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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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AL-Eitan LN, Almasri AY, Alnaamneh AH, Mihyar A. Effect of MEF2A and SLC22A3-LPAL2-LPA gene polymorphisms on warfarin sensitivity and responsiveness in Jordanian cardiovascular patients. PLoS One 2023; 18:e0294226. [PMID: 37948393 PMCID: PMC10637663 DOI: 10.1371/journal.pone.0294226] [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] [Received: 01/01/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023] Open
Abstract
AIMS This study aims to investigate the influence of MEF2A and SLC22A3-LPAL2-LPA polymorphisms on cardiovascular disease susceptibility and responsiveness to warfarin medication in Jordanian patients, during the initiation and maintenance phases of treatment. BACKGROUNDS Several candidate genes have been reported to be involved in warfarin metabolism and studying such genes may help in finding an accurate way to determine the needed warfarin dose to lower the risk of adverse drug effects, resulting in more safe anticoagulant therapy. METHODS The study population included 212 cardiovascular patients and 213 healthy controls. Genotyping of MEF2A and SLC22A3-LPAL2-LPA polymorphisms was conducted to examine their effects on warfarin efficiency and cardiovascular disease susceptibility using PCR-based methods. RESULTS One SNP (SLC22A3-LPAL2-LPA rs10455872) has been associated with cardiovascular disease in the Jordanian population, whereas the other SNPs in the MEF2A gene and SLC22A3-LPAL2-LPA gene cluster did not have any significant differences between cardiovascular patients and healthy individuals. Moreover, SLC22A3-LPAL2-LPA rs10455872 was correlated with moderate warfarin sensitivity, the other SNPs examined in the current study have not shown any significant associations with warfarin sensitivity and responsiveness. CONCLUSION Our data refer to a lack of correlation between the MEF2A polymorphism and the efficacy of warfarin treatment in both phases of treatment, the initiation, and maintenance phases. However, only rs10455872 SNP was associated with sensitivity to warfarin during the initiation phase. Furthermore, rs3125050 has been found to be associated with the international normalized number treatment outcomes in the maintenance phase.
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Affiliation(s)
- Laith N. AL-Eitan
- Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Ayah Y. Almasri
- Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Adan H. Alnaamneh
- Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid, Jordan
| | - Ahmad Mihyar
- Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid, Jordan
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Elsadig AE, M. Muddath AR, Elamin EM, MA Shrif NE, Waggiallah HA. Effect of CYP2C9*2 and VKORC-1639G/A Polymorphisms on Warfarin Doses Requirements in Sudanese Patients. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.1366.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Koshy L, Vb R, M M, Ben MP, Kishor P, Sudhakaran PR, Abdullakutty J, Venugopal K, Zachariah G, Mohanan PP, Harikrishnan S, G S. Pharmacogenetic variants influence vitamin K anticoagulant dosing in patients with mechanical prosthetic heart valves. Pharmacogenomics 2022; 23:475-485. [PMID: 35608144 DOI: 10.2217/pgs-2022-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Vitamin K antagonists (VKAs) are class I oral anticoagulants that are widely prescribed following surgical heart valve implantation. The objective of this study was to quantify the relative effects of VKORC1, CYP2C9 and CYP4F2 genotypes in predicting VKA dosing. Materials & methods: A total of 506 South Indian patients with mechanical prosthetic heart valves who were prescribed oral VKAs, such as warfarin or acenocoumarol, were genotyped. The discriminatory ability of mutant genotypes to predict dose categories and bleeding events was assessed using regression analysis. Results: The VKORC1 rs9923231, CYP2C9*3 and CYP4F2*3 mutant genotypes significantly influenced VKA-dose requirements and explained 27.47% of the observed dose variation. Conclusion: These results support pharmacogenetic screening for initial VKA dosing among South Indian patients with mechanical prosthetic heart valves.
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Affiliation(s)
- Linda Koshy
- Centre for Advanced Research & Excellence in Heart Failure, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Raghu Vb
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | - Madhuma M
- Centre for Advanced Research & Excellence in Heart Failure, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Midhuna P Ben
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | - Pritam Kishor
- Integrated Science Education & Research Centre, Visva-Bharati, Santineketan, West Bengal, 731235, India
| | - P R Sudhakaran
- Inter-University Centre for Genomics & Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, Kerala, 695581, India
| | | | - K Venugopal
- Department of Cardiology, Pushpagiri Hospital, Thiruvalla, Pathanamthitta, Kerala, 689101, India
| | - Geevar Zachariah
- Department of Cardiology, Mother Hospital, Thrissur, Kerala, 680012, India
| | - P P Mohanan
- Department of Cardiology, Westfort Hi-Tech Hospital, Thrissur, Kerala, 680002, India
| | - S Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
| | - Sanjay G
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, 695011, India
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Kaur N, Pandey A, Shafiq N, Gupta A, Das R, Singh H, Ahluwalia J, Malhotra S. Genetic and Nongenetic Determinants of Variable Warfarin Dose Requirements: A Report from North India. Public Health Genomics 2021; 25:1-9. [PMID: 34673650 PMCID: PMC10233675 DOI: 10.1159/000519462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Warfarin is widely used and will continue to be prescribed especially in developing countries due to its low cost. Given the huge patient load requiring anticoagulation, there is a need to develop strategies to optimize warfarin therapy for ensuring safe and effective anticoagulation. In the present work, we aimed at elucidating the association of genetic and nongenetic variables with warfarin dose requirement in patients attending the cardiovascular clinic in a tertiary care center of North India. METHODS This was a prospective study conducted over 1 year. Patient demographic and clinical details were captured in customized case record forms. Genotyping was done using the polymerase chain reaction-restriction fragment length polymorphism method. Pharmacogenetic influence of CYP2C9 (rs1799853 and rs1057910) and VKORC1 (rs9923231) variant alleles was studied. The association of genetic and nongenetic factors with warfarin dose was quantified using a stepwise multivariate linear regression model. RESULTS Two hundred and forty patients were screened. Data from 82 eligible patients were used for quantifying the association of genetic and nongenetic factors with warfarin dose. A descriptive model based on CYP2C9*3 (rs1057910) and VKORC1 (rs9923231) variant alleles and BMI was developed. The model explains nearly half of the interindividual variation in warfarin dose requirement. CONCLUSION The model explains nearly half of the interindividual variation in warfarin dose in patients with atrial fibrillation and or requiring valve replacement.
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Affiliation(s)
- Navjot Kaur
- Department of Pharmacology, VMMC & Safdarjung Hospital, New Delhi, India
- Clinical Pharmacology Resident, Department of Pharmacology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Avaneesh Pandey
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ankur Gupta
- Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reena Das
- Department of Hematology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harkant Singh
- Department of CTVS, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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EŞKUT N, TAMER P, YILMAZ KÜSBECİ Ö, ATAÇ C, İNCİ İ. Evaluation of Time in Therapeutic Range in Patients with Cerebrovascular Disease Receiving Treatment with Warfarin. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.937769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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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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Veeregowda SH, Krishnaswamy B, Balakrishna S. Effect of Vitamin K Epoxide Reductase Complex 1 Polymorphism on Warfarin Dose Requirement among Patients in Tertiary Care Hospital. Int J Appl Basic Med Res 2020; 10:97-101. [PMID: 32566525 PMCID: PMC7289213 DOI: 10.4103/ijabmr.ijabmr_341_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/11/2019] [Accepted: 01/23/2020] [Indexed: 11/04/2022] Open
Abstract
Background Warfarin, anticoagulant is used for thromboembolic disorders. Inter-individual variation in clinical response to warfarin is due to various factors, including polymorphism of Vitamin K epoxide reductase complex 1 (VKORC1)-1639G>A. The aim of our study was to evaluate the effect of VKORC1 polymorphism on the maintenance dose of warfarin. Materials and Methods Cross-sectional study conducted by the departments of Pharmacology, Cell Biology and Molecular Genetics on patients attending cardiology clinic, receiving warfarin for at least 2 months. Genomic deoxyribonucleic acid was extracted and genotyping was done by Polymerase Chain Reaction - Restriction Fragment Length Polymorphism. The correlation between VKORC1 gene polymorphism and warfarin maintenance dose was analyzed. Results A total of 102 patients with a mean age of 47.72 ± 10.31 years, of which 58 (56.86%) were male. The frequency of VKORC1 G>A for GG, GA, and AA genotypes was 74.51%, 19.61%, and 5.88%, respectively. Variant allele AA was less frequent than the wild type. Mean weekly warfarin dose was 23.12 ± 8.08, 22.93 ± 8.21, and 15.6 ± 5.35 mg in patients with GG, GA, and AA genotypes, respectively. Patients with GG genotype required therapeutic dose compared to variant type (P = 0.001). Multiple stepwise regression model showed 26.3% variability in warfarin dose was due to VKORC1 genotype (R = 0.513, R2 = 0.263, adjusted R2 = 0.256, P = 0.0001). Conclusion VKORC1 polymorphism alone influence 26.3% variability in warfarin dose and AA genotype patients required lower dose.
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Affiliation(s)
- Sahana Hadihalli Veeregowda
- Department of Pharmacology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Bhuvana Krishnaswamy
- Department of Pharmacology, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Sharath Balakrishna
- Department of Cell Biology and Molecular Genetics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
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Antagonists of Vitamin K-Popular Coumarin Drugs and New Synthetic and Natural Coumarin Derivatives. Molecules 2020; 25:molecules25061465. [PMID: 32213944 PMCID: PMC7146486 DOI: 10.3390/molecules25061465] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 12/24/2022] Open
Abstract
Many natural coumarins and their chemically synthesized analogs and derivatives exert diverse properties, such as anticancer, antioxidant, anti-inflammatory, or anticoagulant, with the latter being of the utmost importance. The widely used warfarin, acenocoumarol, and phenprocoumon exert anticoagulant properties by inhibiting the vitamin K epoxide reductase complex. In this interdisciplinary review, we present biochemical principles of the coagulation processes and possible methods for their tuning based on the use of coumarins. We also summarize chemical methods of synthesis of coumarins and discuss structures and properties of those that have been used for a long time, as well as newly synthesized compounds. Brief information on the clinical use of coumarins and other anticoagulant drugs is given, including the severe effects of overdosing and methods for reversing their action.
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Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events. J Neurol Sci 2019; 398:69-74. [PMID: 30684767 DOI: 10.1016/j.jns.2019.01.031] [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: 11/11/2018] [Revised: 12/29/2018] [Accepted: 01/17/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The quality of anticoagulation is closely associated with efficacy and safety in warfarin users. Although genetic polymorphisms have been related to warfarin dosages and vascular events(VE), genetic evaluations have not been recommended for all warfarin users. The aim is to evaluate the significance of the maintenance dose of warfarin (MDW) on VE, considering the time in therapeutic range (TTR). METHODS This retrospective study analyzed the data of patients who received warfarin for any reasons. A total of 11,835 patients with warfarin were divided into quartiles by MDW. We assessed TTR using the Rosendaal method and VE. RESULTS VE occurred in 9.1% of the warfarin users. The mean TTR level was 34.0 ± 25.7%, and the MDW was 3.38 ± 1.06 mg per day. Patients with VE were more likely to have a lower MDW and lower TTR levels. In moderate- or well-controlled TTR status, a lower MDW was significantly related to under-controlled anticoagulation and associated with higher risks of VE. Lower MDW had a higher risk of stroke or arterial/venous thromboembolism (Q1: OR, 1.57; 95% CI 1.25 to 1.96; Q2: OR, 1.40; 95% CI 1.12 to 1.75; Q3: OR, 1.35; 95% CI 1.08 to 1.68). CONCLUSIONS We suggest that patients with very low MDW might be at risk when using warfarin. Therefore, we propose that patients with a very low MDW might be alternatively considered for novel oral anticoagulants rather than warfarin.
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Al-Eitan LN, Almasri AY, Al-Habahbeh SO. Effects of coagulation factor VII polymorphisms on warfarin sensitivity and responsiveness in Jordanian cardiovascular patients during the initiation and maintenance phases of warfarin therapy. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:1-8. [PMID: 30679919 PMCID: PMC6338106 DOI: 10.2147/pgpm.s189458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aims to investigate the relationships between genetic polymorphisms of the coagulation factor VII (FVII) gene and warfarin responsiveness and sensitivity. Patients and methods The study population consisted of 417 subjects (207 Jordanian cardiovascular patients and 210 healthy individuals). Cardiovascular patients were classified into two groups: those sensitive to warfarin dosage (sensitive, moderate, and resistant) and those responsive to warfarin based on International Normalized Ratios (INRs; poor, good, and extensive responders). The HVR4 polymorphism of the FVII gene was genotyped. Results Our results showed that there are significant differences between patients and controls according to both genotypic and allelic frequencies (P<0.0001) in the genetic susceptibility study. Moreover, the pharmacogenetics study reported that HVR4 had no association with warfarin sensitivity or responsiveness during the initiation and maintenance phases of therapy, the only significant differences were in the INR outcome measured during the maintenance phase of therapy (P=0.012). Conclusion Our data suggests lacking of association between the HVR4 polymorphism in the FVII gene and warfarin sensitivity and responsiveness during the initiation and maintenance phases of therapy. It is possible that these patients carry additional mutations in genes involved in the coagulation pathway.
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Affiliation(s)
- Laith N Al-Eitan
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan, .,Department of Biotechnology and Genetic Engineering, Jordan University of Science and Technology, Irbid 22110, Jordan,
| | - Ayah Y Almasri
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan,
| | - Sahar O Al-Habahbeh
- Department of Applied Biological Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan,
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Harikrishnan S, Koshy L, Subramanian R, Sanjay G, Vineeth CP, Nair AJ, Nair GM, Sudhakaran PR. Value of VKORC1 (-1639G>A) rs9923231 genotyping in predicting warfarin dose: A replication study in South Indian population. Indian Heart J 2018; 70 Suppl 3:S110-S115. [PMID: 30595241 PMCID: PMC6310074 DOI: 10.1016/j.ihj.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Warfarin is the most commonly prescribed oral anticoagulant, although having a narrow therapeutic index and wide interindividual variability. The aim of this study was to replicate the utility of VKORC1 (-1639G>A) rs9923231 genotyping in predicting the mean daily dose and to evaluate its ability to categorize warfarin-treated patients to high-, intermediate-, or low-dose categories in the South Indian population. MATERIALS AND METHODS A cohort of 222 warfarin-treated patients was genotyped using restriction fragment length polymorphism method. The influence of the rs9923231 polymorphism on the variations in the mean daily dose was compared using one-way analysis of variance and linear regression analysis. Discriminatory ability of the rs9923231 polymorphism to group the patients into ordered dose categories was assessed by estimating the proportional odds ratios using the ordered logit regression analysis. RESULTS The frequency of AA genotype and A allele in the study sample was found to be 1.8% and 9.23%, respectively, which was similar to reports from other South Indian populations. The mean daily dose required to achieve the optimum international normalized ratio was significantly lower in AA homozygous genotype carriers (3.99 ± 1.67 mg/day) and GA heterozygous (4.26 ± 1.57 mg/day) compared to the GG genotype carriers (5.51 ± 2.13 mg/day), p = 0.003. The A allele carriers (GA+AA genotypes) had a 3.23 higher odds of being grouped as a low-dose requiring category compared to non-carriers (95% CI 1.49-6.98, p = 0.003). CONCLUSIONS These preliminary results strongly support the use of VKORC1 (-1639G>A) rs9923231 polymorphism for genetically guided initial warfarin dosing in South Indian patients with heart valve replacements.
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Affiliation(s)
- S Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - Linda Koshy
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - Ram Subramanian
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - G Sanjay
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - C P Vineeth
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - A Jayakumaran Nair
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - G M Nair
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - P R Sudhakaran
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
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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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Alemayehu C, Nikles J, Mitchell G. N-of-1 trials in the clinical care of patients in developing countries: a systematic review. Trials 2018; 19:246. [PMID: 29685163 PMCID: PMC5914018 DOI: 10.1186/s13063-018-2596-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/16/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND N-of-1 trials have a potential role in promoting patient-centered medicine in developing countries. However, there is limited academic literature regarding the use of N-of-1 trials in the clinical care of patients in resource-poor settings. OBJECTIVE To assess the extent of use, purpose and treatment outcome of N-of-1 trials in developing countries. METHOD A systematic review of clinical N-of-1 trials was conducted between 1985 and September 2015 using PubMed, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials. Grey literature databases and clinical trial registers were also searched. This review included randomized, multi-cycle, crossover within individual patient trials involving drug intervention. Quality assessment and data extraction were conducted by two independent reviewers. RESULT Out of 131 N-of-1 trials identified, only 6 (4.5%) were conducted in developing countries. The major reason that N-of-1 trials were used was to provide evidence on feasibility, effectiveness and safety of therapies. A total of 72 participants were involved in these trials. Five of the studies were conducted in China and all evaluated Chinese traditional medicine. The remaining study was conducted in Brazil. The completion rate was 93%. More than half, 46 (69%) of subjects made medication changes consistent with trial results after trial completion. A number of threats to the validity of the included evidence limited the validity of the evidence. In particular, the estimated overall effect in four of the included studies could have been affected by the "carry over" of the previous treatment effect as no adequate pharmacokinetic evidence regarding traditional medicines was presented. CONCLUSION The prevalence and scope of N-of-1 trials in developing countries is low. A coordinated effort among government, clinicians, researchers and sponsor organizations is needed to increase their uptake and quality in developing countries. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015026841 .
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Biswas M, Bendkhale SR, Deshpande SP, Thaker SJ, Kulkarni DV, Bhatia SJ, Rajadhyaksha AG, Gogtay NJ, Thatte UM. Association between genetic polymorphisms of CYP2C9 and VKORC1 and safety and efficacy of warfarin: Results of a 5 years audit. Indian Heart J 2018; 70 Suppl 3:S13-S19. [PMID: 30595245 PMCID: PMC6309143 DOI: 10.1016/j.ihj.2018.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/02/2018] [Accepted: 02/13/2018] [Indexed: 11/30/2022] Open
Abstract
Objective Genetic polymorphisms of CYP2C9 and VKORC1 play major role in pharmacokinetics and pharmacodynamics of warfarin, respectively. Purpose of our study was to assess the utility of pretesting patients for the above mutations in predicting tendency for bleeding and achieving target INR. Methods This was an audit of data collected between July 2011 and December 2016. For safety and efficacy, patients were divided into two subgroups: those with or without bleeding and those who achieved target INR or not. Chi square test was applied to compare the between group differences and crude Odds Ratio (cOR) calculated. Results Among 521 patients evaluated, most common indication for warfarin therapy was valvular heart disease (210/521 = 40%); 36% (187/521) had at least one bleeding episode; 56% (269/479) had below target INR. 26% (136/521) had polymorphic alleles of CYP2C9 and 69% (358/521) had the GG haplotype of VKORC1. Polymorphic alleles of CYP2C9 or AG/AA haplotype had twice the odds of bleeding (cOR = 2.14 and 2.44 respectively) relative to those with wild CYP2C9 allele or GG haplotype. Combined CYP2C9 mutant alleles and/or AG/AA haplotypes had thrice the odds of bleeding (cOR = 3.12) relative to those with wild CYP2C9 alleles and GG haplotype. Those with GG haplotype had twice the odds (cOR = 1.81) and those with GG haplotype along with wild CYP2C9 allele had four times the odds (cOR = 4.27) of not achieving the target INR relative to those with other haplotype/alleles. All these associations were statistically significant (p < 0.05). Conclusions Pretesting patients for genetic polymorphisms could aid in individualizing warfarin therapy.
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Affiliation(s)
- Mansij Biswas
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shital R Bendkhale
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Saket J Thaker
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Dwarkanath V Kulkarni
- Department of Cardiovascular and Thoracic Surgery, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Shobna J Bhatia
- Department of Gastroenterology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Anjali G Rajadhyaksha
- Department of Medicine, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth G.S. Medical College & KEM Hospital, Acharya Donde Marg, Parel, Mumbai 400012, Maharashtra, India.
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Disease burden and the role of pharmacogenomics in African populations. GLOBAL HEALTH EPIDEMIOLOGY AND GENOMICS 2017; 2:e1. [PMID: 29868213 PMCID: PMC5870420 DOI: 10.1017/gheg.2016.21] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/15/2022]
Abstract
Background The burden of communicable and non-communicable diseases in Sub-Saharan Africa poses a challenge in achieving quality healthcare. Although therapeutic drugs have generally improved health, their efficacy differs from individual to individual. Variability in treatment response is mainly because of genetic variants that affect the pharmacokinetics and pharmacodynamics of drugs. Method The intersection of disease burden and therapeutic intervention is reviewed, and the status of pharmacogenomics knowledge in African populations is explored. Results The most commonly studied variants with pharmacogenomics relevance are discussed, especially in genes coding for enzymes that affect the response to drugs used for HIV, malaria, sickle cell disease and cardiovascular diseases. Conclusions The genetically diverse African population is likely to benefit from a pharmacogenomics-based healthcare approach, especially with respect to reduction of drug side effects, and separation of responders and non-responders leading to optimized drug choices and doses for each patient.
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DNA sensors to assess the effect of VKORC1 and CYP2C9 gene polymorphisms on warfarin dose requirement in Chinese patients with atrial fibrillation. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:249-258. [PMID: 28083852 DOI: 10.1007/s13246-016-0519-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
Abstract
The optimal dose of warfarin depends on polymorphisms in the VKORC1 (the vitamin K epoxide reductase complex subunit (1) and CYP2C9 (cytochrome P450 2C9) genes. To minimize the risk of adverse reactions, warfarin dosages should be adjusted according to results from rapid and simple monitoring methods. However, there are few pharmacogenetic-guided warfarin dosing algorithms that are based on large cohorts from the Chinese population, especially patients with atrial fibrillation. This study aimed to validate a pharmacogenetic-guided warfarin dosing algorithm based on results from a new rapid electrochemical detection method used in a multicenter study. Three SNPs (CYP2C9 *2, *3 and VKORC1 c.-1639G > A) were genotyped by electrochemical detection using a sandwich-type format that included a 3' short thiol capture probe and a 5' ferrocene-labeled signal probe. A total of 1285 samples from four clinical hospitals were evaluated. Concordance rates between the results from the electrochemical DNA biosensor and the sequencing test were 99.8%. The results for gene distribution showed that most Chinese patients had higher warfarin susceptibility because mutant-type and heterozygotes were present in the majority of subjects (99.4%) at locus c.-1639G > A. When the International Warfarin Pharmacogenetics Consortium algorithm was used to estimate therapeutic dosages for 362 patients with AF and the values were compared with their actual dosages, the results revealed that 56.9% were similar to actual dosages (within the 20% range). A novel electrochemical detection method of CYP2C9 *2, *3and VKORC1 c.-1639G > A alleles was evaluated. The warfarin dosing algorithm based on data gathered from a large patient cohort can facilitate the reasonable and effective use of warfarin in Chinese patients with AF.
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Gaikwad T, Ghosh K, Avery P, Kamali F, Shetty S. Warfarin Dose Model for the Prediction of Stable Maintenance Dose in Indian Patients. Clin Appl Thromb Hemost 2017; 24:353-359. [PMID: 28049362 DOI: 10.1177/1076029616683046] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The main aim of this study was to screen various genetic and nongenetic factors that are known to alter warfarin response and to generate a model to predict stable warfarin maintenance dose for Indian patients. The study comprised of 300 warfarin-treated patients. Followed by extensive literature review, 10 single-nucleotide polymorphisms, that is, VKORC1-1639 G>A (rs9923231), CYP2C9*2 (rs1799853), CYP2C9*3 (rs1057910), FVII R353Q (rs6046), GGCX 12970 C>G (rs11676382), CALU c.*4A>G (rs1043550), EPHX1 c.337T>C (rs1051740), GGCX: c.214+597G>A (rs12714145), GGCX: 8016G>A (rs699664), and CYP4F2 V433M (rs2108622), and 5 nongenetic factors, that is, age, gender, smoking, alcoholism, and diet, were selected to find their association with warfarin response. The univariate analysis was carried out for 15 variables (10 genetic and 5 nongenetic). Five variables, that is, VKORC1-1639 G>A, CYP2C9*2, CYP2C9*3, age, and diet, were found to be significantly associated with warfarin response in univariate analysis. These 5 variables were entered in stepwise and multiple regression analysis to generate a prediction model for stable warfarin maintenance dose. The generated model scored R2 of .67, which indicates that this model can explain 67% of warfarin dose variability. The generated model will help in prescribing more accurate warfarin maintenance dosing in Indian patients and will also help in minimizing warfarin-induced adverse drug reactions and a better quality of life in these patients.
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Affiliation(s)
- Tejasvita Gaikwad
- 1 National Institute of Immunohaematology (ICMR), Department of Thrombosis and Haemostasis, KEM Hospital, Parel, Mumbai, India
| | - Kanjaksha Ghosh
- 2 Surat Raktadan Kendra & Research Centre, Regional Blood Transfusion Centre, Surat, Gujarat, India
| | - Peter Avery
- 3 School of Mathematics and Statistics, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Farhad Kamali
- 4 Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Shrimati Shetty
- 1 National Institute of Immunohaematology (ICMR), Department of Thrombosis and Haemostasis, KEM Hospital, Parel, Mumbai, India
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Razavi FE, Zarban A, Hajipoor F, Naseri M. The allele frequency of CYP2C9 and VKORC1 in the Southern Khorasan population. Res Pharm Sci 2017. [PMID: 28626479 PMCID: PMC5465830 DOI: 10.4103/1735-5362.207202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The genetic factors are determinants in required dosage changes of warfarin among which are polymorphisms of CYP2C9 and VKORC1 genes. The present study aimed to determine the allele and genotype frequency of CYP2C9 and VKORC1 genes in Birjand population. This study was conducted on 120 individuals who referred to Imam Reza and Vali-Asr hospitals for PT/INR test. After extracting the genomic DNA, the considered sequences were amplified by PCR, and restriction fragment length polymorphism analysis was done by AvaII and KpnI enzymes to determine allele polymorphisms. Moreover, related sequences of VKORC1, after amplification, were sequenced for determining the genotype. Allelic and genotypic frequencies as well as Hardy-Weinberg equilibrium, observed heterozygosity, expected heterozygosity, and polymorphism information content were calculated by PowerMarker V 3.25 software. Amongst 120 individuals in this study with the mean age of 58.12 ± 12.7 years, 80.8%, 9.1%, and 10% exhibited the alleles of 1, 2, and 3 CYP2C9 gene, respectively. The genotype frequencies of 1/1, 1/2, 2/2, 3/1, 3/2, and 3/3 of this gene were found to be 64.1, 15.8, 0, 17.5, 2.5, and 0 %, respectively. In -1639 G>A region, VKORC1 had normal homozygote genotype (GG) and in 1173 C>T region, heterozygote (CT) with the frequency of 48.7% and 45.9% had the most prevalence. Compared with other populations, there is a considerable difference between the allele frequency of CYP2C9 and VKORC1 genetic variance. Since 35.8% of the selected populations carry an abnormal allele causing sensitivity to warfarin, the specialists at medical centers must be informed about the genotypes of patients before prescribing warfarin.
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Affiliation(s)
- Fariba Emadian Razavi
- Department of Prosthodontics, Faculty of Dentistry, Birjand University of Medical Sciences, Birjand, I.R. Iran
| | - Asghar Zarban
- Department of Biochemistry, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, I.R. Iran
| | - Fatemeh Hajipoor
- Genomics Research Group, Cellular and Molecular Research Center, Birjand University of Medical Sciences, Birjand, I.R. Iran
| | - Mohsen Naseri
- Genomics Research Group, Cellular and Molecular Research Center, Paramedical Faculty, Birjand University of Medical Sciences, Birjand, I.R. Iran
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Pai SA, Kshirsagar N. A Critical Evaluation of Pharmacogenetic Information in Package Inserts for Selected Drugs Marketed in India and Its Comparison With US FDA-Approved Package Inserts. J Clin Pharmacol 2016; 56:1232-42. [PMID: 26873003 DOI: 10.1002/jcph.720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/08/2016] [Indexed: 02/06/2023]
Abstract
Our objective was to compare the pharmacogenetic information provided in the package inserts (PIs) of 7 drugs marketed in the United States and India, namely, abacavir, capecitabine, carbamazepine, clopidogrel, irinotecan, valproic acid, and warfarin. We evaluated the pharmacogenetic information provided in Indian PIs for the highest level where it was included, robustness and completeness, clinical validity, and clinical utility and compared it with corresponding data of US PIs. Pharmacogenetic studies carried out in India were identified using PubMed. Pharmacogenetic information was provided in Indian PIs of all the drugs except irinotecan. It appeared in the same section as in US PIs for abacavir, capecitabine, carbamazepine (HLA-*3101), valproic acid (urea cycle disorders), and warfarin (protein C and protein S), whereas it appeared at lower levels for other drug-gene combinations. The robustness of pharmacogenetic testing was graded convincing for abacavir, adequate for carbamazepine and clopidogrel, and incomplete for the remaining drugs, and only abacavir and clopidogrel PIs provided full details of supporting studies. These details, when provided in the Indian PIs were identical to those in the US PIs. The Indian PIs did not provide data on Indian patients, although published studies are available. Both US and Indian PIs lacked critical information on the clinical validity and utility of pharmacogenetic testing. The pharmacogenetic information should provide country/ethnicity-specific data so that they are useful to clinicians. Where data are not available, the prevalence of genetic variation in the population of a country needs to be determined and should then be translated to the PIs.
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Affiliation(s)
- Sarayu Arvind Pai
- Institute of Chemical Technology, Formerly, Indian Council of Medical Research, Mumbai, India
| | - Nilima Kshirsagar
- National Chair in Clinical Pharmacology, South Asian Chapter of American College of Clinical Pharmacology (SAC-ACCP), Mumbai, India.
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VKORC1 and CYP2C9 genotype distribution in Asian countries. Thromb Res 2014; 134:537-44. [DOI: 10.1016/j.thromres.2014.05.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/04/2014] [Accepted: 05/16/2014] [Indexed: 01/21/2023]
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