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Xia X, Cai X, Chen J, Jiang S, Zhang J. Construction of warfarin population pharmacokinetics and pharmacodynamics model in Han population based on Bayesian method. Sci Rep 2024; 14:14846. [PMID: 38937509 PMCID: PMC11211351 DOI: 10.1038/s41598-024-65048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
The purpose of this paper is to study the genetic polymorphisms of related gene loci (CYP2C9*3, VKORC1-1639G > A) based on demographic and clinical factors, and use the maximum a posterior Bayesian method to construct a warfarin individualized dose prediction model in line with the Chinese Han population. Finally, the built model is compared and analyzed with the widely used models at home and abroad. In this study, a total of 5467 INR measurements are collected from 646 eligible subjects in our hospital, and the maximum a posterior Bayesian method is used to construct a warfarin dose prediction that conforms to the Chinese Han population on the basis of the Hamberg model. The model is verified and compared with foreign models. This study finds that body weight and concomitant use of amiodarone have a significant effect on the anticoagulant effect of warfarin. The model can provide an effective basis for individualized and rational dosing of warfarin in Han population more accurately. In the performance of comparison with different warfarin dose prediction models, the new model has the highest prediction accuracy, and the prediction percentage is as high as 72.56%. The dose predicted by the Huang model is the closest to the actual dose of warfarin. The population pharmacokinetics and pharmacodynamics model established in this study can better reflect the distribution characteristics of INR values after warfarin administration in the Han population, and performs better than the models reported in the literature.
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Affiliation(s)
- Xiaotong Xia
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Xiaofang Cai
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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Hirai T, Aoyama T, Tsuji Y, Itoh T, Matsumoto Y, Iwamoto T. Kinetic-pharmacodynamic model of warfarin for prothrombin time-international normalized ratio in Japanese patients. Br J Clin Pharmacol 2024; 90:828-836. [PMID: 37953511 DOI: 10.1111/bcp.15967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/10/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Genotype-guided dosing algorithms can explain about half of the interindividual variability in prothrombin time-international normalized ratio (PT-INR) under warfarin treatment. This study aimed to refine a published kinetic-pharmacodynamic model and guide warfarin dosage for an optimal PT-INR based on renal function. METHODS Using a retrospective cohort of adult patients (>20 years) who were administered warfarin and underwent PT-INR measurements, we refined the kinetic-pharmacodynamic model with age and the genotypes of cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 using the PRIOR subroutine in the nonlinear-mixed-effect modelling programme. We searched the significant covariates for parameters, such as the dose rate for 50% inhibition of coagulation (EDR50 ), using a stepwise forward and backward method. Monte Carlo simulation determined a required daily dose of warfarin with a target range of PT-INR (2.0-3.0 or 1.6-2.6) based on the significant covariates. RESULTS A total of 350 patients with 2762 PT-INR measurements were enrolled (estimated glomerular filtration rate [eGFR]: 47.5 [range: 2.6-199.0] mL/min/1.73 m2 ). The final kinetic-pharmacodynamic model showed that the EDR50 changed power functionally with body surface area, serum albumin level and eGFR. Monte Carlo simulation revealed that a lower daily dose of warfarin was required to attain the target PT-INR range as eGFR decreased. CONCLUSIONS Model-informed precision dosing of warfarin is a valuable approach for estimating its dosage in patients with renal impairment.
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Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
| | - Takahiko Aoyama
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Yasuhiro Tsuji
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Toshimasa Itoh
- Department of Pharmacy, Tokyo Women's Medical University, Medical Center East, Tokyo, Japan
| | - Yoshiaki Matsumoto
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
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Cai X, Chen J, Chen M, Xia X, Fang G, Zhang J. Application of a warfarin dosing calculator to guide individualized dosing versus empirical adjustment after fixed dosing: a pilot study. Front Pharmacol 2023; 14:1235331. [PMID: 37663245 PMCID: PMC10469691 DOI: 10.3389/fphar.2023.1235331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background: Warfarin has a narrow therapeutic window and individual variation, and patients require regular follow-up and monitoring of the International Normalized Ratio (INR) for dose adjustment. The calculation method of Warfarin Dosing Calculator (WDC) software is based on the European and American populations, and its accuracy in the Chinese population is yet to be verified. Objective: This study was to evaluate the feasibility of applying Warfarin Dosing Calculator software intervention in a real-world clinical research setting in China. Methods: The pilot study divided the included patients after valve replacement into an experimental group and a control group, with 38 cases in each group. In the control group, the initial dose was fixed at 2.5 mg/d and the dose was adjusted empirically during the study period; in the experimental group, the Warfarin Dosing Calculator software was applied to guide the dosing, and patients in both groups were followed up for 3 months. Analysis of the incidence anticoagulation outcomes and excessive anticoagulation events in both groups. Kaplan-Meier survival curves were used to analyze the correlation between different dosing regimens and first International Normalized Ratio attainment, and Logrank tests were performed. Results: The mean time required for first International Normalized Ratio compliance in the experimental group was 4.38 days less than in the control group, and the mean number of tests was 1.43 less (p < 05). Time in therapeutic range (TTR) was significantly higher in the experimental group than in the control group (p < 05). Kaplan-Meier survival curve analysis showed that the first International Normalized Ratio attainment rate was significantly higher in the experimental group than in the control group (p = 01). No major bleeding events occurred in either group, but other excessive anticoagulation events (INR>3.5 and minor bleeding) were significantly reduced in the experimental group compared with the control group (p < 05). Conclusion: Application of Warfarin Dosing Calculator software to guide individualized warfarin dosing may be better than a fixed dose of 2.5 mg/d. It may be shorten the time to first International Normalized Ratio attainment, and the attainment rate in the same time, and can better improve the mean Time in therapeutic range level value and reduce excessive anticoagulation events, which improves the safety of warfarin anticoagulation therapy in clinical practice. Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=52793, ChiCTR2000032393.
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Affiliation(s)
- Xiaofang Cai
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- Zhangpu County Hospital, Zhangzhou, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maohua Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- Pingtan Comprehensive Experimental Area Hospital, Pingtan Comprehensive Experimental Area, Fuzhou, China
| | - Xiaotong Xia
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Guanhua Fang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Anzabi Zadeh S, Street WN, Thomas BW. Optimizing warfarin dosing using deep reinforcement learning. J Biomed Inform 2023; 137:104267. [PMID: 36494060 DOI: 10.1016/j.jbi.2022.104267] [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: 02/07/2022] [Revised: 10/30/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
Warfarin is a widely used anticoagulant, and has a narrow therapeutic range. Dosing of warfarin should be individualized, since slight overdosing or underdosing can have catastrophic or even fatal consequences. Despite much research on warfarin dosing, current dosing protocols do not live up to expectations, especially for patients sensitive to warfarin. We propose a deep reinforcement learning-based dosing model for warfarin. To overcome the issue of relatively small sample sizes in dosing trials, we use a Pharmacokinetic/ Pharmacodynamic (PK/PD) model of warfarin to simulate dose-responses of virtual patients. Applying the proposed algorithm on virtual test patients shows that this model outperforms a set of clinically accepted dosing protocols by a wide margin. We tested the robustness of our dosing protocol on a second PK/PD model and showed that its performance is comparable to the set of baseline protocols.
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Affiliation(s)
- Sadjad Anzabi Zadeh
- Department of Business Analytics, Tippie College of Business, University of Iowa, Iowa City, IA 52242, USA.
| | - W Nick Street
- Department of Business Analytics, Tippie College of Business, University of Iowa, Iowa City, IA 52242, USA
| | - Barrett W Thomas
- Department of Business Analytics, Tippie College of Business, University of Iowa, Iowa City, IA 52242, USA
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Elnour AA, Ahmed IM, Khalid AK, Elmustafa M. Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study. Pharm Pract (Granada) 2022; 20:2722. [PMID: 36733524 PMCID: PMC9851814 DOI: 10.18549/pharmpract.2022.3.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing. Objective The current study's main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects. Method We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms). Main outcome measure The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy. Results We have enrolled 71 Sudanese subjects with mean age (51.7 ± 14 years), of which (49, 69.0%) were females. There was no significant difference between the warfarin 5 mg fixed standard dose strategy and the predicted doses of the two clinical algorithm models (MAE 1.44, 1.45, and 1.49 mg/day [P =0.4]) respectively. In the clinical practicality, all of the three models had a high percent of subjects (95.0%, 51.9%, and 66.7%) in the ideal dose range in middle dose group (3-7 mg/ day) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithm models respectively. However, a small percent of subjects was exhibited in the warfarin low dose group ≤ 3 mg/day (0.0%, 15.0%, and 10.0%) and warfarin high dose group ≥ 7 mg/day (0.0%, 33.3%, and 33.3%) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithms respectively. In terms of clinical safety, the percent of subjects with severely over-prediction were 28.2%, 22.5%, and 22.5% for warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. While the percent of severely under-prediction was 12.7%, 7.0%, and 5.6% for the warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. Conclusion The Gage and IWPC clinical algorithm models were accurate, more clinically practical, and clinically safe than warfarin 5 mg standard dosing in the study population. The cardiologist can use either models (Gage and IWPC) to stratify subjects for accurate, practical, and clinically safe warfarin dosing..
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Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University (AAU), Abu Dhabi campus, Abu Dhabi-United Arab Emirates (UAE). AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Islam Mohammed Ahmed
- PhD student, MSc, B Pharm. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan. b. Faculty of Pharmacy, Managel University for Science and Technology, Managel-Sudan.
| | - Al-Kubaissi Khalid
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
| | - Mohamed Elmustafa
- PhD, Msc. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan.
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Kuang Y, Liu Y, Pei Q, Ning X, Zou Y, Liu L, Song L, Guo C, Sun Y, Deng K, Zou C, Cao D, Cui Y, Wu C, Yang G. Long Short-Term Memory Network for Development and Simulation of Warfarin Dosing Model Based on Time Series Anticoagulant Data. Front Cardiovasc Med 2022; 9:881111. [PMID: 35647078 PMCID: PMC9130657 DOI: 10.3389/fcvm.2022.881111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Background Warfarin is an effective treatment for thromboembolic disease but has a narrow therapeutic index, and dosage can differ tremendously among individuals. The study aimed to develop an individualized international normalized ratio (INR) model based on time series anticoagulant data and simulate individualized warfarin dosing. Methods We used a long short-term memory (LSTM) network to develop an individualized INR model based on data from 4,578 follow-up visits, including clinical and genetic factors from 624 patients whom we enrolled in our previous randomized controlled trial. The data of 158 patients who underwent valvular surgery and were included in a prospective registry study were used for external validation in the real world. Results The prediction accuracy of LSTM_INR was 70.0%, which was much higher than that of MAPB_INR (maximum posterior Bayesian, 53.9%). Temporal variables were significant for LSTM_INR performance (51.7 vs. 70.0%, P < 0.05). Genetic factors played an important role in predicting INR at the onset of therapy, while after 15 days of treatment, we found that it might unnecessary to detect genotypes for warfarin dosing. Using LSTM_INR, we successfully simulated individualized warfarin dosing and developed an application (AI-WAR) for individualized warfarin therapy. Conclusion The results indicate that temporal variables are necessary to be considered in warfarin therapy, except for clinical factors and genetic factors. LSTM network may have great potential for long-term drug individualized therapy. Trial Registration NCT02211326; www.chictr.org.cn:ChiCTR2100052089.
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Affiliation(s)
- Yun Kuang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yaxin Liu
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoyi Ning
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yi Zou
- School of Mathematics and Statisics, Central South University, Changsha, China
| | - Liming Liu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Long Song
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyuan Sun
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Kunhong Deng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chan Zou
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Dongsheng Cao
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
- Hunan Key Laboratory of Diagnostic and Therapeutic Drug Research for Chronic Diseases, Central South University, Changsha, China
| | - Yimin Cui
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Chengkun Wu
- State Key Laboratory of High Performance Computing, Institute for Quantum Information, College of Computer Science and Technology, National University of Defense Technology, Changsha, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- XiangYa School of Pharmaceutical Sciences, Central South University, Changsha, China
- Hunan Key Laboratory of Diagnostic and Therapeutic Drug Research for Chronic Diseases, Central South University, Changsha, China
- National-Local Joint Engineering Laboratory of Drug Clinical Evaluation Technology, Changsha, China
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Ma Z, Wang P, Mahesh M, Elmi CP, Atashpanjeh S, Khalighi B, Cheng G, Krishnamurthy M, Khalighi K. Warfarin sensitivity is associated with increased hospital mortality in critically Ill patients. PLoS One 2022; 17:e0267966. [PMID: 35511891 PMCID: PMC9070894 DOI: 10.1371/journal.pone.0267966] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Warfarin sensitivity has been reported to be associated with increased incidence of international normalized ratio (INR) > 5. However, whether warfarin sensitivity is a risk factor for adverse outcomes in critically ill patients remains unknown. In the present study, we aimed to evaluate the utility of different machine learning algorithms for the prediction of warfarin sensitivity and to determine the impact of warfarin sensitivity on outcomes in critically ill patients. Methods Nine different machine learning algorithms for the prediction of warfarin sensitivity were tested in the International Warfarin Pharmacogenetic Consortium cohort and Easton cohort. Furthermore, a total of 7,647 critically ill patients was analyzed for warfarin sensitivity on in-hospital mortality by multivariable regression. Covariates that potentially confound the association were further adjusted using propensity score matching or inverse probability of treatment weighting. Results We found that logistic regression (AUC = 0.879, 95% CI: 0.834–0.924) was indistinguishable from support vector machine with a linear kernel, neural network, AdaBoost and light gradient boosting trees, and significantly outperformed all the other machine learning algorithms. Furthermore, we found that warfarin sensitivity predicted by the logistic regression model was significantly associated with worse in-hospital mortality in critically ill patients with an odds ratio (OR) of 1.33 (95% CI, 1.01–1.77). Conclusions Our data suggest that the logistic regression model is the best model for the prediction of warfarin sensitivity clinically and that warfarin sensitivity is likely to be a risk factor for adverse outcomes in critically ill patients.
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Affiliation(s)
- Zhiyuan Ma
- Department of Medicine, St Luke’s University Health Network, Easton, PA, United States of America
- * E-mail: (ZM); (KK)
| | - Ping Wang
- Department of Computer Science, East Carolina University College of Engineering and Technology, Greenville, NC, United States of America
| | - Milan Mahesh
- Drexel University College of Arts and Sciences, Philadelphia, PA, United States of America
| | - Cyrus P. Elmi
- Lehigh University College of Arts and Sciences, Bethlehem, PA, United States of America
| | - Saeid Atashpanjeh
- Department of Biology, University of Hartford, West Hartford, CT, United States of America
| | - Bahar Khalighi
- School of Pharmacy, Temple University, Philadelphia, PA, United States of America
| | - Gang Cheng
- Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Mahesh Krishnamurthy
- Department of Medicine, St Luke’s University Health Network, Easton, PA, United States of America
| | - Koroush Khalighi
- Lehigh Valley Heart Institute, Easton, PA, United States of America
- * E-mail: (ZM); (KK)
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Fahmi AM, Elewa H, El Jilany I. Warfarin dosing strategies evolution and its progress in the era of precision medicine, a narrative review. Int J Clin Pharm 2022; 44:599-607. [PMID: 35247148 PMCID: PMC9200678 DOI: 10.1007/s11096-022-01386-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/09/2022] [Indexed: 11/30/2022]
Abstract
Background For decades, vitamin K antagonists and specifically warfarin, have been the sole agents used orally to manage thromboembolic conditions, including stroke and venous thromboembolism (VTE). Several factors lead to warfarin dose variability, including genetic and non-genetic factors which made warfarin management challenging especially at the initiation phase. To overcome the challenges with warfarin dosing at initiation, strategies other than conventional or fixed dosing were introduced and explored. Aim In this narrative review, we aim to discuss and critique the different dosing strategies for warfarin at initiation with more focus on genotype-guided warfarin dosing and the most recent supporting evidence for and against its use. Method Medline database was searched from 1965 to July 2021. Articles addressing different warfarin dosing methods were screened for inclusion. Results A number of methods exist for warfarin initiation. Studies comparing different dosing methods for initiation yielded conflicting outcomes due to differences in study design, population studied, comparator, and outcomes measured. Conclusions Looking at the big picture, the use of genetic dosing for warfarin initiation can lead to better outcomes. Whether these better outcomes are clinically or economically beneficial remains controversial.
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Affiliation(s)
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha, Qatar.
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Ndadza A, Muyambo S, Mntla P, Wonkam A, Chimusa E, Kengne AP, Ntsekhe M, Dandara C. Profiling of warfarin pharmacokinetics-associated genetic variants: Black Africans portray unique genetic markers important for an African specific warfarin pharmacogenetics-dosing algorithm. J Thromb Haemost 2021; 19:2957-2973. [PMID: 34382722 PMCID: PMC9543705 DOI: 10.1111/jth.15494] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Warfarin dose variability observed in patients is attributed to variation in genes involved in the warfarin metabolic pathway. Genetic variation in CYP2C9 and VKORC1 has been the traditional focus in evaluating warfarin dose variability, with little focus on other genes. OBJECTIVE We set out to evaluate 27 single nucleotide polymorphisms (SNPs) in the CYP2C cluster loci and 8 genes (VKORC1, ABCB1, CYP2C9, CYP2C19, CYP2C8, CYP1A2, CYP3A4, and CYP3A5) involved in pharmacokinetics of warfarin. PATIENTS/METHODS 503 participants were recruited among black Africans and Mixed Ancestry population groups, from South Africa and Zimbabwe, and a blood sample taken for DNA. Clinical parameters were obtained from patient medical records, and these were correlated with genetic variation. RESULTS Among black Africans, the SNPs CYP2C rs12777823G>A, CYP2C9 c.449G>A (*8), CYP2C9 c.1003C>T (*11) and CYP2C8 c.805A>T (*2) were significantly associated with warfarin maintenance dose. Conversely, CYP2C9 c.430C>T (*2), CYP2C8 c.792C>G (*4) and VKORC1 g.-1639G>A were significantly associated with maintenance dose among the Mixed Ancestry. The presence of CYP2C8*2 and CYP3A5*6 alleles was associated with increased mean warfarin maintenance dose, whereas CYP2C9*8 allele was associated with reduced warfarin maintenance dose. CONCLUSION African populations present with a diversity of variants that are important in predicting pharmacogenetics-based warfarin dosing in addition to those reported in CYP2C9 and VKORC1. It is therefore important, to include African populations in pharmacogenomics studies to be able to identify all possible biomarkers that are potential predictors for drug response.
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Affiliation(s)
- Arinao Ndadza
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Sarudzai Muyambo
- Department of Clinical PharmacologyCollege of Health ScienceUniversity of ZimbabweHarareZimbabwe
- Department of Biological SciencesFaculty of Science and EngineeringBindura University of Science and EducationBinduraZimbabwe
| | - Pindile Mntla
- Department of CardiologySefako Makgatho Health Sciences University and Dr. George Mukhari HospitalPretoriaSouth Africa
| | - Ambroise Wonkam
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Emile Chimusa
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Andre P. Kengne
- Non‐Communicable Diseases Research UnitSouth African Medical Research Council and University of Cape TownCape TownSouth Africa
| | - Mpiko Ntsekhe
- Division of CardiologyDepartment of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Collet Dandara
- Pharmacogenomics and Drug Metabolism Research GroupDivision of Human GeneticsDepartment of Pathology & Institute of Infectious Disease and Molecular Medicine (IDM)Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Zhang Y, Xie C, Xue L, Tao Y, Yue G, Jiang B. A post-hoc interpretable ensemble model to feature effect analysis in warfarin dose prediction for Chinese patients. IEEE J Biomed Health Inform 2021; 26:840-851. [PMID: 34166206 DOI: 10.1109/jbhi.2021.3092170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
To interprete the importance of clinical features and genotypes for warfarin daily dose prediction, we developed a post-hoc interpretable framework based on an ensemble predictive model. This framework includes permutation importance for global interpretation and local interpretable model-agnostic explanation (LIME) and shapley additive explanations (SHAP) for local explanation. The permutation importance globally ranks the importance of features on the whole data set. This can guide us to build a predictive model with less variables and the complexity of final predictive model can be reduced. LIME and SHAP together explain how the predictive model give the predicted dosage for specific samples. This help clinicians prescribe accurate doses to patients using more effective clinical variables. Results showed that both the permutation importance and SHAP demonstrated that VKORC1, age, serum creatinine (SCr), left atrium (LA) size, CYP2C9 and weight were the most important features on the whole data set. In specific samples, both SHAP and LIME discovered that in Chinese patients, wild-type VKORC1-AA, mutant-type CYP2C9*3, age over 60, abnormal LA size, SCr within the normal range, and using amiodarone definitely required dosage reduction, whereas mutant-type VKORC1-AG/GG, small age, SCr out of normal range, normal LA size, diabetes and heavy weight required dosage enhancement.
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Tao Y, Jiang B, Xue L, Xie C, Zhang Y. Evolutionary synthetic oversampling technique and cocktail ensemble model for warfarin dose prediction with imbalanced data. Neural Comput Appl 2021. [DOI: 10.1007/s00521-020-05568-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Ning X, Kuang Y, Yang G, Xie J, Miao D, Guo C, Huang Z. Influence of renal insufficiency on anticoagulant effects and safety of warfarin in Chinese patients: analysis from a randomized controlled trial. Naunyn Schmiedebergs Arch Pharmacol 2021; 394:1275-1283. [PMID: 33404689 PMCID: PMC8208902 DOI: 10.1007/s00210-020-02037-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022]
Abstract
This study aimed to analyze the influence of renal insufficiency on the anticoagulant effects and safety of warfarin in Chinese patients. Data on the creatinine levels of participants enrolled in a randomized controlled study were screened and divided into the non-renal insufficiency group, mild renal insufficiency group, and moderate renal insufficiency group, according to the creatinine clearance rate. The primary outcome measures were stable dose and average daily dose of warfarin. Secondary outcome measures were percentage of time in the therapeutic international normalized ratio (INR) (%TTR), and the first time to reach the therapeutic INR. Adverse events included bleeding events, thromboembolic events, and mortality. All participants with renal function test results and a baseline INR of less than 1.5 were included in the primary and secondary outcome analysis. The SPSS Statistics 21.0 software was used for statistical analysis. The randomized controlled trial was registered in Clinicaltrials.gov (NCT02211326). A total of 571 patients were included in this analysis. Multiple regression analysis showed that the renal function was correlated with stable dose, average daily dose, and the first time to reach therapeutic INR after adjusting for confounding factors. However, no correlation was noted between kidney function and %TTR. No significant differences were observed across the various safety parameters among the three groups. Renal function is an important consideration in patients using warfarin.
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Affiliation(s)
- Xiaoyi Ning
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Yun Kuang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Guoping Yang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China.,Research Center for Drug Clinical Evaluation of Central South University, Changsha, 410013, Hunan, China.,Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jinlian Xie
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Da Miao
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Chengxian Guo
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China. .,Research Center for Drug Clinical Evaluation of Central South University, Changsha, 410013, Hunan, China. .,Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
| | - Zhijun Huang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China. .,Department of Nephrology, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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Sun B, Wen YF, Culhane-Pera KA, Lo M, Xiong T, Lee K, Peng K, Thyagarajan B, Bishop JR, Zierhut H, Straka RJ. Differences in Predicted Warfarin Dosing Requirements Between Hmong and East Asians Using Genotype-Based Dosing Algorithms. Pharmacotherapy 2020; 41:265-276. [PMID: 33202062 DOI: 10.1002/phar.2487] [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: 01/22/2023]
Abstract
INTRODUCTION Warfarin's narrow therapeutic index and high variability in dosage requirements make dosage selection critical. Genetic factors are known to impact warfarin dosage selection. The Hmong are a unique Asian subpopulation numbering over 278,000 in the United States whose participation in genetics-based research is virtually nonexistent. The translational significance of early reports of warfarin pharmacogene differences in Hmong has not been evaluated. OBJECTIVES (i) To validate previously identified allele frequency differences relevant to warfarin dosing in Hmong versus East Asians and (ii) to compare predicted warfarin sensitivity and maintenance doses between a Hmong population and an East Asian cohort. METHOD DNA collected from two independent cohorts (n=236 and n=198) of Hmong adults were genotyped for CYP2C9 (*2, *3), VKORC1 (G-1639A), and CYP4F2 (*3). Allele frequencies between the combined Hmong cohort (n=433) and East Asians (n=1165) from the 2009 International Warfarin Pharmacogenetics Consortium (IWPC) study were compared using a χ2 test. Percentages of Hmong and East Asian participants predicted to be very sensitive to warfarin were compared using a χ2 test, and the predicted mean warfarin maintenance dose was compared with a t test. RESULTS The allele frequencies of CYP2C9*3 in the combined Hmong cohort and CYP4F2*3 in the VIP-Hmong cohort are significantly different from those in East Asians (18.9% vs 3.0%, p<0.001 and 9.8% vs 22.1%, p<0.001, respectively). Comparing the combined Hmong cohort to the East Asian cohort, the percentage of participants predicted to be very sensitive to warfarin was significantly higher (28% vs 5%, p<0.01) and the mean predicted warfarin maintenance dose was significantly lower (19.8 vs 21.3 mg/week, p<0.001), respectively. CONCLUSION The unique allele frequencies related to warfarin when combined with nongenetic factors observed in the Hmong translate into clinically relevant differences in predicted maintenance dose requirements for Hmong versus East Asians.
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Affiliation(s)
- Boguang Sun
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ya-Feng Wen
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Muaj Lo
- Minnesota Community Care, St. Paul, Minnesota, USA
| | - Txia Xiong
- Minnesota Community Care, St. Paul, Minnesota, USA
| | - Koobmeej Lee
- Minnesota Community Care, St. Paul, Minnesota, USA
| | - Kerui Peng
- Titus Family Department of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Bharat Thyagarajan
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Heather Zierhut
- Department of Genetics, Cell Biology and Development, College of Biological Science, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert J Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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Asiimwe IG, Zhang EJ, Osanlou R, Jorgensen AL, Pirmohamed M. Warfarin dosing algorithms: A systematic review. Br J Clin Pharmacol 2020; 87:1717-1729. [PMID: 33080066 PMCID: PMC8056736 DOI: 10.1111/bcp.14608] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Numerous algorithms have been developed to guide warfarin dosing and improve clinical outcomes. We reviewed the algorithms available for various populations and the covariates, performances and risk of bias of these algorithms. Methods We systematically searched MEDLINE up to 20 May 2020 and selected studies describing the development, external validation or clinical utility of a multivariable warfarin dosing algorithm. Two investigators conducted data extraction and quality assessment. Results Of 10 035 screened records, 266 articles were included in the review, describing the development of 433 dosing algorithms, 481 external validations and 52 clinical utility assessments. Most developed algorithms were for dose initiation (86%), developed by multiple linear regression (65%) and mostly applicable to Asians (49%) or Whites (43%). The most common demographic/clinical/environmental covariates were age (included in 401 algorithms), concomitant medications (270 algorithms) and weight (229 algorithms) while CYP2C9 (329 algorithms), VKORC1 (319 algorithms) and CYP4F2 (92 algorithms) variants were the most common genetic covariates. Only 26% and 7% algorithms were externally validated and evaluated for clinical utility, respectively, with <2% of algorithm developments and external validations being rated as having a low risk of bias. Conclusion Most warfarin dosing algorithms have been developed in Asians and Whites and may not be applicable to under‐served populations. Few algorithms have been externally validated, assessed for clinical utility, and/or have a low risk of bias which makes them unreliable for clinical use. Algorithm development and assessment should follow current methodological recommendations to improve reliability and applicability, and under‐represented populations should be prioritized.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Eunice J Zhang
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Rostam Osanlou
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
| | - Andrea L Jorgensen
- Department of Biostatistics, Institute of Population Health Sciences, University of Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom
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15
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Choudhary SK, Mathew AB, Parhar A, Hote MP, Talwar S, Rajashekhar P. Genetic polymorphisms and dosing of vitamin K antagonist in Indian patients after heart valve surgery. Indian J Thorac Cardiovasc Surg 2020; 35:539-547. [PMID: 33061049 DOI: 10.1007/s12055-019-00812-3] [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: 01/16/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022] Open
Abstract
Purpose Vitamin K antagonists (VKAs), such as warfarin and acenocoumarol, exert their anti-coagulant effect by inhibiting the subunit 1 of vitamin K epoxide reductase complex (VKORC1). CYP2C9 is a hepatic drug-metabolizing enzyme in the CYP450 superfamily and is the primary metabolizing enzyme of warfarin. Three single nucleotide polymorphisms, two in the CYP2C9 gene, namely CYP2C9*2 and CYP2C9*3, and one in the VKORC1 gene (c.- 1639G > A, rs9923231), have been identified to reduce VKA metabolism and enhance their anti-coagulation effect. The purpose of this study is to evaluate the prevalence of CYP2C9 and VKORC1 polymorphism in Indians receiving VKA-based anti-coagulation after valve surgery and to evaluate the usefulness of genetic information in managing VKA-based anti-coagulation. Methods In the current prospective observational study, 150 patients who underwent heart valve surgery and had stable INR were genotyped for VKORC1 (- 1639 G > A), CYP2C9*2, and CYP2C9*3. The VKA dosage was estimated from published algorithms and compared to the clinically stabilized dosage. Results Out of 150 patients, 101 (67.33%) were on warfarin and 49 (32.66%) were on acenocoumarol. Majority of the patients, the 83 in warfarin group and the 40 in acenocoumarol group, had a wild CYP2C9 diplotype. The rest had a mutant (CYP2C9*2 or CYP2C9*3) diplotype. Similarly, 67 patients in the warfarin group and 35 patients in the acenocoumarol group had wild type (G/G) of VKORC1 genotype. The rest had a mutant (G/A or A/A) VKORC1 genotype. In the warfarin group, based on the genotype, 51.5% of the patients were extensive or normal metabolizers, and 47.4% of the patients were intermediate metabolizers of VKAs. In the acenocoumarol group, 61.2% of the patients were extensive or normal metabolizers, and 38.8% of the patients were intermediate metabolizers. Individually, alleles of VKORC1 (- 1639 G > A), CYP2C9*2, and CYP2C9*3 had mean dosage reduction effect on VKA dosage, which co-related to the clinically stabilized dosages (P < 0.0001). Among the VKORC1 (- 1639 G > A) cohort, the reduction in warfarin mean weekly dosage was 13.48 mg as compared to the wild-type category (P < 0.0001) and similarly, the reduction in the mean weekly acenocoumarol dose was 6.07 mg (P < 0.03) as compared to the wild type after adjusting for age, gender, and body mass index. Conclusion Single nucleotide polymorphism in the CYP2C9 gene and in the VKORC1 gene is present in nearly 40% of Indian patients. VKORC1 (- 1639 G > A), CYP2C9*2, and CYP2C9*3 genotypes have significant dosage-lowering effects on VKA-based anti-coagulation therapy. The trend in estimated dosages of VKAs co-related to that of observed the clinically stabilized dosage in the cohort. The pharmacogenomic calculators used in this study tend to overestimate the VKA dosages as compared to clinical dosage due to the limitations in the algorithms and in our study. A new algorithm based on a larger dataset capturing the vast genetic variability across the Indian population and relevant clinical factors could provide better results.
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Affiliation(s)
- Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Arun Basil Mathew
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Amit Parhar
- Mendelian Health Technologies Pvt. Ltd, Pune, India
| | - Milind Padmakar Hote
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - Palleti Rajashekhar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
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Dietz N, Ruff C, Giugliano RP, Mercuri MF, Antman EM. Pharmacogenetic-guided and clinical warfarin dosing algorithm assessments with bleeding outcomes risk-stratified by genetic and covariate subgroups. Int J Cardiol 2020; 317:159-166. [DOI: 10.1016/j.ijcard.2020.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
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17
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Li Y, Yu J, Kuang Y, Wu C, Yang L, Fang Q, Pei Q, Yang G. Quality of oral anticoagulation control in Chinese patients with non-valvular atrial fibrillation: a prospective controlled study. Curr Med Res Opin 2020; 36:1433-1439. [PMID: 32677855 DOI: 10.1080/03007995.2020.1796611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The sex, age, medical history, treatment, tobacco use, race risk (SAMe-TT2R2) Score; the sex, age, medical history, treatment, tobacco use, genotype combination (SAMe-TT2G2) Score; and the so-called modified SAMe-TT2R2 scores have been proposed to predict the anticoagulation quality for patients with non-valvular atrial fibrillation (NVAF). The data from a prospective controlled study is used to validate the SAMe-TT2R2 and SAMe-TT2G2 scores in Chinese NVAF patients treated with warfarin and to evaluate the association of factors with time in therapeutic range (TTR) to predict the quality of oral anticoagulation control. METHODS A total of 379 patients with NVAF under warfarin treatment for a three-month follow-up were included in this prospective, multicenter study. The quality of oral anticoagulation control was evaluated by the TTR. The TTR was dichotomized for binary logistic regression analysis, using a cutoff point for classification as an inadequate (TTR < 65.0%) control. RESULTS The 379 NVAF patients had a mean TTR of 58.35 ± 26.33% and median SAMe-TT2R2 and SAMe-TT2G2 scores of 3 and 2, respectively. The discrimination performances of the SAMe-TT2R2 and SAMe-TT2G2 scores for inadequate anticoagulation control (TTR < 65.0%) were poor (c-index < 0.60). The gene frequency of CYP2C9*3 was 3.2% and that of VKORC1-1639 G > A was 89.3%. Genetic variation of CYP2C9*3 and VKORC1-1639 G > A did not affect TTR after initial treatment. The condition TTR < 65.0% was associated with an age below 60 without genotype-guided warfarin dose initiation and concomitant torasemide. CONCLUSIONS A warfarin-dosing algorithm used for initial treatment of patients older than 60 helps to achieve a better quality of oral anticoagulation control, whereas concomitant torasemide can produce a negative effect. These findings provide useful information for future investigations on the quality of oral anticoagulation control in Chinese anticoagulation clinical practice.
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Affiliation(s)
- Yaqian Li
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jingjing Yu
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yun Kuang
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chengkun Wu
- State Key Laboratory of High Performance Computing, College of Computer, National University of Defense Technology, Changsha, China
| | - Liu Yang
- School of Mathematics and Statistics, Central South University, Changsha, China
| | - Qiulian Fang
- School of Mathematics and Statistics, Central South University, Changsha, China
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Guoping Yang
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
- Research Center of Drug Clinical Evaluation of Central South University, Changsha, China
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Cho EH, Lee K, Yang M, Choi R, Baek SY, Sohn I, Kim JS, On YK, Bang OY, Cho HJ, Lee SY. Development and Validation of a Novel Warfarin Dosing Algorithm for Korean Patients With VKORC1 1173C. Ann Lab Med 2020; 40:216-223. [PMID: 31858761 PMCID: PMC6933054 DOI: 10.3343/alm.2020.40.3.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/08/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Differences in the performance of suggested warfarin dosing algorithms among different ethnicities and genotypes have been reported; this necessitates the development of an algorithm with enhanced performance for specific population groups. Previous warfarin dosing algorithms underestimated warfarin doses in VKORC1 1173C carriers. We aimed to develop and validate a new warfarin dosing algorithm for Korean patients with VKORC1 1173C. METHODS A total of 109 patients carrying VKORC1 1173CT (N=105) or 1173CC (N=4) were included in this study. Multiple regression analysis was performed to deduce a new dosing algorithm. Following literature searches for genotype-guided warfarin dosing algorithms, 21 algorithms were selected and evaluated using the correlation coefficient (ρ) of actual dose and estimated dose, mean error, and root mean square error. RESULTS The developed algorithm is as follows: maintenance dose (mg/week)=exp [3.223-0.009×(age)+0.577×(body surface area [BSA])+0.178×(sex)-0.481×(CYP2C9 genotype)+0.227×(VKORC1 genotype)]. Integrated variables explained 44% of the variance in the maintenance dose. The predicted and actual doses showed moderate correlation (ρ=0.641) with the best performance with a mean error of -1.30 mg/week. The proportion of underestimated groups was 17%, which was lower than with the other algorithms. CONCLUSIONS This is the first study to develop and validate a warfarin dosing algorithm based on data from VKORC1 1173C carriers; it showed superior predictive performance compared with previously published algorithms.
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Affiliation(s)
- Eun Hye Cho
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunghoon Lee
- Department of Laboratory Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mina Yang
- Department of Laboratory Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Green Cross Laboratories, Yongin, Korea
| | - Sun Young Baek
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - Insuk Sohn
- Statistics and Data Center, Samsung Medical Center, Seoul, Korea
| | - June Soo Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Keun On
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Jung Cho
- Department of Laboratory Medicine, Konyang University Hospital, Konyang University School of Medicine, Daejeon, Korea.
| | - Soo Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Clinical Pharmacology & Therapeutics, Samsung Medical Center, Seoul, Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea.
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Agrawal S, Heiss MS, Fenter RB, Abramova TV, Perera MA, Pacheco JA, Smith ME, Rasmussen-Torvik LJ, George AL. Impact of CYP2C9-Interacting Drugs on Warfarin Pharmacogenomics. Clin Transl Sci 2020; 13:941-949. [PMID: 32270628 PMCID: PMC7485961 DOI: 10.1111/cts.12781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/24/2020] [Indexed: 01/20/2023] Open
Abstract
Precise dosing of warfarin is important to achieve therapeutic benefit without adverse effects. Pharmacogenomics explains some interindividual variability in warfarin response, but less attention has been paid to drug‐drug interactions in the context of genetic factors. We investigated retrospectively the combined effects of cytochrome P450 (CYP)2C9 and vitamin K epoxide reductase complex (VKORC)1 genotypes and concurrent exposure to CYP2C9‐interacting drugs on long‐term measures of warfarin anticoagulation. Study participants predicted to be sensitive responders to warfarin based on CYP2C9 and VKORC1 genotypes, had significantly greater international normalized ratio (INR) variability over time. Participants who were concurrently taking CYP2C9‐interacting drugs were found to have greater INR variability and lesser time in therapeutic range. The associations of INR variability with genotype were driven by the subgroup not exposed to interacting drugs, whereas the effect of interacting drug exposure was driven by the subgroup categorized as normal responders. Our findings emphasize the importance of considering drug interactions in pharmacogenomic studies.
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Affiliation(s)
- Saaket Agrawal
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Meredith S Heiss
- Graduate Program in Genetic Counseling, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Remington B Fenter
- Graduate Program in Genetic Counseling, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tatiana V Abramova
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer A Pacheco
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maureen E Smith
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alfred L George
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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20
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Tao Y, Chen YJ, Xue L, Xie C, Jiang B, Zhang Y. An Ensemble Model With Clustering Assumption for Warfarin Dose Prediction in Chinese Patients. IEEE J Biomed Health Inform 2019; 23:2642-2654. [DOI: 10.1109/jbhi.2019.2891164] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Cîmpan PL, Chira RI, Mocan M, Anton FP, Farcaş AD. Oral Anticoagulant Therapy-When Art Meets Science. J Clin Med 2019; 8:jcm8101747. [PMID: 31640208 PMCID: PMC6832236 DOI: 10.3390/jcm8101747] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Anticoagulant treatment is extremely important and frequently encountered in the therapy of various cardiovascular diseases. Vitamin K antagonists (VKA) are in use for the prevention and treatment of arterial and venous thromboembolism, despite the introduction of new direct-acting oral anticoagulants (NOAC). The VKA still have the clear recommendation in patients with a mechanical prosthetic heart valve replacement or moderate to severe mitral stenosis of the rheumatic origin, in deep vein thrombosis associated with congenital thrombophilia, and in cases where NOAC are prohibited by social condition (financial reason) or by comorbidities (extreme weight, severe renal or liver disease). VKA dosing required to reach the targeted therapeutic range varies largely between patients (inter-individual variability). This inter-individual variability depends on multiple environmental factors such as age, mass, diet, etc. but it is also influenced by genetic determinism. About 30 genes implicated in the metabolism coumarins derivatives were identified, the most important being CYP2C9 and VKORC, each with several polymorphisms. Herein, we review the data regarding genetic alterations in general and specific populations, highlight the diagnosis options in particular cases presenting with genetic alteration causing higher sensitivity and/or resistance to VKA therapy and underline the utility of NOAC in solving such rare and difficult problems.
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Affiliation(s)
| | - Romeo Ioan Chira
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.
- Emergency Clinical County Hospital, 40006 Cluj Napoca, Romania.
| | - Mihaela Mocan
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.
- Emergency Clinical County Hospital, 40006 Cluj Napoca, Romania.
| | - Florin Petru Anton
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.
- Emergency Clinical County Hospital, 40006 Cluj Napoca, Romania.
| | - Anca Daniela Farcaş
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.
- Emergency Clinical County Hospital, 40006 Cluj Napoca, Romania.
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The Prediction Model of Warfarin Individual Maintenance Dose for Patients Undergoing Heart Valve Replacement, Based on the Back Propagation Neural Network. Clin Drug Investig 2019; 40:41-53. [DOI: 10.1007/s40261-019-00850-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Complications from inappropriate warfarin dosing are one of the most common reasons for emergency room visits. Approximately one third of warfarin dose variability results from common genetic variants. Therefore, it is very necessary to recognize warfarin sensitivity in individuals caused by genetic variants. Based on combined polymorphisms in CYP2C9 and VKORC1, we established a clinical classification for warfarin sensitivity. In the International Warfarin Pharmacogenetic Consortium (IWPC) with 5542 patients, we found that 95.1% of the Black in the IWPC cohort were normal warfarin responders, while 74.8% of the Asian were warfarin sensitive (P < 0.001). Moreover, we created a clinical algorithm to predict warfarin sensitivity in individual patients using logistic regression. Compared to a fixed-dose approach, the clinical algorithm provided significantly better performance. In addition, we validated the derived clinical algorithm using the external Easton cohort with 106 chronic warfarin users. The AUC was 0.836 vs. 0.867 for the Easton cohort and the IWPC cohort, respectively. With the use of this algorithm, it is very likely to facilitate patient care regarding warfarin therapy, thereby improving clinical outcomes.
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [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: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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25
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Kampouraki E, Kamali F. Pharmacogenetics of anticoagulants used for stroke prevention in patients with atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:449-458. [PMID: 31120800 DOI: 10.1080/17425255.2019.1623878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: The inclusion of pharmacogenetics alongside clinical information in anticoagulant therapy offers the opportunity for a tailored approach to treatment according to individual patient characteristics. Areas covered: Literature was searched using PubMed database, focusing on pharmacogenetics of oral anticoagulants. Original research articles and review articles in English language were included in the literature reviewed. This article includes all information available for the genetic cause of inter-individual variability in anticoagulation response to oral anticoagulant drugs. The pharmacogenetics of VKAs and NOACs are described in detail. Expert opinion: There have been numerous studies focusing on the pharmacogenetics of VKAs, particularly warfarin. Current evidence suggests that known genetic and clinical factors explain a large proportion of the inter-individual variability in response to warfarin. Pharmacogenetic-based algorithms have been validated to determine their clinical utility with equivocal results. To date, only a limited number of mostly small studies on the pharmacogenetics of NOACs exists. The latter have highlighted genetic polymorphisms in specific genes that may affect clinical outcomes. Further evaluations of these polymorphisms are needed before firm conclusions can be drawn about the significance of pharmacogenetics on NOAC therapy.
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Affiliation(s)
- Emmanouela Kampouraki
- a Institute of Cellular Medicine within Faculty of Medical Sciences , Newcastle University , Newcastle upon Tyne , UK
| | - Farhad Kamali
- b Newcastle upon Tyne Hospitals, NHS Foundation Trust , Newcastle upon Tyne , UK
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26
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Pharmacogenetics Biomarkers Predictive of Drug Pharmacodynamics as an Additional Tool to Therapeutic Drug Monitoring. Ther Drug Monit 2019; 41:121-130. [DOI: 10.1097/ftd.0000000000000591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Li X, Li D, Wu JC, Liu ZQ, Zhou HH, Yin JY. Precision dosing of warfarin: open questions and strategies. THE PHARMACOGENOMICS JOURNAL 2019; 19:219-229. [PMID: 30745565 DOI: 10.1038/s41397-019-0083-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/17/2018] [Accepted: 12/21/2018] [Indexed: 12/30/2022]
Abstract
Warfarin has a very narrow therapeutic window and obvious interindividual variability in its effects, with many factors contributing to the body's response. Algorithms incorporating multiple genetic, environment and clinical factors have been established to select a precision dose for each patient. A number of randomized controlled trials (RCTs) were conducted to explore whether patients could benefit from these algorithms; however, the results were inconsistent. Some questions remain to be resolved. Recently, new genetic and non-genetic factors have been discovered to contribute to variability in optimal warfarin doses. The results of further RCTs have been unveiled, and guidelines for pharmacogenetically guided warfarin dosing have been updated. Based on these most recent advancements, we summarize some open questions in this field and try to propose possible strategies to resolve them.
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Affiliation(s)
- Xi Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Dan Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Chu Wu
- Department of Cardiovascular, Central Hospital of Shaoyang, Shaoyang, 422000, P. R. China
| | - Zhao-Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China
| | - Ji-Ye Yin
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, P. R. China. .,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, P. R. China. .,Hunan Provincial Gynecological Cancer Diagnosis and Treatment Engineering Research Center, Changsha, 410078, P. R. China.
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Dong J, Shi GH, Lu M, Huang S, Liu YH, Yao JC, Li WY, Li LX. Evaluation of the predictive performance of Bayesian dosing for warfarin in Chinese patients. Pharmacogenomics 2019; 20:167-177. [PMID: 30777785 DOI: 10.2217/pgs-2018-0127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the accuracy and predictive performance of Bayesian dosing for warfarin in Chinese patients. Materials & methods: Six multiple linear regression algorithms (Wei, Lou, Miao, Huang, Gage and IWPC) and a Bayesian method implemented in Warfarin Dose Calculator were compared with each other. Results: Six multiple linear regression warfarin dosing algorithms had similar predictive ability, except Miao and Lou. The mean prediction error of Bayesian priori and posteriori method were 0.01 mg/day (95% CI: -0.18 to 0.19) and 0.17 mg/day (95% CI: -0.05 to 0.29), respectively, and Bayesian posteriori method demonstrated better performance in all dose ranges. Conclusion: The Bayesian method showed a good potential for warfarin maintenance dose prediction in Chinese patients requiring less than 6 mg/day.
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Affiliation(s)
- Jing Dong
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Guo-Hua Shi
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Man Lu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Shu Huang
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Yan-Hui Liu
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jia-Chen Yao
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Wen-Yan Li
- Department of Pharmacy, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Long-Xuan Li
- Department of Neurology, Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
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30
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Yang T, Zhou Y, Chen C, Lu M, Ma L, Cui Y. Genotype-guided dosing versus conventional dosing of warfarin: A meta-analysis of 15 randomized controlled trials. J Clin Pharm Ther 2018; 44:197-208. [PMID: 30593674 DOI: 10.1111/jcpt.12782] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/31/2018] [Accepted: 11/18/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Ting Yang
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Ying Zhou
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Chaoyang Chen
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Min Lu
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Lingyue Ma
- Department of Pharmacy; Peking University First Hospital; Beijing China
| | - Yimin Cui
- Department of Pharmacy; Peking University First Hospital; Beijing China
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31
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Claudio-Campos KI, González-Santiago P, Renta JY, Rodríguez J, Carrasquillo K, Gaedigk A, Roche A, Ducongé J. CYP2C9*61, a rare missense variant identified in a Puerto Rican patient with low warfarin dose requirements. Pharmacogenomics 2018; 20:3-8. [PMID: 30518301 DOI: 10.2217/pgs-2018-0143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Warfarin continues to be the mainstay therapy for preventing thrombus formation. Although pharmacogenetic algorithms have shown higher predictability of the optimal warfarin dose and lower occurrence of bleeding episodes, they often do not include ethno-specific genetic variants relevant to non-Europeans. This case report describes a rare missense variant at exon 9 of CYP2C9 (rs202201137; c.1370A>G transition; p.Asn457Ser) found in a Puerto Rican patient with low warfarin dose requirements (3 mg/day). The haplotype characterized by two amino acid changes, Asn457Ser and Arg144Cys (rs1799853; c.430C>T), has been designated CYP2C9*61 by the Pharmacogene Variation Consortium. According to prediction scores assessed with the Combined Annotation Dependent Depletion tool, CYP2C9*61 (p.Asn457Ser) was classified as nondeleterious, therefore its impact on CYP2C9 enzymatic activity cannot be postulated.
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Affiliation(s)
- Karla I Claudio-Campos
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL 36611, USA
| | - Pablo González-Santiago
- Department of Pharmacology, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, PR 00936, Puerto Rico
| | - Jessica Y Renta
- Department of Biochemistry, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, PR 00936, Puerto Rico
| | - Jovaniel Rodríguez
- Department of Chemistry, Rio Piedras Campus, University of Puerto Rico, San Juan, PR 00931, Puerto Rico
| | - Kelvin Carrasquillo
- Research Centers for Minorities Institutions (RCMI) - Integrated Informatics Services University of Puerto Rico, Medical Sciences Campus, San Juan, PR 00936, Puerto Rico
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Abiel Roche
- Research Centers for Minorities Institutions (RCMI) - Integrated Informatics Services University of Puerto Rico, Medical Sciences Campus, San Juan, PR 00936, Puerto Rico
| | - Jorge Ducongé
- Department of Pharmaceutical Sciences, School of Pharmacy, Medical Sciences Campus, University of Puerto Rico, San Juan, PR 00936, Puerto Rico
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Al-Eitan LN, Almasri AY, Khasawneh RH. Impact of CYP2C9 and VKORC1 Polymorphisms on Warfarin Sensitivity and Responsiveness in Jordanian Cardiovascular Patients during the Initiation Therapy. Genes (Basel) 2018; 9:genes9120578. [PMID: 30486437 PMCID: PMC6316567 DOI: 10.3390/genes9120578] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 01/31/2023] Open
Abstract
Warfarin is an oral anticoagulant frequently used in the treatment of different cardiovascular diseases. Genetic polymorphisms in the CYP2C9 and VKORC1 genes have produced variants with altered catalytic properties. A total of 212 cardiovascular patients were genotyped for 17 Single Nucleotide Polymorphisms (SNPs) within the CYP2C9 and VKORC1 genes. This study confirmed a genetic association of the CYP2C9*3 and VKORC1 rs10871454, rs8050894, rs9934438, and rs17708472 SNPs with warfarin sensitivity. This study also found an association between CYP2C9 and VKORC1 genetic haplotype blocks and warfarin sensitivity. The initial warfarin dose was significantly related to the CYP2C9*3 polymorphism and the four VKORC1 SNPs (p < 0.001). There were significant associations between rs4086116 SNP and TAT haplotype within CYP2C9 gene and rs17708472 SNP and CCGG haplotype within VKORC1 gene and warfarin responsiveness. However, possessing a VKORC1 variant allele was found to affect the international normalized ratio (INR) outcomes during initiation of warfarin therapy. In contrast, there was a loose association between the CYP2C9 variant and INR measurements. These findings can enhance the current understanding of the great variability in response to warfarin treatment in Arabs.
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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.
| | - Rame H Khasawneh
- Department of Hematopathology, King Hussein Medical Center (KHMC), Jordan Royal Medical Services (RMS), Amman 11118, Jordan.
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Chen X, Jin DY, Stafford DW, Tie JK. Evaluation of oral anticoagulants with vitamin K epoxide reductase in its native milieu. Blood 2018; 132:1974-1984. [PMID: 30089628 PMCID: PMC6213321 DOI: 10.1182/blood-2018-05-846592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/05/2018] [Indexed: 12/14/2022] Open
Abstract
Warfarin, acenocoumarol, phenprocoumon, and fluindione are commonly prescribed oral anticoagulants for the prevention and treatment of thromboembolic disorders. These anticoagulants function by impairing the biosynthesis of active vitamin K-dependent coagulation factors through the inhibition of vitamin K epoxide reductase (VKOR). Genetic variations in VKOR have been closely associated with the resistant phenotype of oral anticoagulation therapy. However, the relative efficacy of these anticoagulants, their mechanisms of action, and their resistance variations among naturally occurring VKOR mutations remain elusive. Here, we explored these questions using our recently established cell-based VKOR activity assay with the endogenous VKOR function ablated. Our results show that the efficacy of these anticoagulants on VKOR inactivation, from most to least, is: acenocoumarol > phenprocoumon > warfarin > fluindione. This is consistent with their effective clinical dosages for stable anticoagulation control. Cell-based functional studies of how each of the 27 naturally occurring VKOR mutations responds to these 4 oral anticoagulants indicate that phenprocoumon has the largest resistance variation (up to 199-fold), whereas the resistance of acenocoumarol varies the least (<14-fold). Cell-based kinetics studies show that fluindione appears to be a competitive inhibitor of VKOR, whereas warfarin is likely to be a mixed-type inhibitor of VKOR. The anticoagulation effect of these oral anticoagulants can be reversed by the administration of a high dose of vitamin K, apparently due to the existence of a different enzyme that can directly reduce vitamin K. These findings provide new insights into the selection of oral anticoagulants, their effective dosage management, and their mechanisms of anticoagulation.
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Affiliation(s)
- Xuejie Chen
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Da-Yun Jin
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Darrel W Stafford
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jian-Ke Tie
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Effect of genetic and patient factors on warfarin pharmacodynamics following warfarin withdrawal: Implications for patients undergoing surgery. Thromb Res 2018; 171:167-170. [DOI: 10.1016/j.thromres.2018.09.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 01/18/2023]
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35
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Shendre A, Dillon C, Limdi NA. Pharmacogenetics of warfarin dosing in patients of African and European ancestry. Pharmacogenomics 2018; 19:1357-1371. [PMID: 30345882 PMCID: PMC6562764 DOI: 10.2217/pgs-2018-0146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/28/2018] [Indexed: 12/20/2022] Open
Abstract
Despite the introduction of direct acting oral anticoagulants, warfarin remains the most commonly prescribed oral anticoagulant. However, warfarin therapy is plagued by the large inter- and intrapatient variability. The variability in dosing fueled research to identify clinical and genetic predictors and develop more accurate dosing algorithms. Observational studies have demonstrated the significant impact of single nucleotide polymorphisms in CYP2C9 and VKORC1 on warfarin dose in patients of European ancestry and African-Americans. This evidence supported the design and conduct of clinical trials to assess whether genotype-guided dosing results in improved anticoagulation control and outcomes. The trial results have shown discordance by race, with pharmacogenetic algorithms improving dose and anticoagulation control among European ancestry patients compared with African-American patients. Herein, we review the evidence from observational and interventional studies, highlight the need for inclusion of minority race groups and propose the need to develop race specific dosing algorithms.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M Fairbanks School of Public Health, Indiana University Purdue University Indianapolis, IN 46202, USA
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, AL 35294, USA
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Ma Z, Wang P, Gao Z, Wang R, Khalighi K. Ensemble of machine learning algorithms using the stacked generalization approach to estimate the warfarin dose. PLoS One 2018; 13:e0205872. [PMID: 30339708 PMCID: PMC6195267 DOI: 10.1371/journal.pone.0205872] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/02/2018] [Indexed: 11/19/2022] Open
Abstract
Warfarin dosing remains challenging due to narrow therapeutic index and highly individual variability. Incorrect warfarin dosing is associated with devastating adverse events. Remarkable efforts have been made to develop the machine learning based warfarin dosing algorithms incorporating clinical factors and genetic variants such as polymorphisms in CYP2C9 and VKORC1. The most widely validated pharmacogenetic algorithm is the IWPC algorithm based on multivariate linear regression (MLR). However, with only a single algorithm, the prediction performance may reach an upper limit even with optimal parameters. Here, we present novel algorithms using stacked generalization frameworks to estimate the warfarin dose, within which different types of machine learning algorithms function together through a meta-machine learning model to maximize the prediction accuracy. Compared to the IWPC-derived MLR algorithm, Stack 1 and 2 based on stacked generalization frameworks performed significantly better overall. Subgroup analysis revealed that the mean of the percentage of patients whose predicted dose of warfarin within 20% of the actual stable therapeutic dose (mean percentage within 20%) for Stack 1 was improved by 12.7% (from 42.47% to 47.86%) in Asians and by 13.5% (from 22.08% to 25.05%) in the low-dose group compared to that for MLR, respectively. These data suggest that our algorithms would especially benefit patients requiring low warfarin maintenance dose, as subtle changes in warfarin dose could lead to adverse clinical events (thrombosis or bleeding) in patients with low dose. Our study offers novel pharmacogenetic algorithms for clinical trials and practice.
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Affiliation(s)
- Zhiyuan Ma
- Easton Cardiovascular Associates, Easton, PA, United States of America
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Ping Wang
- Easton Cardiovascular Associates, Easton, PA, United States of America
| | - Zehui Gao
- Department of Mathematics and Statistics, San Diego State University, La Mesa, CA, United States of America
| | - Ruobing Wang
- Department of Chemistry and Social Science Research Institute, Duke University, Durham, NC, United States of America
- Science Center of Opera Solutions LLC, San Diego, CA, United States of America
| | - Koroush Khalighi
- Easton Cardiovascular Associates, Easton, PA, United States of America
- Division of Cardiology, Department of Medicine, Easton Hospital, Easton, PA, United States of America
- Drexel University College of Medicine, Philadelphia, PA, United States of America
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Mukerjee G, Huston A, Kabakchiev B, Piquette-Miller M, van Schaik R, Dorfman R. User considerations in assessing pharmacogenomic tests and their clinical support tools. NPJ Genom Med 2018; 3:26. [PMID: 30210808 PMCID: PMC6133969 DOI: 10.1038/s41525-018-0065-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/18/2022] Open
Abstract
Pharmacogenomic (PGx) testing is gaining recognition from physicians, pharmacists and patients as a tool for evidence-based medication management. However, seemingly similar PGx testing panels (and PGx-based decision support tools) can diverge in their technological specifications, as well as the genetic factors that determine test specificity and sensitivity, and hence offer different values for users. Reluctance to embrace PGx testing is often the result of unfamiliarity with PGx technology, a lack of knowledge about the availability of curated guidelines/evidence for drug dosing recommendations, and an absence of wide-spread institutional implementation efforts and educational support. Demystifying an often confusing and variable PGx marketplace can lead to greater acceptance of PGx as a standard-of-care practice that improves drug outcomes and provides a lifetime value for patients. Here, we highlight the key underlying factors of a PGx test that should be considered, and discuss the current progress of PGx implementation.
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Affiliation(s)
| | - Andrea Huston
- GeneYouIn Inc., 156 Front St. W., Toronto, ON Canada
| | - Boyko Kabakchiev
- GeneYouIn Inc., 156 Front St. W., Toronto, ON Canada.,2Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON Canada
| | | | - Ron van Schaik
- 4International Expert Center Pharmacogenetics, Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
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Ooi QX, Wright DFB, Isbister GK, Duffull SB. A factor VII-based method for the prediction of anticoagulant response to warfarin. Sci Rep 2018; 8:12041. [PMID: 30104739 PMCID: PMC6089929 DOI: 10.1038/s41598-018-30516-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 07/25/2018] [Indexed: 11/12/2022] Open
Abstract
Warfarin dosing methods based on existing models for warfarin and the international normalised ratio (INR) give biased maintenance dose predictions at the upper and lower quantiles of dose requirements. The aim of this work is to propose a conceptually different approach to predict INR after warfarin dosing. Factor VII concentration was proposed as the principal driving force for the INR. The time to steady-state INR (tSS,INR) was determined based on the INR response to changes in factor VII concentrations following warfarin initiation, and from this the steady-state INR (INRSS) was derived. The proposed method requires timed, paired blood samples of INR and factor VII. At different simulated warfarin dose rates, the prediction error associated with the proposed method was shown to be within clinically acceptable limits for both the tSS,INR (±2 days) and INRSS (±0.2). The use of the method was demonstrated in two patients who were initiated with 5 mg of warfarin daily. The difference in predicted versus actual steady-state INR were 0.0 and −0.4. The proposed method represents a unique approach to predict the INR. It considers factor VII as the main driver for INR and provides valuable information about the time to steady state INR.
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Affiliation(s)
- Qing-Xi Ooi
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
| | | | - Geoffrey K Isbister
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Tavares LC, Duarte NE, Marcatto LR, Soares RAG, Krieger JE, Pereira AC, Santos PCJL. Impact of incorporating ABCB1 and CYP4F2 polymorphisms in a pharmacogenetics-guided warfarin dosing algorithm for the Brazilian population. Eur J Clin Pharmacol 2018; 74:1555-1566. [PMID: 30051215 DOI: 10.1007/s00228-018-2528-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Interpatient variation of warfarin dose requirements may be explained by genetic variations and general and clinical factors. In this scenario, diverse population-calibrated dosing algorithms, which incorporate the main warfarin dosing influencers, have been widely proposed for predicting supposed warfarin maintenance dose, in order to prevent and reduce adverse events. The aim of the present study was to evaluate the impact of the inclusion of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms as additional covariates in a previously developed pharmacogenetic-based warfarin dosing algorithm calibrated for the Brazilian population. METHODS Two independent cohorts of patients treated with warfarin (n = 832 and n = 133) were included for derivation and replication of the algorithm, respectively. Genotyping of ABCB1 c.3435C>T and CYP4F2 c.1297G>A polymorphisms was performed by polymerase chain reaction followed by melting curve analysis and TaqMan® assay, respectively. A multiple linear regression was performed for the warfarin stable doses as a dependent variable, considering clinical, general, and genetic data as covariates. RESULTS The inclusion of ABCB1 and CYP4F2 polymorphisms was able to improve the algorithm's coefficient of determination (R2) by 2.6%. In addition, the partial determination coefficients of these variants revealed that they explained 3.6% of the warfarin dose variability. We also observed a marginal improvement of the linear correlation between observed and predicted doses (from 59.7 to 61.4%). CONCLUSION Although our study indicates that the contribution of the combined ABCB1 and CYP4F2 genotypes in explaining the overall variability in warfarin dose is not very large, we demonstrated that these pharmacogenomic data are statistically significant. However, the clinical relevance and cost-effective impact of incorporating additional variants in warfarin dosing algorithms should be carefully evaluated.
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Affiliation(s)
- Letícia C Tavares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Nubia E Duarte
- Department of Mathematic and Statistics, Universidad Nacional de Colombia, Manizales, Caldas, Colombia
| | - Leiliane R Marcatto
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Renata A G Soares
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Jose E Krieger
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Paulo Caleb Junior Lima Santos
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, Brazil.
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo UNIFESP, São Paulo, SP, Brazil.
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Ravvaz K, Weissert JA, Ruff CT, Chi CL, Tonellato PJ. Personalized Anticoagulation: Optimizing Warfarin Management Using Genetics and Simulated Clinical Trials. ACTA ACUST UNITED AC 2018; 10:CIRCGENETICS.117.001804. [PMID: 29237680 DOI: 10.1161/circgenetics.117.001804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical trials testing pharmacogenomic-guided warfarin dosing for patients with atrial fibrillation have demonstrated conflicting results. Non-vitamin K antagonist oral anticoagulants are expensive and contraindicated for several conditions. A strategy optimizing anticoagulant selection remains an unmet clinical need. METHODS AND RESULTS Characteristics from 14 206 patients with atrial fibrillation were integrated into a validated warfarin clinical trial simulation framework using iterative Bayesian network modeling and a pharmacokinetic-pharmacodynamic model. Individual dose-response for patients was simulated for 5 warfarin protocols-a fixed-dose protocol, a clinically guided protocol, and 3 increasingly complex pharmacogenomic-guided protocols. For each protocol, a complexity score was calculated using the variables predicting warfarin dose and the number of predefined international normalized ratio (INR) thresholds for each adjusted dose. Study outcomes included optimal time in therapeutic range ≥65% and clinical events. A combination of age and genotype identified different optimal protocols for various subpopulations. A fixed-dose protocol provided well-controlled INR only in normal responders ≥65, whereas for normal responders <65 years old, a clinically guided protocol was necessary to achieve well-controlled INR. Sensitive responders ≥65 and <65 and highly sensitive responders ≥65 years old required pharmacogenomic-guided protocols to achieve well-controlled INR. However, highly sensitive responders <65 years old did not achieve well-controlled INR and had higher associated clinical events rates than other subpopulations. CONCLUSIONS Under the assumptions of this simulation, patients with atrial fibrillation can be triaged to an optimal warfarin therapy protocol by age and genotype. Clinicians should consider alternative anticoagulation therapy for patients with suboptimal outcomes under any warfarin protocol.
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Affiliation(s)
- Kourosh Ravvaz
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.).
| | - John A Weissert
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Christian T Ruff
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Chih-Lin Chi
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
| | - Peter J Tonellato
- From the Aurora Research Institute, Aurora Health Care, Milwaukee, WI (K.R., J.A.W.); Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.T.R., P.J.T.); School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis (C.-L.C.); and University of Wisconsin, Milwaukee (P.J.T.)
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Syn NL, Wong ALA, Lee SC, Teoh HL, Yip JWL, Seet RC, Yeo WT, Kristanto W, Bee PC, Poon LM, Marban P, Wu TS, Winther MD, Brunham LR, Soong R, Tai BC, Goh BC. Genotype-guided versus traditional clinical dosing of warfarin in patients of Asian ancestry: a randomized controlled trial. BMC Med 2018; 16:104. [PMID: 29986700 PMCID: PMC6038204 DOI: 10.1186/s12916-018-1093-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Genotype-guided warfarin dosing has been shown in some randomized trials to improve anticoagulation outcomes in individuals of European ancestry, yet its utility in Asian patients remains unresolved. METHODS An open-label, non-inferiority, 1:1 randomized trial was conducted at three academic hospitals in South East Asia, involving 322 ethnically diverse patients newly indicated for warfarin (NCT00700895). Clinical follow-up was 90 days. The primary efficacy measure was the number of dose titrations within the first 2 weeks of therapy, with a mean non-inferiority margin of 0.5 over the first 14 days of therapy. RESULTS Among 322 randomized patients, 269 were evaluable for the primary endpoint. Compared with traditional dosing, the genotype-guided group required fewer dose titrations during the first 2 weeks (1.77 vs. 2.93, difference -1.16, 90% CI -1.48 to -0.84, P < 0.001 for both non-inferiority and superiority). The percentage of time within the therapeutic range over 3 months and median time to stable international normalized ratio (INR) did not differ between the genotype-guided and traditional dosing groups. The frequency of dose titrations (incidence rate ratio 0.76, 95% CI 0.67 to 0.86, P = 0.001), but not frequency of INR measurements, was lower at 1, 2, and 3 months in the genotype-guided group. The proportions of patients who experienced minor or major bleeding, recurrent venous thromboembolism, or out-of-range INR did not differ between both arms. For predicting maintenance doses, the pharmacogenetic algorithm achieved an R2 = 42.4% (P < 0.001) and mean percentage error of -7.4%. CONCLUSIONS Among Asian adults commencing warfarin therapy, a pharmacogenetic algorithm meets criteria for both non-inferiority and superiority in reducing dose titrations compared with a traditional dosing approach, and performs well in prediction of actual maintenance doses. These findings imply that clinicians may consider applying a pharmacogenetic algorithm to personalize initial warfarin dosages in Asian patients. TRIAL REGISTRATION ClinicalTrials.gov NCT00700895 . Registered on June 19, 2008.
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Affiliation(s)
- Nicholas L Syn
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Andrea Li-Ann Wong
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - James Wei Luen Yip
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Raymond Cs Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - William Kristanto
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ping-Chong Bee
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - L M Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Patrick Marban
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Tuck Seng Wu
- Department of Pharmacy, National University Hospital, Singapore, Singapore
| | - Michael D Winther
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore, Singapore
| | - Liam R Brunham
- Translational Laboratory in Genetic Medicine, Agency for Science, Technology and Research, Singapore, Singapore.,Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - Richie Soong
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Pathology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore
| | - Bee-Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Boon-Cher Goh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore. .,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore. .,Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore, 119228, Singapore.
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Cullell N, Carrera C, Muiño E, Torres N, Krupinski J, Fernandez-Cadenas I. Pharmacogenetic studies with oral anticoagulants. Genome-wide association studies in vitamin K antagonist and direct oral anticoagulants. Oncotarget 2018; 9:29238-29258. [PMID: 30018749 PMCID: PMC6044386 DOI: 10.18632/oncotarget.25579] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/28/2018] [Indexed: 12/17/2022] Open
Abstract
Oral anticoagulants (OAs) are the recommended drugs to prevent cardiovascular events and recurrence in patients with atrial fibrillation (AF) and cardioembolic stroke. We conducted a literature search to review the current state of OAs pharmacogenomics, focusing on Genome Wide Association Studies (GWAs) in patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). VKAs: Warfarin, acenocoumarol, fluindione and phenprocoumon have long been used, but their interindividual variability and narrow therapeutic/safety ratio makes their dosage difficult. GWAs have been useful in finding genetic variants associated with VKAs response. The main genes involved in VKAs pharmacogenetics are: VKORC1, CYP2C19 and CYP4F2. Variants in these genes have been included in pharmacogenetic algorithms to predict the VKAs dose individually in each patient depending on their genotype and clinical variables. DOACs: Dabigatran, apixaban, rivaroxaban and edoxaban have been approved for patients with AF. They have stable pharmacokinetics and do not require routine blood checks, thus avoiding most of the drawbacks of VKAs. Except for a GWAs performed in patients treated with dabigatran, there is no Genome Wide pharmacogenomics data for DOACs. Pharmacogenomics could be useful to predict the better clinical response and avoid adverse events in patients treated with anticoagulants, identifying the most appropriate anticoagulant drug for each patient. Current pharmacogenomics data show that the polymorphisms affecting VKAs or DOACs are different, concluding that personalized medicine based on pharmacogenomics could be possible. However, more studies are required to implement personalized medicine in clinical practice with OA and based on pharmacogenetics of DOACs.
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Affiliation(s)
- Natalia Cullell
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Caty Carrera
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.,Neurovascular Research Laboratory, Institut de Recerca, Universitat Autònoma de Barcelona, Hospital Vall d'Hebron, Barcelona, Spain
| | - Elena Muiño
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Nuria Torres
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Jerzy Krupinski
- Servicio de Neurología, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, Spain.,School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - Israel Fernandez-Cadenas
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics, Institut de Recer ca Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Duconge J, Ruaño G. Preventing the exacerbation of health disparities by iatrogenic pharmacogenomic applications: lessons from warfarin. Pharmacogenomics 2018; 19:875-881. [PMID: 29898627 DOI: 10.2217/pgs-2018-0055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Jorge Duconge
- Pharmaceutical Sciences Department, School of Pharmacy, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936, USA
| | - Gualberto Ruaño
- Institute of Living at Hartford Hospital, Hartford, CT 06102, USA
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Hasan SS, Kow CS, Curley LE, Baines DL, Babar ZUD. Economic evaluation of prescribing conventional and newer oral anticoagulants in older adults. Expert Rev Pharmacoecon Outcomes Res 2018; 18:371-377. [PMID: 29741099 DOI: 10.1080/14737167.2018.1474101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Anticoagulants refer to a variety of agents that inhibit one or more steps in the coagulation cascade. Generally, clinical conditions that require the prescribing of an oral anticoagulant increase in frequency with age. However, a major challenge of anticoagulation use among older patients is that this group of patients also experience the highest bleeding risk. To date, economic evaluation of prescribing of anticoagulants that includes the novel or newer oral anticoagulants (NOACs) in older adults has not been conducted and is warranted. AREAS COVERED A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults. EXPERT COMMENTARY While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin.
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Affiliation(s)
- Syed Shahzad Hasan
- a Department of Pharmacy , University of Huddersfield , Huddersfield , United Kingdom.,e School of Biomedical Sciences and Pharmacy, The University of Newcastle , Newcastle , Australia
| | - Chia Siang Kow
- b Department of Pharmacy , Health Clinic Bukit Kuda , Klang , Malaysia
| | - Louise E Curley
- c School of Pharmacy, The University of Auckland , Auckland , New Zealand
| | - Darrin L Baines
- d Department of Accounting , Finance & Economics, Bournemouth University , Bournemouth , United Kingdom
| | - Zaheer-Ud-Din Babar
- a Department of Pharmacy , University of Huddersfield , Huddersfield , United Kingdom.,c School of Pharmacy, The University of Auckland , Auckland , New Zealand
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Mills RA, Eichmeyer JN, Williams LM, Muskett JA, Schmidlen TJ, Maloney KA, Lemke AA. Patient Care Situations Benefiting from Pharmacogenomic Testing. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Daly AK, Rettie AE, Fowler DM, Miners JO. Pharmacogenomics of CYP2C9: Functional and Clinical Considerations. J Pers Med 2017; 8:E1. [PMID: 29283396 PMCID: PMC5872075 DOI: 10.3390/jpm8010001] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023] Open
Abstract
CYP2C9 is the most abundant CYP2C subfamily enzyme in human liver and the most important contributor from this subfamily to drug metabolism. Polymorphisms resulting in decreased enzyme activity are common in the CYP2C9 gene and this, combined with narrow therapeutic indices for several key drug substrates, results in some important issues relating to drug safety and efficacy. CYP2C9 substrate selectivity is detailed and, based on crystal structures for the enzyme, we describe how CYP2C9 catalyzes these reactions. Factors relevant to clinical response to CYP2C9 substrates including inhibition, induction and genetic polymorphism are discussed in detail. In particular, we consider the issue of ethnic variation in pattern and frequency of genetic polymorphisms and clinical implications. Warfarin is the most well studied CYP2C9 substrate; recent work on use of dosing algorithms that include CYP2C9 genotype to improve patient safety during initiation of warfarin dosing are reviewed and prospects for their clinical implementation considered. Finally, we discuss a novel approach to cataloging the functional capabilities of rare 'variants of uncertain significance', which are increasingly detected as more exome and genome sequencing of diverse populations is conducted.
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Affiliation(s)
- Ann K Daly
- Institute of Cellular Medicine, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK.
| | - Allan E Rettie
- Department of Medicinal Chemistry, University of Washington, Seattle, WA 98195, USA.
| | - Douglas M Fowler
- Department of Genome Sciences and Department of Bioengineering, University of Washington, Seattle, WA 98195, USA.
| | - John O Miners
- Department of Clinical Pharmacology, Flinders University School of Medicine, Adelaide 5042, Australia.
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Yang J, Gao L, Zhang Y, Wang H, Lu C, Zhao Y, Xu Q, Xu B, Zhang Y, Yin T. Estimation of the warfarin dose with a pharmacogenetic refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Thromb Haemost 2017; 108:1132-40. [DOI: 10.1160/th12-05-0362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/14/2012] [Indexed: 12/28/2022]
Abstract
SummaryPharmacogenetic (PG) dosing algorithms have been confirmed to predict warfarin therapeutic dose more accurately;however, most of them are based on standard intensity of warfarin anticoagulation, and their utility outside this range is limited. This study was designed to develop and validate a PG refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Consented Chinese-Han patients (n=310) under stable warfarin treatment were randomly divided into a derivation (n=207) and a validation cohort (n=103), with 83% and 80% of the patients under low-intensity anticoagulation, respectively. In the derivation cohort, a PG algorithm was constructed on the basis of genotypes (CYP2C9*3 and VKORC1–1639A/G) and clinical data. After integrating additional covariates of international normalised ratio (INR) values (INR on day 4 of therapy and target INR) and genotype of CYP4F2 (rs2108622), a PG refinement algorithm was established and explained 54% of warfarin dose variability. In the validation cohort, warfarin dose prediction was more accurate (p <0.01) with the PG refinement algorithm than with the PG algorithm and the fixed dose approach (3 mg/day). In the entire cohort, the PG refinement algorithm could accurately identify larger proportions of patients with lower dose requirement (≤2 mg/day) and higher dose requirement (≥4 mg/day) than did the PG algorithm. In conclusion, PG refinement algorithm integrating early INR response and three genotypes CYP2C9*3, VKORC1–1639A/G, CYP4F2 rs2108622) improves the accuracy of warfarin dose prediction in Chinese patients mainly under low-intensity anticoagulation.
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Influence of Genotype on Warfarin Maintenance Dose Predictions Produced Using a Bayesian Dose Individualization Tool. Ther Drug Monit 2017; 38:677-683. [PMID: 27855133 DOI: 10.1097/ftd.0000000000000347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A previously established Bayesian dosing tool for warfarin was found to produce biased maintenance dose predictions. In this study, we aimed (1) to determine whether the biased warfarin dose predictions previously observed could be replicated in a new cohort of patients from 2 different clinical settings, (2) to explore the influence of CYP2C9 and VKORC1 genotype on predictive performance of the Bayesian dosing tool, and (3) to determine whether the previous population used to develop the kinetic-pharmacodynamic model underpinning the Bayesian dosing tool was sufficiently different from the test (posterior) population to account for the biased dose predictions. METHODS The warfarin maintenance doses for 140 patients were predicted using the dosing tool and compared with the observed maintenance dose. The impact of genotype was assessed by predicting maintenance doses with prior parameter values known to be altered by genetic variability (eg, EC50 for VKORC1 genotype). The prior population was evaluated by fitting the published kinetic-pharmacodynamic model, which underpins the Bayesian tool, to the observed data using NONMEM and comparing the model parameter estimates with published values. RESULTS The Bayesian tool produced positively biased dose predictions in the new cohort of patients (mean prediction error [95% confidence interval]; 0.32 mg/d [0.14-0.5]). The bias was only observed in patients requiring ≥7 mg/d. The direction and magnitude of the observed bias was not influenced by genotype. The prior model provided a good fit to our data, which suggests that the bias was not caused by different prior and posterior populations. CONCLUSIONS Maintenance doses for patients requiring ≥7 mg/d were overpredicted. The bias was not due to the influence of genotype nor was it related to differences between the prior and posterior populations. There is a need for a more mechanistic model that captures warfarin dose-response relationship at higher warfarin doses.
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Tissue Specific Modulation of cyp2c and cyp3a mRNA Levels and Activities by Diet-Induced Obesity in Mice: The Impact of Type 2 Diabetes on Drug Metabolizing Enzymes in Liver and Extra-Hepatic Tissues. Pharmaceutics 2017; 9:pharmaceutics9040040. [PMID: 28954402 PMCID: PMC5750646 DOI: 10.3390/pharmaceutics9040040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/18/2017] [Accepted: 09/22/2017] [Indexed: 12/16/2022] Open
Abstract
Various diseases such as type 2 diabetes (T2D) may alter drug clearance. The objective of this study was to evaluate the effects of T2D on CYP450 expressions and activities using high-fat diet (HFD) as a model of obesity-dependent diabetes in C57BL6 mice. The cyp450 mRNA expression levels for 15 different isoforms were determined in the liver and extra-hepatic tissues (kidneys, lungs and heart) of HFD-treated animals (n = 45). Modulation of cyp450 metabolic activities by HFD was assessed using eight known substrates for specific human ortholog CYP450 isoforms: in vitro incubations were conducted with liver and extra-hepatic microsomes. Expression levels of cyp3a11 and cyp3a25 mRNA were decreased in the liver (>2-14-fold) and kidneys (>2-fold) of HFD groups which correlated with a significant reduction in midazolam metabolism (by 21- and 5-fold in hepatic and kidney microsomes, respectively, p < 0.001). HFD was associated with decreased activities of cyp2b and cyp2c subfamilies in all organs tested except in the kidneys (for tolbutamide). Other cyp450 hepatic activities were minimally or not affected by HFD. Taken together, our data suggest that substrate-dependent and tissue-dependent modulation of cyp450 metabolic capacities by early phases of T2D are observed, which could modulate drug disposition and pharmacological effects in various tissues.
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Saffian SM, Duffull SB, Wright D. Warfarin Dosing Algorithms Underpredict Dose Requirements in Patients Requiring ≥7 mg Daily: A Systematic Review and Meta-analysis. Clin Pharmacol Ther 2017; 102:297-304. [PMID: 28160278 DOI: 10.1002/cpt.649] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/26/2017] [Accepted: 01/29/2017] [Indexed: 01/28/2023]
Abstract
There is preliminary evidence to suggest that some published warfarin dosing algorithms produce biased maintenance dose predictions in patients who require higher than average doses. We conducted a meta-analysis of warfarin dosing algorithms to determine if there exists a systematic under- or overprediction of dose requirements for patients requiring ≥7 mg/day across published algorithms. Medline and Embase databases were searched up to September 2015. We quantified the proportion of over- and underpredicted doses in patients whose observed maintenance dose was ≥7 mg/day. The meta-analysis included 47 evaluations of 22 different warfarin dosing algorithms from 16 studies. The meta-analysis included data from 1,492 patients who required warfarin doses of ≥7 mg/day. All 22 algorithms were found to underpredict warfarin dosing requirements in patients who required ≥7 mg/day by an average of 2.3 mg/day with a pooled estimate of underpredicted doses of 92.3% (95% confidence interval 90.3-94.1, I2 = 24%).
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Affiliation(s)
- S M Saffian
- School of Pharmacy, University of Otago, Dunedin, New Zealand.,Faculty of Pharmacy, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - S B Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Dfb Wright
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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