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Liu Z, Luo F, Zhao J, Chen W, Gao W, Zhou Z. Association between gene polymorphisms and initial warfarin therapy in patients after heart valve surgery. Pharmacol Rep 2024; 76:390-399. [PMID: 38457019 DOI: 10.1007/s43440-024-00575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Warfarin is widely used for the prevention and treatment of thrombotic events. This study aimed to examine the influence of gene polymorphisms on the early stage of warfarin therapy in patients following heart valve surgery. METHODS Nine single nucleotide polymorphisms were genotyped using microarray chips, categorizing patients into three groups: normal responders (Group I), sensitive responders (Group II), and highly sensitive responders (Group III). The primary clinical outcomes examined were time in therapeutic range (TTR) and international normalized ratio (INR) variability. To investigate potential influencing factors, a generalized linear regression model was employed. RESULTS Among 734 patients, the prevalence of CYP2C9*3-1075A > C, CYP2C19*3-636G > A, and CYP2C19*17-806C > T variants were 11.2%, 9.9%, and 1.9% of patients, respectively. VKORC1-1639G > A or the linked -1173C > T variant was observed in 99.0% of the patients. Generalized linear model analysis revealed an impact of sensitivity grouping on INR variability. Compared to Group I, Group II showed higher TTR values (p = 0.023), while INR variability was poorer in Group II (p < 0.001) and Group III (p < 0.001). Individual gene analysis identified significant associations between CYP2C9*3-1075A > C (p < 0.001), VKORC1-1639G > A or the linked -1173 C > T (p = 0.009) and GGCX-3261G > A (p = 0.019) with INR variability. CONCLUSION The genotypes of CYP2C9, VKORC1, and GGCX were found to have a significant impact on INR variability during the initial phase of warfarin therapy. However, no significant association was observed between TTR and gene polymorphisms. These findings suggest that focusing on INR variability is crucial in clinical practice, and preoperative detection of gene polymorphisms should be considered to assist in the initiation of warfarin therapy.
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Affiliation(s)
- Zhaohui Liu
- Department of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Center of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengming Luo
- Department of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Center of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Zhao
- Department of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Center of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Gao
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Center of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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2
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Zhu Y, You J, Gu X, Zhu H, Liu J. Pharmacogenetics of warfarin dosing in Chinese adults with nonvalvular atrial fibrillation. Eur J Clin Pharmacol 2023; 79:427-435. [PMID: 36708395 DOI: 10.1007/s00228-023-03458-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/18/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND The guide for the use of genotype-guided warfarin dosing in patients for the treatment of non-valvular atrial fibrillation (AF) is still lacking. AIM We aimed to evaluate whether genotype-guided warfarin dosing is superior to conventional clinical dosing for the outcomes of interest in Chinese patients. METHOD Our study consisted of 508 newly recruited and 471 existing Chinese AF patients. Among the total 979 patients, 585 patients received their dose of warfarin determined by a genetic and clinical factor (gene group), while the remaining 394 patients whose dosing was determined empirically in control group. We incorporated CYP2C9 and VKORC1 genotypes into the gene group. The international normalized ratio (INR) measurement and standard protocols were used for further dose adjustment in both groups. The primary outcomes were the percentage of time in the therapeutic range (%TTR) and INR during 12-month follow-up. Secondary safety outcome included bleeding and thrombotic events. RESULTS Compared with the control group, the average TTR of the gene group was higher [68.4 ± 20.6% vs 48.5 ± 21.6%, P < 0.001]. The average INR monitoring times to reach the therapeutic time in the gene group was lower (P < 0.001). The risk ratios (RR) for cumulative incidence of total bleeding events, minor bleeding events, gastrointestinal bleeding, and intracerebral bleeding events were not significantly different between the two groups (P > 0.05). Comparing to the analysis using existing 471 patients, the analysis using total 979 patients showed that the gene group experienced a lower (RR 0.4 (95% CI 0.2 to 0.8), P = 0.008) incidence of cumulative ischemic stroke. CONCLUSION Genotype-guided warfarin administration increases the average TTR, reaches higher TTR levels in the early anticoagulant phase, and significantly reduces the risk of ischemic stroke events.
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Affiliation(s)
- Ye Zhu
- Clinical Medical College, Yangzhou University, Nantong West Road No. 98, Yangzhou, 225001, Jiangsu, China
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jia You
- Department of Internal Medicine, Yangzhou Maternal and Child Health Care Hospital, Yangzhou, 225001, Jiangsu, China
| | - Xiang Gu
- Clinical Medical College, Yangzhou University, Nantong West Road No. 98, Yangzhou, 225001, Jiangsu, China
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Hua Zhu
- Clinical Medical College, Yangzhou University, Nantong West Road No. 98, Yangzhou, 225001, Jiangsu, China
- Department of Pharmacy, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jia Liu
- Clinical Medical College, Yangzhou University, Nantong West Road No. 98, Yangzhou, 225001, Jiangsu, China.
- Department of Pharmacy, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China.
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3
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Yang W, Ma J, Hu W, Dai H, Xu H. Associated factors and safety of the rapidly achieving first therapeutic target of warfarin in hospitalized patients: a retrospective cohort study. Int J Clin Pharm 2022; 44:939-946. [PMID: 35449349 DOI: 10.1007/s11096-022-01404-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/10/2022] [Accepted: 03/19/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Warfarin is a commonly used anticoagulant drug in clinical practice. Rapidly achieving the first therapeutic international normalized ratio (INR) of warfarin may reduce the hospital length of stay. However, little research has been carried out to evaluate the influencing factors and the safety of rapidly achieving the first therapeutic INR target of warfarin. AIM To investigate the associated factors and the safety of rapidly achieving the first therapeutic INR target of warfarin. METHOD A retrospective cohort study was conducted in inpatients who took warfarin from November 2018 to October 2019. Patients' information was retrieved from medical records. RESULTS 487 patients were included. The mean achieving first therapeutic target time was 6.0 ± 3.2 days (median, 5.0 days). Age > 65 years, body mass index < 24 kg/m2, and initial warfarin dose ≥ 3 mg/d were independent factors associated with the rapidly achieving first INR target of warfarin therapy. The incidence of INR ≥ 4 was higher in patients achieving the first INR target rapidly than those achieving the first INR target slowly, while there were no significant differences in bleeding events between the two groups. CONCLUSION Hospitalized patients aged > 65 years, with a body mass index < 24 kg/m2, or receiving an initial warfarin dose ≥ 3 mg/d were more likely to achieve the first INR target of warfarin rapidly. Closer INR monitoring and appropriate warfarin dose adjustment are recommended to improve the safety for patients achieving the first INR ≥ 1.8 within 6 days after beginning oral warfarin.
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Affiliation(s)
- Wenjun Yang
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 310009, Hangzhou, China
| | - Jun Ma
- College of Pharmacy, Hangzhou Medical College, 310053, Hangzhou, China
| | - Wei Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 310009, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 310009, Hangzhou, China
| | - Huimin Xu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, 310009, Hangzhou, China.
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4
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Zeng J, Shao J, Lin S, Zhang H, Su X, Lian X, Zhao Y, Ji X, Zheng Z. Optimizing the dynamic treatment regime of in-hospital warfarin anticoagulation in patients after surgical valve replacement using reinforcement learning. J Am Med Inform Assoc 2022; 29:1722-1732. [PMID: 35864720 DOI: 10.1093/jamia/ocac088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Warfarin anticoagulation management requires sequential decision-making to adjust dosages based on patients' evolving states continuously. We aimed to leverage reinforcement learning (RL) to optimize the dynamic in-hospital warfarin dosing in patients after surgical valve replacement (SVR). MATERIALS AND METHODS 10 408 SVR cases with warfarin dosage-response data were retrospectively collected to develop and test an RL algorithm that can continuously recommend daily warfarin doses based on patients' evolving multidimensional states. The RL algorithm was compared with clinicians' actual practice and other machine learning and clinical decision rule-based algorithms. The primary outcome was the ratio of patients without in-hospital INRs >3.0 and the INR at discharge within the target range (1.8-2.5) (excellent responders). The secondary outcomes were the safety responder ratio (no INRs >3.0) and the target responder ratio (the discharge INR within 1.8-2.5). RESULTS In the test set (n = 1260), the excellent responder ratio under clinicians' guidance was significantly lower than the RL algorithm: 41.6% versus 80.8% (relative risk [RR], 0.51; 95% confidence interval [CI], 0.48-0.55), also the safety responder ratio: 83.1% versus 99.5% (RR, 0.83; 95% CI, 0.81-0.86), and the target responder ratio: 49.7% versus 81.1% (RR, 0.61; 95% CI, 0.58-0.65). The RL algorithms performed significantly better than all the other algorithms. Compared with clinicians' actual practice, the RL-optimized INR trajectory reached and maintained within the target range significantly faster and longer. DISCUSSION RL could offer interactive, practical clinical decision support for sequential decision-making tasks and is potentially adaptable for varied clinical scenarios. Prospective validation is needed. CONCLUSION An RL algorithm significantly optimized the post-operation warfarin anticoagulation quality compared with clinicians' actual practice, suggesting its potential for challenging sequential decision-making tasks.
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Affiliation(s)
- Juntong Zeng
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jianzhun Shao
- Department of Automation, Tsinghua University, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Hongchang Zhang
- Department of Automation, Tsinghua University, Beijing, People's Republic of China
| | - Xiaoting Su
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaocong Lian
- Department of Automation, Tsinghua University, Beijing, People's Republic of China.,Beijing National Research Center for Information Science and Technology (BNRist), Tsinghua University, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Xiangyang Ji
- Department of Automation, Tsinghua University, Beijing, People's Republic of China.,Beijing National Research Center for Information Science and Technology (BNRist), Tsinghua University, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.,National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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5
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Asiimwe IG, Pirmohamed M. Ethnic Diversity and Warfarin Pharmacogenomics. Front Pharmacol 2022; 13:866058. [PMID: 35444556 PMCID: PMC9014219 DOI: 10.3389/fphar.2022.866058] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/14/2022] [Indexed: 12/23/2022] Open
Abstract
Warfarin has remained the most commonly prescribed vitamin K oral anticoagulant worldwide since its approval in 1954. Dosing challenges including having a narrow therapeutic window and a wide interpatient variability in dosing requirements have contributed to making it the most studied drug in terms of genotype-phenotype relationships. However, most of these studies have been conducted in Whites or Asians which means the current pharmacogenomics evidence-base does not reflect ethnic diversity. Due to differences in minor allele frequencies of key genetic variants, studies conducted in Whites/Asians may not be applicable to underrepresented populations such as Blacks, Hispanics/Latinos, American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. This may exacerbate health inequalities when Whites/Asians have better anticoagulation profiles due to the existence of validated pharmacogenomic dosing algorithms which fail to perform similarly in the underrepresented populations. To examine the extent to which individual races/ethnicities are represented in the existing body of pharmacogenomic evidence, we review evidence pertaining to published pharmacogenomic dosing algorithms, including clinical utility studies, cost-effectiveness studies and clinical implementation guidelines that have been published in the warfarin field.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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6
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Wang X, Tang B, Zhou M, Liu L, Feng X, Wang X, Qiu K. Efficacy and safety of genotype-guided warfarin dosing versus non-genotype-guided warfarin dosing strategies: A systematic review and meta-analysis of 27 randomized controlled trials. Thromb Res 2021; 210:42-52. [PMID: 34999431 DOI: 10.1016/j.thromres.2021.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/05/2021] [Accepted: 12/20/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of genotype-guided dosing (GD) strategies compared to non-genotype-guided dosing (non-GD) strategies for warfarin. METHODS Databases were searched up to July 2021. Meta-analysis was conducted with the Review Manager software (version 5.4) and R (version 4.0.5). Risk ratio (RR), mean difference (MD), and 95% confidence intervals (CIs) were used. Subgroup analyses were conducted based on ethnicity and dosing regimen in non-GD group. Meta-regression was performed to evaluate the relation of covariates. This study is registered with PROSPERO (CRD42021245654). RESULTS 27 randomized controlled trials with a total of 9906 patients were included. The GD group resulted in a significantly improved time in therapeutic range compared with non-GD group in follow-up duration within 30 days (MD: 5.95, 95%CI: 2.41-9.22, P = 0.001) and beyond 30 days (MD: 4.93, 1.40-8.47, P = 0.006), time to the first therapeutic international normalized ratio (MD: -1.80, -2.69 - -0.92, P < 0.0001), and time to reach stable dose (MD: -5.08, -7.09 - -3.07, P < 0.00001), incidence of major bleeding events (RR: 0.50, 0.33-0.75, P = 0.0008), total bleeding events (RR: 0.83, 0.73-0.95, P = 0.006), and thromboembolism (RR: 0.69, 0.49-0.96, P = 0.03). No differences were found in stable dose achievement, minor bleeding events, over anticoagulation, and all-cause mortality. Four improved efficacy outcomes were observed in GD group compared with fixed dosing group. Only time to the therapeutic INR was shortened in GD group compared with clinical adjusted dosing group. The result showed no difference of safety outcomes between GD group and fixed dosing group whereas a decreased incidence of major bleeding events was observed when comparing to clinical adjusted dosing group. CONCLUSION GD strategy was superior to fixed dosing strategy in term of efficacy outcomes and comparable to fixed dosing strategy in safety outcomes. Clinical adjusted regimen could partly substitute the genotype-guided dosing strategy for efficacy in insufficient conditions, but the risk of major bleeding events should be monitored.
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Affiliation(s)
- Xinrui Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China; Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Borui Tang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Meng Zhou
- Department of Pharmacy, The People's Hospital of Anyang City, Anyang 455000, China
| | - Lihong Liu
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xin Feng
- Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China.
| | - Xin Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Kui Qiu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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7
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Godoy LC, Tomlinson G, Abumuamar AM, Farkouh ME, Rudolph M, Billia F, Cohn I, Marcus G, Kim RH, Rao V, Lawler PR. Association between time to therapeutic INR and length of stay following mechanical heart valve surgery. J Card Surg 2021; 37:62-69. [PMID: 34662458 DOI: 10.1111/jocs.16083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Warfarin is the only oral anticoagulant approved for use following mechanical valve surgery (MeVS). Patients may experience prolonged hospital length of stay (LOS) following MeVS awaiting an appropriate warfarin effect. We aimed to determine whether an association exists between time to achieve the first therapeutic international normalized ratio (INR) and LOS following MeVS. MATERIALS AND METHODS Retrospective single center cohort study. We included consecutive adult patients undergoing elective MeVS from 2013 to 2018. Landmark analyses and multivariable regression with time-updated INR were used to estimate the association between time to therapeutic INR (TTI) and LOS. RESULTS Among 384 patients (median age: 51 years, interquartile range [IQR]: 41-57; 58.3% male), the median TTI was 4 days (IQR: 2-5). Thirty seven percent of patients were discharged with a subtherapeutic INR, many on bridging anticoagulation or with an INR close to target. Those achieving therapeutic INR had an increased rate of hospital discharge (adjusted hazard ratio: 2.17; 95% confidence interval: 1.71-2.76; p < .0001). Attainment of a therapeutic INR anytime between postoperative Days 4 and 13 was significantly associated with a shorter LOS. CONCLUSIONS Prolonged time to achieve a therapeutic INR was independently associated with prolonged LOS. Future strategies aimed at improving attainment of therapeutic INR following MeVS may reduce hospital LOS.
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Affiliation(s)
- Lucas C Godoy
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Sao Paulo, Brazil
| | - George Tomlinson
- Biostatistics Research Unit, Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Asmaa M Abumuamar
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Madeleine Rudolph
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Iris Cohn
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gil Marcus
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Shamir Medical Center, Zeriffin, Israel.,Schulich Heart Program, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Raymond H Kim
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Ted Rogers Centre for Heart Research, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, University Health Network, Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Magavern EF, Kaski JC, Turner RM, Drexel H, Janmohamed A, Scourfield A, Burrage D, Floyd CN, Adeyeye E, Tamargo J, Lewis BS, Kjeldsen KP, Niessner A, Wassmann S, Sulzgruber P, Borry P, Agewall S, Semb AG, Savarese G, Pirmohamed M, Caulfield MJ. The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy: A position statement from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:85-99. [PMID: 33638977 DOI: 10.1093/ehjcvp/pvab018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/05/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite diverse availability, interpretation and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. Aside from the considerable barriers to implementing pharmacogenomic testing and the complexities of clinically actioning results, there are differences in the availability of resources and expertise internationally within Europe. Diverse legal and ethical approaches to genomic testing and clinical therapeutic application also require serious thought. As direct-to-consumer genomic testing becomes more common, it can be anticipated that data may be brought in by patients themselves, which will require critical assessment by the clinical cardiovascular prescriber. In a modern, pluralistic and multi-ethnic Europe, self-identified race/ethnicity may not be concordant with genetically detected ancestry and thus may not accurately convey polymorphism prevalence. Given the broad relevance of pharmacogenomics to areas such as thrombosis and coagulation, interventional cardiology, heart failure, arrhythmias, clinical trials, and policy/regulatory activity within cardiovascular medicine, as well as to genomic and pharmacology subspecialists, this position statement attempts to address these issues at a wide-ranging level.
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Affiliation(s)
- E F Magavern
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J C Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom
| | - R M Turner
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - H Drexel
- Vorarlberg Institute for Vascular Investigation & Treatment (VIVIT), Feldkirch, A Private University of the Principality of Liechtenstein, Triesen, FL.,Drexel University College of Medicine, Philadelphia, USA
| | - A Janmohamed
- Department of Clinical Pharmacology, St George's, University of London, United Kingdom
| | - A Scourfield
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK
| | - D Burrage
- Whittington Health NHS Trust, London, UK
| | - C N Floyd
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, UK.,Department of Clinical Pharmacology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Adeyeye
- Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - B S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - A Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna
| | - S Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany
| | - P Sulzgruber
- Medical University of Vienna, Department of Medicine II, Division of Cardiology
| | - P Borry
- Center for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Leuven Institute for Human Genetics and Society, Leuven, Belgium
| | - S Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - A G Semb
- Preventive Cardio-Rheuma clinic, department of rheumatology, innovation and research, Diakonhjemmet hospital, Oslo, Norway
| | - G Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - M J Caulfield
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Sridharan K, Sivaramakrishnan G. A network meta-analysis of CYP2C9, CYP2C9 with VKORC1 and CYP2C9 with VKORC1 and CYP4F2 genotype-based warfarin dosing strategies compared to traditional. J Clin Pharm Ther 2020; 46:640-648. [PMID: 33346393 DOI: 10.1111/jcpt.13334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/17/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Variations in genotypes were observed in randomized clinical trials (RCTs) that evaluated genotype-based warfarin dosing. We carried out a network meta-analysis to assess whether any clinically significant differences exist between RCTs evaluating CYP2C9 with VKORC1, with CYP2C9 alone and CYP2C9, VKORC1, with CYP4F2 dosing strategies. METHODS Electronic records were searched for RCTs comparing genotype-based warfarin with traditional-dosing strategies. Key outcomes included were the time to first therapeutic international normalized ratio (INR); time to stable INR or warfarin dose; percent time in therapeutic range (TTR); and the proportion of patients with supra-therapeutic INR. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (95% CI) were the effect estimates. RESULTS AND DISCUSSION Twenty-six studies (7898 patients) were included. CYP2C9-based warfarin dosing was associated with a shorter time to first therapeutic INR (WMD: -2.73, 95% CI: -3.41, -2.05) and stable INR/warfarin dose (WMD: -8.1, 95% CI: -12.54, -3.66). CYP2C9 and VKORC1 were observed with a shorter time to first therapeutic INR (WMD: -1.92, 95% CI: -3.23, -0.61) and stable INR/warfarin dose (WMD: -4.6, 95% CI: -6.87, -2.34) along with a longer TTR (%) (WMD: 3.91, 95% CI: 1.18, 6.63). CYP2C9, VKORC1 and CYP4F2 were observed with a reduced proportion of patients with supra-therapeutic INR (OR: 0.68, 95% CI: 0.49, 0.93). Trial sequential analysis confirms the superior benefits of CYP2C9 with VKORC1 genotype. WHAT IS NEW AND CONCLUSION The present evidence is supportive of personalizing warfarin dose based only on CYP2C9 and VKORC1 genotypes compared to traditional strategies. More RCTs are needed to delineate any benefit for adding CYP4F2 to provide sufficient power for pooled analysis. No convincing evidence exists supporting the role of CYP2C9 alone.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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Genotype-guided warfarin dosing may benefit patients with mechanical aortic valve replacements: randomized controlled study. Sci Rep 2020; 10:6988. [PMID: 32332930 PMCID: PMC7181853 DOI: 10.1038/s41598-020-63985-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/07/2020] [Indexed: 11/26/2022] Open
Abstract
This prospective, single-blind, randomized study was designed to evaluate the effect of genotype-based warfarin dosing compared with standard warfarin dosing in Korean patients with mechanical cardiac valves. Patients were assigned to either the genotype-based dosing group or the standard dosing group using stratified block randomization. The genotype-based dosing equation was adopted from a previous study which included VKORC1 rs9934438, CYP2C9 rs1057910, CYP4F2 rs2108622, and age. Primary outcomes included the percentage of time in the therapeutic range (pTTR): (i) during the first week following initiation of warfarin therapy, (ii) during hospitalization and (iii) until the first outpatient visit. A total of 91 patients were included in the analysis, 42 treated with genotype-based warfarin dosing and 49 treated with standard warfarin dosing. The genotype frequency differences of the three SNPs included in this study (ie, VKORC1, CYP2C9, CYP4F2), between the genotype-based dosing and standard dosing groups were not different. The genotype-based dosing group trended toward higher pTTR when compared with the standard dosing group, although this difference was not statistically significant. In patients with aortic valve replacement, TTRTraditional and TTRRosendaal were significantly higher in the genotype-based dosing group when compared with the standard dosing group during the first week following treatment initiation [ie, 58.5% vs. 38.1% (p = 0.009) and 64.0% vs. 44.6% (p = 0.012), respectively]. Based on the results, the genotype-guided dosing did not offer a significant clinical advantage, but a possible benefit in patients with aortic valve replacement has been suggested.
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Shah RR. Genotype‐guided warfarin therapy: Still of only questionable value two decades on. J Clin Pharm Ther 2020; 45:547-560. [DOI: 10.1111/jcpt.13127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022]
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12
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Zhang J, Wu T, Chen W, Fu J, Xia X, Chen L. Effect of Gene-Based Warfarin Dosing on Anticoagulation Control and Clinical Events in a Real-World Setting. Front Pharmacol 2020; 10:1527. [PMID: 32038232 PMCID: PMC6988825 DOI: 10.3389/fphar.2019.01527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022] Open
Abstract
The cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 genotypes are associated with anticoagulation control and the clinical events in warfarin therapy. However, the clinical utility of gene-based warfarin dosing (GBWD) is controversial. We compared the anticoagulation control and clinical events related to warfarin with GBWD to those with clinically fixed dosing (CFD). A retrospective cohort study was conducted in a real-world setting. Of the 915 patients who were reviewed, 844 patients met the study-entry criteria; 413 cases were guided by GBWD using the International Warfarin Pharmacogenetic Consortium algorithm; 431 cases were guided by CFD (2.5 mg/day). The primary outcomes were the time needed to achieve the therapeutic International Normalized Ratio (INR) and the time in the therapeutic range (TTR) during a 3-month timeframe. The time needed to achieve the therapeutic INR (in days) for patients in the GBWD group was shorter than that for patients in the CFD group (10.21 ± 4.68 vs. 14.31 ± 8.26, P < 0.001). The overall TTR (Day 4-90) was significantly different between the GBWD group and CFD group (56.86 ± 10.72 vs. 52.87 ± 13.92, P = 0.007).In subgroup analysis, the TTR was also significantly different between the GBWD group and CFD group during the first month of treatment (Day 4-14: 54.28 ± 21.90 vs. 47.01 ± 26.25, P = 0.012; Day 15-28: 59.60 ± 20.12 vs. 51.71 ± 18.96, P = 0.001). However, no significant difference in the TTR was observed after 29 days of treatment. These data suggest that GBWD provided clinical benefits.
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Affiliation(s)
- Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jinglan Fu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xiaotong Xia
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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13
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Zhou L, Ding Y, Gao Y, Yang B, Bao J, Ma J. Genetic influence on bleeding and over-anticoagulation risk in patients undergoing warfarin treatment after heart valve replacements. Expert Opin Drug Metab Toxicol 2020; 16:1-9. [DOI: 10.1080/17425255.2020.1711883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ling Zhou
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Yinglong Ding
- Department of Cardiovascular Surgery, Soochow University, Suzhou, China
| | - Yuan Gao
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Biwen Yang
- Department of Cardiovascular Surgery, Soochow University, Suzhou, China
| | - Jianan Bao
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Jingjing Ma
- Department of Pharmacy, Soochow University, Suzhou, China
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Li X, Li D, Wu JC, Liu ZQ, Zhou HH, Yin JY. Precision dosing of warfarin: open questions and strategies. THE PHARMACOGENOMICS JOURNAL 2019; 19:219-229. [PMID: 30745565 DOI: 10.1038/s41397-019-0083-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/17/2018] [Accepted: 12/21/2018] [Indexed: 12/30/2022]
Abstract
Warfarin has a very narrow therapeutic window and obvious interindividual variability in its effects, with many factors contributing to the body's response. Algorithms incorporating multiple genetic, environment and clinical factors have been established to select a precision dose for each patient. A number of randomized controlled trials (RCTs) were conducted to explore whether patients could benefit from these algorithms; however, the results were inconsistent. Some questions remain to be resolved. Recently, new genetic and non-genetic factors have been discovered to contribute to variability in optimal warfarin doses. The results of further RCTs have been unveiled, and guidelines for pharmacogenetically guided warfarin dosing have been updated. Based on these most recent advancements, we summarize some open questions in this field and try to propose possible strategies to resolve them.
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Affiliation(s)
- Xi Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Dan Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Chu Wu
- Department of Cardiovascular, Central Hospital of Shaoyang, Shaoyang, 422000, P. R. China
| | - Zhao-Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Ye Yin
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China. .,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China. .,Hunan Provincial Gynecological Cancer Diagnosis and Treatment Engineering Research Center, Changsha, 410078, P. R. China.
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