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Xiong L, Yu F, Ge W, Xu H. Acute kidney injury interacts with VKORC1 genotype on initiative warfarin dose among heart surgery recipients: a real-world research. Sci Rep 2023; 13:21750. [PMID: 38066032 PMCID: PMC10709552 DOI: 10.1038/s41598-023-46895-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Patients who receive heart valve surgery need anticoagulation prophylaxis to reduce the risk of thrombosis. Warfarin often is a choice but its dosage varies due to gene and clinical factors. We aim to study, among them, if there is an interaction between acute kidney injury and two gene polymorphisms from this study. We extracted data of heart valve surgery recipients from the electronic health record (EHR) system of a medical center. The primary outcome is about the average daily dose of warfarin, measured as an additive interaction effect (INTadd) between acute kidney injury (AKI) and warfarin-related gene polymorphisms. The confounders, including age, sex, body surface area (BSA), comorbidities (i.e., atrial fibrillation [AF], hypertension [HTN], congestive heart failure [CHF]), serum albumin level, warfarin-relevant gene polymorphism (i.e., CYP2C9, VKORC1), prosthetic valve type (i.e., metal, bio), and warfarin history were controlled via a multivariate-linear regression model. The study included 200 patients, among whom 108 (54.00%) are female. Further, the mean age is 54.45 years, 31 (15.50%) have CHF, and 40 (20.00%) patients were prescribed concomitant amiodarone, which potentially overlays with the warfarin prophylaxis period. During the follow-up, AKI occurred in 30 (15.00%) patients. VKORC1 mutation (1639G>A) occurred in 25 (12.50%) patients and CYPC29 *2 or *3 mutations presented in 20 patients (10.00%). We found a significant additive interaction effect between AKI and VKORC1 (- 1.17, 95% CI - 1.82 to - 0.53, p = 0.0004). This result suggests it is probable that there is an interaction between acute kidney injury and the VKORC1 polymorphism for the warfarin dose during the initial period of anticoagulation prophylaxis.
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Affiliation(s)
- Liang Xiong
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Feng Yu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China.
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Liu TY, Hsu HY, You YS, Hsieh YW, Lin TC, Peng CW, Huang HY, Chang SS, Tsai FJ. Efficacy of Warfarin Therapy Guided by Pharmacogenetics: A Real-world Investigation Among Han Taiwanese. Clin Ther 2023; 45:662-670. [PMID: 37301690 DOI: 10.1016/j.clinthera.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE The anticoagulation activity of warfarin in populations with CYP2C9, VKORC1, and CYP4F2 variants differs between individuals and is correlated with poor international normalized ratio (INR) control. Pharmacogenetics-guided warfarin dosing has been successfully developed for patients with genetic variations in recent years. However, few real-world data have been used to investigate the INR and warfarin dosage and the time to target INR. This study examined the largest collection of genetic and clinical real-world data related to warfarin to provide further evidence supporting the benefits of pharmacogenetics in clinical outcomes. METHODS We retrieved a total of 69,610 INR-warfarin records after the index date from 2,613 patients in the China Medical University Hospital database between January 2003 and December 2019. Each INR reading was obtained from the latest laboratory data after the hospital visit date. Patients with a history of malignant neoplasms or pregnancy before the index date were excluded, as were patients without data on INR measurements after the fifth day of prescription, genetic information, or gender variables. The primary outcomes were the INR and warfarin dosage during days 7, 14, 28, 56, and 84 after prescription. The secondary outcome was the time required to reach the INR ranges of 1.5 to 3.0 and >4.0. FINDINGS A total of 59,643 INR-warfarin records from 2188 patients were retrieved. The average INR was higher for homozygous carriers of the minor allele at CYP2C9 and VKORC1 during the first 7 days (1.83 [1.03] [CYP2C9*1] and 2.46 [1.44] [CYP2C9*3], P < 0.001; 1.39 [0.36] [rs9923231 G/G], 1.55 [0.79] [rs9923231 G/A], and 1.96 [1.13] [rs9923231 A/A], P < 0.001) than for the wild-type allele. These patients with variants required lower warfarin doses than those with the wild-type allele during the first 28 days. CYP4F2 variant patients seemed to require higher doses of warfarin than those in the wild-type group; however, no significant difference in the average INR was observed (1.95 [1.14] [homozygous V433 carriers], 1.78 [0.98] [heterozygous V433M carriers], and 1.66 [0.91] [homozygous M433 carriers], P = 0.016). IMPLICATIONS Our study indicates that genetic variants in the Han population may enhance warfarin responsiveness, which holds clinical relevance. An increased warfarin dosage was not linked to a shorter time to therapeutic INR between CYP4F2 variant patients and those with a wild-type allele. Assessing CYP2C9 and VKORC1 genetic polymorphisms before initiating warfarin treatment in real-world practice is essential for potentially vulnerable patients and is likely to optimize therapeutic dosing.
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Affiliation(s)
- Ting-Yuan Liu
- Million-Person Precision Medicine Initiative, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
| | - Hsing-Yu Hsu
- Department of Pharmacy, China Medical University Hospital, Taichung, Taiwan.
| | - Ying-Shu You
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Yow-Wen Hsieh
- Department of Pharmacy, China Medical University Hospital, Taichung, Taiwan.
| | - Tzu-Ching Lin
- Department of Pharmacy, China Medical University Hospital, Taichung, Taiwan.
| | - Chun-Wei Peng
- Artificial Intelligence and Data Science, National Chung Hsing University, Taichung, Taiwan.
| | - Hsin-Yi Huang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan.
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.
| | - Fuu-Jen Tsai
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Division of Pediatric Genetics, Children's Hospital of China Medical University, Taichung, Taiwan; Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan.
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Zhao Z, Zhao F, Wang X, Liu D, Liu J, Zhang Y, Hu X, Zhao M, Tian C, Dong S, Jin P. Genetic Factors Influencing Warfarin Dose in Han Chinese Population: A Systematic Review and Meta-Analysis of Cohort Studies. Clin Pharmacokinet 2023; 62:819-833. [PMID: 37273173 DOI: 10.1007/s40262-023-01258-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the association of single nucleotide polymorphisms (SNPs) of various genes known to influence mean daily warfarin dose (MDWD) in the Han Chinese population. METHODS The study is a systematic review and meta-analysis. Selected studies retrieved by searching Pubmed, Embase (Ovid), Medline, CNKI, Wanfang data, and SinoMed (from their inception to 31 August 2022) for the cohort studies assessing genetic variations that may possibly influence MDWD in Chinese patients were included. RESULT A total of 46 studies including a total of 10,102 Han Chinese adult patients were finally included in the meta-analysis. The impact of 20 single nucleotide polymorphisms (SNPs) in 8 genes on MDWD was analyzed. The significant impact of some of these SNPs on MDWD requirements was demonstrated. Patients with CYP4F2 rs2108622 TT, EPHX1 rs2260863 GC, or NQO1 rs1800566 TT genotype required more than 10% higher MDWD. Furthermore, patients with ABCB1 rs2032582 GT or GG, or CALU rs2290228 TT genotype required more than 10% lower MDWD. Subgroup analysis showed that patients with EPHX1 rs2260863 GC genotype required 7% lower MDWD after heart valve replacement (HVR). CONCLUSION This is the first systematic review and meta-analysis assessing the association between single nucleotide polymorphisms (SNPs) of various genes known to influence MDWD besides CYP2C9 and VKORC1 in the Han Chinese population. CYP4F2 (rs2108622), GGCX (rs12714145), EPHX1 (rs2292566 and rs2260863), ABCB1 (rs2032582), NQO1 (rs1800566), and CALU (rs2290228) SNPs might be moderate factors affecting MDWD requirements. REGISTERED INFORMATION PROSPERO International Prospective Register of Systematic Reviews (CRD42022355130).
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Affiliation(s)
- Zinan Zhao
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China
| | - Fei Zhao
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China
| | - Xiang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Deping Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Junpeng Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China
| | - Xin Hu
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China
| | - Ming Zhao
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China
| | - Chao Tian
- Department of Pharmacy, Beijing Children's Hospital, Capital Medicine University, National Center for Children's Health, Beijing, 100045, China
| | - Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, China
| | - Pengfei Jin
- Department of Pharmacy, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences; Beijing Key Laboratory of Assessment of Clinical Drugs Risk and Individual Application (Beijing Hospital), No. 1 Dahua Road, Dongdan, Dongcheng District, Beijing, 100730, China.
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Safety and Tolerability of Tecarfarin (ATI-5923) in Healthy Chinese Volunteers: Multiple Oral Dose-Escalation Phase I Trial. Am J Cardiovasc Drugs 2023; 23:101-112. [PMID: 36622539 DOI: 10.1007/s40256-022-00562-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tecarfarin (ATI-5923), a structural analog of warfarin, was designed to provide more uniform and stable anticoagulation. OBJECTIVE We aimed to evaluate the safety, tolerability, pharmacokinetic and pharmacodynamic profile of tecarfarin when administered in multiple ascending doses (MADs) to healthy Chinese volunteers. METHODS Forty healthy Chinese volunteers were enrolled into four sequential cohorts (10, 20, 30, and 40 mg), with 10 subjects in each cohort. Participants in the MAD study for each sequential cohort were dose-titrated to achieve the target international normalized ratio (INR 1.7-2.0) for 14 days. Safety and tolerability were assessed throughout the study. RESULTS The pharmacokinetic and pharmacodynamic profile of tecarfarin was investigated in a healthy Chinese population. Dose titration of tecarfarin was necessary to keep the INR in the target range in all subjects in the 20, 30 and 40 mg cohorts and a few subjects (n = 3) in the 10 mg cohort. Tecarfarin was well tolerated without serious adverse events. Only one treatment-related adverse event (hematochezia) resulted in early withdrawal from the MAD 40 mg cohort. CONCLUSION Tecarfarin was well-tolerated by Chinese volunteers. Dose titration was needed for tecarfarin doses larger than 20 mg to keep the INR in the target range. REGISTRATION ClinicalTrials.gov identifier: NCT04627116.
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Wang D, Wu H, Dong M, Zhang Q, Zhao A, Zhao X, Chong J, Du M, Wang Y, Shi H, Wang S, Wang F, Cai J, Yang J, Dai D, Chen H. Clinical significance of the series of CYP2C9*non3 variants, an unignorable predictor of warfarin sensitivity in Chinese population. Front Cardiovasc Med 2022; 9:1052521. [PMID: 36505370 PMCID: PMC9729276 DOI: 10.3389/fcvm.2022.1052521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
Backgrounds Gene polymorphisms are critical for variations in warfarin dose. To date, more than 70 CYP2C9 alleles have been identified. This study was designed to clarify the clinical significance of CYP2C9*non-3 variants to warfarin sensitivity in Chinese Han patients. Methods The entire CYP2C9 gene region was sequenced in 1,993 individuals, and clinical data and VKORC1 genotypes were collected from 986 patients with atrial fibrillation treated with warfarin. The SKAT-O method was used to analyze the effects of CYP2C9*non-3 variants on warfarin sensitivity. Results A total of 20 CYP2C9 variants were identified, of which four were novel. Carriers with CYP2C9*non-3 variants may have lower warfarin dose requirements, and similar to CYP2C9*3, CYP2C9*non-3 variants are clearly relevant to warfarin-sensitive and highly sensitive responders. Conclusion Our results showed that, besides CYP2C9*3, the series of CYP2C9*non-3 variants is an unignorable predictor for warfarin sensitivity in Chinese population. From a safety consideration, people carried such variants may need a preferred choice of NOACs when they started anticoagulation therapy.
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Affiliation(s)
- Dongxu Wang
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China,Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hualan Wu
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Min Dong
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Qing Zhang
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Anxu Zhao
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Xinlong Zhao
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Jia Chong
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Minghui Du
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Yan Wang
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Haifeng Shi
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Shuanghu Wang
- Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, China
| | - Fang Wang
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Jianping Cai
- The Key Laboratory of Geriatrics, National Centre of Gerontology, Beijing Hospital, Beijing Institute of Geriatrics, Beijing, China
| | - Jiefu Yang
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Dapeng Dai
- The Key Laboratory of Geriatrics, National Centre of Gerontology, Beijing Hospital, Beijing Institute of Geriatrics, Beijing, China,Dapeng Dai,
| | - Hao Chen
- Department of Cardiology, National Center of Gerontology, Beijing Hospital, Beijing, China,*Correspondence: Hao Chen,
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Effects and Mechanism of Action of Panax notoginseng Saponins on the Pharmacokinetics of Warfarin. Eur J Drug Metab Pharmacokinet 2022; 47:331-342. [PMID: 35138605 DOI: 10.1007/s13318-022-00753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUD The interactions between Chinese herbs and drugs pose a great challenge to the combined clinical application of Chinese herbs and drugs. Chinese medicinal products contain complex pharmacologically active components that may influence the in vivo processes of drugs in a variety of ways. In China, drugs based on Panax ginseng total saponins (PNS) are often combined with warfarin for the treatment of cardiovascular diseases. OBJECTIVES To assess the effects of Panax notoginseng saponins (PNS) on the pharmacokinetics of warfarin and its mechanism. METHOD Blood was collected for the determination of the prothrombin time (PT) and international normalized ratio (INR) from rats treated with warfarin alone or with warfarin + PNS. The plasma concentration of warfarin was determined by high-performance liquid chromatography. Western blot was used to detect the expression of cytochrome P450 (CYP) enzymes. RESULTS When warfarin and PNS were co-administered, the PT and INR increased compared to when warfarin was given alone. 72 hours after administration, compared to the warfarin alone group, the warfarin + low-dose PNS, warfarin + medium-dose PNS, and warfarin + high-dose PNS groups showed 110%, 122%, and 126% increases in PT, respectively (all P < 0.05), as well as 111%, 124%, and 128% increases in INR (all P < 0.05). Compared with the warfarin alone group, the clearance rate (CL/F) of warfarin in the warfarin + low-dose PNS, warfarin + medium-dose PNS, and warfarin + high-dose PNS groups was 10% (P > 0.05), 23% (P < 0.05), and 33% (P < 0.05) lower, respectively, while the systemic exposure (area under the concentration-time curve, AUC0-t) increased by 106% (P > 0.05), 119% (P < 0.05), and 134% (P < 0.05), respectively, and the blood concentration of warfarin incresed by 112%, 113%, and 114%, respectively (all P > 0.05). After combined treatment of HepG2 cells with warfarin + PNS, CYP1A2 expression was upregulated (P < 0.05) and CYP3A4 was downregulated (P < 0.05) but there was no effect on CYP2C9. In animal experiments, PNS had different effect on the expression of CYP1A2 in different doses. While a low dose of PNS resulted in downregulated CYP1A2 expression (P < 0.05), a medium dose resulted in upregulation (P < 0.05), and CYP1A2 expression was not significantly affected by a high dose of PNS (P > 0.05). Meanwhile, PNS at all doses downregulated the expression of CYP3A4 (P < 0.05) but had no effect on the expression of CYP2C9 (P > 0.05). CONCLUSION PNS can increase the blood concentration of warfarin, as well as the exposure time, and it can enhance the anticoagulant effect of warfarin by inhibiting the expression of the liver enzyme CYP3A4.
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Gao W, Li Z, Chen W, Zhang S. Performance Evaluation of Warfarin Dose Prediction Algorithms and Effects of Clinical Factors on Warfarin Dose in Chinese Patients. Ther Drug Monit 2021; 43:527-535. [PMID: 34250965 DOI: 10.1097/ftd.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The clinical utility of warfarin dose prediction algorithms remains controversial, our purpose is to evaluate the performance of warfarin dose prediction algorithms and the effects of clinical factors on warfarin dose in Chinese patients. METHODS Clinical data of 217 patients who received warfarin treatment were used to assess 6 warfarin dose prediction algorithms (OHNO, IWPC [International Warfarin Pharmacogenetics Consortium], HUANG, KIM, BRESS, and MIAO). The predicted dose (PD) was compared with the warfarin optimal dose (WOD, defined as the dose that maintains the international normalized ratio within the target range of 2.0-3.0). A multiple regression analysis with WOD as the dependent variable was performed to evaluate the effects of clinical factors on warfarin dose. RESULTS The mean absolute error analysis ranked the predictive accuracies of the algorithms as OHNO > IWPC > HUANG > KIM > BRESS > MIAO. Stratified analysis indicated that HUANG most accurately predicted that patients required lower WODs (≤3 mg/d), whereas OHNO was the most effective in predicting medium WODs (3-5 mg/d). KIM was effective in predicting high WODs (>5 mg/d). Multiple linear regression analysis showed that VKORC1 (rs9923231) and body mass index were significantly positively correlated with WOD, whereas concurrent atrial fibrillation status, CYP2C9*3 (rs1057910), and sex were significantly negatively correlated with WOD. CONCLUSIONS In Chinese patients, OHNO should be given priority during the prediction and selection of warfarin dose. When using OHNO to predict warfarin dose (≤3 mg/d or >5 mg/d), HUANG or KIM algorithms can provide precise predictions. At the same time, physicians should pay close attention to clinical factors, such as VKORC1 (rs9923231), concurrent atrial fibrillation status, CYP2C9*3 (rs1057910), body mass index, and sex, to improve warfarin dose adjustment strategies in Chinese patients.
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Affiliation(s)
- Weiqi Gao
- School of Pharmacy, Shanxi Medical University, Taiyuan, China; and
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Zhihong Li
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Weihong Chen
- Department of Pharmacy, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Shuqiu Zhang
- School of Pharmacy, Shanxi Medical University, Taiyuan, China; and
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Xu Q, Zhang S, Wu C, Xiong Y, Niu J, Li F, Zhu J, Shen L, Zhu B, Xing Q, He L, Chen L, Li M, Li H, Ge J, Qin S. Genetic Associations With Stable Warfarin Dose Requirements in Han Chinese Patients. J Cardiovasc Pharmacol 2021; 78:e105-e111. [PMID: 33958549 DOI: 10.1097/fjc.0000000000001048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Warfarin is a commonly prescribed anticoagulant for valvular heart disease that plays an important role in clinical management to prevent thrombotic events. In this study, we aim to perform a comprehensive study to investigate the genetic biomarkers of stable warfarin dose in the Han Chinese population. We performed an integrative study on 211 Han Chinese patients with valvular heart disease. A total of 40 single nucleotide polymorphisms (SNPs) in 10 important genes (CYP2C9, VKORC1, ABCB1, CYP4F2, APOE, PROC, GGCX, EPHX1, CALU, and SETD1A) which are involved in the warfarin metabolic pathway and equilibrium of coagulation and anticoagulation were selected. We applied MassARRAY technology to genotype the 40 SNPs identified in these Han Chinese patients. Our results showed that 13 SNPs on 6 genes (CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A) were associated with the individual stable warfarin dose. Two VKORC1 SNPs (rs9934438 and rs2359612) were the strongest genetic factors determining warfarin dose requirements (P = 8 × 10-6 and 9 × 10-6, respectively). Rs4889599 in SETD1A was first reported to be associated with warfarin dose at a significant level of 0.001 in our study (Padjust = 0.040 after Bonferroni correction). We discovered that genetic variants in CYP2C9, VKORC1, ABCB1, PROC, EPHX1, and SETD1A may affect the stable warfarin dose requirement in Han Chinese patients with valvular disease. The discovery of these potential genetic markers will facilitate the development of advanced personalized anticoagulation therapy in Han Chinese patients.
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Affiliation(s)
- Qingqing Xu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Suli Zhang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Chaoneng Wu
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuyu Xiong
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Jiamin Niu
- Laiwu People's Hospital, Shandong, China
| | | | - Jinhang Zhu
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Lu Shen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Bin Zhu
- Shanghai Baio Technology Co, Ltd Shanghai, China
| | | | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Luan Chen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Mo Li
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
| | - Hua Li
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengying Qin
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai, China
- The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
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Xie C, Xue L, Zhang Y, Zhu J, Zhou L, Hang Y, Ding X, Jiang B, Miao L. Comparison of the prediction performance of different warfarin dosing algorithms based on Chinese patients. Pharmacogenomics 2020; 21:23-32. [PMID: 31849278 DOI: 10.2217/pgs-2019-0124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Aim: To compare the prediction performance of different warfarin dosing algorithms based on Chinese patients. Materials & methods: A total of 18 algorithms were tested in 325 patients. The predictive efficacy of selected algorithms was evaluated by calculating the percentage of patients whose predicted dose fell within ±20% of their actual stable warfarin dose and the mean absolute error. Results: The percentage within ± 20% and the mean absolute error of the algorithms ranged from 11.9 to 41.2% and -0.20 (-0.29 to -0.11) mg/d to -1.63 (-1.75 to -1.50) mg/d. The algorithms established by Miao et al. and Wei et al. had optimal predictive performance. Conclusion: Algorithms based on geographical populations might be more suitable for the prediction of stable warfarin doses in local patients.
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Affiliation(s)
- Cheng Xie
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Ling Xue
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Yuzhen Zhang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Jianguo Zhu
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Ling Zhou
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Yongfu Hang
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Xiaoliang Ding
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Bin Jiang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
| | - Liyan Miao
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou 215006, PR China
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Ren Y, Yang C, Chen H, Dai D, Wang Y, Zhu H, Wang F. Pharmacogenetic-Guided Algorithm to Improve Daily Dose of Warfarin in Elder Han-Chinese Population. Front Pharmacol 2020; 11:1014. [PMID: 32754031 PMCID: PMC7365937 DOI: 10.3389/fphar.2020.01014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/23/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives To verify the accuracy of the International Warfarin Pharmacogenetics Consortium (IWPC) algorithm, identify the effects of genetic and clinical factors on warfarin stable dose, and to establish a new warfarin stable dose prediction algorithm for the elderly Han-Chinese population under the guidance of pharmacogenetics. Methods According to the inclusion criteria, 544 non-valvular atrial fibrillation patients taking warfarin for anticoagulation treatment were enrolled. Data information of three groups including the whole population, people under 65 years old and over 65 years old were substituted into the IWPC algorithm respectively to verify its accuracy. The basic data and clinical information of 360 elderly people were collected for statistical analysis and the genotypes of VKORC1-G1639A and CYP2C9 were detected by Sanger sequencing. The new algorithm of the elder pharmacogenetics warfarin dosing was obtained by stepwise multiple regression. The determination coefficient (R2), root mean squared error (RMSE), and the proportion of the predicted value within the true value range of ±20%(20%-p) were used to evaluate the accuracy of the IWPC algorithm and the new algorithm. Results Among the three different age groups, the warfarin stable dose predictive accuracy of IWPC algorithm was the lowest in the elderly patients above 65-year-old. In this study, the important factors influencing the stable dose of warfarin in the elderly Han-Chinese were height, weight, body surface area, serum creatinine level, amiodarone usage, CYP2C9 (*1*2, *1*3), and VKORC1 (GG/GA) genotypes. By means of stepwise multiple regression analysis, we established a new elder warfarin dosing algorithm (R2=0.3714) containing height, creatinine, amiodarone usage, CYP2C9 (*1*2 or *1*3), and VKORC1 (GA or GG) genotypes. The prediction accuracy and clinical availability of the Elderly algorithm was significantly better than that of IWPC algorithm verified by RMSE, R2, and (20%-p) methods. Conclusions The IWPC model may not be suitable for the elder Han-Chinese population. Polymorphism of CYP2C9 and VKORC1 obviously affected warfarin stable dose of the elder Han-Chinese. Combination of genetic data with demographic and clinical factors could help to better improve warfarin doses in the elder Han-Chinese population.
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Affiliation(s)
- Yirong Ren
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Chenguang Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hao Chen
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Dapeng Dai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Huolan Zhu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fang Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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11
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Efficacy and Safety of Genotype-Guided Warfarin Dosing in the Chinese Population: A Meta-analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2020; 73:127-135. [PMID: 30688796 DOI: 10.1097/fjc.0000000000000656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS To evaluate the efficacy and safety of using genetic information to guide warfarin dosing in the Chinese population. METHODS This meta-analysis was conducted among the published, randomized, controlled trials (RCTs) in the Chinese population comparing genotype-guided warfarin dosing (PG group) with clinical or standard warfarin dosing (STD group). RCTs published on or before January 2018 were identified using the PubMed, Embase, Cochrane Library, CNKI, Chinese VIP database, and Chinese Wanfang database. RESULT Intotal, 2137 participants from 14 RCTs were included in the meta-analysis. Primary analysis showed that both bleeding events [odds ratio (OR) = 0.24; 95% confidence interval (CI), 0.11-0.52; P = 0.0003] and adverse events (OR = 0.60; 95% CI, 0.43-0.83; P = 0.002) were significantly lower in the genotype-guided group than in the clinical or standard group. The percentage of patients who received a warfarin-stable therapeutic dose during follow-up was increased in the genotype-guided group compared with the percentage in the clinical or standard group (OR = 2.68; 95% CI, 1.82-3.95; P < 0.00001). In the genotype-guided group, the time to a stable therapeutic dose (mean difference = -7.98; 95% CI, -9.08 to -6.87; P < 0.00001) and the time to the first target value (mean difference = -1.87; 95% CI, -3.41 to -0.32; P = 0.02) were shortened compared with those of the clinical or standard group, but there was no difference for international normalized ratio >4, between the 2 groups (OR = 0.42; 95% CI, 0.14-1.25; P = 0.12). CONCLUSIONS Genotype-guided warfarin-dosing algorithms could improve the efficacy and safety of warfarin anticoagulation in the Chinese population.
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12
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Shah RR. Genotype‐guided warfarin therapy: Still of only questionable value two decades on. J Clin Pharm Ther 2020; 45:547-560. [DOI: 10.1111/jcpt.13127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022]
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13
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Zhang J, Wu T, Chen W, Fu J, Xia X, Chen L. Effect of Gene-Based Warfarin Dosing on Anticoagulation Control and Clinical Events in a Real-World Setting. Front Pharmacol 2020; 10:1527. [PMID: 32038232 PMCID: PMC6988825 DOI: 10.3389/fphar.2019.01527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022] Open
Abstract
The cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 genotypes are associated with anticoagulation control and the clinical events in warfarin therapy. However, the clinical utility of gene-based warfarin dosing (GBWD) is controversial. We compared the anticoagulation control and clinical events related to warfarin with GBWD to those with clinically fixed dosing (CFD). A retrospective cohort study was conducted in a real-world setting. Of the 915 patients who were reviewed, 844 patients met the study-entry criteria; 413 cases were guided by GBWD using the International Warfarin Pharmacogenetic Consortium algorithm; 431 cases were guided by CFD (2.5 mg/day). The primary outcomes were the time needed to achieve the therapeutic International Normalized Ratio (INR) and the time in the therapeutic range (TTR) during a 3-month timeframe. The time needed to achieve the therapeutic INR (in days) for patients in the GBWD group was shorter than that for patients in the CFD group (10.21 ± 4.68 vs. 14.31 ± 8.26, P < 0.001). The overall TTR (Day 4-90) was significantly different between the GBWD group and CFD group (56.86 ± 10.72 vs. 52.87 ± 13.92, P = 0.007).In subgroup analysis, the TTR was also significantly different between the GBWD group and CFD group during the first month of treatment (Day 4-14: 54.28 ± 21.90 vs. 47.01 ± 26.25, P = 0.012; Day 15-28: 59.60 ± 20.12 vs. 51.71 ± 18.96, P = 0.001). However, no significant difference in the TTR was observed after 29 days of treatment. These data suggest that GBWD provided clinical benefits.
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Affiliation(s)
- Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jinglan Fu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Xiaotong Xia
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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14
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Liang JB, Lao CK, Tian L, Yang YY, Wu HM, Tong HHY, Chan A. Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:97-106. [PMID: 31576625 DOI: 10.1111/ijpp.12584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study was designed to evaluate the impact of a pharmacist-led anticoagulation service on international normalised ratio (INR) control and other outcomes among patients receiving warfarin therapy at a tertiary hospital in Zhuhai, China. METHODS In this randomised controlled trial, adult patients who were newly initiated on warfarin with intended treatment duration of at least 3 months were recruited. Participants were randomly allocated to receive the pharmacist-led education and follow-up service (PEFS) or usual care (UC). Anticoagulation control was calculated as the proportions of time within the target INR range (TTR) and time within the expanded target range (TER). KEY FINDINGS A total of 152 participants (77 in the PEFS group and 75 in the UC group) were included. Within 180 days after hospital discharge, the PEFS group spent more TER than the UC group (54.4% versus 42.0%; P = 0.024), whereas the difference in TTR did not reach statistical significance (35.9% versus 29.5%; P = 0.203). No major bleeding events were observed, and the cumulative incidences of major thromboembolic events (6.5% versus 9.3%) and mortality (1.3% versus 1.3%) were similar between the two groups (P> 0.05). At 30 days postdischarge, the PEFS group had better warfarin knowledge by answering 57.5% of questions correctly, compared with the UC group (43.0%) (P = 0.003). CONCLUSIONS The PEFS markedly enhanced anticoagulation control and warfarin knowledge but there was room for improvement. The expansion of pharmacists' clinical role and the development of more effective education and follow-up strategies are warranted to optimise anticoagulation management services in China.
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Affiliation(s)
- Jia-Bi Liang
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Cheng-Kin Lao
- School of Health Sciences and Sports, Macao Polytechnic Institute, Macao S.A.R., China
| | - Lin Tian
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Ying-Ying Yang
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Hui-Min Wu
- Department of Pharmacy, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, China
| | - Henry Hoi-Yee Tong
- School of Health Sciences and Sports, Macao Polytechnic Institute, Macao S.A.R., China
| | - Alexandre Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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15
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Clinical and genetic factors influencing acenocoumarol dosing: a cross-sectional study. Blood Coagul Fibrinolysis 2018; 29:496-500. [PMID: 29916837 DOI: 10.1097/mbc.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Coumadin oral anticoagulants are widely used in multiple clinical scenarios. Their narrow therapeutic range and a dosing strategy based on 'a posteriori' algorithms, pose them as an interesting group for prediction modelling research. Extensive literature explaining the association between clinical and genetic variables with the dose of warfarin have been published. Limited information exists regarding these factors and acenocoumarol dosing. The aim of the study is to explain through clinical/genetic variables, the weekly dose of acenocoumarol necessary for achieving stable anticoagulation status. We performed a cross-sectional study enrolling adults under treatment with acenocoumarol with at least three consecutive INRs between 2 and 3. To explain the association between demographic, clinical and genotype data (VKORC1, CYP2C9 and CYP4F2) and the mean weekly dose of acenocoumarol, we performed a multiple linear regression model. In our cohort, a higher age, the presence of atrial fibrillation, chronic renal failure and VKORC1 haplotype A were associated with a lower mean weekly dose of acenocoumarol. On the other side, a higher weight was associated with a higher weekly dose. Amongst anticoagulated adult patients, VKORC1 genotype and baseline clinical factors can explain acenocoumarol dosing, and therefore, help clinicians while deciding the initial anticoagulant dose.
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16
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Frequency of vitamin K oxidoreductase complex subunit-1 (VKORC1) polymorphisms and warfarin dose management in patients with venous thromboembolism. THE PHARMACOGENOMICS JOURNAL 2018; 18:646-651. [DOI: 10.1038/s41397-018-0037-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/14/2018] [Accepted: 06/19/2018] [Indexed: 12/25/2022]
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17
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Tse G, Gong M, Li G, Wong SH, Wu WKK, Wong WT, Roever L, Lee APW, Lip GYH, Wong MCS, Liu T. Genotype-guided warfarin dosing vs. conventional dosing strategies: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol 2018; 84:1868-1882. [PMID: 29704269 DOI: 10.1111/bcp.13621] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/03/2018] [Accepted: 04/17/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS Previous trials on the effectiveness of genotype-guided warfarin dosing vs. conventional dosing have been inconclusive. We conducted a systematic review and meta-analysis of randomized trials comparing genotype-guided to conventional dosing strategies. METHODS PubMed and the Cochrane Library were searched up to 23 October 2017. RESULTS A total of 76 and 94 entries were retrieved were retrieved from PubMed and the Cochrane Library, respectively. A total of 2626 subjects in the genotype-guided dosing (mean age 63.3 ± 5.8 years; 46% male) and 2604 subjects in the conventional dosing (mean age 64.7 ± 6.1 years; 46% male) groups (mean follow-up duration 64 days) from 18 trials were included. Compared with conventional dosing, genotype-guided dosing significantly shortened the time to first therapeutic international normalized ratio (INR) (mean difference 2.6 days, standard error 0.3 days; P < 0.0001; I2 0%) and time to first stable INR (mean difference 5.9 days, standard error 2.0 days; P < 0.01; I2 94%). Genotype-guided dosing also increased the time in therapeutic range (mean difference 3.1%, standard error 1.2%; P < 0.01; I2 80%) and reduced the risks of both excessive anticoagulation, defined as INR ≥4 [risk ratio (RR) 0.87; 95% confidence interval (CI) 0.78, 0.98; P < 0.05; I2 : 0%), and bleeding (RR 0.82; 95% CI 0.69, 0.98; P < 0.05; I2 31%). No difference in thromboembolism (RR 0.84; 95% CI 0.56, 1.26; P = 0.40; I2 0%) or mortality (RR 1.16; 95% CI 0.46, 2.91; P = 0.76; I2 0%) was observed between the two groups. CONCLUSIONS Genotype-guided warfarin dosing offers better safety with less bleeding compared with conventional dosing strategies. No significant benefit on thromboembolism or mortality was evident.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, MG, Brazil
| | - Alex Pui Wai Lee
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Martin C S Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
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18
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Cai LL, Huang WQ, Su ZY, Ye HM, Wang LS, Wu Y, Zhang ZY, Zhang W, Tzeng CM. Identification of two novel genes SLC15A2 and SLCO1B3 associated with maintenance dose variability of warfarin in a Chinese population. Sci Rep 2017; 7:17379. [PMID: 29234073 PMCID: PMC5727167 DOI: 10.1038/s41598-017-17731-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/29/2017] [Indexed: 01/12/2023] Open
Abstract
Warfarin is a commonly prescribed and effective oral anticoagulant. Genetic polymorphisms associated with warfarin metabolism and sensitivity have been implicated in the wide inter-individual dose variation that is observed. Several algorithms integrating patients’ clinical characteristics and genetic polymorphism information have been explored to predict warfarin dose. However, most of these algorithms could explain only over half of the variation in a warfarin maintenance dose, suggesting that additional genetic factors may exist and need to be identified. Here, a drug absorption, distribution, metabolism and excretion (ADME) Core Panel Kit-based pharmacogenetic study was performed to screen for warfarin dose-associated SNP sites in Han-Chinese population patients taking warfarin therapy, and the screen was followed by pyrosequencing-based validation. Finally, we confirmed that the common variant rs9923231 in VKORC1 and two novel genes, SLC15A2 (rs1143671 and rs1143672) and SLCO1B3 (rs4149117 and rs7311358), are associated with the warfarin maintenance dose. As has been shown for those carriers with the variant rs9923231 in VKORC1, it was suggested that those subjects with homozygous minor alleles in those four SNPs should take a lower warfarin dose than those carrying the wild type alleles. Together with the established predictor rs9923231 in VKORC1, those four novel variants on SLC15A2 and SLCO1B3 should be considered as useful biomarkers for warfarin dose adjustment in clinical practice in Han-Chinese populations.
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Affiliation(s)
- Liang-Liang Cai
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China
| | - Wen-Qing Huang
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China
| | - Zhi-Ying Su
- Clinical Research Laboratory, Xiamen's Maternal and Child Health Hospital, Teaching Hospital of Xiamen University, Xiamen, Fujian Sheng, China
| | - Hui-Ming Ye
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China.,Clinical Research Laboratory, Xiamen's Maternal and Child Health Hospital, Teaching Hospital of Xiamen University, Xiamen, Fujian Sheng, China
| | - Lian-Sheng Wang
- Department of Clinical Pharmacology, Xiangya Hospital, Institute of Clinical Pharmacology, Central South University, Changsha, Hunan Sheng, China
| | - Yuan Wu
- Department of cardiac surgery, Xiamen Cardiovascular Hospital, School of Medicine, Xiamen University, Xiamen, Fujian Sheng, China
| | - Zhong-Ying Zhang
- Department of Clinical laboratory, Zhongshan Hospital, Xiamen University, Xiamen, Fujian Sheng, China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Institute of Clinical Pharmacology, Central South University, Changsha, Hunan Sheng, China.
| | - Chi-Meng Tzeng
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian Sheng, China.
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Zhang J, Liu M, Chen Q, Wu J, Cao H. Outcomes of an online pharmacist-managed anticoagulation clinic for individuals on warfarin therapy living in rural communities. Thromb Res 2017; 157:136-138. [PMID: 28746903 DOI: 10.1016/j.thromres.2017.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Jianmei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China.
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20
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Jiang HH, Liu J, Wang YC, Ye HM, Li X, Zhou YX, Zhang W, Wang LS. The Impact of Gene Polymorphisms on Anticoagulation Control With Warfarin. Clin Appl Thromb Hemost 2017; 24:640-646. [PMID: 28401802 DOI: 10.1177/1076029617703483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Differences in warfarin maintenance dosages based on the presence of polymorphisms in VKORC1, CYP2C9, CYP4F2, and ORM1 can be determined through dosage adjustment according to routine guidelines. Little is known about whether routine therapy could provide consensus anticoagulation control for patients with different genotypes. This study was carried out to compare anticoagulant control in patients with different genotypes. Six hundred seventy patients using warfarin according to Chinese guidelines were enrolled. Warfarin dosages and monitored international normalized ratios (INRs) were recorded. Genotypes of VKORC1 rs9923231, CYP4F2 rs2108622, CYP2C9 rs1057910, and ORM1 rs17650 polymorphisms were determined. Warfarin dosages and INR were compared between genotypes. Patients with the AGCC*F*F*1*1 polymorphism took longer than patients with the AACC*F*F*1*1 polymorphism (20 vs 5 days, P < .001) to achieve the targeted INR range. The INR values of patients with AACC*F*F*1*3 were unstable and did not enter the stable state control phase until after 35 days. The peak INR of patients with the AACC*F*F*1*3 polymorphism was exceedingly high, with some values exceeding the control range limit of 3.0. Patients with the AACC*F*S*1*1 or AACT*F*F*1*1 polymorphisms exhibited similar INR values as the patients with the AACC*F*F*1*1 polymorphism. This study found that routine medication with warfarin provides significantly different levels of anticoagulant control between patients with wild-type genotypes and patients with heterozygous polymorphism genotypes of VKORC1 rs9923231 or CYP2C9 rs1057910. Patients with heterozygous polymorphism genotypes of VKORC1 or CYP2C9 require genotype-directed therapy with warfarin to increase efficacy and safety in anticoagulant treatment.
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Affiliation(s)
- Hai He Jiang
- 1 Department of Cardiothoracic Surgery, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China
| | - Jia Liu
- 2 Translational Medicine Center, Zhengzhou Central Hospital, Zhengzhou University, Zhengzhou, Henan Sheng, China
| | - Yi Chen Wang
- 3 Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China.,4 Institute of Clinical Pharmacology, Central South University, Chang Sha, Hu Na, China
| | - Hui Ming Ye
- 5 Department of Clinical Laboratory, Zhongshan Hospital, Xiamen University Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Fujian, China
| | - Xi Li
- 3 Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China.,4 Institute of Clinical Pharmacology, Central South University, Chang Sha, Hu Na, China
| | - Ya Xing Zhou
- 3 Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China.,4 Institute of Clinical Pharmacology, Central South University, Chang Sha, Hu Na, China
| | - Wei Zhang
- 3 Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China.,4 Institute of Clinical Pharmacology, Central South University, Chang Sha, Hu Na, China
| | - Lian Sheng Wang
- 3 Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Chang Sha, Hu Na, China.,4 Institute of Clinical Pharmacology, Central South University, Chang Sha, Hu Na, China
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