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Choi H, Kang HJ, Ahn I, Gwon H, Kim Y, Seo H, Cho HN, Han J, Kim M, Kee G, Park S, Kwon O, Roh JH, Kim AR, Kim JH, Jun TJ, Kim YH. Machine learning models to predict the warfarin discharge dosage using clinical information of inpatients from South Korea. Sci Rep 2023; 13:22461. [PMID: 38105280 PMCID: PMC10725866 DOI: 10.1038/s41598-023-49831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023] Open
Abstract
As warfarin has a narrow therapeutic window and obvious response variability among individuals, it is difficult to rapidly determine personalized warfarin dosage. Adverse drug events(ADE) resulting from warfarin overdose can be critical, so that typically physicians adjust the warfarin dosage through the INR monitoring twice a week when starting warfarin. Our study aimed to develop machine learning (ML) models that predicts the discharge dosage of warfarin as the initial warfarin dosage using clinical data derived from electronic medical records within 2 days of hospitalization. During this retrospective study, adult patients who were prescribed warfarin at Asan Medical Center (AMC) between January 1, 2018, and October 31, 2020, were recruited as a model development cohort (n = 3168). Additionally, we created an external validation dataset (n = 891) from a Medical Information Mart for Intensive Care III (MIMIC-III). Variables for a model prediction were selected based on the clinical rationale that turned out to be associated with warfarin dosage, such as bleeding. The discharge dosage of warfarin was used the study outcome, because we assumed that patients achieved target INR at discharge. In this study, four ML models that predicted the warfarin discharge dosage were developed. We evaluated the model performance using the mean absolute error (MAE) and prediction accuracy. Finally, we compared the accuracy of the predictions of our models and the predictions of physicians for 40 data point to verify a clinical relevance of the models. The MAEs obtained using the internal validation set were as follows: XGBoost, 0.9; artificial neural network, 0.9; random forest, 1.0; linear regression, 1.0; and physicians, 1.3. As a result, our models had better prediction accuracy than the physicians, who have difficulty determining the warfarin discharge dosage using clinical information obtained within 2 days of hospitalization. We not only conducted the internal validation but also external validation. In conclusion, our ML model could help physicians predict the warfarin discharge dosage as the initial warfarin dosage from Korean population. However, conducting a successfully external validation in a further work is required for the application of the models.
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Affiliation(s)
- Heejung Choi
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hee Jun Kang
- Division of Cardiology, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Imjin Ahn
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Hansle Gwon
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Yunha Kim
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Hyeram Seo
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ha Na Cho
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - JiYe Han
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Minkyoung Kim
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Gaeun Kee
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Seohyun Park
- Department of Information Medicine, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Osung Kwon
- Division of Cardiology Department of Internal Medicine, Eunpyeong St Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Jae-Hyung Roh
- Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong-si, 30099, Sejong, Republic of Korea
| | - Ah-Ram Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
| | - Tae Joon Jun
- Big Data Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea
| | - Young-Hak Kim
- Division of Cardiology, Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympicro 43gil, Songpagu, Seoul, 05505, Republic of Korea.
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Masimirembwa C, Ramsay M, Botha J, Ellis E, Etheredge H, Hurrell T, Kanji CR, Kapungu NN, Maher H, Mthembu B, Naidoo J, Scholefield J, Rambarran S, van der Schyff F, Smyth N, Strobele B, Thelingwani RS, Loveland J, Fabian J. The African Liver Tissue Biorepository Consortium: Capacitating Population-Appropriate Drug Metabolism, Pharmacokinetics, and Pharmacogenetics Research in Drug Discovery and Development. Drug Metab Dispos 2023; 51:1551-1560. [PMID: 37751997 DOI: 10.1124/dmd.123.001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/21/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Pharmaceutical companies subject all new molecular entities to a series of in vitro metabolic characterizations that guide the selection and/or design of compounds predicted to have favorable pharmacokinetic properties in humans. Current drug metabolism research is based on liver tissue predominantly obtained from people of European origin, with limited access to tissue from people of African origin. Given the interindividual and interpopulation genomic variability in genes encoding drug-metabolizing enzymes, efficacy and safety of some drugs are poorly predicted for African populations. To address this gap, we have established the first comprehensive liver tissue biorepository inclusive of people of African origin. The African Liver Tissue Biorepository Consortium currently includes three institutions in South Africa and one in Zimbabwe, with plans to expand to other African countries. The program has collected 67 liver samples as of July 2023. DNA from the donors was genotyped for 120 variants in 46 pharmacogenes and revealed variants that are uniquely found in African populations, including the low-activity, African-specific CYP2C9*5 and *8 variants relevant to the metabolism of diclofenac. Larger liver tissue samples were used to isolate primary human hepatocytes. Viability of the hepatocytes and microsomal fractions was demonstrated by the activity of selected cytochrome P450s. This resource will be used to ensure the safety and efficacy of existing and new drugs in African populations. This will be done by characterizing compounds for properties such as drug clearance, metabolite and enzyme identification, and drug-drug and drug-gene interactions. SIGNIFICANCE STATEMENT: Standard optimization of the drug metabolism of new molecular entities in the pharmaceutical industry uses subcellular fractions such as microsomes and isolated primary hepatocytes, being done mainly with tissue from donors of European origin. Pharmacogenetics research has shown that variants in genes coding for drug-metabolizing enzymes have interindividual and interpopulation differences. We established an African liver tissue biorepository that will be useful in ensuring drug discovery and development research takes into account drug responses in people of African origin.
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Affiliation(s)
- Collen Masimirembwa
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Michele Ramsay
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jean Botha
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Ewa Ellis
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Harriet Etheredge
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Tracey Hurrell
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Comfort Ropafadzo Kanji
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Nyasha Nicole Kapungu
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Heather Maher
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Busisiwe Mthembu
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jerolen Naidoo
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Janine Scholefield
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Sharan Rambarran
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Francisca van der Schyff
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Natalie Smyth
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Bernd Strobele
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Roslyn Stella Thelingwani
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - Jerome Loveland
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
| | - June Fabian
- African institute of biomedical Science and Technology (AiBST), Harare, Zimbabwe (C.M., C.R.K., N.N.K., R.S.T.); Sydney Brenner Institute of Molecular Bioscience (SBIMB), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (C.M., M.R., B.M., N.S.); Wits Donald Gordon Medical Centre (WDGMC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (H.E., H.M., S.R., B.S., F.V.S., J.L., J.F.); Karolinska Institute, Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Sweden (E.E.); Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa (T.H., J.N., J.S.); and Transplant Services, Intermountain Medical Center, Salt Lake City, Utah (J.B.)
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Jahmunah V, Chen S, Oh SL, Acharya UR, Chowbay B. Automated warfarin dose prediction for Asian, American, and Caucasian populations using a deep neural network. Comput Biol Med 2023; 153:106548. [PMID: 36652867 DOI: 10.1016/j.compbiomed.2023.106548] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 12/06/2022] [Accepted: 12/31/2022] [Indexed: 01/15/2023]
Abstract
Existing warfarin dose prediction algorithms based on pharmacogenetics and clinical parameters have not been used clinically due to the absence of external validation, lack of assessment for clinical utility, and high risk of bias. Moreover, given the high degree of heterogeneity across different datasets used to develop these algorithms, it is unsurprising that prediction errors remain high, and dosing accuracy is dependent on specific ethnic populations. To circumvent these challenges, deep neural models are increasingly used to improve the precision and accuracy of warfarin dose predictions. Hence, this study sought to develop a deep learning-based model using a well-established curated dataset of over 6000 patients from the International Warfarin Pharmacogenomics Consortium (IWPC). Clinically-relevant input data such as physical attributes, medical conditions, concomitant medications, genotype status of functional warfarin genetic polymorphisms, and therapeutic INR were entered followed by applying a unique and robust training and validation method. The deep model yielded a low average mean absolute error (MAE) of 7.6 mg/week and a relatively low mean percentage of error of 40.9% in Asians, 14.2 mg/week MAE and 36.9% in African Americans, and 12.7 mg/week MAE and 45.4% mean percentage of error in White Caucasians. This model also resulted in 36.4% of all patients with a predicted dose within 20% of the administered dose. Hence, our proposed deep model provides an alternative to predicting warfarin dose in the clinical setting upon validation in ethnically-similar datasets.
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Affiliation(s)
- V Jahmunah
- School of Engineering, Ngee Ann Polytechnic, Singapore
| | - Sylvia Chen
- Laboratory of Clinical Pharmacology, Division of Cellular & Molecular Research, National Cancer Centre Singapore, Singapore
| | - Shu Lih Oh
- School of Engineering, Ngee Ann Polytechnic, Singapore
| | - U Rajendra Acharya
- School of Engineering, Ngee Ann Polytechnic, Singapore; Biomedical Engineering, School of Social Science and Technology, Singapore University of Social Sciences, Singapore; International Research Organization for Advanced Science and Technology (IROAST), Kumamoto University, Kumamoto, Japan; Department Bioinformatics and Medical Engineering, Asia University, Taiwan; School of Management and Enterprise, University of Southern Queensland, Australia.
| | - Balram Chowbay
- Laboratory of Clinical Pharmacology, Division of Cellular & Molecular Research, National Cancer Centre Singapore, Singapore; Singapore Immunology Network, Agency for Science, Technology & Research (A*STAR), Singapore; Centre for Clinician Scientist Development, Duke-NUS Medical School, Singapore.
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Wen YF, Gaedigk A, Boone EC, Wang WY, Straka RJ. The Identification of Novel CYP2D6 Variants in US Hmong: Results From Genome Sequencing and Clinical Genotyping. Front Pharmacol 2022; 13:867331. [PMID: 35387332 PMCID: PMC8979107 DOI: 10.3389/fphar.2022.867331] [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: 02/01/2022] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Hmong individuals represent a unique East Asian subpopulation in whom limited information concerning pharmacogenetic variation exists. The objectives of this study were to comprehensively characterize the highly polymorphic CYP2D6 gene in Hmong, estimate allele and phenotype frequencies and to compare results between two testing platforms. Methods: DNA from 48 self-identified Hmong participants were sequenced using a targeted next-generation sequencing (NGS) panel. Star allele calls were made using Astrolabe, manual inspection of NGS variant calls and confirmatory Sanger sequencing. Structural variation was determined by long-range (XL)-PCR and digital droplet PCR (ddPCR). The consensus diplotypes were subsequently translated into phenotype utilizing the activity score system. Clinical grade pharmacogenetic testing was obtained for 12 of the 48 samples enabling an assessment of concordance between the consensus calls and those determined by clinical testing platforms. Results: A total of 13 CYP2D6 alleles were identified. The most common alleles were CYP2D6*10 and its structural arrangements (37.5%, 36/96) and the *5 gene deletion (13.5%, 13/96). Three novel suballeles (*10.007, *36.004, and *75.002) were also identified. Phenotype frequencies were as follows: ultrarapid metabolizers (4.2%, 2/48), normal metabolizers (41.7%, 20/48) and intermediate metabolizers (52.1%, 25/48); none of the 48 participants were predicted to be poor metabolizers. Concordance of diplotype and phenotype calls between the consensus and clinical testing were 66.7 and 50%, respectively. Conclusion: Our study to explore CYP2D6 genotypes in the Hmong population suggests that this subpopulation is unique regarding CYP2D6 allelic variants; also, a higher portion of Hmong participants (50%) are predicted to have an intermediate metabolizer phenotype for CYP2D6 compared to other East Asians which range between 27 and 44%. Results from different testing methods varied considerably. These preliminary findings underscore the importance of thoroughly interrogating unique subpopulations to accurately predict a patient's CYP2D6 metabolizer status.
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Affiliation(s)
- Ya Feng Wen
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, MN, United States
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, MO, United States.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Erin C Boone
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, MO, United States
| | - Wendy Y Wang
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, MO, United States
| | - Robert J Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, MN, United States
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O’Brien TJ, Fenton K, Sidahmed A, Barbour A, Harralson AF. Race and Drug Toxicity: A Study of Three Cardiovascular Drugs with Strong Pharmacogenetic Recommendations. J Pers Med 2021; 11:jpm11111226. [PMID: 34834577 PMCID: PMC8622254 DOI: 10.3390/jpm11111226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022] Open
Abstract
The Clinical Pharmacogenetics Implementation Consortium (CPIC®) establishes evidence-based guidelines for utilizing pharmacogenetic information for certain priority drugs. Warfarin, clopidogrel and simvastatin are cardiovascular drugs that carry strong prescribing guidance by CPIC. The respective pharmacogenes for each of these drugs exhibit considerable variability amongst different ethnic/ancestral/racial populations. Race and ethnicity are commonly employed as surrogate biomarkers in clinical practice and can be found in many prescribing guidelines. This is controversial due to the large variability that exists amongst different racial/ethnic groups, lack of detailed ethnic information and the broad geographic categorization of racial groups. Using a retrospective analysis of electronic health records (EHR), we sought to determine the degree to which self-reported race/ethnicity contributed to the probability of adverse drug reactions for these drugs. All models used individuals self-reporting as White as the comparison group. The majority of apparent associations between different racial groups and drug toxicity observed in the "race only" model failed to remain significant when we corrected for covariates. We did observe self-identified Asian race as a significant predictor (p = 0.016) for warfarin hemorrhagic events in all models. In addition, patients identifying as either Black/African-American (p = 0.001) or Other/Multiple race (p = 0.019) had a lower probability of reporting an adverse reaction than White individuals while on simvastatin even after correcting for other covariates. In both instances where race/ethnicity was predictive of drug toxicity (i.e., warfarin, simvastatin), the findings are consistent with the known global variability in the pharmacogenes described in the CPIC guidelines for these medications. These results confirm that the reliability of using self-identified race/ethnic information extracted from EHRs as a predictor of adverse drug reactions is likely limited to situations where the genes influencing drug toxicity display large, distinct ethnogeographic variability.
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Affiliation(s)
- Travis J. O’Brien
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20052, USA
- Correspondence:
| | - Kevin Fenton
- Department of Biostatistics, George Washington University, Washington, DC 20052, USA;
| | - Alfateh Sidahmed
- Department of Medicine, George Washington University, Washington, DC 20052, USA; (A.S.); (A.B.)
| | - April Barbour
- Department of Medicine, George Washington University, Washington, DC 20052, USA; (A.S.); (A.B.)
| | - Arthur F. Harralson
- Department of Pharmacogenomics, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA 22601, USA;
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Debortoli G, de Araujo GS, Fortes-Lima C, Parra EJ, Suarez-Kurtz G. Identification of ancestry proportions in admixed groups across the Americas using clinical pharmacogenomic SNP panels. Sci Rep 2021; 11:1007. [PMID: 33441860 PMCID: PMC7806998 DOI: 10.1038/s41598-020-80389-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/14/2020] [Indexed: 11/09/2022] Open
Abstract
We evaluated the performance of three PGx panels to estimate biogeographical ancestry: the DMET panel, and the VIP and Preemptive PGx panels described in the literature. Our analysis indicate that the three panels capture quite well the individual variation in admixture proportions observed in recently admixed populations throughout the Americas, with the Preemptive PGx and DMET panels performing better than the VIP panel. We show that these panels provide reliable information about biogeographic ancestry and can be used to guide the implementation of PGx clinical decision-support (CDS) tools. We also report that using these panels it is possible to control for the effects of population stratification in association studies in recently admixed populations, as exemplified with a warfarin dosing GWA study in a sample from Brazil.
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Affiliation(s)
- Guilherme Debortoli
- Department of Anthropology, University of Toronto at Mississauga, Mississauga, ON, Canada
| | | | - Cesar Fortes-Lima
- Sub-Department of Human Evolution, Department of Organismal Biology, Evolutionary Biology Centre, Uppsala University, Uppsala, Sweden
| | - Esteban J Parra
- Department of Anthropology, University of Toronto at Mississauga, Mississauga, ON, Canada.
| | - Guilherme Suarez-Kurtz
- Instituto Nacional de Câncer and Rede Nacional de Farmacogenética, Rio de Janeiro, Brazil.
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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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Bargal SA, Kight JN, Augusto de Oliveira F, Shahin MH, Langaee T, Gong Y, Hamadeh IS, Cooper-DeHoff RM, Cavallari LH. Implications of Polymorphisms in the BCKDK and GATA-4 Gene Regions on Stable Warfarin Dose in African Americans. Clin Transl Sci 2020; 14:492-496. [PMID: 33278335 PMCID: PMC7993290 DOI: 10.1111/cts.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/04/2020] [Indexed: 11/28/2022] Open
Abstract
VKORC1 and CYP2C9 genotypes explain less variability in warfarin dose requirements in African Americans compared with Europeans. Variants in BCKDK and GATA-4 gene regions, purported to regulate VKORC1 and CYP2C9 expression, have been shown to play an important role in warfarin dose requirements in Europeans and Asians, respectively. We sought to determine whether rs56314408 near BCKDK or GATA-4 rs2645400 influence warfarin dose requirements in 200 African Americans. Unlike the strong linkage disequilibrium (LD) between rs56314408 and VKORC1 rs9923231 in Europeans, they were not in LD in African Americans. No associations were found on univariate analysis. On multivariable analysis, rs56314408 was associated (P = 0.027) with dose in a regression model excluding VKORC1 rs9923231, and GATA-4 rs2645400 was associated (P = 0.032) with dose in a model excluding CYP2C (CYP2C9*2, *3, *5, *6, *8, and *11, CYP2C rs12777823) variants. Neither variant contributed to dose in the model that included both VKORC1 rs9923231 and CYP2C variants. Our results do not support contributions of the studied variants to warfarin dose requirements in African Americans. However, they illustrate the value of studies in African descent populations, who have low LD in their genome, in teasing out genetic variation underlying drug response associations. They also emphasize the importance of confirming associations in persons of African ancestry.
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Affiliation(s)
- Salma A Bargal
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jennifer N Kight
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Felipe Augusto de Oliveira
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Mohamed H Shahin
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Taimour Langaee
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Issam S Hamadeh
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Rollinson V, Turner R, Pirmohamed M. Pharmacogenomics for Primary Care: An Overview. Genes (Basel) 2020; 11:E1337. [PMID: 33198260 PMCID: PMC7696803 DOI: 10.3390/genes11111337] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Most of the prescribing and dispensing of medicines happens in primary care. Pharmacogenomics (PGx) is the study and clinical application of the role of genetic variation on drug response. Mounting evidence suggests PGx can improve the safety and/or efficacy of several medications commonly prescribed in primary care. However, implementation of PGx has generally been limited to a relatively few academic hospital centres, with little adoption in primary care. Despite this, many primary healthcare providers are optimistic about the role of PGx in their future practice. The increasing prevalence of direct-to-consumer genetic testing and primary care PGx studies herald the plausible gradual introduction of PGx into primary care and highlight the changes needed for optimal translation. In this article, the potential utility of PGx in primary care will be explored and on-going barriers to implementation discussed. The evidence base of several drug-gene pairs relevant to primary care will be outlined with a focus on antidepressants, codeine and tramadol, statins, clopidogrel, warfarin, metoprolol and allopurinol. This review is intended to provide both a general introduction to PGx with a more in-depth overview of elements relevant to primary care.
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10
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Asiimwe IG, Zhang EJ, Osanlou R, Krause A, Dillon C, Suarez-Kurtz G, Zhang H, Perini JA, Renta JY, Duconge J, Cavallari LH, Marcatto LR, Beasly MT, Perera MA, Limdi NA, Santos PCJL, Kimmel SE, Lubitz SA, Scott SA, Kawai VK, Jorgensen AL, Pirmohamed M. Genetic Factors Influencing Warfarin Dose in Black-African Patients: A Systematic Review and Meta-Analysis. Clin Pharmacol Ther 2020; 107:1420-1433. [PMID: 31869433 PMCID: PMC7217737 DOI: 10.1002/cpt.1755] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022]
Abstract
Warfarin is the most commonly used oral anticoagulant in sub-Saharan Africa. Dosing is challenging due to a narrow therapeutic index and high interindividual variability in dose requirements. To evaluate the genetic factors affecting warfarin dosing in black-Africans, we performed a meta-analysis of 48 studies (2,336 patients). Significant predictors for CYP2C9 and stable dose included rs1799853 (CYP2C9*2), rs1057910 (CYP2C9*3), rs28371686 (CYP2C9*5), rs9332131 (CYP2C9*6), and rs28371685 (CYP2C9*11) reducing dose by 6.8, 12.5, 13.4, 8.1, and 5.3 mg/week, respectively. VKORC1 variants rs9923231 (-1639G>A), rs9934438 (1173C>T), rs2359612 (2255C>T), rs8050894 (1542G>C), and rs2884737 (497T>G) decreased dose by 18.1, 21.6, 17.3, 11.7, and 19.6 mg/week, respectively, whereas rs7294 (3730G>A) increased dose by 6.9 mg/week. Finally, rs12777823 (CYP2C gene cluster) was associated with a dose reduction of 12.7 mg/week. Few studies were conducted in Africa, and patient numbers were small, highlighting the need for further work in black-Africans to evaluate genetic factors determining warfarin response.
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Affiliation(s)
- Innocent G. Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool
| | - Eunice J. Zhang
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool
| | - Rostam Osanlou
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool
| | - Amanda Krause
- Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, The University of the Witwatersrand, Johannesburg, South Africa
| | - Chrisly Dillon
- Department of Neurology & Epidemiology, Hugh Kaul Precision Medicine Institute, The University of Alabama at Birmingham
| | | | - Honghong Zhang
- Department of Pharmacology, Center for Pharmacogenomics, Northwestern University, Chicago IL
| | - Jamila A Perini
- Research Laboratory of Pharmaceutical Sciences, West Zone State University-UEZO, Rio de Janeiro, Brazil
| | - Jessicca Y. Renta
- University of Puerto Rico School of Pharmacy, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067
| | - Jorge Duconge
- University of Puerto Rico School of Pharmacy, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067
| | - Larisa H Cavallari
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Leiliane R. Marcatto
- Laboratory of Genetics and Molecular Cardiology, Faculdade de Medicina FMUSP, Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Mark T. Beasly
- Department of Neurology & Epidemiology, Hugh Kaul Precision Medicine Institute, The University of Alabama at Birmingham
| | - Minoli A Perera
- Department of Pharmacology, Center for Pharmacogenomics, Northwestern University, Chicago IL
| | - Nita A. Limdi
- Department of Neurology & Epidemiology, Hugh Kaul Precision Medicine Institute, The University of Alabama at Birmingham
| | - Paulo C. J. L. Santos
- Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, EPM-Unifesp, São Paulo, Brazil
| | - Stephen E. Kimmel
- Perelman School of Medicine at the University of Pennsylvania, Department of Biostatistics, Epidemiology, and Informatics
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Stuart A. Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Sema4, a Mount Sinai venture, Stamford, CT 06902, USA
| | - Vivian K. Kawai
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrea L. Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool
- These authors contributed equally: Andrea Jorgensen and Munir Pirmohamed
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool
- These authors contributed equally: Andrea Jorgensen and Munir Pirmohamed
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Pratt VM, Cavallari LH, Del Tredici AL, Hachad H, Ji Y, Kalman LV, Ly RC, Moyer AM, Scott SA, Whirl-Carrillo M, Weck KE. Recommendations for Clinical Warfarin Genotyping Allele Selection: A Report of the Association for Molecular Pathology and the College of American Pathologists. J Mol Diagn 2020; 22:847-859. [PMID: 32380173 DOI: 10.1016/j.jmoldx.2020.04.204] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/18/2020] [Accepted: 04/01/2020] [Indexed: 11/19/2022] Open
Abstract
The goal of the Association for Molecular Pathology (AMP) Clinical Practice Committee's AMP Pharmacogenomics (PGx) Working Group is to define the key attributes of PGx alleles recommended for clinical testing and a minimum set of variants that should be included in clinical PGx genotyping assays. This document series provides recommendations for a minimum panel of variant alleles (tier 1) and an extended panel of variant alleles (tier 2) that will aid clinical laboratories when designing assays for PGx testing. The AMP PGx Working Group considered functional impact of the variants, allele frequencies in multiethnic populations, the availability of reference materials, as well as other technical considerations for PGx testing when developing these recommendations. The ultimate goal is to promote standardization of PGx gene/allele testing across clinical laboratories. These recommendations are not to be interpreted as prescriptive but to provide a reference guide. Of note, a separate article with recommendations for CYP2C9 allele selection was previously developed by the PGx Working Group that can be applied broadly to CYP2C9-related medications. The warfarin allele recommendations in this report incorporate the previous CYP2C9 allele recommendations and additional genes and alleles that are specific to warfarin testing.
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Affiliation(s)
- Victoria M Pratt
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Larisa H Cavallari
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida
| | - Andria L Del Tredici
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Millennium Health, LLC, San Diego, California
| | - Houda Hachad
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Translational Software, Bellevue, Washington
| | - Yuan Ji
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Pathology and ARUP Laboratories, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lisa V Kalman
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Reynold C Ly
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ann M Moyer
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Stuart A Scott
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York; Sema4, a Mount Sinai venture, Stamford, Connecticut
| | - Michelle Whirl-Carrillo
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Karen E Weck
- The Pharmacogenomics Working Group of the Clinical Practice Committee, Association for Molecular Pathology, Rockville, Maryland; Departments of Pathology and Laboratory Medicine and Genetics, University of North Carolina, Chapel Hill, North Carolina
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12
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Zhang H, De T, Zhong Y, Perera MA. The Advantages and Challenges of Diversity in Pharmacogenomics: Can Minority Populations Bring Us Closer to Implementation? Clin Pharmacol Ther 2020; 106:338-349. [PMID: 31038731 DOI: 10.1002/cpt.1491] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/18/2019] [Indexed: 01/01/2023]
Abstract
Health disparities exist among minorities in the United States, with differences seen in disease prevalence, mortality, and responses to medications. These differences are multifactorial with genetic variation explaining a portion of this variability. Pharmacogenomics aims to find the effect of genetic variations on drug response, with the goal of optimizing drug therapy and development. Although genome-wide association studies have been useful in unbiasedly surveying the genome for genetic drivers of clinically relevant phenotypes, most of these studies have been conducted in mainly participants of European and Asian descent, contributing to a growing health disparity in precision medicine. Diversity is important to pharmacogenomic studies, and there may be real advantages to the use of these complex genomes in pharmacogenomics. In this review we will outline some of the advantages and confounders of pharmacogenomics in minorities, describe the role of genetic variation in pharmacologic pathways, and highlight a number of population-specific findings.
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Affiliation(s)
- Honghong Zhang
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Yizhen Zhong
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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13
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Hernandez W, Danahey K, Pei X, Yeo KTJ, Leung E, Volchenboum SL, Ratain MJ, Meltzer DO, Stranger BE, Perera MA, O'Donnell PH. Pharmacogenomic genotypes define genetic ancestry in patients and enable population-specific genomic implementation. THE PHARMACOGENOMICS JOURNAL 2020; 20:126-135. [PMID: 31506565 PMCID: PMC7184888 DOI: 10.1038/s41397-019-0095-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/02/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022]
Abstract
The importance of genetic ancestry characterization is increasing in genomic implementation efforts, and clinical pharmacogenomic guidelines are being published that include population-specific recommendations. Our aim was to test the ability of focused clinical pharmacogenomic SNP panels to estimate individual genetic ancestry (IGA) and implement population-specific pharmacogenomic clinical decision-support (CDS) tools. Principle components and STRUCTURE were utilized to assess differences in genetic composition and estimate IGA among 1572 individuals from 1000 Genomes, two independent cohorts of Caucasians and African Americans (AAs), plus a real-world validation population of patients undergoing pharmacogenomic genotyping. We found that clinical pharmacogenomic SNP panels accurately estimate IGA compared to genome-wide genotyping and identify AAs with ≥70 African ancestry (sensitivity >82%, specificity >80%, PPV >95%, NPV >47%). We also validated a new AA-specific warfarin dosing algorithm for patients with ≥70% African ancestry and implemented it at our institution as a novel CDS tool. Consideration of IGA to develop an institutional CDS tool was accomplished to enable population-specific pharmacogenomic guidance at the point-of-care. These capabilities were immediately applied for guidance of warfarin dosing in AAs versus Caucasians, but also provide a real-world model that can be extended to other populations and drugs as actionable genomic evidence accumulates.
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Affiliation(s)
- Wenndy Hernandez
- University of Chicago, Department of Medicine, Section of Genetic Medicine, Section of Cardiology, Chicago, IL, USA
| | - Keith Danahey
- University of Chicago, Center for Personalized Therapeutics, Chicago, IL, USA
- University of Chicago, Center for Research Informatics, Chicago, IL, USA
| | - Xun Pei
- University of Chicago, Center for Personalized Therapeutics, Chicago, IL, USA
- University of Chicago, Department of Pathology, UChicago Advanced Technology Clinical Pharmacogenomics Laboratory, Chicago, IL, USA
| | - Kiang-Teck J Yeo
- University of Chicago, Department of Pathology, UChicago Advanced Technology Clinical Pharmacogenomics Laboratory, Chicago, IL, USA
| | - Edward Leung
- University of Chicago, Department of Pathology, UChicago Advanced Technology Clinical Pharmacogenomics Laboratory, Chicago, IL, USA
- University of Southern California, Keck School of Medicine, Department of Pathology and Laboratory Medicine, Los Angeles, CA, USA
| | | | - Mark J Ratain
- University of Chicago, Center for Personalized Therapeutics, Chicago, IL, USA
- University of Chicago, Department of Medicine, Chicago, IL, USA
- University of Chicago, Committee on Clinical Pharmacology and Pharmacogenomics, Chicago, IL, USA
| | - David O Meltzer
- University of Chicago, Department of Medicine, Chicago, IL, USA
| | - Barbara E Stranger
- University of Chicago, Department of Medicine, Section of Genetic Medicine, Section of Cardiology, Chicago, IL, USA
- University of Chicago, Institute of Genomics and Systems Biology, and Center for Data Intensive Science, Chicago, IL, USA
| | - Minoli A Perera
- Northwestern University, Department of Pharmacology, Chicago, IL, USA
| | - Peter H O'Donnell
- University of Chicago, Center for Personalized Therapeutics, Chicago, IL, USA.
- University of Chicago, Department of Medicine, Chicago, IL, USA.
- University of Chicago, Committee on Clinical Pharmacology and Pharmacogenomics, Chicago, IL, USA.
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Prospective validation of the International Warfarin Pharmacogenetics Consortium algorithm in high-risk elderly people (VIALE study). THE PHARMACOGENOMICS JOURNAL 2019; 20:451-461. [DOI: 10.1038/s41397-019-0129-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 11/13/2019] [Accepted: 11/20/2019] [Indexed: 01/10/2023]
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15
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Thorn CF, Whirl-Carrillo M, Hachad H, Johnson JA, McDonagh EM, Ratain MJ, Relling MV, Scott SA, Altman RB, Klein TE. Essential Characteristics of Pharmacogenomics Study Publications. Clin Pharmacol Ther 2019; 105:86-91. [PMID: 30406943 DOI: 10.1002/cpt.1279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/02/2018] [Indexed: 12/17/2022]
Abstract
Pharmacogenomics (PGx) can be seen as a model for biomedical studies: it includes all disease areas of interest and spans in vitro studies to clinical trials, while focusing on the relationships between genes and drugs and the resulting phenotypes. This review will examine different characteristics of PGx study publications and provide examples of excellence in framing PGx questions and reporting their resulting data in a way that maximizes the knowledge that can be built on them.
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Affiliation(s)
- Caroline F Thorn
- Department of Biomedical Data Sciences, Stanford University, Stanford, California, USA
| | | | - Houda Hachad
- Translational Software, Bellevue, Washington, USA
| | - Julie A Johnson
- College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | - Mark J Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Mary V Relling
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Sema4, a Mount Sinai Venture, Stamford, Connecticut, USA
| | - Russ B Altman
- Department of Genetics, Department of Computer Science, Department of Biomedical Engineering, Stanford University, Stanford, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA
| | - Teri E Klein
- Department of Biomedical Data Sciences, Stanford University, Stanford, California, USA
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Bush WS, Cooke Bailey JN, Beno MF, Crawford DC. Bridging the Gaps in Personalized Medicine Value Assessment: A Review of the Need for Outcome Metrics across Stakeholders and Scientific Disciplines. Public Health Genomics 2019; 22:16-24. [PMID: 31454805 DOI: 10.1159/000501974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/07/2019] [Indexed: 12/14/2022] Open
Abstract
Despite monumental advances in genomics, relatively few health care provider organizations in the United States offer personalized or precision medicine as part of the routine clinical workflow. The gaps between research and applied genomic medicine may be a result of a cultural gap across various stakeholders representing scientists, clinicians, patients, policy makers, and third party payers. Scientists are trained to assess the health care value of genomics by either quantifying population-scale effects, or through the narrow lens of clinical trials where the standard of care is compared with the predictive power of a single or handful of genetic variants. While these metrics are an essential first step in assessing and documenting the clinical utility of genomics, they are rarely followed up with other assessments of health care value that are critical to stakeholders who use different measures to define value. The limited value assessment in both the research and implementation science of precision medicine is likely due to necessary logistical constraints of these teams; engaging bioethicists, health care economists, and individual patient belief systems is incredibly daunting for geneticists and informaticians conducting research. In this narrative review, we concisely describe several definitions of value through various stakeholder viewpoints. We highlight the existing gaps that prevent clinical translation of scientific findings generally as well as more specifically using two present-day, extreme scenarios: (1) genetically guided warfarin dosing representing a handful of genetic markers and more than 10 years of basic and translational research, and (2) next-generation sequencing representing genome-dense data lacking substantial evidence for implementation. These contemporary scenarios highlight the need for various stakeholders to broadly adopt frameworks designed to define and collect multiple value measures across different disciplines to ultimately impact more universal acceptance of and reimbursement for genomic medicine.
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Affiliation(s)
- William S Bush
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jessica N Cooke Bailey
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark F Beno
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dana C Crawford
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA, .,Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA, .,Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, Ohio, USA,
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17
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Differences in Warfarin Pharmacodynamics and Predictors of Response Among Three Racial Populations. Clin Pharmacokinet 2019; 58:1077-1089. [DOI: 10.1007/s40262-019-00745-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Hooker SE, Woods-Burnham L, Bathina M, Lloyd S, Gorjala P, Mitra R, Nonn L, Kimbro KS, Kittles RA. Genetic Ancestry Analysis Reveals Misclassification of Commonly Used Cancer Cell Lines. Cancer Epidemiol Biomarkers Prev 2019; 28:1003-1009. [PMID: 30787054 DOI: 10.1158/1055-9965.epi-18-1132] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/20/2018] [Accepted: 02/14/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Given the scarcity of cell lines from underrepresented populations, it is imperative that genetic ancestry for these cell lines is characterized. Consequences of cell line mischaracterization include squandered resources and publication retractions. METHODS We calculated genetic ancestry proportions for 15 cell lines to assess the accuracy of previous race/ethnicity classification and determine previously unknown estimates. DNA was extracted from cell lines and genotyped for ancestry informative markers representing West African (WA), Native American (NA), and European (EUR) ancestry. RESULTS Of the cell lines tested, all previously classified as White/Caucasian were accurately described with mean EUR ancestry proportions of 97%. Cell lines previously classified as Black/African American were not always accurately described. For instance, the 22Rv1 prostate cancer cell line was recently found to carry mixed genetic ancestry using a much smaller panel of markers. However, our more comprehensive analysis determined the 22Rv1 cell line carries 99% EUR ancestry. Most notably, the E006AA-hT prostate cancer cell line, classified as African American, was found to carry 92% EUR ancestry. We also determined the MDA-MB-468 breast cancer cell line carries 23% NA ancestry, suggesting possible Afro-Hispanic/Latina ancestry. CONCLUSIONS Our results suggest predominantly EUR ancestry for the White/Caucasian-designated cell lines, yet high variance in ancestry for the Black/African American-designated cell lines. In addition, we revealed an extreme misclassification of the E006AA-hT cell line. IMPACT Genetic ancestry estimates offer more sophisticated characterization leading to better contextualization of findings. Ancestry estimates should be provided for all cell lines to avoid erroneous conclusions in disparities literature.
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Affiliation(s)
- Stanley E Hooker
- Division of Health Equities, Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Leanne Woods-Burnham
- Division of Health Equities, Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Madhavi Bathina
- Division of Health Equities, Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Stacy Lloyd
- Department of Molecular and Cellular Biology and Alkek Center for Molecular Discovery, Baylor College of Medicine, Houston, Texas
| | - Priyatham Gorjala
- College of Medicine, Roseman University of Health Sciences, Las Vegas, Nevada
| | - Ranjana Mitra
- College of Medicine, Roseman University of Health Sciences, Las Vegas, Nevada
| | - Larisa Nonn
- The Department of Pathology, University of Illinois, Chicago, Illinois
| | - K Sean Kimbro
- Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, Durham, North Carolina
| | - Rick A Kittles
- Division of Health Equities, Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California.
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19
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Ampong DN. Landmarks of pharmacogenomics and some considerations for clinical practice. Ther Adv Psychopharmacol 2019; 9:2045125319896650. [PMID: 35186262 PMCID: PMC8851126 DOI: 10.1177/2045125319896650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/26/2019] [Indexed: 11/15/2022] Open
Abstract
Since the completion of the Human Genome Project 28 years ago, myriad genomics applications have risen in areas such as agriculture, livestock, infectious agents, forensics, bioenergy, ancestry, health, disease, and medicine. This was driven partly by the US government's ability to use a unique program to facilitate genome sequencing to the point where the cost of sequencing a whole human genome is not prohibitive. However, application of this knowledge of the double helix twisted DNA at the bedside in psychiatric clinical practice has little to report, despite US Food and Drug Administration (FDA) approval of nearly 40 psychotropic drugs, as well as specific guidelines for their application. Patients with treatment-resistant mental illness, history of unresponsiveness to psychotropic medications, and history or family history of serious adverse effects to psychotropic drugs may qualify for pharmacogenomics (PGx) testing with insurance reimbursement, or a low, out-of-pocket, payment of not greater than US $300. Psychiatric mental health nurse practitioners and providers who utilize PGx will not only improve patient care outcomes, but also contribute to the acceleration of the potential diagnostic and preventive capabilities of PGx testing.
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Affiliation(s)
- David Nana Ampong
- College of Health, University of Alaska Anchorage, 3211 Providence Driver, Anchorage, AK 99508, USA
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20
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Harikrishnan S, Koshy L, Subramanian R, Sanjay G, Vineeth CP, Nair AJ, Nair GM, Sudhakaran PR. Value of VKORC1 (-1639G>A) rs9923231 genotyping in predicting warfarin dose: A replication study in South Indian population. Indian Heart J 2018; 70 Suppl 3:S110-S115. [PMID: 30595241 PMCID: PMC6310074 DOI: 10.1016/j.ihj.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Warfarin is the most commonly prescribed oral anticoagulant, although having a narrow therapeutic index and wide interindividual variability. The aim of this study was to replicate the utility of VKORC1 (-1639G>A) rs9923231 genotyping in predicting the mean daily dose and to evaluate its ability to categorize warfarin-treated patients to high-, intermediate-, or low-dose categories in the South Indian population. MATERIALS AND METHODS A cohort of 222 warfarin-treated patients was genotyped using restriction fragment length polymorphism method. The influence of the rs9923231 polymorphism on the variations in the mean daily dose was compared using one-way analysis of variance and linear regression analysis. Discriminatory ability of the rs9923231 polymorphism to group the patients into ordered dose categories was assessed by estimating the proportional odds ratios using the ordered logit regression analysis. RESULTS The frequency of AA genotype and A allele in the study sample was found to be 1.8% and 9.23%, respectively, which was similar to reports from other South Indian populations. The mean daily dose required to achieve the optimum international normalized ratio was significantly lower in AA homozygous genotype carriers (3.99 ± 1.67 mg/day) and GA heterozygous (4.26 ± 1.57 mg/day) compared to the GG genotype carriers (5.51 ± 2.13 mg/day), p = 0.003. The A allele carriers (GA+AA genotypes) had a 3.23 higher odds of being grouped as a low-dose requiring category compared to non-carriers (95% CI 1.49-6.98, p = 0.003). CONCLUSIONS These preliminary results strongly support the use of VKORC1 (-1639G>A) rs9923231 polymorphism for genetically guided initial warfarin dosing in South Indian patients with heart valve replacements.
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Affiliation(s)
- S Harikrishnan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - Linda Koshy
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - Ram Subramanian
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - G Sanjay
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - C P Vineeth
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695 011, Kerala, India.
| | - A Jayakumaran Nair
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - G M Nair
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
| | - P R Sudhakaran
- Inter-University Centre for Genomics and Gene Technology, Department of Biotechnology, University of Kerala, Trivandrum, 695 581, Kerala, India.
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Shendre A, Dillon C, Limdi NA. Pharmacogenetics of warfarin dosing in patients of African and European ancestry. Pharmacogenomics 2018; 19:1357-1371. [PMID: 30345882 DOI: 10.2217/pgs-2018-0146] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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22
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Galvez JM, Restrepo CM, Contreras NC, Alvarado C, Calderón-Ospina CA, Peña N, Cifuentes RA, Duarte D, Laissue P, Fonseca DJ. Creating and validating a warfarin pharmacogenetic dosing algorithm for Colombian patients. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:169-178. [PMID: 30410385 PMCID: PMC6198877 DOI: 10.2147/pgpm.s170515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose Warfarin is an oral anticoagulant associated with adverse reaction to drugs due to wide inter- and intra-individual dosage variability. Warfarin dosage has been related to non-genetic and genetic factors. CYP2C9 and VKORC1 gene polymorphisms affect warfarin metabolism and dosage. Due to the central role of populations’ ethnical and genetic origin on warfarin dosage variability, novel algorithms for Latin American subgroups are necessary to establish safe anticoagulation therapy. Patients and methods We genotyped CYP2C9*2 (c.430C > T), CYP2C9*3 (c.1075A > C), CYP4F2 (c.1297G > A), and VKORC1 (−1639 G > A) polymorphisms in 152 Colombian patients who received warfarin. We evaluated the impact on the variability of patients’ warfarin dose requirements. Multiple linear regression analysis, using genetic and non-genetic variables, was used for creating an algorithm for optimal warfarin maintenance dose. Results Median weekly prescribed warfarin dosage was significantly lower in patients having the VKORC1-1639 AA genotype and poor CYP2C9*2/*2,*2/*3 metabolizers than their wild-type counterparts. We found a 2.3-fold increase in mean dose for normal sensitivity patients (wild-type VKORC1/CYP2C9 genotypes) compared to the other groups (moderate and high sensitivity); 31.5% of the patients in our study group had warfarin sensitivity-related genotypes. The estimated regression equation accounted for 44.4% of overall variability in regard to warfarin maintenance dose. The algorithm was validated, giving 45.9% correlation (R2=0.459). Conclusion Our results describe and validate the first algorithm for predicting warfarin maintenance in a Colombian mestizo population and have contributed toward the understanding of pharmacogenetics in a Latin American population subgroup.
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Affiliation(s)
- Jubby Marcela Galvez
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos Martin Restrepo
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nora Constanza Contreras
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Clara Alvarado
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Carlos-Alberto Calderón-Ospina
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Nidia Peña
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Ricardo A Cifuentes
- Area of Basic Sciences, College of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Daniela Duarte
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Paul Laissue
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
| | - Dora Janeth Fonseca
- GENIUROS Research Group, Center For Research in Genetics and Genomics - CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia,
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Differential effects of predictors of warfarin dose according to race/color categories in the admixed Brazilian population. Pharmacogenet Genomics 2018; 27:210-211. [PMID: 28263279 DOI: 10.1097/fpc.0000000000000273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sharabiani A, Nutescu EA, Galanter WL, Darabi H. A New Approach towards Minimizing the Risk of Misdosing Warfarin Initiation Doses. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2018; 2018:5340845. [PMID: 29861781 PMCID: PMC5971298 DOI: 10.1155/2018/5340845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
It is a challenge to be able to prescribe the optimal initial dose of warfarin. There have been many studies focused on an efficient strategy to determine the optimal initial dose. Numerous clinical, genetic, and environmental factors affect the warfarin dose response. In practice, it is common that the initial warfarin dose is substantially different from the stable maintenance dose, which may increase the risk of bleeding or thrombosis prior to achieving the stable maintenance dose. In order to minimize the risk of misdosing, despite popular warfarin dose prediction models in the literature which create dose predictions solely based on patients' attributes, we have taken physicians' opinions towards the initial dose into consideration. The initial doses selected by clinicians, along with other standard clinical factors, are used to determine an estimate of the difference between the initial dose and estimated maintenance dose using shrinkage methods. The selected shrinkage method was LASSO (Least Absolute Shrinkage and Selection Operator). The estimated maintenance dose was more accurate than the original initial dose, the dose predicted by a linear model without involving the clinicians initial dose, and the values predicted by the most commonly used model in the literature, the Gage clinical model.
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Affiliation(s)
- Ashkan Sharabiani
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A. Nutescu
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - William L. Galanter
- Department of Pharmacy Systems Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Houshang Darabi
- Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Chicago, IL, USA
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Wilson JL, Altman RB. Biomarkers: Delivering on the expectation of molecularly driven, quantitative health. Exp Biol Med (Maywood) 2018; 243:313-322. [PMID: 29199461 PMCID: PMC5813871 DOI: 10.1177/1535370217744775] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Biomarkers are the pillars of precision medicine and are delivering on expectations of molecular, quantitative health. These features have made clinical decisions more precise and personalized, but require a high bar for validation. Biomarkers have improved health outcomes in a few areas such as cancer, pharmacogenetics, and safety. Burgeoning big data research infrastructure, the internet of things, and increased patient participation will accelerate discovery in the many areas that have not yet realized the full potential of biomarkers for precision health. Here we review themes of biomarker discovery, current implementations of biomarkers for precision health, and future opportunities and challenges for biomarker discovery. Impact statement Precision medicine evolved because of the understanding that human disease is molecularly driven and is highly variable across patients. This understanding has made biomarkers, a diverse class of biological measurements, more relevant for disease diagnosis, monitoring, and selection of treatment strategy. Biomarkers' impact on precision medicine can be seen in cancer, pharmacogenomics, and safety. The successes in these cases suggest many more applications for biomarkers and a greater impact for precision medicine across the spectrum of human disease. The authors assess the status of biomarker-guided medical practice by analyzing themes for biomarker discovery, reviewing the impact of these markers in the clinic, and highlight future and ongoing challenges for biomarker discovery. This work is timely and relevant, as the molecular, quantitative approach of precision medicine is spreading to many disease indications.
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Affiliation(s)
- Jennifer L Wilson
- Bioengineering Department, Stanford University, Stanford, CA 94305, USA
| | - Russ B Altman
- Bioengineering Department, Stanford University, Stanford, CA 94305, USA
- Department of Genetics, Stanford University, Stanford, CA 94305, USA
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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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Pharmacogenomics Guided-Personalization of Warfarin and Tamoxifen. J Pers Med 2017; 7:jpm7040020. [PMID: 29236081 PMCID: PMC5748632 DOI: 10.3390/jpm7040020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/23/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023] Open
Abstract
The use of pharmacogenomics to personalize drug therapy has been a long-sought goal for warfarin and tamoxifen. However, conflicting evidence has created reason for hesitation in recommending pharmacogenomics-guided care for both drugs. This review will provide a summary of the evidence to date on the association between cytochrome P450 enzymes and the clinical end points of warfarin and tamoxifen therapy. Further, highlighting the clinical experiences that we have gained over the past ten years of running a personalized medicine program, we will offer our perspectives on the utility and the limitations of pharmacogenomics-guided care for warfarin and tamoxifen therapy.
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Kaye JB, Schultz LE, Steiner HE, Kittles RA, Cavallari LH, Karnes JH. Warfarin Pharmacogenomics in Diverse Populations. Pharmacotherapy 2017; 37:1150-1163. [PMID: 28672100 DOI: 10.1002/phar.1982] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Genotype-guided warfarin dosing algorithms are a rational approach to optimize warfarin dosing and potentially reduce adverse drug events. Diverse populations, such as African Americans and Latinos, have greater variability in warfarin dose requirements and are at greater risk for experiencing warfarin-related adverse events compared with individuals of European ancestry. Although these data suggest that patients of diverse populations may benefit from improved warfarin dose estimation, the vast majority of literature on genotype-guided warfarin dosing, including data from prospective randomized trials, is in populations of European ancestry. Despite differing frequencies of variants by race/ethnicity, most evidence in diverse populations evaluates variants that are most common in populations of European ancestry. Algorithms that do not include variants important across race/ethnic groups are unlikely to benefit diverse populations. In some race/ethnic groups, development of race-specific or admixture-based algorithms may facilitate improved genotype-guided warfarin dosing algorithms above and beyond that seen in individuals of European ancestry. These observations should be considered in the interpretation of literature evaluating the clinical utility of genotype-guided warfarin dosing. Careful consideration of race/ethnicity and additional evidence focused on improving warfarin dosing algorithms across race/ethnic groups will be necessary for successful clinical implementation of warfarin pharmacogenomics. The evidence for warfarin pharmacogenomics has a broad significance for pharmacogenomic testing, emphasizing the consideration of race/ethnicity in discovery of gene-drug pairs and development of clinical recommendations for pharmacogenetic testing.
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Affiliation(s)
- Justin B Kaye
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Lauren E Schultz
- Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rick A Kittles
- Department of Public Health, University of Arizona College of Medicine, Tucson, Arizona.,Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, Florida
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona.,Center for Applied Genetics and Genomic Medicine, University of Arizona College of Medicine, Tucson, Arizona.,Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona
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29
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Evidence of selection on splicing-associated loci in human populations and relevance to disease loci mapping. Sci Rep 2017; 7:5980. [PMID: 28729732 PMCID: PMC5519721 DOI: 10.1038/s41598-017-05744-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 06/14/2017] [Indexed: 12/27/2022] Open
Abstract
We performed a whole-genome scan of genetic variants in splicing regulatory elements (SREs) and evaluated the extent to which natural selection has shaped extant patterns of variation in SREs. We investigated the degree of differentiation of single nucleotide polymorphisms (SNPs) in SREs among human populations and applied long-range haplotype- and multilocus allelic differentiation-based methods to detect selection signatures. We describe an approach, sampling a large number of loci across the genome from functional classes and using the consensus from multiple tests, for identifying candidates for selection signals. SRE SNPs in various SNP functional classes show different patterns of population differentiation compared with their non-SRE counterparts. Intronic regions display a greater enrichment for extreme population differentiation among the potentially tissue-dependent transcript ratio quantitative trait loci (trQTLs) than SRE SNPs in general and includ outlier trQTLs for cross-population composite likelihood ratio, suggesting that incorporation of context annotation for regulatory variation may lead to improved detection of signature of selection on these loci. The proportion of extremely rare SNPs disrupting SREs is significantly higher in European than in African samples. The approach developed here will be broadly useful for studies of function and disease-associated variation in the human genome.
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Deng J, Vozmediano V, Rodriguez M, Cavallari LH, Schmidt S. Genotype-guided dosing of warfarin through modeling and simulation. Eur J Pharm Sci 2017; 109S:S9-S14. [PMID: 28502675 DOI: 10.1016/j.ejps.2017.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 12/23/2022]
Abstract
Current genotype-guided algorithms for warfarin dosing fail to deliver optimal performance in two aspects: 1) these algorithms are not able to achieve the same level of benefits in non-white populations, since they were developed based on multivariate regression analysis with mostly European/White data and did not include genetic variants found frequently in non-white populations; 2) these algorithms do not account for the dynamic dose/response relationship and were limited in their usefulness to guide dosing during the initiation phase, as the possession of variant VKORC1 and/or CYP2C9 polymorphisms has been associated with a more rapid attainment of target international normalized ratio (INR) and higher risk of over-anticoagulation even in genotype-guided patients. To address these shortcomings, we report on the novel use of a previously published kinetic/pharmacodynamic (K/PD) model to develop a warfarin dosing nomogram to be used across genotypes and ethnicities. Our approach leverages data from both ethnically diverse and European patients, while accounting for the differential dose/response behaviors due to VKORC1 and CYP2C9 genotypes. According to simulations, the utilization of our dosing nomogram could enable effective attainment of therapeutic INR within one week in both ethnically diverse and European populations, while maintaining uniform INR response profiles across genotypes. Furthermore, in silico clinical trial simulations using the K/PD model could be a feasible approach to help to further refine our dosing nomogram to be more applicable in the clinical setting and explore possible outcomes even before prospective clinical trials are initiated.
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Affiliation(s)
- Jiexin Deng
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida at Lake Nona, Orlando, FL, USA
| | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida at Lake Nona, Orlando, FL, USA; Drug Modeling & Consulting, Dynakin, S.L., Bilbao, Spain
| | - Monica Rodriguez
- Department of Pharmaceutics, University of Florida, Gainesville, FL, USA; Drug Modeling & Consulting, Dynakin, S.L., Bilbao, Spain
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida at Lake Nona, Orlando, FL, USA.
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Hernandez W, Gamazon ER, Aquino-Michaels K, Smithberger E, O'Brien TJ, Harralson AF, Tuck M, Barbour A, Cavallari LH, Perera MA. Integrated analysis of genetic variation and gene expression reveals novel variant for increased warfarin dose requirement in African Americans. J Thromb Haemost 2017; 15:735-743. [PMID: 28135054 PMCID: PMC5862636 DOI: 10.1111/jth.13639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Indexed: 11/26/2022]
Abstract
Essentials Genetic variants controlling gene regulation have not been explored in pharmacogenomics. We tested liver expression quantitative trait loci for association with warfarin dose response. A novel predictor for increased warfarin dose response in African Americans was identified. Precision medicine must take into account population-specific variation in gene regulation. SUMMARY Background Warfarin is commonly used to control and prevent thromboembolic disorders. However, because of warfarin's complex dose-requirement relationship, safe and effective use is challenging. Pharmacogenomics-guided warfarin dosing algorithms that include the well-established VKORC1 and CYP2C9 polymorphisms explain only a small proportion of inter-individual variability in African Americans (AAs). Objectives We aimed to assess whether transcriptomic analyses could be used to identify regulatory variants associated with warfarin dose response in AAs. Patients/Methods We identified a total of 56 expression quantitative trait loci (eQTLs) for CYP2C9, VKORC1 and CALU derived from human livers and evaluated their association with warfarin dose response in two independent AA warfarin patient cohorts. Results We found that rs4889606, a strong cis-eQTL for VKORC1 (log10 Bayes Factor = 12.02), is significantly associated with increased warfarin daily dose requirement (β = 1.1; 95% confidence interval [CI] 0.46 to 1.8) in the discovery cohort (n = 305) and in the replication cohort (β = 1.04; 95% CI 0.33 -1.7; n = 141) after conditioning on relevant covariates and the VKORC1 -1639G>A (rs9923231) variant. Inclusion of rs4889606 genotypes, along with CYP2C9 alleles, rs9923231 genotypes and clinical variables, explained 31% of the inter-patient variability in warfarin dose requirement. We demonstrate different linkage disequilibrium patterns in the region encompassing rs4889606 and rs9923231 between AAs and European Americans, which may explain the increased dose requirement found in AAs. Conclusion Our approach of interrogating eQTLs identified in liver has revealed a novel predictor of warfarin dose response in AAs. Our work highlights the utility of leveraging information from regulatory variants mapped in the liver to uncover novel variants associated with drug response and the importance of population-specific research.
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Affiliation(s)
- W Hernandez
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - E R Gamazon
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - K Aquino-Michaels
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - E Smithberger
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - T J O'Brien
- Department of Pharmacology and Physiology, George Washington University, Washington, DC, USA
| | - A F Harralson
- Department of Medicine, George Washington University, Washington, DC, USA
- Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
| | - M Tuck
- Veterans Affairs Medical Center, Washington, DC, USA
| | - A Barbour
- Department of Medicine, George Washington University, Washington, DC, USA
| | - L H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - M A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Takahashi H, Ohara M, Shibata S, Lee MTM, Cavallari LH, Nutescu EA, Scordo MG, Pengo V, Padrini R, Atsuda K, Matsubara H, Chen YT, Echizen H. Correlations between the enantio- and regio-selective metabolisms of warfarin. Pharmacogenomics 2016; 18:133-142. [PMID: 27995809 DOI: 10.2217/pgs-2016-0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To clarify whether the activities of multiple CYPs associated with warfarin metabolism would be correlated with each other. METHODS Oral clearances (CLpo) of warfarin enantiomers were estimated in 378 Chinese, Caucasians and African-Americans. The partial metabolic clearances (CLm) for 7-hydroxywarfarin enantiomers were also measured. In addition, CLpo and CLm were determined in a patient on warfarin and rifampicin. RESULTS Correlations between CLpo for warfarin enantiomers existed across the three populations. In addition, there was a significant correlation between the CLm for 7-hydroxylation of warfarin enantiomers. Under induced conditions by rifampicin, there were significant correlations between the enantio- and regio-selective metabolisms of warfarin. CONCLUSION Metabolic activities of CYP2C9, CYP1A2 and CYP3A4 may be regulated by common transcriptional mechanism(s).
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Affiliation(s)
- Harumi Takahashi
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Minami Ohara
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Soichi Shibata
- Department of Pharmacy, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
| | - Ming Ta Michael Lee
- Geisinger Health System, Danville, PN, USA.,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Maria G Scordo
- Department of Medical Sciences, Clinical Pharmacology, Uppsala University Hospital, Uppsala, Sweden
| | - Vittorio Pengo
- Department of Cardiothoracic & Vascular Sciences, University of Padova, Padova, Italy
| | - Roberto Padrini
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Koichiro Atsuda
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | - Hajime Matsubara
- Department of Pharmacy, Kitasato Institute Hospital, Kitasato University, Tokyo, Japan
| | - Yuan Tsong Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Hirotoshi Echizen
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Tokyo, Japan
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Cruz-Correa OF, León-Cachón RBR, Barrera-Saldaña HA, Soberón X. Prediction of atorvastatin plasmatic concentrations in healthy volunteers using integrated pharmacogenetics sequencing. Pharmacogenomics 2016; 18:121-131. [PMID: 27976987 DOI: 10.2217/pgs-2016-0072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To use variants found by next-generation sequencing to predict atorvastatin plasmatic concentration profiles (AUC) in healthy volunteers. SUBJECTS & METHODS A total of 60 healthy Mexican volunteers were enrolled in this study. We used variants with a predicted functional effect across 20 genes involved in atorvastatin metabolism to construct a regression model using a support vector approach with a radial basis function kernel to predict AUC refining it afterwards in order to explain a greater extent of the variance. RESULTS The final support vector regression model using 60 variants (including six novel variants) explained 94.52% of the variance in atorvastatin AUC. CONCLUSION An integrated analysis of several genes known to intervene in the different steps of metabolism is required to predict atorvastatin's AUC.
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Affiliation(s)
- Omar Fernando Cruz-Correa
- Instituto Nacional de Medicina Genómica, Periférico Sur No. 4809, Col. Arenal Tepepan, Delegación Tlalpan, México, D.F. C.P. 14610, Mexico
| | - Rafael Baltazar Reyes León-Cachón
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Ave. Madero, Col. Mitras Centro, Monterrey, Nuevo León, C.P. 64640, Mexico.,División Ciencias de la Salud, Departamento de Ciencias Básicas, Centro de Diagnóstico Molecular y Medicina Personalizada, Universidad de Monterrey, Ave. Ignacio Morones Prieto Pte. 4500, Col. Jesús M. Garza, San Pedro Garza García, Nuevo León, C.P. 66238, Mexico
| | - Hugo Alberto Barrera-Saldaña
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Ave. Madero, Col. Mitras Centro, Monterrey, Nuevo León, C.P. 64640, Mexico.,Vitagénesis, SA de CV., Col. Colinas de San Jerónimo. Monterrey, Nuevo León, C.P. 64630, Mexico
| | - Xavier Soberón
- Instituto Nacional de Medicina Genómica, Periférico Sur No. 4809, Col. Arenal Tepepan, Delegación Tlalpan, México, D.F. C.P. 14610, Mexico.,Instituto de Biotecnología, Universidad Nacional Autónoma de México, Avenida Universidad 2001, Cuernavaca, Morelos, C.P. 62210, Mexico
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Grimson S, Cox AJ, Pringle KG, Burns C, Lumbers ER, Blackwell CC, Scott RJ. The prevalence of unique SNPs in the renin-angiotensin system highlights the need for pharmacogenetics in Indigenous Australians. Clin Exp Pharmacol Physiol 2016; 43:157-60. [PMID: 26667052 DOI: 10.1111/1440-1681.12525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/15/2015] [Accepted: 12/09/2015] [Indexed: 11/27/2022]
Abstract
Genetic differences between ethnic populations affect susceptibility to disease and efficacy of drugs. This study examined and compared the prevalence of single nucleotide polymorphisms (SNPs) in genes of the renin-angiotensin system (RAS) in a desert community of Indigenous Australians and in non-Indigenous Australians. The polymorphisms were angiotensinogen, AGT G-217A (rs5049); AGT G+174A (rs4762); Angiotensin II type 1 receptor, AGTR1 A+1166C (rs5186); angiotensin converting enzyme, ACE A-240T (rs4291), ACE T-93C (rs4292); renin, REN T+1142C (rs5706). They were measured using allelic discrimination assays. The prevalence of REN T+1142C SNP was similar in the two populations; 99% were homozygous for the T allele. All other SNPs were differently distributed between the two populations (P < 0.0001). In non-Indigenous Australians, the A allele at position 204 of ACE rs4291 was prevalent (61.8%) whereas in the Indigenous Australians the A allele was less prevalent (28%). For rs4292, the C allele had a prevalence of 37.9% in non-Indigenous Australians but in Indigenous Australians the prevalence was only 1%. No Indigenous individuals were homozygous for the C allele of AGTR1 (rs5186). Thus the prevalence of RAS SNPs in this Indigenous Australian desert community was different from non-Indigenous Australians as was the prevalence of cytokine SNPs (as shown in a previous study). These differences may affect susceptibility to chronic renal and cardiovascular disease and may alter the efficacy of drugs used to inhibit the RAS. These studies highlight the need to study the pharmacogenetics of drug absorption, distribution, metabolism and excretion in Indigenous Australians for safe prescribing guidelines.
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Affiliation(s)
- Steven Grimson
- School of Medicine and Public Health, University of Newcastle, Nathan, Queensland, Australia
| | - Amanda J Cox
- Griffith Health Institute - Molecular Basis of Disease, Nathan, Queensland, Australia.,School of Medical Science, Griffith University, Nathan, Queensland, Australia
| | - Kirsty G Pringle
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Christine Burns
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Immunology Department, Pathology North, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Eugenie R Lumbers
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - C Caroline Blackwell
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Rodney J Scott
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia.,Molecular Medicine, Pathology North, John Hunter Hospital, Newcastle, New South Wales, Australia
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Abstract
We aim to develop warfarin dosing algorithm for African-Americans. We explored demographic, clinical, and genetic data from a previously collected cohort of 163 African-American patients with a stable warfarin dose. We explored 2 approaches to develop the algorithm: multiple linear regression and artificial neural network (ANN). The clinical significance of the 2 dosing algorithms was evaluated by calculating the percentage of patients whose predicted dose of warfarin was within 20% of the actual dose. Linear regression model and ANN model predicted the ideal dose in 52% and 48% of the patients, respectively. The mean absolute error using linear regression model was estimated to be 10.8 mg compared with 10.9 mg using ANN. Linear regression and ANN models identified several predictors of warfarin dose including age, weight, CYP2C9 genotype *1/*1, VKORC1 genotype, rs12777823 genotype, rs2108622 genotype, congestive heart failure, and amiodarone use. In conclusion, we developed a warfarin dosing algorithm for African-Americans. The proposed dosing algorithm has the potential to recommend warfarin doses that are close to the appropriate doses. The use of more sophisticated ANN approach did not result in improved predictive performance of the dosing algorithm except for patients of a dose of ≥49 mg/wk.
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French B, Wang L, Gage BF, Horenstein RB, Limdi NA, Kimmel SE. A systematic analysis and comparison of warfarin initiation strategies. Pharmacogenet Genomics 2016; 26:445-52. [PMID: 27383664 PMCID: PMC5014593 DOI: 10.1097/fpc.0000000000000235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Randomized trials have reported inconsistent evidence on the effectiveness of algorithms that use genotypes to initiate warfarin therapy. The Clarification of Optimal Anticoagulation through Genetics (COAG) trial initiated therapy on the basis of predicted maintenance doses, with a pharmacogenetic-guided algorithm in one study group and a clinically guided algorithm in the other. The European Pharmacogenetics of Anticoagulant Therapy (EU-PACT) consortium initiated therapy on the basis of loading doses, with an algorithm-based prediction in one study group and a fixed-dose regimen in the other. To understand the differences between these trials, we compared the initial doses between alternative dosing algorithms (the pharmacogenetic-guided and clinically guided algorithms developed by Gage and colleagues and those developed by the International Warfarin Pharmacogenetics Consortium) and between the COAG and EU-PACT dose-initiation strategies. METHODS This was a secondary analysis of the COAG trial - a double-blind, randomized-controlled trial (2009-2013) - conducted at 18 clinical centers in the USA, which included 1010 adults initiating warfarin therapy, of whom 719 achieved maintenance dose. RESULTS Among COAG participants, the distribution of initial doses differed between algorithms, but showed similar prediction accuracy for maintenance dose. However, had the COAG trial implemented the EU-PACT strategy, the 3-day initial dose would have been 4.8 mg greater among participants randomized to pharmacogenetic-guided dosing, but only 2.5 mg greater among participants randomized to clinically guided dosing (P<0.001). CONCLUSION Compared with the COAG trial, the EU-PACT trial used systematically larger loading doses in the pharmacogenetic-guided group and might have inadequately adjusted for clinical variability in warfarin dose requirements in the fixed-dose group.
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Affiliation(s)
- Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Le Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian F. Gage
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | | | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen E. Kimmel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Shahabi P, Scheinfeldt LB, Lynch DE, Schmidlen TJ, Perreault S, Keller MA, Kasper R, Wawak L, Jarvis JP, Gerry NP, Gordon ES, Christman MF, Dubé MP, Gharani N. An expanded pharmacogenomics warfarin dosing table with utility in generalised dosing guidance. Thromb Haemost 2016; 116:337-48. [PMID: 27121899 PMCID: PMC6375065 DOI: 10.1160/th15-12-0955] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/19/2016] [Indexed: 12/14/2022]
Abstract
Pharmacogenomics (PGx) guided warfarin dosing, using a comprehensive dosing algorithm, is expected to improve dose optimisation and lower the risk of adverse drug reactions. As a complementary tool, a simple genotype-dosing table, such as in the US Food and Drug Administration (FDA) Coumadin drug label, may be utilised for general risk assessment of likely over- or under-anticoagulation on a standard dose of warfarin. This tool may be used as part of the clinical decision support for the interpretation of genetic data, serving as a first step in the anticoagulation therapy decision making process. Here we used a publicly available warfarin dosing calculator (www.warfarindosing.org) to create an expanded gene-based warfarin dosing table, the CPMC-WD table that includes nine genetic variants in CYP2C9, VKORC1, and CYP4F2. Using two datasets, a European American cohort (EUA, n=73) and the Quebec Warfarin Cohort (QWC, n=769), we show that the CPMC-WD table more accurately predicts therapeutic dose than the FDA table (51 % vs 33 %, respectively, in the EUA, McNemar's two-sided p=0.02; 52 % vs 37 % in the QWC, p<1×10(-6)). It also outperforms both the standard of care 5 mg/day dosing (51 % vs 34 % in the EUA, p=0.04; 52 % vs 31 % in the QWC, p<1×10(-6)) as well as a clinical-only algorithm (51 % vs 38 % in the EUA, trend p=0.11; 52 % vs 45 % in the QWC, p=0.003). This table offers a valuable update to the PGx dosing guideline in the drug label.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Neda Gharani
- Neda Gharani, PhD, 1 Templemere, Weybridge, Surrey KT13 9PA, UK, Tel.: +44 7984005796, Fax:+44 1932976519, E-mail:
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Stack G, Maurice CB. Warfarin Pharmacogenetics Reevaluated: Subgroup Analysis Reveals a Likely Underestimation of the Maximum Pharmacogenetic Benefit by Clinical Trials. Am J Clin Pathol 2016; 145:671-86. [PMID: 27247371 DOI: 10.1093/ajcp/aqw049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Various patient subgroups were examined to determine which ones obtain the largest pharmacogenetic improvements in warfarin dose accuracy. Subgrouping schemes of recent clinical trials were analyzed for comparison. METHODS The accuracy of a pharmacogenetic dose algorithm was determined retrospectively in comparison to that of a clinical algorithm in subgroups of the International Warfarin Pharmacogenetics Consortium (IWPC) patient database (n = 2,274) and of newly studied clinic patients (n = 146). RESULTS White patients with low-dose genotypes (*1*3/AA, *2*2/AA, *2*3/GA, *2*3/AA, *3*3/GG, *3*3/GA, and *3*3/AA) achieved the largest pharmacogenetic improvements in warfarin dose accuracy. Mean absolute dosing error (MAE) in this subgroup of IWPC and newly studied patients was reduced 75.7% and 89.7%, respectively. White IWPC patients with >2 variants or ≥2 mg/day absolute difference between pharmacogenetic and clinical dose predictions obtained MAE reductions of 71.1% and 65.3%, respectively. By comparison, unstratified populations and subgroups of a major clinical trial, when replicated in IWPC patients, obtained smaller MAE reductions of 31.8% to 48.2%. Blacks and Asians obtained substantially smaller dose accuracy improvements overall than whites. CONCLUSIONS Patient subgroups were identified that obtained the largest pharmacogenetic improvements in warfarin dose accuracy. These subgroups have not been analyzed in clinical trials to date, likely resulting in underestimation of the pharmacogenetic benefit.
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Affiliation(s)
- Gary Stack
- From the Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven; Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT.
| | - Carleta B Maurice
- From the Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
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Shendre A, Brown TM, Liu N, Hill CE, Beasley TM, Nickerson DA, Limdi NA. Race-Specific Influence of CYP4F2 on Dose and Risk of Hemorrhage Among Warfarin Users. Pharmacotherapy 2016; 36:263-72. [PMID: 26877068 DOI: 10.1002/phar.1717] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The p.V433M in cytochrome P450 4F2 (rs2108622, CYP4F2*3) is associated with a higher warfarin dose and lower risk of hemorrhage among European Americans. We evaluate the influence of CYP4F2*3 on warfarin dose, time to target international normalized ratio (INR), and stable dose, proportion of time spent in target range (PTTR), as well as the risk of overanticoagulation and hemorrhage among European and African Americans. DESIGN CYP4F2*3 was genotyped in 1238 patients initiated on warfarin in a prospective inception cohort. Multivariable linear regression was used to assess warfarin dose and PTTR; proportional hazards analysis was performed to evaluate time to target INR and stable dose, overanticoagulation, and hemorrhage. SETTING Two outpatient anticoagulation clinics. PARTICIPANTS A total of 1238 anticoagulated patients. OUTCOMES Warfarin dose (mg/day), time to target INR and stable dose, PTTR, overanticoagulation (INR more than 4), and major hemorrhage. RESULTS Minor allele frequency for the CYP4F2*3 variant was 30.3% among European Americans and 8.4% among African Americans. CYP4F2*3 was associated with higher dose among European Americans but not African Americans. Compared to CYP4F2*1/*1, *1/*3 was associated with a statistically nonsignificant increase in dose (4.5%, p=0.22) and *3/*3 was associated with a statistically significant increase in dose (13.2%, p=0.02). CYP4F2 genotype did not influence time to target INR, time to stable dose, or PTTR in either race group. CYP4F2*3/*3 was associated with a 31% lower risk of over anticoagulation (p=0.06). Incidence of hemorrhage was lower among participants with CYP4F2 *3/*3 compared with *1/*3 or *1/*1 (incidence rate ratio = 0.45, 95% confidence interval 0.14-1.11, p=0.09). After controlling for covariates, CYP4F2 *3/*3 was associated with a 52% lower risk of hemorrhage, although this was not statistically significant (p=0.24). CONCLUSION Possession of CYP4F2*3 variant influences warfarin dose among European Americans but not African Americans. The CYP4F2-dose, CYP4F2-overanticoagulation, and CYP4F2-hemorrhage association follows a recessive pattern with possession of CYP4F2*3/*3 genotype likely demonstrating a protective effect. These findings need further confirmation.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Todd M Brown
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nianjun Liu
- Biostatistics, Section on Statistical Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles E Hill
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - T Mark Beasley
- Biostatistics, Section on Statistical Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Deborah A Nickerson
- Genome Sciences, School of Medicine, University of Washington, Seattle, Washington
| | - Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Novel genetic predictors of venous thromboembolism risk in African Americans. Blood 2016; 127:1923-9. [PMID: 26888256 DOI: 10.1182/blood-2015-09-668525] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/07/2016] [Indexed: 11/20/2022] Open
Abstract
Venous thromboembolism (VTE) is the third most common life-threatening cardiovascular condition in the United States, with African Americans (AAs) having a 30% to 60% higher incidence compared with other ethnicities. The mechanisms underlying population differences in the risk of VTE are poorly understood. We conducted the first genome-wide association study in AAs, comprising 578 subjects, followed by replication of highly significant findings in an independent cohort of 159 AA subjects. Logistic regression was used to estimate the association between genetic variants and VTE risk. Through bioinformatics analysis of the top signals, we identified expression quantitative trait loci (eQTLs) in whole blood and investigated the messenger RNA expression differences in VTE cases and controls. We identified and replicated single-nucleotide polymorphisms on chromosome 20 (rs2144940, rs2567617, and rs1998081) that increased risk of VTE by 2.3-fold (P< 6 × 10(-7)). These risk variants were found in higher frequency among populations of African descent (>20%) compared with other ethnic groups (<10%). We demonstrate that SNPs on chromosome 20 are cis-eQTLs for thrombomodulin (THBD), and the expression of THBD is lower among VTE cases compared with controls (P= 9.87 × 10(-6)). We have identified novel polymorphisms associated with increased risk of VTE in AAs. These polymorphisms are predominantly found among populations of African descent and are associated with THBD gene expression. Our findings provide new molecular insight into a mechanism regulating VTE susceptibility and identify common genetic variants that increase the risk of VTE in AAs, a population disproportionately affected by this disease.
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Poor warfarin dose prediction with pharmacogenetic algorithms that exclude genotypes important for African Americans. Pharmacogenet Genomics 2015; 25:73-81. [PMID: 25461246 DOI: 10.1097/fpc.0000000000000108] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Recent clinical trial data cast doubt on the utility of genotype-guided warfarin dosing, specifically showing worse dosing with a pharmacogenetic versus clinical dosing algorithm in African Americans. However, many genotypes important in African Americans were not accounted for. We aimed to determine whether omission of the CYP2C9*5, CYP2C9*6, CYP2C9*8, CYP2C9*11 alleles and rs12777823 G > A genotype affects performance of dosing algorithms in African Americans. METHODS In a cohort of 274 warfarin-treated African Americans, we examined the association between the CYP2C9*5, CYP2C9*6, CYP2C9*8, CYP2C9*11 alleles and rs12777823 G > A genotype and warfarin dose prediction error with pharmacogenetic algorithms used in clinical trials. RESULTS The http://www.warfarindosing.org algorithm overestimated doses by a median (interquartile range) of 1.2 (0.02-2.6) mg/day in rs12777823 heterozygotes (P<0.001 for predicted vs. observed dose), 2.0 (0.6-2.8) mg/day in rs12777823 variant homozygotes (P = 0.004), and 2.2 (0.5-2.9) mg/day in carriers of a CYP2C9 variant (P < 0.001). The International Warfarin Pharmacogenetics Consortium (IWPC) algorithm underdosed warfarin by 0.8 (-2.3 to 0.4) mg/day for patients with the rs12777823 GG genotype (P < 0.001) and overdosed warfarin by 0.7 (-0.4 to 1.9) mg/day in carriers of a variant CYP2C9 allele (P = 0.04). Modifying the http://www.warfarindosing.org algorithm to adjust for variants important in African Americans led to better dose prediction than either the original http://www.warfarindosing.org (P < 0.01) or IWPC (P < 0.01) algorithm. CONCLUSION These data suggest that, when providing genotype-guided warfarin dosing, failure to account for variants important in African Americans leads to significant dosing error in this population.
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Patel SR, Langaee TY, Wong SS, Cavallari LH. Pyrosequencing of the CYP2C9 -1766T>C polymorphism as a means of detecting the CYP2C9*8 allele. Pharmacogenomics 2015; 15:1717-22. [PMID: 25410896 DOI: 10.2217/pgs.14.130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The CYP2C9 c.449G>A (p.R150H, rs7900194) polymorphism, which confers the CYP2C9*8 allele, is common in persons of African descent and results in reduced clearance of the narrow therapeutic index drugs, warfarin and phenytoin. Because of significant homology in DNA sequence at the 449G>A locus among CYP2C genes, the 449G>A variant cannot be reliably detected via PCR-based genotyping assays that require a short PCR product, such as pyrosequencing. Herein, we propose genotyping for the CYP2C9 c.-1766T>C polymorphism via pyrosequencing as an alternative and accurate means of identifying the CYP2C9*8 allele.
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Affiliation(s)
- Shitalben R Patel
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
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Karaca S, Bozkurt NC, Cesuroglu T, Karaca M, Bozkurt M, Eskioglu E, Polimanti R. International warfarin genotype-guided dosing algorithms in the Turkish population and their preventive effects on major and life-threatening hemorrhagic events. Pharmacogenomics 2015. [PMID: 26216670 DOI: 10.2217/pgs.15.58] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
AIM To determine the accuracy of international warfarin pharmacogenetic algorithms developed on large multiethnic cohorts (comprising more than 1000 subjects) to predict therapeutic warfarin doses in Turkish patients. MATERIALS & METHODS We investigated two Turkish warfarin-treated cohorts: patients with no history of hemorrhagic or thromboembolic event and patients with major and life-threatening hemorrhagic events. RESULTS International pharmacogenetic algorithms showed good performances in predicting the therapeutic dose of patients with no history of bleedings, but they did not significantly detect the incorrect warfarin dose of patients with major and life-threatening hemorrhagic events. CONCLUSION Although genetic information can predict the therapeutic warfarin dose, the accuracy of the international pharmacogenetic algorithms is not sufficient to be used for warfarin screening in Turkish patients.
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Affiliation(s)
- Sefayet Karaca
- School of Health Science, Aksaray University, Aksaray, Turkey.,GENAR Institute for Public Health & Genomics Research, Ankara, Turkey
| | - Nujen Colak Bozkurt
- Department of Endocrinology & Metabolism, Diskapi Yildirim Beyazit Training & Research Hospital, Ankara, Turkey
| | - Tomris Cesuroglu
- GENAR Institute for Public Health & Genomics Research, Ankara, Turkey.,Department of Social Medicine, Maastricht University, Maastricht, The Netherlands
| | - Mehmet Karaca
- Department of Biology, Faculty of Science & Arts, Aksaray University, Aksaray, Turkey
| | - Mehmet Bozkurt
- Department of Cardiology, Ataturk Training & Research Hospital, Ankara, Turkey
| | - Erdal Eskioglu
- Metabolism Unit, Numune Training & Research Hospital, Ankara, Turkey
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, West Haven, Connecticut, USA
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Revisiting Warfarin Dosing Using Machine Learning Techniques. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:560108. [PMID: 26146514 PMCID: PMC4471424 DOI: 10.1155/2015/560108] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/11/2015] [Accepted: 05/21/2015] [Indexed: 12/23/2022]
Abstract
Determining the appropriate dosage of warfarin is an important yet challenging task. Several prediction models have been proposed to estimate a therapeutic dose for patients. The models are either clinical models which contain clinical and demographic variables or pharmacogenetic models which additionally contain the genetic variables. In this paper, a new methodology for warfarin dosing is proposed. The patients are initially classified into two classes. The first class contains patients who require doses of >30 mg/wk and the second class contains patients who require doses of ≤30 mg/wk. This phase is performed using relevance vector machines. In the second phase, the optimal dose for each patient is predicted by two clinical regression models that are customized for each class of patients. The prediction accuracy of the model was 11.6 in terms of root mean squared error (RMSE) and 8.4 in terms of mean absolute error (MAE). This was 15% and 5% lower than IWPC and Gage models (which are the most widely used models in practice), respectively, in terms of RMSE. In addition, the proposed model was compared with fixed-dose approach of 35 mg/wk, and the model proposed by Sharabiani et al. and its outperformance were proved in terms of both MAE and RMSE.
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Hernandez W, Aquino-Michaels K, Drozda K, Patel S, Jeong Y, Takahashi H, Cavallari LH, Perera MA. Novel single nucleotide polymorphism in CYP2C9 is associated with changes in warfarin clearance and CYP2C9 expression levels in African Americans. Transl Res 2015; 165:651-7. [PMID: 25499099 PMCID: PMC4433569 DOI: 10.1016/j.trsl.2014.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 12/23/2022]
Abstract
Warfarin is a widely used anticoagulant whose active S-enantiomer is primarily metabolized by the CYP2C9 enzyme. The CYP2C9*2 and CYP2C9*3 alleles are associated with lower warfarin dose requirement and decreased enzyme activity. In contrast, we previously identified a novel single-nucleotide polymorphism (SNP) (rs7089580A > T) in CYP2C9 that is associated with higher warfarin dose requirement in African Americans (AAs). In this study, we examine the effect of rs7089580 on warfarin pharmacokinetics and CYP2C9 expression in 63 AA patients and 32 AA liver tissues, respectively. We found oral clearance of S-warfarin to be higher among carriers of the minor rs7089580 allele (T) compared with wild-type homozygotes (3.73 ± 1.46 vs 2.95 ± 1.39 mL/min; P = 0.04). CYP2C9 messenger RNA expression in liver tissue was also higher among A/T and T/T genotypes compared with A/A (P < 0.02). Our findings indicate that rs7089580 is associated with higher S-warfarin clearance and CYP2C9 expression and may help explain the higher dose requirement of warfarin in AAs. Furthermore, rs7089580 is in complete linkage disequilibrium with the promoter SNP rs12251841 in AAs, which may provide a biologically plausible explanation for the observed effect on CYP2C9 expression levels. Given the many clinically relevant substrates of CYP2C9, identifying polymorphisms that affect expression levels and metabolism across ethnicities is essential for individualization of doses with a narrow therapeutic index.
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Affiliation(s)
- Wenndy Hernandez
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Keston Aquino-Michaels
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Katarzyna Drozda
- Department of Pharmacy Practice, University of Illinois, College of Pharmacy, Chicago, Ill
| | - Shitalban Patel
- Department of Pharmacy Practice, University of Illinois, College of Pharmacy, Chicago, Ill
| | - Young Jeong
- Department of Pharmacy Practice, University of Illinois, College of Pharmacy, Chicago, Ill
| | - Harumi Takahashi
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Larisa H Cavallari
- Department of Pharmacy Practice, University of Illinois, College of Pharmacy, Chicago, Ill
| | - Minoli A Perera
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, Ill.
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Race influences warfarin dose changes associated with genetic factors. Blood 2015; 126:539-45. [PMID: 26024874 DOI: 10.1182/blood-2015-02-627042] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/27/2015] [Indexed: 12/11/2022] Open
Abstract
Warfarin dosing algorithms adjust for race, assigning a fixed effect size to each predictor, thereby attenuating the differential effect by race. Attenuation likely occurs in both race groups but may be more pronounced in the less-represented race group. Therefore, we evaluated whether the effect of clinical (age, body surface area [BSA], chronic kidney disease [CKD], and amiodarone use) and genetic factors (CYP2C9*2, *3, *5, *6, *11, rs12777823, VKORC1, and CYP4F2) on warfarin dose differs by race using regression analyses among 1357 patients enrolled in a prospective cohort study and compared predictive ability of race-combined vs race-stratified models. Differential effect of predictors by race was assessed using predictor-race interactions in race-combined analyses. Warfarin dose was influenced by age, BSA, CKD, amiodarone use, and CYP2C9*3 and VKORC1 variants in both races, by CYP2C9*2 and CYP4F2 variants in European Americans, and by rs12777823 in African Americans. CYP2C9*2 was associated with a lower dose only among European Americans (20.6% vs 3.0%, P < .001) and rs12777823 only among African Americans (12.3% vs 2.3%, P = .006). Although VKORC1 was associated with dose decrease in both races, the proportional decrease was higher among European Americans (28.9% vs 19.9%, P = .003) compared with African Americans. Race-stratified analysis improved dose prediction in both race groups compared with race-combined analysis. We demonstrate that the effect of predictors on warfarin dose differs by race, which may explain divergent findings reported by recent warfarin pharmacogenetic trials. We recommend that warfarin dosing algorithms should be stratified by race rather than adjusted for race.
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Pirmohamed M, Kamali F, Daly AK, Wadelius M. Oral anticoagulation: a critique of recent advances and controversies. Trends Pharmacol Sci 2015; 36:153-63. [PMID: 25698605 DOI: 10.1016/j.tips.2015.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/18/2015] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
There have recently been significant advances in the field of oral anticoagulation, but these have also led to many controversies. Warfarin is still the commonest drug used for clotting disorders but its use is complicated owing to wide inter-individual variability in dose requirement and its narrow therapeutic index. Warfarin dose requirement can be influenced by both genetic and environmental factors. Two recent randomized controlled trials (RCTs) came to different conclusion regarding the utility of genotype-guided dosing; we critically explore the reasons for the differences. The new generation of oral anticoagulants have been demonstrated to be as efficacious as warfarin, but further work is needed to evaluate their safety in real clinical settings.
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Affiliation(s)
- Munir Pirmohamed
- The University of Liverpool, Liverpool L69 3BX, UK; Royal Liverpool and Broadgreen University Hospital National Health Service (NHS) Trust, Prescot Street, Liverpool L7 8XP, UK.
| | - Farhad Kamali
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Ann K Daly
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
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Baranova EV, Verhoef TI, Asselbergs FW, de Boer A, Maitland-van der Zee AH. Genotype-guided coumarin dosing: where are we now and where do we need to go next? Expert Opin Drug Metab Toxicol 2015; 11:509-22. [DOI: 10.1517/17425255.2015.1004053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Scott SA, Lubitz SA. Warfarin pharmacogenetic trials: is there a future for pharmacogenetic-guided dosing? Pharmacogenomics 2015; 15:719-22. [PMID: 24897277 DOI: 10.2217/pgs.14.18] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Stuart A Scott
- Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1497, New York, NY 10029, USA
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Johnson JA, Cavallari LH. Warfarin pharmacogenetics. Trends Cardiovasc Med 2014; 25:33-41. [PMID: 25282448 DOI: 10.1016/j.tcm.2014.09.001] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/18/2014] [Accepted: 09/01/2014] [Indexed: 02/02/2023]
Abstract
The cytochrome P450 (CYP) 2C9 and vitamin K epoxide reductase complex 1 (VKORC1) genotypes have been strongly and consistently associated with warfarin dose requirements, and dosing algorithms incorporating genetic and clinical information have been shown to be predictive of stable warfarin dose. However, clinical trials evaluating genotype-guided warfarin dosing produced mixed results, calling into question the utility of this approach. Recent trials used surrogate markers as endpoints rather than clinical endpoints, further complicating translation of the data to clinical practice. The present data do not support genetic testing to guide warfarin dosing, but in the setting where genotype data are available, use of such data in those of European ancestry is reasonable. Outcomes data are expected from an on-going trial, observational studies continue, and more work is needed to define dosing algorithms that incorporate appropriate variants in minority populations; all these will further shape guidelines and recommendations on the clinical utility of genotype-guided warfarin dosing.
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Affiliation(s)
- Julie A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Box 100486, Gainesville, FL 32610-0486.
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Box 100486, Gainesville, FL 32610-0486
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