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Fahmi AM, El Bardissy A, Saad MO, Elshafei MN, Bader L, Mahfouz A, Kasem M, Abdelsamad O, Elzouki A, Aquilante CL, Mraiche F, Soaly E, El Madhoun I, Asaad N, Arabi A, Alhmoud E, Elewa H. Clinical versus fixed warfarin dosing and the impact on quality of anticoagulation (The ClinFix trial). Clin Transl Sci 2024; 17:e13797. [PMID: 38859626 PMCID: PMC11164972 DOI: 10.1111/cts.13797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 06/12/2024] Open
Abstract
Different dosing strategies exist to initiate warfarin, most commonly fixed warfarin dosing (FWD), clinical warfarin dosing (CWD), and genetic-guided warfarin dosing (GWD). Landmark trials have shown GWD to be superior when compared to FWD in the EU-PACT trial or CWD in the GIFT trial. COAG trial did not show differences between GWD and CWD. We aim to compare the anticoagulation quality outcomes of CWD and FWD. This is a prospective cohort study with a retrospective comparator. Recruited subjects in the CWD (prospective) arm were initiated on warfarin according to the clinical dosing component of the algorithm published in www.warfarindosing.org. The primary efficacy outcome was the percentage time in the therapeutic range (PTTR) from day 3 to 6 till day 28 to 35. The study enrolled 122 and 123 patients in the CWD and FWD, respectively. The PTTR did not differ statistically between CWD and FWD (62.2 ± 26.2% vs. 58 ± 25.4%, p = 0.2). There was also no difference between both arms in the percentage of visits with extreme subtherapeutic international normalized ratio (INR) (<1.5; 15 ± 18.3% vs. 16.8 ± 19.1%, p = 0.44) or extreme supratherapeutic INR (>4; 7.7 ± 14.7% vs. 7.5 ± 12.4%, p = 0.92). We conclude that CWD did not improve the anticoagulation quality parameters compared to the FWD method.
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Affiliation(s)
- Amr M. Fahmi
- Pharmacy DepartmentHamad Medical CorporationDohaQatar
| | | | | | | | | | - Ahmed Mahfouz
- Pharmacy DepartmentHamad Medical CorporationDohaQatar
| | - Mohamed Kasem
- Pharmacy DepartmentHamad Medical CorporationDohaQatar
| | | | - Abdelnasser Elzouki
- Department of Medicine, Hamad General HospitalHamad Medical CorporationDohaQatar
| | - Christina L. Aquilante
- Department of Pharmaceutical SciencesSkaggs School of Pharmacy and Pharmaceutical Sciences, University of ColoradoAuroraUSA
| | - Fatima Mraiche
- Department of Pharmacology, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
| | - Ezeldin Soaly
- Department of CardiologyAlWakra Hospital, Hamad Medical CorporationAlWakraQatar
| | - Ihab El Madhoun
- Department of MedicineAlWakra Hospital, Hamad Medical CorporationAlWakraQatar
| | - Nidal Asaad
- Department of CardiologyHeart Hospital, Hamad Medical CorporationDohaQatar
| | - Abdulrahman Arabi
- Department of CardiologyHeart Hospital, Hamad Medical CorporationDohaQatar
| | - Eman Alhmoud
- Pharmacy DepartmentHamad Medical CorporationDohaQatar
| | - Hazem Elewa
- College of PharmacyQatar UniversityDohaQatar
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Rakicevic L. DNA and RNA Molecules as a Foundation of Therapy Strategies for Treatment of Cardiovascular Diseases. Pharmaceutics 2023; 15:2141. [PMID: 37631355 PMCID: PMC10459020 DOI: 10.3390/pharmaceutics15082141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
There has always been a tendency of medicine to take an individualised approach to treating patients, but the most significant advances were achieved through the methods of molecular biology, where the nucleic acids are in the limelight. Decades of research of molecular biology resulted in setting medicine on a completely new platform. The most significant current research is related to the possibilities that DNA and RNA analyses can offer in terms of more precise diagnostics and more subtle stratification of patients in order to identify patients for specific therapy treatments. Additionally, principles of structure and functioning of nucleic acids have become a motive for creating entirely new therapy strategies and an innovative generation of drugs. All this also applies to cardiovascular diseases (CVDs) which are the leading cause of mortality in developed countries. This review considers the most up-to-date achievements related to the use of translatory potential of DNA and RNA in treatment of cardiovascular diseases, and considers the challenges and prospects in this field. The foundations which allow the use of translatory potential are also presented. The first part of this review focuses on the potential of the DNA variants which impact conventional therapies and on the DNA variants which are starting points for designing new pharmacotherapeutics. The second part of this review considers the translatory potential of non-coding RNA molecules which can be used to formulate new generations of therapeutics for CVDs.
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Affiliation(s)
- Ljiljana Rakicevic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Vojvode Stepe 444a, 11042 Belgrade, Serbia
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Alqahtani AA, Ahmed MM, Mohammed AA, Ahmad J. 3D Printed Pharmaceutical Systems for Personalized Treatment in Metabolic Syndrome. Pharmaceutics 2023; 15:pharmaceutics15041152. [PMID: 37111638 PMCID: PMC10144629 DOI: 10.3390/pharmaceutics15041152] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
The current healthcare system is widely based on the concept of “one size fit for all”, which emphasizes treating a disease by prescribing the same drug to all patients with equivalent doses and dosing frequency. This medical treatment scenario has shown varied responses with either no or weak pharmacological effects and exaggerated adverse reactions preceded by more patient complications. The hitches to the concept of “one size fits all” have devoted the attention of many researchers to unlocking the concept of personalized medicine (PM). PM delivers customized therapy with the highest safety margin for an individual patient’s needs. PM has the potential to revolutionize the current healthcare system and pave the way to alter drug choices and doses according to a patient’s clinical responses, providing physicians with the best treatment outcomes. The 3D printing techniques is a solid-form fabrication method whereby successive layers of materials based on computer-aided designs were deposited to form 3D structures. The 3D printed formulation achieves PM goals by delivering the desired dose according to patient needs and drug release profile to achieve a patient’s personal therapeutic and nutritional needs. This pre-designed drug release profile attains optimum absorption and distribution, exhibiting maximum efficacy and safety profiles. This review aims to focus on the role of the 3D printing technique as a promising tool to design PM in metabolic syndrome (MS).
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Affiliation(s)
- Abdulsalam A. Alqahtani
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran 11001, Saudi Arabia
| | - Mohammed Muqtader Ahmed
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Abdul Aleem Mohammed
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran 11001, Saudi Arabia
| | - Javed Ahmad
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran 11001, Saudi Arabia
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Cheng S, Flora DR, Rettie AE, Brundage RC, Tracy TS. Pharmacokinetic Modeling of Warfarin І - Model-based Analysis of Warfarin Enantiomers with a Target Mediated Drug Disposition Model Reveals CYP2C9 Genotype-dependent Drug-drug Interactions of S-Warfarin. Drug Metab Dispos 2022; 50:DMD-AR-2022-000876. [PMID: 35798369 PMCID: PMC9488981 DOI: 10.1124/dmd.122.000876] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/22/2022] Open
Abstract
The objective of this study is to characterize the impact of CYP2C9 genotype on warfarin drug-drug interactions when warfarin is taken together with fluconazole, a cytochrome P450 (CYP) inhibitor, or rifampin, a CYP inducer with a nonlinear mixed effect modeling approach. A target mediated drug disposition model with a urine compartment was necessary to characterize both S-warfarin and R-warfarin plasma and urine pharmacokinetic profiles sufficiently. Following the administration of fluconazole, our study found subjects with CYP2C9 *2 or *3 alleles experience smaller changes in S-warfarin CL compared with subjects without these alleles (69.5%, 64.8%, 59.7% and 47.8% decrease in subjects with CYP2C9 *1/*1, *1/*3, *2/*3 and *3/*3 respectively). Whereas, following the administration of rifampin, subjects with CYP2C9 *2/*3 or CYP2C9 *3/*3 experience larger changes in S-warfarin CL compared with subjects with at least one copy of CYP2C9 *1 or *1B (115%, 111%, 119%, 198% and 193% increase in subjects with CYP2C9 *1/*1, *1B/*1B, *1/*3, *2/*3 and *3/*3 respectively). The results suggest different dose adjustments are potentially required for patients with different CYP2C9 genotypes if warfarin is administered together with CYP inhibitors or inducers. Significance Statement The present study found a target mediated drug disposition model is needed to sufficiently characterize the clinical pharmacokinetic profiles of warfarin racemates under different co-treatments in subjects with various CYP2C9 genotypes, following a single dose of warfarin administration. The study also found S-warfarin, the pharmacologically more active ingredient in warfarin, exhibits CYP2C9 genotype-dependent drug-drug interactions, which indicates the dose of warfarin may need to be adjusted differently in subjects with different CYP2C9 genotypes in the presence of drug-drug interactions.
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Affiliation(s)
| | - Darcy R Flora
- Present Affiliation: GRYT Health Inc., United States
| | - Allan E Rettie
- Dept. of Medicinal Chemistry, University of Washington, United States
| | - Richard C Brundage
- Experimental and Clinical Pharmacology, University of Minnesota, United States
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Elnour AA, Ahmed IM, Khalid AK, Elmustafa M. Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study. Pharm Pract (Granada) 2022; 20:2722. [PMID: 36733524 PMCID: PMC9851814 DOI: 10.18549/pharmpract.2022.3.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing. Objective The current study's main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects. Method We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms). Main outcome measure The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy. Results We have enrolled 71 Sudanese subjects with mean age (51.7 ± 14 years), of which (49, 69.0%) were females. There was no significant difference between the warfarin 5 mg fixed standard dose strategy and the predicted doses of the two clinical algorithm models (MAE 1.44, 1.45, and 1.49 mg/day [P =0.4]) respectively. In the clinical practicality, all of the three models had a high percent of subjects (95.0%, 51.9%, and 66.7%) in the ideal dose range in middle dose group (3-7 mg/ day) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithm models respectively. However, a small percent of subjects was exhibited in the warfarin low dose group ≤ 3 mg/day (0.0%, 15.0%, and 10.0%) and warfarin high dose group ≥ 7 mg/day (0.0%, 33.3%, and 33.3%) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithms respectively. In terms of clinical safety, the percent of subjects with severely over-prediction were 28.2%, 22.5%, and 22.5% for warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. While the percent of severely under-prediction was 12.7%, 7.0%, and 5.6% for the warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. Conclusion The Gage and IWPC clinical algorithm models were accurate, more clinically practical, and clinically safe than warfarin 5 mg standard dosing in the study population. The cardiologist can use either models (Gage and IWPC) to stratify subjects for accurate, practical, and clinically safe warfarin dosing..
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Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University (AAU), Abu Dhabi campus, Abu Dhabi-United Arab Emirates (UAE). AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Islam Mohammed Ahmed
- PhD student, MSc, B Pharm. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan. b. Faculty of Pharmacy, Managel University for Science and Technology, Managel-Sudan.
| | - Al-Kubaissi Khalid
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
| | - Mohamed Elmustafa
- PhD, Msc. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan.
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Nirvik P, Kertai MD. Future of Perioperative Precision Medicine: Integration of Molecular Science, Dynamic Health Care Informatics, and Implementation of Predictive Pathways in Real Time. Anesth Analg 2022; 134:900-908. [PMID: 35320133 DOI: 10.1213/ane.0000000000005966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Conceptually, precision medicine is a deep dive to discover disease origin at the molecular or genetic level, thus providing insights that allow clinicians to design corresponding individualized patient therapies. We know that a disease state is created by not only certain molecular derangements but also a biologic milieu promoting the expression of such derangements. These factors together lead to manifested symptoms. At the level of molecular definition, every average, "similar" individual stands to be "dissimilar." Hence, there is the need for customized therapy, moving away from therapy based on aggregate statistics. The perioperative state is a mix of several, simultaneously active molecular mechanisms, surgical insult, drugs, severe inflammatory response, and the body's continuous adaptation to maintain a state of homeostasis. Postoperative outcomes are a net result of several of those rapid genetic and molecular transformations that do or do not ensue. With the advent and advances of artificial intelligence, the translation from identifying these intricate mechanisms to implementing them in clinical practice has made a huge leap. Precision medicine is gaining ground with the help of personalized health recorders and personal devices that identify disease mechanics, patient-reported outcomes, adverse drug reactions, and drug-drug interaction at the individual level in a closed-loop feedback system. This phenomenon is especially true given increasing surgeries in older adults, many of whom are on multiple medications and varyingly frail. In this era of precision medicine, to provide a comprehensive remedy, the perioperative surgical home must expand, incorporating not only clinicians but also basic science experts and data scientists.
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Affiliation(s)
- Pal Nirvik
- From the Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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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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8
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Ndadza A, Muyambo S, Mntla P, Wonkam A, Chimusa E, Kengne AP, Ntsekhe M, Dandara C. Profiling of warfarin pharmacokinetics-associated genetic variants: Black Africans portray unique genetic markers important for an African specific warfarin pharmacogenetics-dosing algorithm. J Thromb Haemost 2021; 19:2957-2973. [PMID: 34382722 PMCID: PMC9543705 DOI: 10.1111/jth.15494] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Warfarin dose variability observed in patients is attributed to variation in genes involved in the warfarin metabolic pathway. Genetic variation in CYP2C9 and VKORC1 has been the traditional focus in evaluating warfarin dose variability, with little focus on other genes. OBJECTIVE We set out to evaluate 27 single nucleotide polymorphisms (SNPs) in the CYP2C cluster loci and 8 genes (VKORC1, ABCB1, CYP2C9, CYP2C19, CYP2C8, CYP1A2, CYP3A4, and CYP3A5) involved in pharmacokinetics of warfarin. PATIENTS/METHODS 503 participants were recruited among black Africans and Mixed Ancestry population groups, from South Africa and Zimbabwe, and a blood sample taken for DNA. Clinical parameters were obtained from patient medical records, and these were correlated with genetic variation. RESULTS Among black Africans, the SNPs CYP2C rs12777823G>A, CYP2C9 c.449G>A (*8), CYP2C9 c.1003C>T (*11) and CYP2C8 c.805A>T (*2) were significantly associated with warfarin maintenance dose. Conversely, CYP2C9 c.430C>T (*2), CYP2C8 c.792C>G (*4) and VKORC1 g.-1639G>A were significantly associated with maintenance dose among the Mixed Ancestry. The presence of CYP2C8*2 and CYP3A5*6 alleles was associated with increased mean warfarin maintenance dose, whereas CYP2C9*8 allele was associated with reduced warfarin maintenance dose. CONCLUSION African populations present with a diversity of variants that are important in predicting pharmacogenetics-based warfarin dosing in addition to those reported in CYP2C9 and VKORC1. It is therefore important, to include African populations in pharmacogenomics studies to be able to identify all possible biomarkers that are potential predictors for drug response.
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Affiliation(s)
- Arinao Ndadza
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Sarudzai Muyambo
- Department of Clinical PharmacologyCollege of Health ScienceUniversity of ZimbabweHarareZimbabwe
- Department of Biological SciencesFaculty of Science and EngineeringBindura University of Science and EducationBinduraZimbabwe
| | - Pindile Mntla
- Department of CardiologySefako Makgatho Health Sciences University and Dr. George Mukhari HospitalPretoriaSouth Africa
| | - Ambroise Wonkam
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Emile Chimusa
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Andre P. Kengne
- Non‐Communicable Diseases Research UnitSouth African Medical Research Council and University of Cape TownCape TownSouth Africa
| | - Mpiko Ntsekhe
- Division of CardiologyDepartment of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Collet Dandara
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Development of a system to support warfarin dose decisions using deep neural networks. Sci Rep 2021; 11:14745. [PMID: 34285309 PMCID: PMC8292496 DOI: 10.1038/s41598-021-94305-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/09/2021] [Indexed: 11/09/2022] Open
Abstract
The first aim of this study was to develop a prothrombin time international normalized ratio (PT INR) prediction model. The second aim was to develop a warfarin maintenance dose decision support system as a precise warfarin dosing platform. Data of 19,719 inpatients from three institutions was analyzed. The PT INR prediction algorithm included dense and recurrent neural networks, and was designed to predict the 5th-day PT INR from data of days 1-4. Data from patients in one hospital (n = 22,314) was used to train the algorithm which was tested with the datasets from the other two hospitals (n = 12,673). The performance of 5th-day PT INR prediction was compared with 2000 predictions made by 10 expert physicians. A generator of individualized warfarin dose-PT INR tables which simulated the repeated administration of varying doses of warfarin was developed based on the prediction model. The algorithm outperformed humans with accuracy terms of within ± 0.3 of the actual value (machine learning algorithm: 10,650/12,673 cases (84.0%), expert physicians: 1647/2000 cases (81.9%), P = 0.014). In the individualized warfarin dose-PT INR tables generated by the algorithm, the 8th-day PT INR predictions were within 0.3 of actual value in 450/842 cases (53.4%). An artificial intelligence-based warfarin dosing algorithm using a recurrent neural network outperformed expert physicians in predicting future PT INRs. An individualized warfarin dose-PT INR table generator which was constructed based on this algorithm was acceptable.
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McDonough CW. Pharmacogenomics in Cardiovascular Diseases. Curr Protoc 2021; 1:e189. [PMID: 34232575 DOI: 10.1002/cpz1.189] [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: 11/11/2022]
Abstract
Cardiovascular pharmacogenomics is the study and identification of genomic markers that are associated with variability in cardiovascular drug response, cardiovascular drug-related outcomes, or cardiovascular drug-related adverse events. This overview presents an introduction and historical background to cardiovascular pharmacogenomics, and a protocol for designing a cardiovascular pharmacogenomics study. Important considerations are also included for constructing a cardiovascular pharmacogenomics phenotype, designing the replication or validation strategy, common statistical approaches, and how to put the results in context with the cardiovascular drug or cardiovascular disease under investigation. © 2021 Wiley Periodicals LLC. Basic Protocol: Designing a cardiovascular pharmacogenomics study.
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Affiliation(s)
- Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
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11
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Amekyeh H, Tarlochan F, Billa N. Practicality of 3D Printed Personalized Medicines in Therapeutics. Front Pharmacol 2021; 12:646836. [PMID: 33912058 PMCID: PMC8072378 DOI: 10.3389/fphar.2021.646836] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/02/2021] [Indexed: 11/13/2022] Open
Abstract
Technological advances in science over the past century have paved the way for remedial treatment outcomes in various diseases. Pharmacogenomic predispositions, the emergence of multidrug resistance, medication and formulation errors contribute significantly to patient mortality. The concept of "personalized" or "precision" medicines provides a window to addressing these issues and hence reducing mortality. The emergence of three-dimensional printing of medicines over the past decades has generated interests in therapeutics and dispensing, whereby the provisions of personalized medicines can be built within the framework of producing medicines at dispensaries or pharmacies. This plan is a good replacement of the fit-for-all modality in conventional therapeutics, where clinicians are constrained to prescribe pre-formulated dose units available on the market. However, three-dimension printing of personalized medicines faces several hurdles, but these are not insurmountable. In this review, we explore the relevance of personalized medicines in therapeutics and how three-dimensional printing makes a good fit in current gaps within conventional therapeutics in order to secure an effective implementation of personalized medicines. We also explore the deployment of three-dimensional printing of personalized medicines based on practical, legal and regulatory provisions.
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Affiliation(s)
- Hilda Amekyeh
- Department of Pharmaceutics, School of Pharmacy, University of Health and Allied Sciences, Ho, Ghana
| | | | - Nashiru Billa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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12
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Asiimwe IG, Zhang EJ, Osanlou R, Jorgensen AL, Pirmohamed M. Warfarin dosing algorithms: A systematic review. Br J Clin Pharmacol 2020; 87:1717-1729. [PMID: 33080066 PMCID: PMC8056736 DOI: 10.1111/bcp.14608] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Numerous algorithms have been developed to guide warfarin dosing and improve clinical outcomes. We reviewed the algorithms available for various populations and the covariates, performances and risk of bias of these algorithms. Methods We systematically searched MEDLINE up to 20 May 2020 and selected studies describing the development, external validation or clinical utility of a multivariable warfarin dosing algorithm. Two investigators conducted data extraction and quality assessment. Results Of 10 035 screened records, 266 articles were included in the review, describing the development of 433 dosing algorithms, 481 external validations and 52 clinical utility assessments. Most developed algorithms were for dose initiation (86%), developed by multiple linear regression (65%) and mostly applicable to Asians (49%) or Whites (43%). The most common demographic/clinical/environmental covariates were age (included in 401 algorithms), concomitant medications (270 algorithms) and weight (229 algorithms) while CYP2C9 (329 algorithms), VKORC1 (319 algorithms) and CYP4F2 (92 algorithms) variants were the most common genetic covariates. Only 26% and 7% algorithms were externally validated and evaluated for clinical utility, respectively, with <2% of algorithm developments and external validations being rated as having a low risk of bias. Conclusion Most warfarin dosing algorithms have been developed in Asians and Whites and may not be applicable to under‐served populations. Few algorithms have been externally validated, assessed for clinical utility, and/or have a low risk of bias which makes them unreliable for clinical use. Algorithm development and assessment should follow current methodological recommendations to improve reliability and applicability, and under‐represented populations should be prioritized.
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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, United Kingdom
| | - Eunice J Zhang
- 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, United Kingdom
| | - Rostam Osanlou
- 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, United Kingdom
| | - Andrea L Jorgensen
- Department of Biostatistics, Institute of Population Health Sciences, University of 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, United Kingdom
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13
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Dietz N, Ruff C, Giugliano RP, Mercuri MF, Antman EM. Pharmacogenetic-guided and clinical warfarin dosing algorithm assessments with bleeding outcomes risk-stratified by genetic and covariate subgroups. Int J Cardiol 2020; 317:159-166. [DOI: 10.1016/j.ijcard.2020.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
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Ndadza A, Thomford NE, Mukanganyama S, Wonkam A, Ntsekhe M, Dandara C. The Genetics of Warfarin Dose-Response Variability in Africans: An Expert Perspective on Past, Present, and Future. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 23:152-166. [PMID: 30883300 DOI: 10.1089/omi.2019.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Coumarins such as warfarin are prescribed for prevention and treatment of thromboembolic disorders. Warfarin remains the most widely prescribed and an anticoagulant of choice in Africa. Warfarin use is, however, limited by interindividual variability in pharmacokinetics and a narrow therapeutic index. The difference in patients' pharmacodynamic responses to warfarin has been attributed to genetic variation in warfarin metabolism and molecular targets (e.g., CYP2C9 and VKORC1) and host-environment interactions. This expert review offers a synthesis of human genetics studies in Africans with respect to pharmacogenetics-informed warfarin dosing. We identify areas that need future research attention or could benefit from harnessing existing pharmacogenetics knowledge toward rational and optimal therapeutics with warfarin in African patients. A literature search was conducted until January 2019. A total of 343 articles were retrieved from nine African countries: Botswana, Ethiopia, Egypt, Ghana, Kenya, South Africa, Sudan, Tanzania, and Mozambique. We found 19 studies on genetics of warfarin treatment specifically among Africans. Genes examined included CYP2C9, VKORC1, CYP4F2, APOE, CALU, GGCX, and EPHX1. CYP2C9*2 and *3 alleles were highly frequent among Egyptians, while rare in other African populations. CYP2C9*5, *8, *9, and *11, and VKORC1 Asp36Tyr genetic variants explained warfarin variability in Africans better, compared to CYP2C9*2 and *3. In Africa, there is limited pharmacogenetics data on warfarin. Therefore, future research and funding commitments should be prioritized to ensure safe and effective use of warfarin in Africa. Lessons learned in Africa from the science of pharmacogenetics would inform rational therapeutics in hematology, cardiology, and surgical specialties worldwide.
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Affiliation(s)
- Arinao Ndadza
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nicholas Ekow Thomford
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Ambroise Wonkam
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mpiko Ntsekhe
- 3 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Collet Dandara
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Non-genetic factors and polymorphisms in genes CYP2C9 and VKORC1: predictive algorithms for TTR in Brazilian patients on warfarin. Eur J Clin Pharmacol 2019; 76:199-209. [DOI: 10.1007/s00228-019-02772-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/24/2019] [Indexed: 01/06/2023]
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Ohgushi A, Nakayama N, Namiki A, Nagashima A, Ogawa R, Akazawa M, Echizen H. A Retrospective Evaluation of the Impact of Multi-disciplinary Approach for Improving the Quality of Anticoagulation Therapy in Ambulatory Patients with Non-valvular Atrial Fibrillation Receiving Warfarin. YAKUGAKU ZASSHI 2019; 139:1177-1183. [DOI: 10.1248/yakushi.18-00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Atsushi Ohgushi
- Department of Hospital Pharmacy, Japan Organization of Occupational Health and Safety, Kanto Rosai Hospital
| | - Natsumi Nakayama
- Department of Hospital Pharmacy, Japan Organization of Occupational Health and Safety, Kanto Rosai Hospital
| | - Atsuo Namiki
- Department of Cardiology, Japan Organization of Occupational Health and Safety, Kanto Rosai Hospital
| | - Akira Nagashima
- Department of Hospital Pharmacy, Japan Organization of Occupational Health and Safety, Spinal Injuries Center
| | - Ryuichi Ogawa
- Department of Pharmacotherapy, Meiji Pharmaceutical University
| | - Manabu Akazawa
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University
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Dávila-Fajardo CL, Díaz-Villamarín X, Antúnez-Rodríguez A, Fernández-Gómez AE, García-Navas P, Martínez-González LJ, Dávila-Fajardo JA, Barrera JC. Pharmacogenetics in the Treatment of Cardiovascular Diseases and Its Current Progress Regarding Implementation in the Clinical Routine. Genes (Basel) 2019; 10:genes10040261. [PMID: 30939847 PMCID: PMC6523655 DOI: 10.3390/genes10040261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
There is a special interest in the implementation of pharmacogenetics in clinical practice, although there are some barriers that are preventing this integration. A large part of these pharmacogenetic tests are focused on drugs used in oncology and psychiatry fields and for antiviral drugs. However, the scientific evidence is also high for other drugs used in other medical areas, for example, in cardiology. In this article, we discuss the evidence and guidelines currently available on pharmacogenetics for clopidogrel, warfarin, acenocoumarol, and simvastatin and its implementation in daily clinical practice.
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Affiliation(s)
- Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Alba Antúnez-Rodríguez
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | - Ana Estefanía Fernández-Gómez
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Paloma García-Navas
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Luis Javier Martínez-González
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
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Dong J, Shi GH, Lu M, Huang S, Liu YH, Yao JC, Li WY, Li LX. Evaluation of the predictive performance of Bayesian dosing for warfarin in Chinese patients. Pharmacogenomics 2019; 20:167-177. [PMID: 30777785 DOI: 10.2217/pgs-2018-0127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the accuracy and predictive performance of Bayesian dosing for warfarin in Chinese patients. Materials & methods: Six multiple linear regression algorithms (Wei, Lou, Miao, Huang, Gage and IWPC) and a Bayesian method implemented in Warfarin Dose Calculator were compared with each other. Results: Six multiple linear regression warfarin dosing algorithms had similar predictive ability, except Miao and Lou. The mean prediction error of Bayesian priori and posteriori method were 0.01 mg/day (95% CI: -0.18 to 0.19) and 0.17 mg/day (95% CI: -0.05 to 0.29), respectively, and Bayesian posteriori method demonstrated better performance in all dose ranges. Conclusion: The Bayesian method showed a good potential for warfarin maintenance dose prediction in Chinese patients requiring less than 6 mg/day.
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Affiliation(s)
- Jing Dong
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Guo-Hua Shi
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Man Lu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Shu Huang
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Yan-Hui Liu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jia-Chen Yao
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Wen-Yan Li
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Long-Xuan Li
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
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Shukla A, Jain A, Kahalekar V, Bendkhale S, Gogtay N, Thatte U, Bhatia S. Mutations in CYP2C9 and/or VKORC1 haplotype are associated with higher bleeding complications in patients with Budd-Chiari syndrome on warfarin. Hepatol Int 2019; 13:214-221. [PMID: 30617764 DOI: 10.1007/s12072-018-9922-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Anticoagulation is universally recommended in Budd-Chiari syndrome [BCS]. Vitamin K epoxide reductase complex 1 (VKORC1) and CYP2C9 are involved in the metabolism of warfarin. The present study was done to assess whether these mutations are associated with the risk of bleeding in patients with BCS receiving warfarin. PATIENTS AND METHODS Patients diagnosed with BCS underwent genotyping for three single nucleotide polymorphisms [SNPs]-two for the CYP2C9 and one for the VKORC1 haplotype. The patients were followed up for at least 12 months and all bleeding episodes were recorded. Patients with and without mutations were compared for bleeding complications and a crude odds ratio [crude OR] was derived for the association between bleeding and presence or absence of mutant alleles. RESULTS Eighty patients [mean (SD) age 27.47 (8.93) years, 35 male] with BCS underwent genetic testing. 37/80 (46.2%) patients had mutation of CYP2C9 and/or VKORC1; 22/80 (27.5%) had either of the mutant alleles of CYP2C9 and, similarly, 22/80 (27.5%) had the VKORC mutation. Over a median follow-up of 20 (range 12-96) months, 21/80 (26.3%) patients had bleeding complications. Patients with mutant SNPs had a higher risk of bleeding than those without [14/37 vs. 7/43, p = 0.04, crude OR (95% CI) 3.13 (1.1-8.9)]. CONCLUSION The presence of mutations in VKORC1 or CYP2C9 is associated with increased risk of bleeding in patients with BCS on warfarin. Such patients with SNPs of CY2C9 or VKORC1 haplotype should be monitored intensively while receiving warfarin.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India.
| | - Abhinav Jain
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Vinit Kahalekar
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Sheetal Bendkhale
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Nithya Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Urmila Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, 400012, India
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Tan-Koi WC, Limenta M, Mohamed EHM, Lee EJD. The Importance of Ethnicity Definitions and Pharmacogenomics in Ethnobridging and Pharmacovigilance. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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22
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Ndadza A, Cindi Z, Makambwa E, Chimusa E, Wonkam A, Kengne AP, Ntsekhe M, Dandara C. Warfarin Dose and CYP2C Gene Cluster: An African Ancestral-Specific Variant Is a Strong Predictor of Dose in Black South African Patients. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2018; 23:36-44. [PMID: 30566377 DOI: 10.1089/omi.2018.0174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Warfarin is a widely prescribed anticoagulant with a narrow therapeutic index. The rs12777823G>A single-nucleotide polymorphism (SNP) in the CYP2C gene cluster has been shown to influence optimal warfarin doses in African Americans. We report here effects of rs12777823G>A SNP on warfarin dose requirements in two South African population groups, black Africans (BA) and mixed ancestry (MA). A total of 425 participants on warfarin treatment were enrolled in the study. The age group of the studied population ranged between 44 and 66 years, with 69% females enrolled. Genetic characterization of the rs12777823G>A was done using the TaqMan SNP genotyping assay. To further compare effects of rs12777823G>A to those of other SNPs, VKORC1 g.-1639G>A and 4 SNPs in CYP2C9 gene (i.e., CYP2C9 c.430C>T, c.1075A>C, c.449G>A, and c.1003C>T) were analyzed. The rs12777823A variant allele frequencies were 0.28 and 0.25 in the BA and MA, respectively. The rs12777823A/A genotype was associated with significantly (p = 0.002) reduced mean warfarin dosage (27 ± 5.3 mg/week) compared with the G/G genotype (45 ± 16.1 mg/week) among BA, but not among the MA. The rs12777823G>A is located in a nongenomic region, suggesting that this SNP might be in linkage disequilibrium with another, likely causal SNP that is present in BA only. Given ongoing worldwide efforts to identify clinically relevant human genetic variation impacting on optimal warfarin dose selection, the African ancestry-specific genetic variant in the CYP2C cluster and others warrant further research and consideration in development of future warfarin dosing algorithms for precision medicine guidelines.
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Affiliation(s)
- Arinao Ndadza
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Zinhle Cindi
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Edson Makambwa
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Emile Chimusa
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Ambroise Wonkam
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Andre P Kengne
- 3 Non-Communicable Diseases Research Unit, South African Medical Research Council and University of Cape Town , Cape Town, South Africa
| | - Mpiko Ntsekhe
- 2 Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
| | - Collet Dandara
- 1 Pharmacogenomics and Drug Metabolism Research Group, Division of Human Genetics, Department of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
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FREQUENCIES OF POLYMORPHISMS IN THE CYTOCHROME’S P450 GENES OF WARFARIN TRANSFORMATION IN A EUROPEAN POPULATION OF EASTERN SIBERIA. ACTA BIOMEDICA SCIENTIFICA 2018. [DOI: 10.29413/abs.2018-3.5.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. Genotypes of the cytochrome p450 isoform (CYP2C9 and CYP4F2) determine warfarin dose requirements. Frequencies of risk alleles and genotypes of CYP2C9 and CYP4F2 gene vary in different races and ethnic groups.Aim. This study analyzed the frequencies of *2, *3 alleles of CYP2C9 gene and the 1347 C>T allele of CYP4F2 gene in the Caucasians of Eastern Siberia, and compare with other populations.Materials and methods. Participants were 147 patients (Caucasians): 67 (45.58 %) man and 80 (54.42 %) women), taking warfarin for the prevention of thrombosis with a mean age of 64.74 ± 14.29 years. There were patients with atrial fibrillation – 77 (52.38 %) persons, coronary artery disease – 10 (6.80 %), pulmonary embolism – 5 (3.40 %), 15 (10.20 %) patients after implantation of an mechanical heart valve, etc. The subjects were genotyped for CYP2C9 (*1,*2,*3), and CYP4F2 (1347 C>T) by real-time polymerase chain reaction (RT-PCR) using “Pharmacogenetics Warfarin” reagent kits (DNA technology, Russia).Results. 69.4 % of Caucasians of Eastern Siberia (Russians), have two functional alleles (*1/*1) of CYP2C9 (they’re extensive/normal metabolizers), the number of intermediate metabolizers (*1/*2, *1/*3) was 29.8 % and 0.68 % of slow metabolizers (*3/*3). Homozygous carriers of two non-functional alleles *2 and *3 (*2/*2, *2/*3) were absent. Carriers of one coumarin-resistant Т-allele of CYP4F2 were 57 (38.7 %) respondents, two coumarin-resistant alleles – 10 (6.8 %) respondents.Conclusions. Frequencies of polymorphisms in the Cytochrome’s p450 genes of warfarin transformation in a European population of Eastern Siberia have no differences with other European populations of the world
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Drozda K, Pacanowski MA, Grimstein C, Zineh I. Pharmacogenetic Labeling of FDA-Approved Drugs: A Regulatory Retrospective. JACC Basic Transl Sci 2018; 3:545-549. [PMID: 30175278 PMCID: PMC6115648 DOI: 10.1016/j.jacbts.2018.06.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/17/2022]
Abstract
The U.S. Food and Drug Administration recently marked 10 years since first updating the labeling for warfarin (often referred to as the “poster child” of pharmacogenomics) to include information regarding the potential impact of CYP2C9 and VKORC1 genetic variation on warfarin dosing requirements and risks. Herein, we opine on the experience updating the warfarin labeling, highlighting more generally the enabling factors and challenges encountered when considering incorporation of pharmacogenomic information into the prescribing recommendations for already approved drugs. We also provide a historical perspective of implemented changes in regulatory policies related to personalized medicine.
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Affiliation(s)
- Katarzyna Drozda
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Michael A Pacanowski
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Christian Grimstein
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Issam Zineh
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Syn NL, Wong ALA, Lee SC, Teoh HL, Yip JWL, Seet RC, Yeo WT, Kristanto W, Bee PC, Poon LM, Marban P, Wu TS, Winther MD, Brunham LR, Soong R, Tai BC, Goh BC. Genotype-guided versus traditional clinical dosing of warfarin in patients of Asian ancestry: a randomized controlled trial. BMC Med 2018; 16:104. [PMID: 29986700 PMCID: PMC6038204 DOI: 10.1186/s12916-018-1093-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Genotype-guided warfarin dosing has been shown in some randomized trials to improve anticoagulation outcomes in individuals of European ancestry, yet its utility in Asian patients remains unresolved. METHODS An open-label, non-inferiority, 1:1 randomized trial was conducted at three academic hospitals in South East Asia, involving 322 ethnically diverse patients newly indicated for warfarin (NCT00700895). Clinical follow-up was 90 days. The primary efficacy measure was the number of dose titrations within the first 2 weeks of therapy, with a mean non-inferiority margin of 0.5 over the first 14 days of therapy. RESULTS Among 322 randomized patients, 269 were evaluable for the primary endpoint. Compared with traditional dosing, the genotype-guided group required fewer dose titrations during the first 2 weeks (1.77 vs. 2.93, difference -1.16, 90% CI -1.48 to -0.84, P < 0.001 for both non-inferiority and superiority). The percentage of time within the therapeutic range over 3 months and median time to stable international normalized ratio (INR) did not differ between the genotype-guided and traditional dosing groups. The frequency of dose titrations (incidence rate ratio 0.76, 95% CI 0.67 to 0.86, P = 0.001), but not frequency of INR measurements, was lower at 1, 2, and 3 months in the genotype-guided group. The proportions of patients who experienced minor or major bleeding, recurrent venous thromboembolism, or out-of-range INR did not differ between both arms. For predicting maintenance doses, the pharmacogenetic algorithm achieved an R2 = 42.4% (P < 0.001) and mean percentage error of -7.4%. CONCLUSIONS Among Asian adults commencing warfarin therapy, a pharmacogenetic algorithm meets criteria for both non-inferiority and superiority in reducing dose titrations compared with a traditional dosing approach, and performs well in prediction of actual maintenance doses. These findings imply that clinicians may consider applying a pharmacogenetic algorithm to personalize initial warfarin dosages in Asian patients. TRIAL REGISTRATION ClinicalTrials.gov NCT00700895 . Registered on June 19, 2008.
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Affiliation(s)
- Nicholas L Syn
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Andrea Li-Ann Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - James Wei Luen Yip
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Raymond Cs Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - William Kristanto
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ping-Chong Bee
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - L M Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Patrick Marban
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Tuck Seng Wu
- Department of Pharmacy, National University Hospital, Singapore, Singapore
| | - Michael D Winther
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore, Singapore
| | - Liam R Brunham
- Translational Laboratory in Genetic Medicine, Agency for Science, Technology and Research, Singapore, Singapore.,Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - Richie Soong
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Pathology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore
| | - Bee-Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Boon-Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore. .,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore. .,Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, 119228, Singapore.
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26
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Abstract
Precision medicine is an integrative approach to cardiovascular disease prevention and treatment that considers an individual's genetics, lifestyle, and exposures as determinants of their cardiovascular health and disease phenotypes. This focus overcomes the limitations of reductionism in medicine, which presumes that all patients with the same signs of disease share a common pathophenotype and, therefore, should be treated similarly. Precision medicine incorporates standard clinical and health record data with advanced panomics (ie, transcriptomics, epigenomics, proteomics, metabolomics, and microbiomics) for deep phenotyping. These phenotypic data can then be analyzed within the framework of molecular interaction (interactome) networks to uncover previously unrecognized disease phenotypes and relationships between diseases, and to select pharmacotherapeutics or identify potential protein-drug or drug-drug interactions. In this review, we discuss the current spectrum of cardiovascular health and disease, population averages and the response of extreme phenotypes to interventions, and population-based versus high-risk treatment strategies as a pretext to understanding a precision medicine approach to cardiovascular disease prevention and therapeutic interventions. We also consider the search for resilience and Mendelian disease genes and argue against the theory of a single causal gene/gene product as a mediator of the cardiovascular disease phenotype, as well as an Erlichian magic bullet to solve cardiovascular disease. Finally, we detail the importance of deep phenotyping and interactome networks and the use of this information for rational polypharmacy. These topics highlight the urgent need for precise phenotyping to advance precision medicine as a strategy to improve cardiovascular health and prevent disease.
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Affiliation(s)
- Jane A Leopold
- From the Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Joseph Loscalzo
- From the Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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Abstract
SummaryThe traditional approach to selecting antipsychotic medication involves little more than trial and error. Recent advances in genetics and molecular science offer the hope of a ‘personalised medicine’ approach to antipsychotic development and prescribing in schizophrenia. Personalised medicine is the practice of tailoring medical treatment to the individual characteristics of each patient. In schizophrenia, this will involve the identification of more homogeneous subsets of patients through the application of genetics, epigenetics, proteomics and metabolomics, neuroimaging and other biomarkers, and the use of these findings to stratify patients according to their response to treatment. In this article, we focus on the emerging evidence in pharmacogenetics and biomarkers for assessing individual response and tolerability of antipsychotic medication in schizophrenia.
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Influence of Genotype on Warfarin Maintenance Dose Predictions Produced Using a Bayesian Dose Individualization Tool. Ther Drug Monit 2017; 38:677-683. [PMID: 27855133 DOI: 10.1097/ftd.0000000000000347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A previously established Bayesian dosing tool for warfarin was found to produce biased maintenance dose predictions. In this study, we aimed (1) to determine whether the biased warfarin dose predictions previously observed could be replicated in a new cohort of patients from 2 different clinical settings, (2) to explore the influence of CYP2C9 and VKORC1 genotype on predictive performance of the Bayesian dosing tool, and (3) to determine whether the previous population used to develop the kinetic-pharmacodynamic model underpinning the Bayesian dosing tool was sufficiently different from the test (posterior) population to account for the biased dose predictions. METHODS The warfarin maintenance doses for 140 patients were predicted using the dosing tool and compared with the observed maintenance dose. The impact of genotype was assessed by predicting maintenance doses with prior parameter values known to be altered by genetic variability (eg, EC50 for VKORC1 genotype). The prior population was evaluated by fitting the published kinetic-pharmacodynamic model, which underpins the Bayesian tool, to the observed data using NONMEM and comparing the model parameter estimates with published values. RESULTS The Bayesian tool produced positively biased dose predictions in the new cohort of patients (mean prediction error [95% confidence interval]; 0.32 mg/d [0.14-0.5]). The bias was only observed in patients requiring ≥7 mg/d. The direction and magnitude of the observed bias was not influenced by genotype. The prior model provided a good fit to our data, which suggests that the bias was not caused by different prior and posterior populations. CONCLUSIONS Maintenance doses for patients requiring ≥7 mg/d were overpredicted. The bias was not due to the influence of genotype nor was it related to differences between the prior and posterior populations. There is a need for a more mechanistic model that captures warfarin dose-response relationship at higher warfarin doses.
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Cerezo-Manchado JJ, Rosafalco M, Antón A, Perez-Andreu V, Garcia-Barberá N, Martínez AB, Corral J, Vicente V, González-Conejero R, Roldán V. Creating a genotype-based dosing algorithm for acenocoumarol steady dose. Thromb Haemost 2017. [DOI: 10.1160/th12-08-0631] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
SummaryAcenocoumarol is a commonly prescribed anticoagulant drug for the prophylaxis and treatment of venous and arterial thromboembolic disorders in several countries. In counterpart of warfarin, there is scarce information about pharmacogenetic algorithms for steady acenocoumarol dose estimation. The aim of this study was to develop an algorithm of prediction for acenocoumarol.The algorithm was created using the data from 973 retrospectively selected anticoagulated patients and was validated in a second independent cohort adding up to 2,683 patients. The best regression model to predict stable dosage in the Primary Cohort included clinical factors (age and body mass index, BSA) and genetic variants (VKORC1, CYP2C9* and CYP4F2 polymorphisms) and explained up to 50% of stable dose. In the validation study the clinical algorithm yielded an adjusted R2=0.15 (estimation´s standard error=4.5) and the genetic approach improved the dose forecast up to 30% (estimation´s standard error=4.6). Again, the best model combined clinical and genetic factors (R2= 0.48; estimation´s standard error=4) which provided the best results of doses estimates within 20% of the real dose in patients taking lower (≤7mg/week) or higher (≥25mg/week) acenocoumarol doses. In conclusion, we developed a prediction algorithm using clinical data and three polymorphisms in VKORC1, CYP2C9* and CYP4F2 genes that provided a steady acenocoumarol dose for about 50% of patients in the Validation Cohort. Such algorithm was especially useful to patients who need higher or lower acenocoumarol doses, those patients with higher time required until their stabilisation and are more prone to suffer a treatment derived complication.
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Kim DJ, Kim HS, Oh M, Kim EY, Shin JG. Cost Effectiveness of Genotype-Guided Warfarin Dosing in Patients with Mechanical Heart Valve Replacement Under the Fee-for-Service System. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:657-667. [PMID: 28247199 DOI: 10.1007/s40258-017-0317-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Although studies assessing the cost effectiveness of genotype-guided warfarin dosing for the management of atrial fibrillation, deep vein thrombosis, and pulmonary embolism have been reported, no publications have addressed genotype-guided warfarin therapy in mechanical heart valve replacement (MHVR) patients or genotype-guided warfarin therapy under the fee-for-service (FFS) insurance system. OBJECTIVE The aim of this study was to evaluate the cost effectiveness of genotype-guided warfarin dosing in patients with MHVR under the FFS system from the Korea healthcare sector perspective. METHODS A decision-analytic Markov model was developed to evaluate the cost effectiveness of genotype-guided warfarin dosing compared with standard dosing. Estimates of clinical adverse event rates and health state utilities were derived from the published literature. The outcome measure was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY). One-way and probabilistic sensitivity analyses were performed to explore the range of plausible results. RESULTS In a base-case analysis, genotype-guided warfarin dosing was associated with marginally higher QALYs than standard warfarin dosing (6.088 vs. 6.083, respectively), at a slightly higher cost (US$6.8) (year 2016 values). The ICER was US$1356.2 per QALY gained. In probabilistic sensitivity analysis, there was an 82.7% probability that genotype-guided dosing was dominant compared with standard dosing, and a 99.8% probability that it was cost effective at a willingness-to-pay threshold of US$50,000 per QALY gained. CONCLUSION Compared with only standard warfarin therapy, genotype-guided warfarin dosing was cost effective in MHVR patients under the FFS insurance system.
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Affiliation(s)
- Dong-Jin Kim
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea
| | - Ho-Sook Kim
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea.
- Department of Clinical Pharmacology, Inje University Busan Paik Hospital, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea.
| | - Minkyung Oh
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea
| | - Eun-Young Kim
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea
- Department of Clinical Pharmacology, Inje University Busan Paik Hospital, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea
| | - Jae-Gook Shin
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea.
- Department of Clinical Pharmacology, Inje University Busan Paik Hospital, 633-165 Gaegum 2-dong, Busan Jin-gu, Busan, Republic of Korea.
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Johnson JA, Caudle KE, Gong L, Whirl-Carrillo M, Stein CM, Scott SA, Lee MT, Gage BF, Kimmel SE, Perera MA, Anderson JL, Pirmohamed M, Klein TE, Limdi NA, Cavallari LH, Wadelius M. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Pharmacogenetics-Guided Warfarin Dosing: 2017 Update. Clin Pharmacol Ther 2017; 102:397-404. [PMID: 28198005 DOI: 10.1002/cpt.668] [Citation(s) in RCA: 400] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/19/2017] [Accepted: 02/02/2017] [Indexed: 01/06/2023]
Abstract
This document is an update to the 2011 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2C9 and VKORC1 genotypes and warfarin dosing. Evidence from the published literature is presented for CYP2C9, VKORC1, CYP4F2, and rs12777823 genotype-guided warfarin dosing to achieve a target international normalized ratio of 2-3 when clinical genotype results are available. In addition, this updated guideline incorporates recommendations for adult and pediatric patients that are specific to continental ancestry.
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Affiliation(s)
- J A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, and Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - L Gong
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - M Whirl-Carrillo
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - C M Stein
- Division of Clinical Pharmacology Vanderbilt Medical School, Nashville, Tennessee, USA
| | - S A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - M T Lee
- Laboratory for International Alliance on Genomic Research, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; National Center for Genome Medicine; Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan; Genomic Medicine Institute, Geisinger Health system, Danville, Pennsylvania, USA
| | - B F Gage
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - S E Kimmel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medicine and Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - M A Perera
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - J L Anderson
- Intermountain Heart Institute, Intermountain Medical Center, and Department of Internal Medicine (Cardiology), University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology; The Wolfson Centre for Personalised Medicine; Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - T E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - N A Limdi
- Department of Neurology and Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, and Center for Pharmacogenomics, University of Florida, Gainesville, Florida, USA
| | - M Wadelius
- Department of Medical Sciences, Clinical Pharmacology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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Kim S, Yun YM, Chae HJ, Cho HJ, Ji M, Kim IS, Wee KA, Lee W, Song SH, Woo HI, Lee SY, Chun S. Clinical Pharmacogenetic Testing and Application: Laboratory Medicine Clinical Practice Guidelines. Ann Lab Med 2017; 37:180-193. [PMID: 28029011 PMCID: PMC5204002 DOI: 10.3343/alm.2017.37.2.180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/07/2016] [Accepted: 12/11/2016] [Indexed: 12/15/2022] Open
Abstract
Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings.
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Affiliation(s)
- Sollip Kim
- Department of Laboratory Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yeo Min Yun
- Department of Laboratory Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyo Jin Chae
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Jung Cho
- Department of Laboratory Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Korea
| | - Misuk Ji
- Department of Laboratory Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - In Suk Kim
- Department of Laboratory Medicine, School of Medicine, Pusan National University, Busan, Korea
| | - Kyung A Wee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Woochang Lee
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Sang Hoon Song
- Department of Laboratory Medicine, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Hye In Woo
- Department of Laboratory Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Soo Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Sail Chun
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea.
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Sloane HS, Carter MB, Cecil AEC, Le Roux D, Mills DL, Landers JP. Warfarin genotyping with hybridization-induced aggregation on a poly(ethylene terephthalate) microdevice. Analyst 2017; 142:366-374. [DOI: 10.1039/c6an02325h] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A novel genotyping method is established, using allele-specific PCR followed by hybridization-induced aggregation (HIA) of microbeads on a multiplexed microdevice.
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Affiliation(s)
| | | | | | | | - Daniel L. Mills
- Department of Chemistry
- University of Virginia
- Charlottesville
- USA
| | - James P. Landers
- Department of Chemistry
- University of Virginia
- Charlottesville
- USA
- Department of Pathology
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López I, Sangüesa E, Vancraenendonck Y, Zuriaga E, Ribate MP, García CB. Can pharmacogenetics help patients under chronic treatment with coumarin anticoagulants? Drug Metab Pers Ther 2016; 31:191-196. [PMID: 27740916 DOI: 10.1515/dmpt-2016-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/02/2016] [Indexed: 11/15/2022]
Abstract
Vitamin K antagonists are highly effective antithrombotic drugs. However, appropriate dosing is difficult to establish owing to its narrow therapeutic window as well as widespread inter- and intra-individual variability in dosage. Compared with dosing solely based on clinical information, pharmacogenetics can help improve the therapy with coumarins by decreasing the time to reach a stable dose and reducing the risk of bleeding. Most of the studies about genotyping of patients using vitamin K antagonists have focused on predicting the stable dose. Two genes have been shown to have the most influence on dosing: VKORC1 and CYP2C9. Furthermore, genotyping of more genes, such as CYP4F2 and APOE, is also being included in some dosing algorithms. The role of genotype beyond the initial dose-titration phase is less clear. Thus, a proven genetically determined risk of unstable dose or bleeding could help with the selection of patients who require more frequent monitoring of dose. On the other hand, patients who have a genetically determined stable dose could self-monitor their international normalized ratio (INR), making the therapy less expensive and more convenient.
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Zaiou M, El Amri H. Cardiovascular pharmacogenetics: a promise for genomically‐guided therapy and personalized medicine. Clin Genet 2016; 91:355-370. [DOI: 10.1111/cge.12881] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 12/28/2022]
Affiliation(s)
- M. Zaiou
- Faculté de PharmacieUniversité de Lorraine Nancy France
| | - H. El Amri
- Laboratoire de Génétique de la Gendarmerie RoyaleAvenue Ibn Sina Rabat Maroc
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Shahabi P, Scheinfeldt LB, Lynch DE, Schmidlen TJ, Perreault S, Keller MA, Kasper R, Wawak L, Jarvis JP, Gerry NP, Gordon ES, Christman MF, Dubé MP, Gharani N. An expanded pharmacogenomics warfarin dosing table with utility in generalised dosing guidance. Thromb Haemost 2016; 116:337-48. [PMID: 27121899 PMCID: PMC6375065 DOI: 10.1160/th15-12-0955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/19/2016] [Indexed: 12/14/2022]
Abstract
Pharmacogenomics (PGx) guided warfarin dosing, using a comprehensive dosing algorithm, is expected to improve dose optimisation and lower the risk of adverse drug reactions. As a complementary tool, a simple genotype-dosing table, such as in the US Food and Drug Administration (FDA) Coumadin drug label, may be utilised for general risk assessment of likely over- or under-anticoagulation on a standard dose of warfarin. This tool may be used as part of the clinical decision support for the interpretation of genetic data, serving as a first step in the anticoagulation therapy decision making process. Here we used a publicly available warfarin dosing calculator (www.warfarindosing.org) to create an expanded gene-based warfarin dosing table, the CPMC-WD table that includes nine genetic variants in CYP2C9, VKORC1, and CYP4F2. Using two datasets, a European American cohort (EUA, n=73) and the Quebec Warfarin Cohort (QWC, n=769), we show that the CPMC-WD table more accurately predicts therapeutic dose than the FDA table (51 % vs 33 %, respectively, in the EUA, McNemar's two-sided p=0.02; 52 % vs 37 % in the QWC, p<1×10(-6)). It also outperforms both the standard of care 5 mg/day dosing (51 % vs 34 % in the EUA, p=0.04; 52 % vs 31 % in the QWC, p<1×10(-6)) as well as a clinical-only algorithm (51 % vs 38 % in the EUA, trend p=0.11; 52 % vs 45 % in the QWC, p=0.003). This table offers a valuable update to the PGx dosing guideline in the drug label.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Neda Gharani
- Neda Gharani, PhD, 1 Templemere, Weybridge, Surrey KT13 9PA, UK, Tel.: +44 7984005796, Fax:+44 1932976519, E-mail:
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Cifuentes RA, Murillo-Rojas J, Avella-Vargas E. Prediction of sensitivity to warfarin based on VKORC1 and CYP2C9 polymorphisms in patients from different places in Colombia. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2016; 36:91-100. [PMID: 27622442 DOI: 10.7705/biomedica.v36i1.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/14/2015] [Indexed: 06/06/2023]
Abstract
INTRODUCTION In the search to prevent hemorrhages associated with anticoagulant therapy, a major goal is to validate predictors of sensitivity to warfarin. However, previous studies in Colombia that included polymorphisms in the VKORC1 and CYP2C9 genes as predictors reported different algorithm performances to explain dose variations, and did not evaluate the prediction of sensitivity to warfarin. OBJECTIVE To determine the accuracy of the pharmacogenetic analysis, which includes the CYP2C9 *2 and *3 and VKORC1 1639G>A polymorphisms in predicting patients' sensitivity to warfarin at the Hospital Militar Central, a reference center for patients born in different parts of Colombia. MATERIALS AND METHODS Demographic and clinical data were obtained from 130 patients with stable doses of warfarin for more than two months. Next, their genotypes were obtained through a melting curve analysis. After verifying the Hardy-Weinberg equilibrium of the genotypes from the polymorphisms, a statistical analysis was done, which included multivariate and predictive approaches. RESULTS A pharmacogenetic model that explained 52.8% of dose variation (p<0.001) was built, which was only 4% above the performance resulting from the same data using the International Warfarin Pharmacogenetics Consortium algorithm. The model predicting the sensitivity achieved an accuracy of 77.8% and included age (p=0.003), polymorphisms *2 and *3 (p=0.002) and polymorphism 1639G>A (p<0.001) as predictors. CONCLUSIONS These results in a mixed population support the prediction of sensitivity to warfarin based on polymorphisms in VKORC1 and CYP2C9 as a valid approach in Colombian patients.
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Affiliation(s)
- Ricardo A Cifuentes
- Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, D.C., Colombia Grupo Insight, Universidad Militar Nueva Granada, Bogotá, D.C., Colombia.
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Marchant GE, Scheckel K, Campos-Outcalt D. Contrasting Medical and Legal Standards of Evidence: A Precision Medicine Case Study. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:194-204. [PMID: 27256135 PMCID: PMC5137582 DOI: 10.1177/1073110516644210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
As the health care system transitions to a precision medicine approach that tailors clinical care to the genetic profile of the individual patient, there is a potential tension between the clinical uptake of new technologies by providers and the legal system's expectation of the standard of care in applying such technologies. We examine this tension by comparing the type of evidence that physicians and courts are likely to rely on in determining a duty to recommend pharmacogenetic testing of patients prescribed the oral anti-coagulant drug warfarin. There is a large body of inconsistent evidence and factors for and against such testing, but physicians and courts are likely to weigh this evidence differently. The potential implications for medical malpractice risk are evaluated and discussed.
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Affiliation(s)
- Gary E. Marchant
- Corresponding author: Phone: 480-965-3246 (office); 480-388-7004 (cell); 480-727-6973 (fax);
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Liu R, Zhang K, Gong ZZ, Shi XM, Zhang Q, Pan XD, Dong R. Association of apolipoprotein E (APOE) polymorphisms with warfarin maintenance dose in a northern Han Chinese population. Lipids Health Dis 2016; 15:34. [PMID: 26912074 PMCID: PMC4765220 DOI: 10.1186/s12944-016-0205-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 02/16/2016] [Indexed: 02/07/2023] Open
Abstract
Background Apolipoprotein E (apoE) induces the uptake of vitamin K-rich lipoproteins by the liver, which likely affects inter-individual variation of warfarin dosing requirements. Associations between APOE polymorphisms and warfarin dosing were previously reported inconsistently among different ethnic groups, so the present study investigated this association in northern Han Chinese patients with mechanical heart valve prosthesis. Methods A total of 186 patients who underwent mechanical heart valve replacement and attained a stable warfarin dose were included. APOE single nucleotide polymorphisms (SNPs) rs7412 and rs429358 were genotyped using Illumina SNP GoldenGate Assay. Genotyping results were confirmed by direct sequencing. PHASE v2.1 software was used to construct rs7412 and rs429358 haplotypes. The effects of different APOE genotypes on warfarin dose were analyzed statistically. Results The mean warfarin maintenance dose was 3.10 ± 0.96 mg/day, and the mean international normalized ratio (INR) was 2.09 ± 0.24. APOE E2, E3, and E4 allele frequencies were 11.6 %, 82.5 %, and 5.9 %, respectively. No E2/E2 or E4/E4 genotypes were detected in this population. E2/E3, E3/E3, E2/E4, and E3/E4 genotype frequencies were 21.0 %, 67.2 %, 2.2 %, and 9.7 %, respectively. Significant differences in warfarin dose requirements were observed among patients with E2/E3, E3/E3, and E3/E4 genotypes (p < 0.05). In post hoc comparison, daily warfarin maintenance doses were significantly higher in E2/E3 heterozygotes compared with E3/E3 homozygotes (p < 0.05), but no differences in dose requirements were found between E3/E4 and E3/E3, or E2/E3 and E3/E4 (p > 0.05). Patients were divided into low-intensity anticoagulant treatment group (1.6 ≤ INR <2.0) and relatively high-intensity anticoagulant treatment group (2.0 ≤ INR ≤2.5), and significantly higher warfarin dose requirements were observed in E2/E3 heterozygotes compared with E3/E3 homozygotes in both subgroups (p < 0.05). Multivariable analysis adjusting for other confounders showed that E2/E3 genotype was associated with a significantly higher warfarin dose compared with E3/E3 genotype (p < 0.05). Conclusions APOE allele and genotype frequencies in the northern Han Chinese population appear to differ from other racial groups or populations living in other regions of China. The APOE E2 variant was associated with a significantly higher warfarin maintenance dose. Thus, APOE polymorphisms could be one of the predictors influencing warfarin doses in this population.
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Affiliation(s)
- Rui Liu
- Cardiac Surgery, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China.
| | - Kui Zhang
- Cardiac Surgery, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China.
| | - Zhi-zhong Gong
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China
| | - Xin-miao Shi
- Division of Cardiology, Department of pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jingwuweiqi Street, Huaiyin District, Jinan, 250000, China.
| | - Qian Zhang
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China.
| | - Xiao-dong Pan
- Experimental Center, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China.
| | - Ran Dong
- Cardiac Surgery, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Street, Chaoyang District, Beijing, 100029, China.
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Hamadeh IS, Shahin MH, Lima SM, Oliveira F, Wilson L, Khalifa SI, Langaee TY, Cooper-DeHoff RM, Cavallari LH, Johnson JA. Impact of GGCX, STX1B and FPGS Polymorphisms on Warfarin Dose Requirements in European-Americans and Egyptians. Clin Transl Sci 2016; 9:36-42. [PMID: 26751406 PMCID: PMC4760888 DOI: 10.1111/cts.12385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/17/2015] [Indexed: 12/24/2022] Open
Abstract
Genotype-based algorithms that include VKORC1 and CYP2C9 genotypes are less predictive of warfarin dose variability in Africans as opposed to Europeans. Polymorphisms in GGCX, FPGS, or STX1B are associated with warfarin dose requirements in African-Americans. We sought to determine if they influenced warfarin dose in European-Americans, and another African population, specifically Egyptians. We genotyped 529 adults (n = 325 European-Americans, 204 Egyptians) on a stable warfarin dose for GGCX rs12714145 and rs10654848, FPGS rs7856096, and STX1B rs4889606. Rs12714145, rs10654848, and rs7856096 were not associated with warfarin dose, whereas STX1B rs4889606 was a significant determinant in univariate analysis (P < 0.0001) in both cohorts. However, STX1B rs4889606 was in high linkage disequilibrium with VKORC1-1639 G>A, and was no longer significant after including VKORC1-1639 G>A in the regression model. Based on these data, the polymorphisms do not appear to influence, in a clinically important way, warfarin dose requirements in European-Americans and Egyptians.
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Affiliation(s)
- I S Hamadeh
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - M H Shahin
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - S M Lima
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - F Oliveira
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - L Wilson
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Florida A&M University College of Pharmacy, Tallahassee, Florida, USA
| | - S I Khalifa
- College of Pharmacy, Qatar University, Doha, Qatar
| | - T Y Langaee
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - R M Cooper-DeHoff
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - L H Cavallari
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - J A Johnson
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida, USA.,Division of Cardiology, Department of Medicine, University of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
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Bourgeois S, Jorgensen A, Zhang EJ, Hanson A, Gillman MS, Bumpstead S, Toh CH, Williamson P, Daly AK, Kamali F, Deloukas P, Pirmohamed M. A multi-factorial analysis of response to warfarin in a UK prospective cohort. Genome Med 2016; 8:2. [PMID: 26739746 PMCID: PMC4702374 DOI: 10.1186/s13073-015-0255-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/10/2015] [Indexed: 01/13/2023] Open
Abstract
Background Warfarin is the most widely used oral anticoagulant worldwide, but it has a narrow therapeutic index which necessitates constant monitoring of anticoagulation response. Previous genome-wide studies have focused on identifying factors explaining variance in stable dose, but have not explored the initial patient response to warfarin, and a wider range of clinical and biochemical factors affecting both initial and stable dosing with warfarin. Methods A prospective cohort of 711 patients starting warfarin was followed up for 6 months with analyses focusing on both non-genetic and genetic factors. The outcome measures used were mean weekly warfarin dose (MWD), stable mean weekly dose (SMWD) and international normalised ratio (INR) > 4 during the first week. Samples were genotyped on the Illumina Human610-Quad chip. Statistical analyses were performed using Plink and R. Results VKORC1 and CYP2C9 were the major genetic determinants of warfarin MWD and SMWD, with CYP4F2 having a smaller effect. Age, height, weight, cigarette smoking and interacting medications accounted for less than 20 % of the variance. Our multifactorial analysis explained 57.89 % and 56.97 % of the variation for MWD and SMWD, respectively. Genotypes for VKORC1 and CYP2C9*3, age, height and weight, as well as other clinical factors such as alcohol consumption, loading dose and concomitant drugs were important for the initial INR response to warfarin. In a small subset of patients for whom data were available, levels of the coagulation factors VII and IX (highly correlated) also played a role. Conclusion Our multifactorial analysis in a prospectively recruited cohort has shown that multiple factors, genetic and clinical, are important in determining the response to warfarin. VKORC1 and CYP2C9 genetic polymorphisms are the most important determinants of warfarin dosing, and it is highly unlikely that other common variants of clinical importance influencing warfarin dosage will be found. Both VKORC1 and CYP2C9*3 are important determinants of the initial INR response to warfarin. Other novel variants, which did not reach genome-wide significance, were identified for the different outcome measures, but need replication. Electronic supplementary material The online version of this article (doi:10.1186/s13073-015-0255-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephane Bourgeois
- Wellcome Trust Sanger Institute, Genome Campus, Hinxton, Cambridgeshire, CB10 1SA, UK.
| | | | - Eunice J Zhang
- University of Liverpool, Liverpool, Merseyside, L69 3GE, UK.
| | - Anita Hanson
- University of Liverpool, Liverpool, Merseyside, L69 3GE, UK.
| | - Matthew S Gillman
- Wellcome Trust Sanger Institute, Genome Campus, Hinxton, Cambridgeshire, CB10 1SA, UK.
| | - Suzannah Bumpstead
- Wellcome Trust Sanger Institute, Genome Campus, Hinxton, Cambridgeshire, CB10 1SA, UK.
| | - Cheng Hock Toh
- University of Liverpool, Liverpool, Merseyside, L69 3GE, UK.
| | | | - Ann K Daly
- Newcastle University, Newcastle upon Tyne, UK.
| | | | - Panos Deloukas
- Wellcome Trust Sanger Institute, Genome Campus, Hinxton, Cambridgeshire, CB10 1SA, UK. .,William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Munir Pirmohamed
- University of Liverpool, Liverpool, Merseyside, L69 3GE, UK. .,Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, L7 8XP, UK. .,The Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Block A: Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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Abstract
eHealth is an umbrella term incorporating any area that combines healthcare and technology to improve efficiencies and reduce costs. The ultimate goal of eHealth is to rationalize treatment selection to improve patient safety and outcomes. Telemedicine, first used in the 1920s, is the oldest form of eHealth. The introduction of broadband Internet, followed by wireless technologies, has allowed an explosion of mHealth applications within this field. Wearable technologies, such as smartwatches, are now being used for diagnostics and patient monitoring. Challenges remain to develop reusable Clinical Decision Support systems that will streamline the flow of data from clinical laboratories to point of care. This review explores the history of eHealth, and describes some of the remaining integration and implementation challenges.
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Affiliation(s)
- Tibor van Rooij
- Department of Computer Science, University of Victoria, Victoria, British Columbia, Canada
| | - Sharon Marsh
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
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Oztaner SM, Taskaya Temizel T, Erdem SR, Ozer M. A Bayesian Estimation Framework for Pharmacogenomics Driven Warfarin Dosing: A Comparative Study. IEEE J Biomed Health Inform 2015; 19:1724-33. [DOI: 10.1109/jbhi.2014.2336974] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Peng Q, Huang S, Chen X, Yuan Y, Yu Y, Tao L, Zhang Z, Xu M. Validation of warfarin pharmacogenetic algorithms in 586 Han Chinese patients. Pharmacogenomics 2015; 16:1465-74. [PMID: 26255607 DOI: 10.2217/pgs.15.87] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To compare the accuracy of the nine selected algorithms for predicting warfarin dose with 586 Han Chinese patients. MATERIALS & METHODS Genotyping of VKORC1 1639G>A, CYP2C9*2 and CYP2C9*3 variants was performed. Both the mean absolute error and ideal estimation value were used for comparison. RESULTS The top three performers were from East Asians. The algorithms from Caucasians generally performed better in the medium-dose subgroup (>3 and <7 mg/day), while the algorithms from East Asians generally performed better in the low-dose subgroup (≤ 3 mg/day). None of the algorithms performed well in the high-dose subgroup (≥ 7 mg/day). CONCLUSION Algorithms built for specific ethnic groups and preassigned-dose groups are suggested for better prediction.
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Affiliation(s)
- Qi Peng
- Cardiac Surgery, Wuhan Asia Heart Hospital, 753 Jinghan Ave, Jianghan District, Wuhan, Hubei, 430022, China
| | - Shujun Huang
- Hubei Vidagen Gene Technology Co., Ltd, Building C6-208, 666 Gaoxin Ave, Donghu High-Tech Developmental District, Wuhan, Hubei, 430075, China
| | - Xiaoying Chen
- Department of Cardiology, Wuhan Asia Heart Hospital, 753 Jinghan Ave, Jianghan District, Wuhan, Hubei, 430022, China
| | - Yayan Yuan
- Hubei Vidagen Gene Technology Co., Ltd, Building C6-208, 666 Gaoxin Ave, Donghu High-Tech Developmental District, Wuhan, Hubei, 430075, China
| | - Yajun Yu
- Hubei Vidagen Gene Technology Co., Ltd, Building C6-208, 666 Gaoxin Ave, Donghu High-Tech Developmental District, Wuhan, Hubei, 430075, China
| | - Liang Tao
- Cardiac Surgery, Wuhan Asia Heart Hospital, 753 Jinghan Ave, Jianghan District, Wuhan, Hubei, 430022, China
| | - Zhenlu Zhang
- Clinical Test Center, Wuhan Asia Heart Hospital, 753 Jinghan Ave, Jianghan District, Wuhan, Hubei, 430022, China
| | - Mousheng Xu
- Hubei Vidagen Gene Technology Co., Ltd, Building C6-208, 666 Gaoxin Ave, Donghu High-Tech Developmental District, Wuhan, Hubei, 430075, China
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46
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Clinical Practice Recommendations on Genetic Testing of CYP2C9 and VKORC1 Variants in Warfarin Therapy. Ther Drug Monit 2015; 37:428-36. [DOI: 10.1097/ftd.0000000000000192] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Yang Y, Peter I, Scott SA. Pharmacogenetics in Jewish populations. ACTA ACUST UNITED AC 2015; 29:221-33. [PMID: 24867283 DOI: 10.1515/dmdi-2013-0069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/04/2014] [Indexed: 12/24/2022]
Abstract
Spanning over 2000 years, the Jewish population has a long history of migration, population bottlenecks, expansions, and geographical isolation, which has resulted in a unique genetic architecture among the Jewish people. As such, many Mendelian disease genes and founder mutations for autosomal recessive diseases have been discovered in several Jewish groups, which have prompted recent genomic studies in the Jewish population on common disease susceptibility and other complex traits. Although few studies on the genetic determinants of drug response variability have been reported in the Jewish population, a number of unique pharmacogenetic variants have been discovered that are more common in Jewish populations than in other major racial groups. Notable examples identified in the Ashkenazi Jewish (AJ) population include the vitamin K epoxide reductase complex subunit 1 (VKORC1) c.106G>T (p.D36Y) variant associated with high warfarin dosing requirements and the recently reported cytochrome P450 2C19 (CYP2C19) allele, CYP2C19*4B, that harbors both loss-of-function [*4 (c.1A>G)] and increased-function [*17 (c.-806C>T)] variants on the same haplotype. These data are encouraging in that like other ethnicities and subpopulations, the Jewish population likely harbors numerous pharmacogenetic variants that are uncommon or absent in other larger racial groups and ethnicities. In addition to unique variants, common multi-ethnic variants in key drug metabolism genes (e.g., ABCB1, CYP2C8, CYP2C9, CYP2C19, CYP2D6, NAT2) have also been detected in the AJ and other Jewish groups. This review aims to summarize the currently available pharmacogenetics literature and discuss future directions for related research with this unique population.
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Fox CS, Hall JL, Arnett DK, Ashley EA, Delles C, Engler MB, Freeman MW, Johnson JA, Lanfear DE, Liggett SB, Lusis AJ, Loscalzo J, MacRae CA, Musunuru K, Newby LK, O'Donnell CJ, Rich SS, Terzic A. Future translational applications from the contemporary genomics era: a scientific statement from the American Heart Association. Circulation 2015; 131:1715-36. [PMID: 25882488 DOI: 10.1161/cir.0000000000000211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The field of genetics and genomics has advanced considerably with the achievement of recent milestones encompassing the identification of many loci for cardiovascular disease and variable drug responses. Despite this achievement, a gap exists in the understanding and advancement to meaningful translation that directly affects disease prevention and clinical care. The purpose of this scientific statement is to address the gap between genetic discoveries and their practical application to cardiovascular clinical care. In brief, this scientific statement assesses the current timeline for effective translation of basic discoveries to clinical advances, highlighting past successes. Current discoveries in the area of genetics and genomics are covered next, followed by future expectations, tools, and competencies for achieving the goal of improving clinical care.
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Rooij TV, Roederer M, Wareham T, Rooij IV, McLeod HL, Marsh S. Fast and frugal trees: translating population-based pharmacogenomics to medication prioritization. Per Med 2015; 12:117-128. [DOI: 10.2217/pme.14.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: Fast and frugal decision trees (FFTs) can simplify clinical decision making by providing a heuristic approach to contextual guidance. We wanted to use FFTs for pharmacogenomic knowledge translation at point-of-care. Materials & Methods: The Pharmacogenomics for Every Nation Initiative (PGENI), an international nonprofit organization, collects data on regional polymorphisms as a predictor of metabolism for individual drugs and dosages. We advanced FFTs to work with PGENI pharmacogenomic data to produce medication recommendations that are accurate, transparent and straightforward to automate. Results: By streamlining medication selection processes in the PGENI workflow, information technology applications can now be deployed. Conclusion: We developed a decision tree approach that can translate pharmacogenomic data to provide up-to-date recommended care for populations based on their medication-specific markers.
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Affiliation(s)
- Tibor van Rooij
- Faculty of Pharmacy & Pharmaceutical Sciences, Katz Group Centre for Pharmacy & Health Research, University of Alberta, Edmonton, Alberta T6G 2E1, Canada
| | - Mary Roederer
- Eshelman School of Pharmacy, Department of Pharmacy Practice, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Todd Wareham
- Department of Computer Science, Memorial University of Newfoundland, St. John's, Newfoundland & Labrador, Canada
| | - Iris van Rooij
- Donders Institute for Brain, Cognition & Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Sharon Marsh
- Faculty of Pharmacy & Pharmaceutical Sciences, Katz Group Centre for Pharmacy & Health Research, University of Alberta, Edmonton, Alberta T6G 2E1, Canada
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Pirmohamed M, Kamali F, Daly AK, Wadelius M. Oral anticoagulation: a critique of recent advances and controversies. Trends Pharmacol Sci 2015; 36:153-63. [PMID: 25698605 DOI: 10.1016/j.tips.2015.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/18/2015] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
There have recently been significant advances in the field of oral anticoagulation, but these have also led to many controversies. Warfarin is still the commonest drug used for clotting disorders but its use is complicated owing to wide inter-individual variability in dose requirement and its narrow therapeutic index. Warfarin dose requirement can be influenced by both genetic and environmental factors. Two recent randomized controlled trials (RCTs) came to different conclusion regarding the utility of genotype-guided dosing; we critically explore the reasons for the differences. The new generation of oral anticoagulants have been demonstrated to be as efficacious as warfarin, but further work is needed to evaluate their safety in real clinical settings.
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Affiliation(s)
- Munir Pirmohamed
- The University of Liverpool, Liverpool L69 3BX, UK; Royal Liverpool and Broadgreen University Hospital National Health Service (NHS) Trust, Prescot Street, Liverpool L7 8XP, UK.
| | - Farhad Kamali
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Ann K Daly
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
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