rs2108622 (CYP4F2), and rs699664 (GGCX) involved in the warfarin action mechanism and the circulatory vitamin K were selected to investigate their polymorphism characteristics and their effects on the pharmacodynamics and pharmacokinetics of warfarin in Chinese population. METHODS 220 patients with cardiac valve replacement were recruited. International normalized ratio and plasma warfarin concentrations were determined. The five genetic polymorphisms were genotyping by pyro-sequencing. The relationships of maintenance dose, plasma warfarin concentration and INR were assessed among groups categorized by genotypes. RESULTS rs9923231 and rs7294 in VKORC1 had the analogous genotype frequencies (D': 0.969). 158 of 220 recruited individuals had the target INR (1.5-2.5). Patients with AA of rs9923231 and CC of rs7294 required a significantly lower maintenance dose and plasma concentration than those with AG and TC, respectively. The mean weekly maintenance dose was also significantly lower in CYP2C9 rs1057910 mutated heterozygote than in patients with the wild homozygote. Eliminating the influence from environment factors (age, body weight and gender), rs9923231 and rs1057910 could explain about 32.0% of the variability in warfarin maintenance dose; rs7294 could explain 26.7% of the variability in plasma concentration. For patients with allele G of rs9923231 and allele T of rs7294, higher plasma concentration was needed to achieve the similar goal INR. CONCLUSIONS A better understanding of the genetic variants in individuals can be the foundation of warfarin dosing algorithm and facilitate the reasonable and effective use of warfarin in Chinese.
Collapse
Affiliation(s)
- Siyue Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Yuangao Zou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Xia Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Xunbei Huang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Yong Sun
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Yuqing Wang
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Li Dong
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chengdu, P. R. China
- * E-mail: (LD); (HJ)
| | - Hong Jiang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
- * E-mail: (LD); (HJ)
| |
Collapse
|
13
|
Influence of two common polymorphisms in the EPHX1 gene on warfarin maintenance dosage: a meta-analysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:564149. [PMID: 25629049 PMCID: PMC4299922 DOI: 10.1155/2015/564149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023]
Abstract
We conducted a meta-analysis to investigate the influence of two common single nucleotide polymorphisms (SNPs) (rs2292566 G>A and rs4653436 A>G) in the EPHX1 gene on warfarin maintenance dosages. Relevant literatures were searched using the PubMed, Embase, Web of Science, Cochrane Library, CISCOM, CINAHL, Google Scholar, CBM, and CNKI databases without any language restrictions. STATA Version 12.0 software (Stata Corporation, College Station, TX, USA) was used for this meta-analysis. Standard mean difference and its corresponding 95% confidence interval (95% CI) were calculated. Seven studies met the inclusion criteria, including 2,063 warfarin-treated patients. Meta-analysis results illustrated that EPHX1 rs2292566 G>A polymorphism might be strongly correlated with a higher maintenance dose of warfarin. However, no interaction of EPHX1 rs4653436 A>G polymorphism with warfarin maintenance dosage was detected. A further subgroup analysis based on stratification by ethnicity indicated that EPHX1 rs2292566 G>A polymorphism was positively correlated with warfarin maintenance dosage among Caucasians, but not Asians. No associations were observed between EPHX1 rs4653436 A>G polymorphism warfarin maintenance dosage among both Caucasians and Asians. Our meta-analysis provides robust and unambiguous evidence that EPHX1 rs2292566 polymorphism may affect the maintenance dose of warfarin in Caucasians.
Collapse
|
14
|
Issac MSM, El-Nahid MS, Wissa MY. Is there a role for MDR1, EPHX1 and protein Z gene variants in modulation of warfarin dosage? a study on a cohort of the Egyptian population. Mol Diagn Ther 2014; 18:73-83. [PMID: 24092646 DOI: 10.1007/s40291-013-0055-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is considerable inter-individual variability in warfarin dosages necessary to achieve target therapeutic anticoagulation. Polymorphisms in genes, which master warfarin pharmacokinetics and pharmacodynamics, might influence warfarin dose variation. Genes encoding drug transporters, such as human multidrug resistance (MDR1), as well as epoxide hydrolase 1 (EPHX1), which is a putative subunit of the vitamin K epoxide reductase, and Protein Z (PZ), which is a vitamin K-dependent plasma glycoprotein, are among those candidate genes. OBJECTIVE The purpose of this study was to investigate the contribution of MDR1 C3435T, EPHX1 H139R and PZ A-13G gene polymorphisms in warfarin dose variation in a cohort of the Egyptian population. METHODS Eighty-four patients whose international normalized ratio (INR) was in the range of 2-3, 41 males and 43 females, with a mean (±SD) age of 40.9 (13.3) years were recruited into this study. MDR1 C3435T, EPHX1 H139R and PZ A-13G gene polymorphisms were detected by polymerase chain reaction-restriction fragment length polymorphism. Primarily, linear regression analysis, including the variables age, gender, MDR1 C3435T, EPHX1 H139R and combined MDR1 C3435T, EPHX1 H139R and PZ A-13G genotypes, was used to assess the effective factors for warfarin maintenance dose. Secondly, the previously examined cytochrome P450 (CYP) 2C9 A1075C and vitamin K epoxide reductase complex subunit 1 (VKORC1) C1173T were added to the regression analysis. RESULTS Warfarin dose/week was not influenced by each of the MDR1 C3435T, EPHX1 H139R, and PZ A-13G gene polymorphisms when examined separately. However, when these single nucleotide polymorphisms (SNPs) were combined, MDR1 TT/EPHX1 RH,RR/PZ AA subjects showed statistically significant increase in warfarin dose/week when compared with MDR1 CC/EPHX1 RH,RR/PZ AA subjects [median (25th-75th percentiles): 49.0 (42.0-59.5) vs. 35.0 (24.5-42.0) mg/week, respectively] (p = 0.014). In contrast, in the presence of wild-type EPHX1 HH, there was a decrease in warfarin dose/week in MDR1 TT subjects when compared with CT and CC subjects [median (25th-75th percentiles): 22.0 (17.5-30.6), 42.0 (35.0-49.0) and 42.0 (28.0-54.3) mg/week, respectively] (p = 0.005 and 0.030, respectively). Age had a significant contribution (p = 0.048) to the overall variability in warfarin dose. Calculated weekly dose = 52.928 - (0.289 × age) + (9.709 × combined genotype). The multivariate linear regression equation of warfarin maintenance dose accounted for about 8 % of variation in dose (R (2) = 0.079), age accounted for 5 % of variation, while combined genotypes added the extra 3 %. However, the new regression equation accounted for 20.9 % of variation in dose. Age accounted for 5 %, while VKORC1 C1173T accounted for an extra 13 % of variation and MDR1 C3435T accounted for the remaining 3 % of variation. Calculated dose = 64.909 - (0.282 × age) - (13.390 × VKORC1) - (7.164 × MDR1). Correlation analysis showed a close and significant relationship between the calculated and actual warfarin dose (r = 0.457; p < 0.0005). CONCLUSION Warfarin dose/week was significantly influenced by the combined MDR1 C3435T and EPHX1 H139R gene polymorphism since no polymorphism of PZ A-13G SNP was detected in our studied Egyptian population. Future studies with larger sample size will be needed to confirm our findings before definitive conclusions can be made.
Collapse
Affiliation(s)
- Marianne Samir Makboul Issac
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, El Saray St, El Manial, 11956, Cairo, Egypt,
| | | | | |
Collapse
|
15
|
Tao T, Chen S, Xu B, Liu C, Wang Y, Huang Y, Chen M. Association between hsa-miR-34b/c rs4938723 T > C promoter polymorphism and cancer risk: a meta-analysis based on 6,036 cases and 6,204 controls. Chin J Cancer Res 2014; 26:315-22. [PMID: 25035659 DOI: 10.3978/j.issn.1000-9604.2014.06.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/17/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Emerging evidence shows that microRNAs (miRNAs) function as tumor suppressors or oncogenes in human carcinogenesis. A single nucleotide polymorphism (SNP) located in the pri-miRNA promoter may affect the processing and expression of mature miRNA. However, previous studies showed conflicting results regarding the association of hsa-miR-34b/c rs4938723 T > C promoter polymorphism with cancer. Therefore, we conducted a meta-analysis to determine the association of polymorphism with cancer risk. METHODS A computerized search of PubMed, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) for publications on hsa-miR-34b/c rs4938723 T > C promoter polymorphism and cancer risk was performed and the genotype data were analyzed in a meta-analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated to assess the association. Test of heterogeneity, cumulative meta-analysis, sensitivity analysis and assessment of bias were performed in our meta-analysis by STATA software 12.0. RESULTS There was no significant association between hsa-miR-34b/c rs4938723 polymorphism and overall cancer risk in the comparison models. Moreover, subgroup analysis revealed that the variant CT (OR =1.19, 95% CI: 1.03-1.37) and CC/CT (OR =1.18, 95% CI: 1.03-2.35) genotypes were associated with an increased risk of hepatocellular carcinoma (HCC) compared with wild-type TT genotype. However, a decreased risk of colorectal cancer (CRC) was found in the genetic model of CC/TT (OR =0.66, 95% CI: 0.47-0.92) and CC/CTTT (OR =0.67, 95% CI: 0.49-0.93). CONCLUSIONS The results suggest that hsa-miR-34b/c rs4938723 polymorphism may play an opposite role in different types of cancer based on current studies, which is the main origin of heterogeneity in this meta-analysis. Further large-scale studies and functional studies between this polymorphism and cancer risk are warranted.
Collapse
Affiliation(s)
- Tao Tao
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Shuqiu Chen
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Bin Xu
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Chunhui Liu
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Yiduo Wang
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Yeqing Huang
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| | - Ming Chen
- 1 Department of Urology, Affiliated Zhongda Hospital, Medical School, 2 Surgical Research Center, Medical School, 3 Institute of Urology, Southeast University, Nanjing 210009, China
| |
Collapse
|
16
|
Moreau C, Pautas E, Duverlie C, Berndt C, Andro M, Mahé I, Emmerich J, Lacut K, Le Gal G, Peyron I, Gouin-Thibault I, Golmard JL, Loriot MA, Siguret V. A model predicting fluindione dose requirement in elderly inpatients including genotypes, body weight, and amiodarone. Thromb Haemost 2014; 111:705-12. [PMID: 24337438 DOI: 10.1160/th13-07-0555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/16/2013] [Indexed: 01/11/2023]
Abstract
Indandione VKAs have been widely used for decades, especially in Eastern Europe and France. Contrary to coumarin VKAs, the relative contribution of individual factors to the indandione-VKA response is poorly known. In the present multicentre study, we sought to develop and validate a model including genetic and non-genetic factors to predict the daily fluindione dose requirement in elderly patients in whom VKA dosing is challenging. We prospectively recorded clinical and therapeutic data in 230 Caucasian inpatients mean aged 85 ± 6 years, who had reached international normalized ratio stabilisation (range 2.0-3.0) on fluindione. In the derivation cohort (n=156), we analysed 13 polymorphisms in seven genes potentially involved in the pharmacological effect or vitamin-K cycle (VKORC1, CYP4F2, EPHX1) and fluindione metabolism/transport (CYP2C9, CYP2C19, CYP3A5, ABCB1). We built a regression model incorporating non-genetic and genetic data and evaluated the model performances in a separate cohort (n=74).Body-weight, amiodarone intake, VKORC1, CYP4F2, ABCB1 genotypes were retained in the final model, accounting for 31.5% of dose variability. None influence of CYP2C9 was observed. Our final model showed good performances: in 83.3% of the validation cohort patients, the dose was accurately predicted within 5 mg, i.e.the usual step used for adjusting fluindione dosage. In conclusion, in addition to body-weight and amiodarone-intake, pharmacogenetic factors (VKORC1, CYP4F2, ABCB1) related to the pharmacodynamic effect and transport of fluindione significantly influenced the dose requirement in elderly patients while CYP2C9 did not. Studies are required to know whether fluindione could be an alternative VKA in carriers of polymorphic CYP2C9 alleles, hypersensitive to coumarins.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Virginie Siguret
- Ass Prof. Virginie Siguret, INSERM UMR-S-765, 4 Av. de l'Observatoire, 75006 Paris, France, Tel.: +33 1 56 09 50 56, Fax: +33 1 56 09 39 13, E-mail:
| |
Collapse
|
17
|
McMillin GA, Vazquez SR, Pendleton RC. Current challenges in personalizing warfarin therapy. Expert Rev Clin Pharmacol 2014; 4:349-62. [DOI: 10.1586/ecp.11.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
18
|
Abstract
Warfarin is a common anticoagulant with narrow therapeutic window and variable anticoagulation effects. Single gene polymorphisms in cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKORC1) have been shown to impact warfarin dosing in adults. Insufficient data exists on genetic and clinical factors which influence warfarin dosing in children. Pediatric patients with heart disease who received long-term warfarin therapy were tested for VKORC1 and CYP2C9 polymorphisms. Clinical and demographic data were reviewed in those children who achieved stable therapeutic international normalized ratio (INR). Multiple linear regression modeling was used to assess relationships between stable warfarin doses and genetic or clinical variables. Fifty children were tested for VKORC1 and CYP2C9 polymorphisms; 37 patients (M 26: F 11) had complete data, achieved stable therapeutic INR, and were included in dose variability analysis. There were predominance of white race 73% and male sex 70.3%. The mean age was 9.6 years (1.8-18.6 years). The mean weight was 37.8 kg (7.7-95 kg). Fontan physiology and mechanical cardiac valves were two most common indications for chronic warfarin therapy (25/37 or 67.6%). Twelve patients (32.4%) had ≥ 2 indications for warfarin therapy. Three patients had documented venous or arterial clots, and 5 patients had strokes. Congenital heart disease was present in 29 patients (78.4%), including Fontan physiology (20), complex biventricular physiology (4), and congenital mitral valve disease (5). Acquired heart disease was present in 8 patients (21.6%), including Kawasaki disease with coronary aneurysms (3), acquired mitral valve disease (3), and Marfan syndrome (2). Stable warfarin dose (mg/kg/day) was strongly associated with VKORC1 polymorphism (p < 0.0001) and goal therapeutic INR (p = 0.009). Negative correlations were observed between stable warfarin dose and age, weight, height, and BSA (p = 0.04, 0.02, 0.02, and 0.02 respectively). Factors which did not influence warfarin dose included CYP2C9 polymorphism (p = 0.17), concurrent medications (p = 0.85), sex (p = 0.4), race (p = 0.14), congenital heart disease (p = 0.09), and Fontan physiology (p = 0.76). The gene-dose effect was observed in children with homozygous wild type VKORC1 CC, who required higher warfarin dose compared to those carrying heterozygous TC or homozygous TT (p = 0.028 and 0.0004 respectively). The full multiple linear regression model revealed that VKORC1 genotypes accounted for 47% of dosing variability; CYPC29 accounted for 5%. Overall, the combination of VKORC1, CYP2C9, age, and target INR accounted for 82% of dosing variability. In children with heart disease, VKORC1 genotypes, age, and target INR are important determinants influencing warfarin dosing in children with heart disease. Future warfarin dosing algorithm in children should factor both genetic and clinical factors.
Collapse
|
19
|
Impact of the CYP4F2 p.V433M polymorphism on coumarin dose requirement: systematic review and meta-analysis. Clin Pharmacol Ther 2012; 92:746-56. [PMID: 23132553 DOI: 10.1038/clpt.2012.184] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A systematic review and a meta-analysis were performed to quantify the accumulated information from genetic association studies investigating the impact of the CYP4F2 rs2108622 (p.V433M) polymorphism on coumarin dose requirement. An additional aim was to explore the contribution of the CYP4F2 variant in comparison with, as well as after stratification for, the VKORC1 and CYP2C9 variants. Thirty studies involving 9,470 participants met prespecified inclusion criteria. As compared with CC-homozygotes, T-allele carriers required an 8.3% (95% confidence interval (CI): 5.6-11.1%; P < 0.0001) higher mean daily coumarin dose than CC homozygotes to reach a stable international normalized ratio (INR). There was no evidence of publication bias. Heterogeneity among studies was present (I(2) = 43%). Our results show that the CYP4F2 p.V433M polymorphism is associated with interindividual variability in response to coumarin drugs, but with a low effect size that is confirmed to be lower than those contributed by VKORC1 and CYP2C9 polymorphisms.
Collapse
|
20
|
Belozerceva LA, Voronina EN, Kokh NV, Tsvetovskay GA, Momot AP, Lifshits GI, Filipenko ML, Shevela AI, Vlasov VV. Personalized approach of medication by indirect anticoagulants tailored to the patient-Russian context: what are the prospects? EPMA J 2012; 3:10. [PMID: 23016735 PMCID: PMC3492156 DOI: 10.1186/1878-5085-3-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 09/19/2012] [Indexed: 11/26/2022]
Abstract
Indirect anticoagulants such as warfarin are the ‘gold standard’ for prevention and treatment of thromboembolic complications in patients at risk (in atrial fibrillation of valvular and nonvalvular etiology, the presence of artificial heart valves, orthopedic and trauma interventions, and other pathological conditions). A wide range of doses required to achieve a therapeutic effect indicates the need for a personalized approach to the appointment of warfarin. In addition to the dependence on the patient's clinical characteristics (sex, age, smoking status, diagnosis), there is a clear association between the warfarin dose and the carriage of certain allelic variants of key genes that makes it possible to apply molecular genetic testing for individual dose adjustment. This provides a more rapid target anticoagulant effect and also reduces the risk of bleeding associated with a possible overdose of warfarin. Implementation of this approach will allow more wide and safe application of indirect anticoagulants in Russia for needy patients.
Collapse
Affiliation(s)
- Liliya Alexandrovna Belozerceva
- Institute of Chemical Biology and Fundamental Medicine, Siberian Branch of the Russian Academy of Sciences (RAS ICBFM), Ac, Lavrentiev 8, Novosibirsk, 630090, Russia.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
|
22
|
Bazan NS, Sabry NA, Rizk A, Mokhtar S, Badary O. Validation of pharmacogenetic algorithms and warfarin dosing table in Egyptian patients. Int J Clin Pharm 2012; 34:837-44. [PMID: 22851439 DOI: 10.1007/s11096-012-9678-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Accepted: 07/16/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Warfarin remains a difficult drug to use due to the large variability in dose response. Clear understanding of the accuracy of warfarin pharmacogenetic dosing methods might lead to appropriate control of anticoagulation. OBJECTIVE This study aims to evaluate the accuracy of warfarin dosing table and two pharmacogenetic algorithms, namely the algorithms of Gage et al. (Clin Pharmacol Ther 84:326-331, 2008), and the International Warfarin Pharmacogenetics Consortium algorithm (IWPC) in a real Egyptian clinical setting. Additionally, three non-pharmacogenetic dosing methods (the Gage, IWPC clinical algorithms and the empiric 5 mg/day dosing) were evaluated. SETTING Sixty-three Egyptian patients on a stable therapeutic warfarin dose were included. Patients were recruited from the outpatient clinic of the critical care medicine department. METHODS CYP2C9 and VKORC1 polymorphisms were genotyped by real time PCR system. Predicted doses by all dosing methods were calculated and compared with the actual therapeutic warfarin doses. RESULTS The Gage algorithm (adjusted R(2) = 0.421, and mean absolute error (MAE) = 3.3), and IWPC algorithm (adjusted R(2) = 0.419, MAE = 3.2) produced better accuracy than did the warfarin dosing table (adjusted R(2) = 0.246, MAE = 3.5), the two clinical algorithms (R(2) = 0.24, MAE = 3.7) and the fixed dose approach (MAE = 3.9). However, all dosing models produced comparable clinical accuracy with respect to proportion of patients within 1 mg/day of actual dose (ideal dose). Non-pharmacogenetic methods severely over-predicted dose (defined as ≥2 mg/day more than actual dose) compared to the three pharmacogenetic models. In comparison to non-pharmacogenetic methods, the three pharmacogenetic models performed better regarding the low dose group in terms of percentage of patients within ideal dose. In the high dose group, none of the dosing models predicted warfarin doses within ideal dose. CONCLUSION Our study showed that genotype-based dosing improved prediction of warfarin therapeutic dose beyond that available with the fixed-dose approach or the clinical algorithms, especially in the low-dose group. However, the two pharmacogenetic algorithms were the most accurate.
Collapse
Affiliation(s)
- Naglaa Samir Bazan
- Critical Care Medicine Department, Cairo University Hospitals, Cairo, Egypt.
| | | | | | | | | |
Collapse
|
23
|
Abstract
Warfarin is a commonly used oral anticoagulant with a narrow therapeutic range and large interindividual variability in daily dose. Compared with Caucasians, Chinese are known to require lower doses of warfarin. Differences between Caucasians and Chinese in the allelic frequencies of two genes, CYP2C9 and VKORC1, largely explain the difference in dose requirement. There are other genetic polymorphisms that may further explain the response to warfarin. The VKORC1 genotype is an important determinant of response to warfarin in Chinese, but some genetic variants found in other ethnic groups that have a large effect on warfarin response and dosing are not commonly found in Chinese. Therefore, it is important to recognize and beware of ethnic differences in the pharmacogenetics of the response to warfarin, especially in the design of algorithms to aid dosing in clinical practice.
Collapse
Affiliation(s)
- May P S Lam
- Department of Medicine Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | | |
Collapse
|
24
|
Shuen AY, Wong BYL, Fu L, Selby R, Cole DEC. Evaluation of the warfarin-resistance polymorphism, VKORC1 Asp36Tyr, and its effect on dosage algorithms in a genetically heterogeneous anticoagulant clinic. Clin Biochem 2012; 45:397-401. [PMID: 22266406 DOI: 10.1016/j.clinbiochem.2012.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 12/15/2011] [Accepted: 01/03/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To assess allele frequency and potential predictive value of recurrent polymorphisms affecting warfarin metabolism in an unselected patient cohort attending an anticoagulant clinic (n=186). DESIGN AND METHODS Genotyping of ten SNPs in five candidate genes (VKORC1, CYP2C9, CALU, EPHX and GGCX) was carried out by ABI PRISM SNaPshot multiplex method. RESULTS We confirm the association between high-frequency SNPs, VKORC1 c.-1639G>A and CYP2C9 *2/*3 and warfarin sensitivity, and contribute additional evidence that the VKORC1 p.Asp36Tyr variant is recurrent and independently associated with warfarin resistance in our population. Other SNPs made little contribution. CONCLUSION Warfarin sensitivity was predicted by known VKORC1 and CYP2C9 SNPs. However, resistance associated with p.Asp36Tyr in VKORC1 would not be predicted by the usual markers. Despite its relatively low frequency (3/186 or 1.6%) clinical considerations may warrant its inclusion in pharmacogenetic screening for initial warfarin dosing in clinic populations with a heterogeneous population base.
Collapse
Affiliation(s)
- Andrew Y Shuen
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | | | | | | |
Collapse
|
25
|
Liang R, Wang C, Zhao H, Huang J, Hu D, Sun Y. Influence of CYP4F2 genotype on warfarin dose requirement-a systematic review and meta-analysis. Thromb Res 2011; 130:38-44. [PMID: 22192158 DOI: 10.1016/j.thromres.2011.11.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/30/2011] [Accepted: 11/24/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Warfarin is a commonly used oral anticoagulant and the dosage is individually adjusted on the basis of the international normalized ratio (INR) monitoring. It is well known that gene polymorphisms of CytochromeP450 (CYP) 2C9 gene and the vitamin K epoxide reductase complex 1 (VKORC1) were significantly associated with warfarin dose. However, the association between Cytochrome P450 4F2 (CYP4F2) polymorphism and warfarin dose requirement is still controversial. This study was to investigate the influence of the CYP4F2 polymorphism, V433M (rs2108622) on warfarin dose for patients by meta-analysis. METHODS Strict inclusion and exclusion criteria were set, and the studies prior to December 19, 2010 were searched in PubMed, EMBASE and CNKI. References were examined and experts of primary studies were consulted for additional information. Revman 5.0.2 software was used to analyze the relationship between warfarin maintenance dose and CYP4F2 polymorphism RESULTS Thirteen studies were included in the meta-analysis which consisted of Caucasian, Asian and African populations. Compared to individuals with the homozygous CYP4F2 genotype (CC), carriers of CT, TT genotypes required 10.0% (95% confidence interval(CI) 4.0-15.0) and 21.0% (95% CI 9.0-33.0) higher warfarin doses respectively (P value <0.05). In addition, T carriers required 11.0% (95% CI 6.0-17.0) higher warfarin dose than CC genotype. CONCLUSIONS Our study showed that polymorphism of CYP4F2 had a moderate but statistically significant association with the variation of interindividual warfarin dose. However, whether CYP4F2 can improve the prediction of warfarin dose warrants need further investigation when combined with environmental factors.
Collapse
Affiliation(s)
- Ruijuan Liang
- Heart Center, Peking University People's Hospital, Beijing, China
| | | | | | | | | | | |
Collapse
|
26
|
Nakamura K, Obayashi K, Araki T, Aomori T, Fujita Y, Okada Y, Kurabayashi M, Hasegawa A, Ohmori S, Nakamura T, Yamamoto K. CYP4F2 gene polymorphism as a contributor to warfarin maintenance dose in Japanese subjects. J Clin Pharm Ther 2011; 37:481-5. [PMID: 22172097 DOI: 10.1111/j.1365-2710.2011.01317.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Polymorphisms in the gene encoding CYP4F2 may partly explain the variability in warfarin maintenance dose by altering the metabolism of vitamin K. To determine the genetic factors that cause large inter-patient variability in warfarin efficacy, we investigated the relationship between serum warfarin concentration and CYP4F2 V433M (1347C>T, rs2108622) polymorphism in Japanese subjects. METHODS Gene variations in VKORC1, CYP2C9 and CYP4F2 were analysed in 126 Japanese patients treated with warfarin. The daily dosage of warfarin, concentration of S- and R-warfarin in plasma, and prothrombin time international normalized ratio (PT-INR) was used as the pharmacokinetic and pharmacodynamic indices. RESULTS AND DISCUSSION The maintenance dose of warfarin was larger in the CYP4F2 1347 CT genotype group (3·59±1·80 mg/day, P=0·027) than in the CYP4F2 CC genotype group (2·88±1·00 mg/day). CYP4F2 1347C>T polymorphism significantly affected serum R-warfarin concentration when the VKORC1-1639 genotypes are AG and GG. WHAT IS NEW AND CONCLUSION Although a significant inter-patient difference in warfarin maintenance dose was observed between the CYP4F2 CC and CT genotypes, serum S-warfarin concentration was not significantly different between them. An effect of CYP4F2 V433M polymorphism on warfarin maintenance dose was observed but was relatively small when compared to the effects of CYP2C9 and VKOR polymorphism.
Collapse
Affiliation(s)
- K Nakamura
- Department of Clinical Pharmacology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Vitamin K antagonists in children with heart disease: height and VKORC1 genotype are the main determinants of the warfarin dose requirement. Blood 2011; 119:861-7. [PMID: 22130800 DOI: 10.1182/blood-2011-07-365502] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Managing vitamin K antagonist (VKA) therapy is challenging in children because of a narrow therapeutic range and wide inter- and intra-individual variability in dose response. Only a few small studies have investigated the effect of nongenetic and genetic factors on the dose response to VKAs in children. In a cohort study including 118 children (median age 9 years; range, 3 months-18 years) mostly with cardiac disease, we evaluated by multivariate analysis the relative contribution of nongenetic factors and VKORC1/CYP2C9/CYP4F2 genotypes on warfarin (n = 83) or fluindione (n = 35) maintenance dose and the influence of these factors on the time spent within/above/below the range. The results showed that height, target international normalized ratio and VKORC1 and CYP2C9 genotypes were the main determinants of warfarin dose requirement, accounting for 48.1%, 4.4%, 18.2%, and 2.0% of variability, respectively, and explaining 69.7% of the variability. Our model predicted the warfarin dose within 7 mg/wk in 86.7% of patients. None of the covariates was associated with the time spent above or below the international normalized ratio range. Whether this model predicts accurately the effective maintenance dose is currently being investigated.
Collapse
|
28
|
Moreau C, Loriot MA, Pautas E, Siguret V. Response to “EPHX1 Polymorphisms Are Not Associated With Warfarin Response in an Italian Population”. Clin Pharmacol Ther 2011. [DOI: 10.1038/clpt.2011.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
29
|
EPHX1 Polymorphisms Are Not Associated With Warfarin Response in an Italian Population. Clin Pharmacol Ther 2011; 89:791; author reply 792. [DOI: 10.1038/clpt.2011.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
30
|
Finkelman BS, Gage BF, Johnson JA, Brensinger CM, Kimmel SE. Genetic warfarin dosing: tables versus algorithms. J Am Coll Cardiol 2011; 57:612-8. [PMID: 21272753 DOI: 10.1016/j.jacc.2010.08.643] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 07/16/2010] [Accepted: 08/24/2010] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The aim of this study was to compare the accuracy of genetic tables and formal pharmacogenetic algorithms for warfarin dosing. BACKGROUND Pharmacogenetic algorithms based on regression equations can predict warfarin dose, but they require detailed mathematical calculations. A simpler alternative, recently added to the warfarin label by the U.S. Food and Drug Administration, is to use genotype-stratified tables to estimate warfarin dose. This table may potentially increase the use of pharmacogenetic warfarin dosing in clinical practice; however, its accuracy has not been quantified. METHODS A retrospective cohort study of 1,378 patients from 3 anticoagulation centers was conducted. Inclusion criteria were stable therapeutic warfarin dose and complete genetic and clinical data. Five dose prediction methods were compared: 2 methods using only clinical information (empiric 5 mg/day dosing and a formal clinical algorithm), 2 genetic tables (the new warfarin label table and a table based on mean dose stratified by genotype), and 1 formal pharmacogenetic algorithm, using both clinical and genetic information. For each method, the proportion of patients whose predicted doses were within 20% of their actual therapeutic doses was determined. Dosing methods were compared using McNemar's chi-square test. RESULTS Warfarin dose prediction was significantly more accurate (all p < 0.001) with the pharmacogenetic algorithm (52%) than with all other methods: empiric dosing (37%; odds ratio [OR]: 2.2), clinical algorithm (39%; OR: 2.2), warfarin label (43%; OR: 1.8), and genotype mean dose table (44%; OR: 1.9). CONCLUSIONS Although genetic tables predicted warfarin dose better than empiric dosing, formal pharmacogenetic algorithms were the most accurate.
Collapse
Affiliation(s)
- Brian S Finkelman
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | | | | | | |
Collapse
|