1
|
Wang X, Zhao D, Ma J, Wang X, Liu J. Correlation between Metabolic Parameters and Warfarin Dose in Patients with Heart Valve Replacement of Different Genotypes. Rev Cardiovasc Med 2024; 25:128. [PMID: 39076565 PMCID: PMC11264039 DOI: 10.31083/j.rcm2504128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 07/31/2024] Open
Abstract
Background Warfarin has become the first choice for anticoagulation in patients who need lifelong anticoagulation due to its clinical efficacy and low price. However, the anticoagulant effect of warfarin is affected by many drugs, foods, etc. accompanied by a high risk of bleeding and embolism. The Vitamin K epoxide reductase complex 1 (VKORC1) and Cytochrome P450 2C9 (CYP2C9) genotypic variation can influence the therapeutic dose of warfarin. However, it is not clear whether there is a correlation between warfarin dose and liver function, kidney function and metabolic markers such as uric acid (UA) in patients with different genotypes. We performed a single-center retrospective cohort study to evaluate the factors affecting warfarin dose and to establish a dose conversion model for warfarin patients undergoing heart valve replacement. Methods We studied 343 patients with a mechanical heart valve replacement, compared the doses of warfarin in patients with different warfarin-related genotypes (CYP2C9 and VKORC1), and analyzed the correlation between liver function, kidney function, UA and other metabolic markers and warfarin dose in patients with different genotypes following heart valve replacement. Results Genotype analysis showed that 72.01% of patients had CYP2C9*1/*1 and VKORC1 mutant AA genotypes. Univariate regression analysis revealed that the warfarin maintenance dose was significantly correlated with gender, age, body surface area (BSA), UA and genotype. There was no correlation with liver or kidney function. Multiple linear regression analysis showed that BSA, genotype and UA were the independent factors influencing warfarin dose. Conclusions There is a significant correlation between UA content and warfarin dose in patients with heart valve replacement genotypes CYP2C9*1/*1/VKORC1(GA+GG), CYP2C9*1/*1/VKORC1AA and CYP2C9*1/*1/VKORC1AA.
Collapse
Affiliation(s)
- Xiaowu Wang
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 710032 Xi'an, Shaanxi, China
| | - Diancai Zhao
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 710032 Xi'an, Shaanxi, China
| | - Jipeng Ma
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 710032 Xi'an, Shaanxi, China
| | - Xia Wang
- Department of Health Statistics, Faculty of Preventive Medicine, Fourth Military Medical University, 710032 Xi'an, Shaanxi, China
| | - Jincheng Liu
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 710032 Xi'an, Shaanxi, China
| |
Collapse
|
2
|
Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
Collapse
Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
| |
Collapse
|
3
|
Siemens A, Anderson SJ, Rassekh SR, Ross CJD, Carleton BC. A Systematic Review of Polygenic Models for Predicting Drug Outcomes. J Pers Med 2022; 12:jpm12091394. [PMID: 36143179 PMCID: PMC9505711 DOI: 10.3390/jpm12091394] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Polygenic models have emerged as promising prediction tools for the prediction of complex traits. Currently, the majority of polygenic models are developed in the context of predicting disease risk, but polygenic models may also prove useful in predicting drug outcomes. This study sought to understand how polygenic models incorporating pharmacogenetic variants are being used in the prediction of drug outcomes. A systematic review was conducted with the aim of gaining insights into the methods used to construct polygenic models, as well as their performance in drug outcome prediction. The search uncovered 89 papers that incorporated pharmacogenetic variants in the development of polygenic models. It was found that the most common polygenic models were constructed for drug dosing predictions in anticoagulant therapies (n = 27). While nearly all studies found a significant association with their polygenic model and the investigated drug outcome (93.3%), less than half (47.2%) compared the performance of the polygenic model against clinical predictors, and even fewer (40.4%) sought to validate model predictions in an independent cohort. Additionally, the heterogeneity of reported performance measures makes the comparison of models across studies challenging. These findings highlight key considerations for future work in developing polygenic models in pharmacogenomic research.
Collapse
Affiliation(s)
- Angela Siemens
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
| | - Spencer J. Anderson
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
| | - S. Rod Rassekh
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3V4, Canada
- Division of Oncology, Hematology and Bone Marrow Transplant, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Colin J. D. Ross
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Bruce C. Carleton
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3V4, Canada
- Pharmaceutical Outcomes Programme, British Columbia Children’s Hospital, Vancouver, BC V5Z 4H4, Canada
- Correspondence:
| |
Collapse
|
4
|
Vuorinen AL, Lehto M, Niemi M, Harno K, Pajula J, van Gils M, Lähteenmäki J. Pharmacogenetics of Anticoagulation and Clinical Events in Warfarin-Treated Patients: A Register-Based Cohort Study with Biobank Data and National Health Registries in Finland. Clin Epidemiol 2021; 13:183-195. [PMID: 33727862 PMCID: PMC7954279 DOI: 10.2147/clep.s289031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/19/2021] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To assess the association between VKORC1 and CYP2C9 variants and the incidence of adverse drug reactions in warfarin-treated patients in a real-world setting. MATERIALS AND METHODS This was a register-based cohort study (PreMed) linking data from Finnish biobanks, national health registries and patient records between January 1st 2007 and June 30th 2018. The inclusion criteria were: 1) ≥18 years of age, 2) CYP2C9 and VKORC1 genotype information available, 3) a diagnosis of a cardiovascular disease, 4) at least one warfarin purchase, 5) regular INR tests. Eligible individuals were divided into two warfarin sensitivity groups; normal responders, and sensitive and highly sensitive responders based on their VKORC1 and CYP2C9 genotypes. The incidences of clinical events were compared between the groups using Cox regression models. RESULTS The cohort consisted of 2508 participants (45% women, mean age of 69 years), of whom 65% were categorized as normal responders and 35% sensitive or highly sensitive responders. Compared to normal responders, sensitive and highly sensitive responders had fewer INR tests below 2 (median: 33.3% vs 43.8%, 95% CI: -13.3%, -10.0%) and more above 3 (median: 18.2% vs 6.7%, 95% Cl: 8.3%, 10.8%). The incidence (per 100 patient-years) of bleeding outcomes was 5.4 for normal responders and 5.6 for the sensitive and highly sensitive responder group (HR=1.03, 95% CI: 0.74, 1.44). The incidence of thromboembolic outcomes was 4.9 and 7.8, respectively (HR=1.48, 95% CI: 1.08, 2.03). CONCLUSION In a real-world setting, genetically sensitive and highly sensitive responders to warfarin had more high INR tests and required a lower daily dose of warfarin than normal responders. However, the risk for bleeding events was not increased in sensitive and highly sensitive responders. Interestingly, the risk of thromboembolic outcomes was lower in normal responders compared to the sensitive and highly sensitive responders. TRIAL REGISTRATION NCT04001166.
Collapse
Affiliation(s)
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Kari Harno
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Juha Pajula
- VTT Technical Research Centre of Finland, Tampere, Finland
| | - Mark van Gils
- VTT Technical Research Centre of Finland, Tampere, Finland
| | | |
Collapse
|
5
|
Stevenson JM, Alexander GC, Palamuttam N, Mehta HB. Projected Utility of Pharmacogenomic Testing Among Individuals Hospitalized With COVID-19: A Retrospective Multicenter Study in the United States. Clin Transl Sci 2021; 14:153-162. [PMID: 33085221 PMCID: PMC7877860 DOI: 10.1111/cts.12919] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/07/2020] [Indexed: 12/24/2022] Open
Abstract
Many academic institutions are collecting blood samples from patients seeking treatment for coronavirus disease 2019 (COVID-19) to build research biorepositories. It may be feasible to extract pharmacogenomic (PGx) information from biorepositories for clinical use. We sought to characterize the potential value of multigene PGx testing among individuals hospitalized with COVID-19 in the United States. We performed a cross-sectional analysis of electronic health records from consecutive individuals hospitalized with COVID-19 at a large, urban academic health system. We characterized medication orders, focusing on medications with actionable PGx guidance related to 14 commonly assayed genes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, DPYD, G6PD, HLA-A, HLA-B, IFNL3, NUDT15, SLCO1B1, TPMT, UGT1A1, and VKORC1). A simulation analysis combined medication data with population phenotype frequencies to estimate how many treatment modifications would be enabled if multigene PGx results were available. Sixty-four unique medications with PGx guidance were ordered at least once in the cohort (n = 1,852, mean age 60.1 years). Nearly nine in 10 individuals (89.7%) had at least one order for a medication with PGx guidance and 427 patients (23.1%) had orders for 4 or more actionable medications. Using a simulation, we estimated that 17 treatment modifications per 100 patients would be enabled if PGx results were available. The genes CYP2D6 and CYP2C19 were responsible for the majority of treatment modifications, and the medications most often affected were ondansetron, oxycodone, and clopidogrel. PGx results would be relevant for nearly all individuals hospitalized with COVID-19 and would provide the opportunity to improve clinical care.
Collapse
Affiliation(s)
- James M. Stevenson
- Division of Clinical PharmacologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - G. Caleb Alexander
- Center for Drug Safety and EffectivenessJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of General Internal MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Natasha Palamuttam
- Division of Health Sciences InformaticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Hemalkumar B. Mehta
- Center for Drug Safety and EffectivenessJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| |
Collapse
|
6
|
Agrawal S, Heiss MS, Fenter RB, Abramova TV, Perera MA, Pacheco JA, Smith ME, Rasmussen-Torvik LJ, George AL. Impact of CYP2C9-Interacting Drugs on Warfarin Pharmacogenomics. Clin Transl Sci 2020; 13:941-949. [PMID: 32270628 PMCID: PMC7485961 DOI: 10.1111/cts.12781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/24/2020] [Indexed: 01/20/2023] Open
Abstract
Precise dosing of warfarin is important to achieve therapeutic benefit without adverse effects. Pharmacogenomics explains some interindividual variability in warfarin response, but less attention has been paid to drug‐drug interactions in the context of genetic factors. We investigated retrospectively the combined effects of cytochrome P450 (CYP)2C9 and vitamin K epoxide reductase complex (VKORC)1 genotypes and concurrent exposure to CYP2C9‐interacting drugs on long‐term measures of warfarin anticoagulation. Study participants predicted to be sensitive responders to warfarin based on CYP2C9 and VKORC1 genotypes, had significantly greater international normalized ratio (INR) variability over time. Participants who were concurrently taking CYP2C9‐interacting drugs were found to have greater INR variability and lesser time in therapeutic range. The associations of INR variability with genotype were driven by the subgroup not exposed to interacting drugs, whereas the effect of interacting drug exposure was driven by the subgroup categorized as normal responders. Our findings emphasize the importance of considering drug interactions in pharmacogenomic studies.
Collapse
Affiliation(s)
- Saaket Agrawal
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Meredith S Heiss
- Graduate Program in Genetic Counseling, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Remington B Fenter
- Graduate Program in Genetic Counseling, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tatiana V Abramova
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Minoli A Perera
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer A Pacheco
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maureen E Smith
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alfred L George
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Pharmacogenomics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
7
|
Shah RR. Genotype‐guided warfarin therapy: Still of only questionable value two decades on. J Clin Pharm Ther 2020; 45:547-560. [DOI: 10.1111/jcpt.13127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022]
|
8
|
Panchenko E, Kropacheva E, Dobrovolsky A, Titaeva E, Zemlyanskaya O, Trofimov D, Galkina I, Lifshits G, Vereina N, Sinitsin S, Vorobyeva N, Grehova L, Zateyshchikov D, Zotova I, Vavilova T, Sirotkina O, Grontkovskaya A. CYP2C9 and VKORC1 genotyping for the quality of long-standing warfarin treatment in Russian patients. THE PHARMACOGENOMICS JOURNAL 2020; 20:687-694. [DOI: 10.1038/s41397-020-0157-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 01/26/2023]
|
9
|
El Rouby N, Alrwisan A, Langaee T, Lipori G, Angiolillo DJ, Franchi F, Riva A, Elsey A, Johnson JA, Cavallari LH, Winterstein AG. Clinical Utility of Pharmacogene Panel-Based Testing in Patients Undergoing Percutaneous Coronary Intervention. Clin Transl Sci 2020; 13:473-481. [PMID: 31758664 PMCID: PMC7214641 DOI: 10.1111/cts.12729] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/02/2019] [Indexed: 12/19/2022] Open
Abstract
We aimed to estimate the utility of panel‐based pharmacogenetic testing of patients undergoing percutaneous coronary intervention (PCI). Utilization of Clinical Pharmacogenetic Implementation Consortium (CPIC) level A/B drugs after PCI was estimated in a national sample of IBM MarketScan beneficiaries. Genotype data from University of Florida (UF) patients (n = 211) who underwent PCI were used to project genotype‐guided opportunities among MarketScan beneficiaries with at least one (N = 105,547) and five (N = 12,462) years of follow‐up data. The actual incidence of genotype‐guided prescribing opportunities was determined among UF patients. In MarketScan, 50.0% (52,799/105,547) over 1 year and 68.0% (8,473/12,462) over 5 years had ≥ 1 CPIC A/B drug besides antiplatelet therapy prescribed, with a projected incidence of genotype‐guided prescribing opportunities of 39% at 1 year and 52% at 5 years. Genotype‐guided prescribing opportunities occurred in 32% of UF patients. Projected and actual incidence of genotype‐guided opportunities among two cohorts supports the utility of panel‐based testing among patients who underwent PCI.
Collapse
Affiliation(s)
- Nihal El Rouby
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Adel Alrwisan
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Saudi Food and Drug Authority, Riyadh, Saudi Arabia
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Gloria Lipori
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,UF Health & UF Health Sciences Center, Gainesville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Alberto Riva
- Bioinformatics Core, Interdisciplinary Center for Biotechnology Research, University of Florida, Gainesville, Florida, USA
| | - Amanda Elsey
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Epidemiology, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
10
|
Zhou L, Ding Y, Gao Y, Yang B, Bao J, Ma J. Genetic influence on bleeding and over-anticoagulation risk in patients undergoing warfarin treatment after heart valve replacements. Expert Opin Drug Metab Toxicol 2020; 16:1-9. [DOI: 10.1080/17425255.2020.1711883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ling Zhou
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Yinglong Ding
- Department of Cardiovascular Surgery, Soochow University, Suzhou, China
| | - Yuan Gao
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Biwen Yang
- Department of Cardiovascular Surgery, Soochow University, Suzhou, China
| | - Jianan Bao
- Department of Pharmacy, Soochow University, Suzhou, China
| | - Jingjing Ma
- Department of Pharmacy, Soochow University, Suzhou, China
| |
Collapse
|
11
|
Ragia G, Manolopoulos VG. Pharmacogenomics of anticoagulation therapy: the last 10 years. Pharmacogenomics 2019; 20:1113-1117. [DOI: 10.2217/pgs-2019-0149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- DNALEX SA, Leontaridou 2, Alexandroupolis, Greece
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Clinical Pharmacology & Pharmacogenetics Unit, Academic General Hospital of Alexandroupolis, Alexandroupolis, Greece
| |
Collapse
|
12
|
Skripka AI, Kogay VV, Listratov AI, Sokolova AA, Napalkov DA, Fomin VV. [Personalized approach for direct oral anticoagulant prescription: from theory to practice]. TERAPEVT ARKH 2019; 91:111-120. [PMID: 32598744 DOI: 10.26442/00403660.2019.07.000045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 12/14/2022]
Abstract
Data on possibilities of personalized approach for direct oral anticoagulants (DOAC) choice in patients with atrial fibrillation are presented in the article. We also review clinical and fundamental studies and future perspectives on pharmacogenetic and pharmacokinetic tests to predict the efficacy and safety of DOAC.
Collapse
Affiliation(s)
- A I Skripka
- Sechenov First Moscow State Medical University (Sechenov University)
| | - V V Kogay
- Sechenov First Moscow State Medical University (Sechenov University)
| | - A I Listratov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - A A Sokolova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - D A Napalkov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - V V Fomin
- Sechenov First Moscow State Medical University (Sechenov University)
| |
Collapse
|
13
|
Kampouraki E, Kamali F. Pharmacogenetics of anticoagulants used for stroke prevention in patients with atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:449-458. [PMID: 31120800 DOI: 10.1080/17425255.2019.1623878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: The inclusion of pharmacogenetics alongside clinical information in anticoagulant therapy offers the opportunity for a tailored approach to treatment according to individual patient characteristics. Areas covered: Literature was searched using PubMed database, focusing on pharmacogenetics of oral anticoagulants. Original research articles and review articles in English language were included in the literature reviewed. This article includes all information available for the genetic cause of inter-individual variability in anticoagulation response to oral anticoagulant drugs. The pharmacogenetics of VKAs and NOACs are described in detail. Expert opinion: There have been numerous studies focusing on the pharmacogenetics of VKAs, particularly warfarin. Current evidence suggests that known genetic and clinical factors explain a large proportion of the inter-individual variability in response to warfarin. Pharmacogenetic-based algorithms have been validated to determine their clinical utility with equivocal results. To date, only a limited number of mostly small studies on the pharmacogenetics of NOACs exists. The latter have highlighted genetic polymorphisms in specific genes that may affect clinical outcomes. Further evaluations of these polymorphisms are needed before firm conclusions can be drawn about the significance of pharmacogenetics on NOAC therapy.
Collapse
Affiliation(s)
- Emmanouela Kampouraki
- a Institute of Cellular Medicine within Faculty of Medical Sciences , Newcastle University , Newcastle upon Tyne , UK
| | - Farhad Kamali
- b Newcastle upon Tyne Hospitals, NHS Foundation Trust , Newcastle upon Tyne , UK
| |
Collapse
|
14
|
Jorgensen AL, Prince C, Fitzgerald G, Hanson A, Downing J, Reynolds J, Zhang JE, Alfirevic A, Pirmohamed M. Implementation of genotype-guided dosing of warfarin with point-of-care genetic testing in three UK clinics: a matched cohort study. BMC Med 2019; 17:76. [PMID: 30961588 PMCID: PMC6454722 DOI: 10.1186/s12916-019-1308-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/15/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Warfarin is a widely used oral anticoagulant. Determining the correct dose required to maintain the international normalised ratio (INR) within a therapeutic range can be challenging. In a previous trial, we showed that a dosing algorithm incorporating point-of-care genotyping information ('POCT-GGD' approach) led to improved anticoagulation control. To determine whether this approach could translate into clinical practice, we undertook an implementation project using a matched cohort design. METHODS At three clinics (implementation group; n = 119), initial doses were calculated using the POCT-GGD approach; at another three matched clinics (control group; n = 93), patients were dosed according to the clinic's routine practice. We also utilised data on 640 patients obtained from routinely collected data at comparable clinics. Primary outcome was percentage time in target INR range. Patients and staff from the implementation group also provided questionnaire feedback on POCT-GGD. RESULTS Mean percentage time in INR target range was 55.25% in the control group and 62.74% in the implementation group; therefore, 7.49% (95% CI 3.41-11.57%) higher in the implementation group (p = 0.0004). Overall, patients and staff viewed POCT-GGD positively, suggesting minor adjustments to allow smooth implementation into practice. CONCLUSIONS In the first demonstration of the implementation of genotype-guided dosing, we show that warfarin dosing determined using an algorithm incorporating genetic and clinical factors can be implemented smoothly into clinic, to ensure target INR range is reached sooner and maintained. The findings are like our previous randomised controlled trial, providing an alternative method for improving the risk-benefit of warfarin use in daily practice.
Collapse
Affiliation(s)
- Andrea L Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK.
| | - Clare Prince
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Gail Fitzgerald
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anita Hanson
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jennifer Downing
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK.,NIHR Collaboration for Leadership in Applied Health Research and Care, North West Coast, UK
| | - Julia Reynolds
- Innovation Agency, Academic Health Science Network for the North West Coast, Daresbury, Warrington, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK
| | - Ana Alfirevic
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, member of Liverpool Health Partners, Liverpool, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool and The Royal Liverpool and Broadgreen University Hospitals NHS Trust, members of Liverpool Health Partners, Liverpool, UK
| |
Collapse
|
15
|
Kanuri SH, Kreutz RP. Pharmacogenomics of Novel Direct Oral Anticoagulants: Newly Identified Genes and Genetic Variants. J Pers Med 2019; 9:jpm9010007. [PMID: 30658513 PMCID: PMC6463033 DOI: 10.3390/jpm9010007] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/01/2023] Open
Abstract
Direct oral anticoagulants (DOAC) have shown an upward prescribing trend in recent years due to favorable pharmacokinetics and pharmacodynamics without requirement for routine coagulation monitoring. However, recent studies have documented inter-individual variability in plasma drug levels of DOACs. Pharmacogenomics of DOACs is a relatively new area of research. There is a need to understand the role of pharmacogenomics in the interpatient variability of the four most commonly prescribed DOACs, namely dabigatran, rivaroxaban, apixaban, and edoxaban. We performed an extensive search of recently published research articles including clinical trials and in-vitro studies in PubMed, particularly those focusing on genetic loci, single nucleotide polymorphisms (SNPs), and DNA polymorphisms, and their effect on inter-individual variation of DOACs. Additionally, we also focused on commonly associated drug-drug interactions of DOACs. CES1 and ABCB1 SNPs are the most common documented genetic variants that contribute to alteration in peak and trough levels of dabigatran with demonstrated clinical impact. ABCB1 SNPs are implicated in alteration of plasma drug levels of rivaroxaban and apixaban. Studies conducted with factor Xa, ABCB1, SLCOB1, CYP2C9, and VKORC1 genetic variants did not reveal any significant association with plasma drug levels of edoxaban. Pharmacokinetic drug-drug interactions of dabigatran are mainly mediated by p-glycoprotein. Strong inhibitors and inducers of CYP3A4 and p-glycoprotein should be avoided in patients treated with rivaroxaban, apixaban, and edoxaban. We conclude that some of the inter-individual variability of DOACs can be attributed to alteration of genetic variants of gene loci and drug-drug interactions. Future research should be focused on exploring new genetic variants, their effect, and molecular mechanisms that contribute to alteration of plasma levels of DOACs.
Collapse
Affiliation(s)
- Sri H Kanuri
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Rolf P Kreutz
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA.
| |
Collapse
|
16
|
Pirmohamed M. Warfarin: The End or the End of One Size Fits All Therapy? J Pers Med 2018; 8:jpm8030022. [PMID: 29958440 PMCID: PMC6163581 DOI: 10.3390/jpm8030022] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
Oral anticoagulants are required for both treatment and prophylaxis in many different diseases. Clinicians and patients now have a choice of oral anticoagulants, including the vitamin K antagonists (of which warfarin is the most widely used and is used as the exemplar in this paper), and direct oral anticoagulants (DOACs: dabigatran, apixaban, rivaroxaban, and edoxaban). This paper explores the recent advances and controversies in oral anticoagulation. While some commentators may favour a complete switchover to DOACs, this paper argues that warfarin still has a place in therapy, and a stratified approach that enables the correct choice of both drug and dose would improve both patient outcomes and affordability.
Collapse
Affiliation(s)
- Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool L69 3GL, UK.
| |
Collapse
|
17
|
Ašić A, Marjanović D, Mirat J, Primorac D. Pharmacogenetics of novel oral anticoagulants: a review of identified gene variants & future perspectives. Per Med 2018; 15:209-221. [PMID: 29767545 DOI: 10.2217/pme-2017-0092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Novel oral anticoagulants (NOACs) are becoming a therapy of choice in everyday clinical practice after almost 50 years during which warfarin and related coumarin derivatives were used as the main anticoagulants. Advantages of NOACs over standard anticoagulants include their predictable pharmacodynamics and pharmacokinetics, stable plasma concentrations and less drug-drug and food-drug interactions. However, pharmacogenetics has its place in administration of NOACs, as considerable interindividual variations have been detected. In this review, previous findings in pharmacogenetics of dabigatran, rivaroxaban, apixaban and edoxaban are summarized, along with recommendations for studying genes encoding metabolically important enzymes for four selected NOACs. Future directions include identification of clinically relevant SNPs, and change in optimum dosage for patients who are carriers of significant variants.
Collapse
Affiliation(s)
- Adna Ašić
- Department of Genetics & Bioengineering, International Burch University, Francuske revolucije bb, 71210 Ilidža, Sarajevo, Bosnia & Herzegovina
| | - Damir Marjanović
- Department of Genetics & Bioengineering, International Burch University, Francuske revolucije bb, 71210 Ilidža, Sarajevo, Bosnia & Herzegovina.,Institute for Anthropological Research, University of Zagreb, Ljudevita Gaja 32, 10000 Zagreb, Croatia
| | - Jure Mirat
- Polyclinic Kardioton, Kaptol 26, 10000 Zagreb, Croatia
| | - Dragan Primorac
- St. Catherine Specialty Hospital, Zagreb & Zabok, Croatia.,Eberly College of Science, 517 Thomas St, State College, Penn State University, PA 16803, USA.,School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia.,School of Medicine, University of Osijek, Ulica cara Hadrijana 10, 31000 Osijek, Croatia.,Children's Hospital Srebrnjak, Srebrnjak 100, 10000 Zagreb, Croatia
| |
Collapse
|