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Acenocoumarol Pharmacogenetic Dosing Algorithm versus Usual Care in Patients with Venous Thromboembolism: A Randomised Clinical Trial. J Clin Med 2021; 10:jcm10132949. [PMID: 34209131 PMCID: PMC8268204 DOI: 10.3390/jcm10132949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 01/21/2023] Open
Abstract
Patients with venous thromboembolism (VTE) require immediate treatment with anticoagulants such as acenocoumarol. This multicentre randomised clinical trial evaluated the effectiveness of a dosing pharmacogenetic algorithm versus a standard-of-care dose adjustment at the beginning of acenocoumarol treatment. We included 144 patients with VTE. On the day of recruitment, a blood sample was obtained for genotyping (CYP2C9*2, CYP2C9*3, VKORC1, CYP4F2, APOE). Dose adjustment was performed on day 3 or 4 after the start of treatment according to the assigned group and the follow-up was at 12 weeks. The principal variable was the percentage of patients with an international normalised ratio (INR) within the therapeutic range on day 7. Thirty-four (47.2%) patients had an INR within the therapeutic range at day 7 after the start of treatment in the genotype-guided group compared with 14 (21.9%) in the control group (p = 0.0023). There were no significant differences in the time to achieve a stable INR, the number of INRs within the range in the first 6 weeks and at the end of study. Our results suggest the use of a pharmacogenetic algorithm for patients with VTE could be useful in achieving target INR control in the first days of treatment.
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Roco A, Nieto E, Suárez M, Rojo M, Bertoglia MP, Verón G, Tamayo F, Arredondo A, Cruz D, Muñoz J, Bravo G, Salas P, Mejías F, Godoy G, Véliz P, Quiñones LA. A Pharmacogenetically Guided Acenocoumarol Dosing Algorithm for Chilean Patients: A Discovery Cohort Study. Front Pharmacol 2020; 11:325. [PMID: 32327994 PMCID: PMC7153463 DOI: 10.3389/fphar.2020.00325] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/05/2020] [Indexed: 12/18/2022] Open
Abstract
Background Vitamin K antagonists (VKA) are used as prophylaxis for thromboembolic events in patients with cardiovascular diseases. The most common VKA are warfarin and acenocoumarol. These drugs have a narrow therapeutic margin and high inter-individual response variability due to clinical and pharmacogenetic variables. Objective The authors aim to develop an algorithm comprised of clinical and genetic factors to explain the variability in the therapeutic dose of acenocoumarol among Chilean patients Methodology DNA was obtained from 304 patients as a discovery cohort with an international normalized ratio (INR) range of 2.0–3.0. The non-genetic (demographic and clinical) variables were also recorded. Genotype analyses were performed using real-time PCR for VKORC1 (rs9923231), VKORC1 (rs7294), GGCx (rs11676382), CYP4F2 (rs2108622), ABCB1 (rs1045642), CYP2C9*2 (rs1799853), ApoE (rs429358), and CYP2C9*3 (rs1057910). Results The clinical variables that significantly influenced the weekly therapeutic dose of VKA were age, sex, body mass index (BMI), and initial INR, collectively accounting for 19% of the variability, and the genetic variables with a significant impact were VKORC1 (rs9923231), CYP2C9*2 (rs1799853), and CYP2C9*3 (rs1057910), explaining for another 37% of the variability. Conclusion We developed an algorithm that explains 49.99% of the variability in therapeutic VKA dosage in the Chilean population studied. Factors that significantly affected the dosage included VKORC1, CYP2C9*2, and CYP2C9*3 polymorphisms, as well as age, sex, BMI, and initial INR.
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Affiliation(s)
- Angela Roco
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile.,Escuela de Bioquímica Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Western Metropolitan Health Service, Santiago, Chile
| | | | - Marcelo Suárez
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Mario Rojo
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | | | - Gabriel Verón
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Francisca Tamayo
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | | | | | | | - Patricio Salas
- Dr. Salvador Allende G. Reference Health Center, Santiago, Chile
| | - Fanny Mejías
- San José de Melipilla Hospital, Melipilla, Chile
| | - Gerald Godoy
- San José de Melipilla Hospital, Melipilla, Chile
| | - Paulo Véliz
- San José de Melipilla Hospital, Melipilla, Chile
| | - Luis Abel Quiñones
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic and Clinical Oncology, Faculty of Medicine, University of Chile, Santiago, Chile.,Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
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3
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Genome-Wide Association Study of VKORC1 and CYP2C9 on acenocoumarol dose, stroke recurrence and intracranial haemorrhage in Spain. Sci Rep 2020; 10:2806. [PMID: 32071341 PMCID: PMC7028945 DOI: 10.1038/s41598-020-59641-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/08/2020] [Indexed: 12/26/2022] Open
Abstract
Acenocoumarol is an oral anticoagulant with significant interindividual dose variations. Variants in CYP2C9 and VKORC1 have been associated with acenocoumarol maintenance dose. We analysed whether any of the 49 polymorphisms in CYP2C9 and VKORC1 previously associated with acenocoumarol maintenance dose in a Genome-Wide Association study (GWAs) in Dutch population are associated with stroke recurrence, intracranial haemorrhage (ICH) and acenocoumarol maintenance dose in a Spanish population. We performed a GWAs using Human Core Exome-chip (Illumina) in 78 patients stroke patients treated with acenocoumarol for secondary prevention enrolled as part of the prospective investigator-initiated study (IIS) SEDMAN Study. Patients were followed-up a median of 12.8 months. Three and eight patients had recurrent stroke and ICH events, respectively. We found 14 of the 49 published variants associated with acenocoumarol maintenance dose (p < 0.05). Six polymorphisms were associated with stroke recurrence and four variants with ICH (p < 0.05). In conclusion, variants in VKORC1 and CYP2C9 are associated with acenocoumarol maintenance dose, stroke recurrence and ICH in a Spanish cohort. These results highlight the relevance of studying pharmacogenetics associated with efficacy and safety of anticoagulant drugs and justify studies with larger sample size and different ethnic populations.
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4
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Danese E, Raimondi S, Montagnana M, Tagetti A, Langaee T, Borgiani P, Ciccacci C, Carcas AJ, Borobia AM, Tong HY, Dávila-Fajardo C, Botton MR, Bourgeois S, Deloukas P, Caldwell MD, Burmester JK, Berg RL, Cavallari LH, Drozda K, Huang M, Zhao LZ, Cen HJ, Gonzalez-Conejero R, Roldan V, Nakamura Y, Mushiroda T, Gong IY, Kim RB, Hirai K, Itoh K, Isaza C, Beltrán L, Jiménez-Varo E, Cañadas-Garre M, Giontella A, Kringen MK, Foss Haug KB, Gwak HS, Lee KE, Minuz P, Lee MTM, Lubitz SA, Scott S, Mazzaccara C, Sacchetti L, Genç E, Özer M, Pathare A, Krishnamoorthy R, Paldi A, Siguret V, Loriot MA, Kutala VK, Suarez-Kurtz G, Perini J, Denny JC, Ramirez AH, Mittal B, Rathore SS, Sagreiya H, Altman R, Shahin MHA, Khalifa SI, Limdi NA, Rivers C, Shendre A, Dillon C, Suriapranata IM, Zhou HH, Tan SL, Tatarunas V, Lesauskaite V, Zhang Y, Maitland-van der Zee AH, Verhoef TI, de Boer A, Taljaard M, Zambon CF, Pengo V, Zhang JE, Pirmohamed M, Johnson JA, Fava C. Effect of CYP4F2, VKORC1, and CYP2C9 in Influencing Coumarin Dose: A Single-Patient Data Meta-Analysis in More Than 15,000 Individuals. Clin Pharmacol Ther 2019; 105:1477-1491. [PMID: 30506689 PMCID: PMC6542461 DOI: 10.1002/cpt.1323] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/18/2018] [Indexed: 11/06/2022]
Abstract
The cytochrome P450 (CYP)4F2 gene is known to influence mean coumarin dose. The aim of the present study was to undertake a meta-analysis at the individual patients level to capture the possible effect of ethnicity, gene-gene interaction, or other drugs on the association and to verify if inclusion of CYP4F2*3 variant into dosing algorithms improves the prediction of mean coumarin dose. We asked the authors of our previous meta-analysis (30 articles) and of 38 new articles retrieved by a systematic review to send us individual patients' data. The final collection consists of 15,754 patients split into a derivation and validation cohort. The CYP4F2*3 polymorphism was consistently associated with an increase in mean coumarin dose (+9% (95% confidence interval (CI) 7-10%), with a higher effect in women, in patients taking acenocoumarol, and in white patients. The inclusion of the CYP4F2*3 in dosing algorithms slightly improved the prediction of stable coumarin dose. New pharmacogenetic equations potentially useful for clinical practice were derived.
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Affiliation(s)
- Elisa Danese
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Raimondi
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Martina Montagnana
- Clinical Biochemistry Section, Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, Italy
| | - Angela Tagetti
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Paola Borgiani
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Cinzia Ciccacci
- Genetics Section, Department of Biomedicine and Prevention, University of Rome “Tor Vergata,” Rome, Italy
| | - Antonio J. Carcas
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Alberto M. Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Hoi Y. Tong
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
- Spanish Clinical Research Network-SCReN, Madrid, Spain
| | - Cristina Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, IBS, Granada, Spain
| | | | - Stephane Bourgeois
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
| | - Panos Deloukas
- William Harvey Research Institute, Barts & the London Medical School, Queen Mary University of London, London, UK
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Michael D. Caldwell
- Center for Hyperbaric Medicine and Tissue Repair, Marshfield Clinic, Marshfield, Wisconsin, USA
| | - Jim K. Burmester
- Grants Office, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Richard L. Berg
- Clinical Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Katarzyna Drozda
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Li-Zi Zhao
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Han-Jing Cen
- Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Rocio Gonzalez-Conejero
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Vanessa Roldan
- Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Yusuke Nakamura
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Taisei Mushiroda
- Research Group for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Inna Y. Gong
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Richard B. Kim
- Division of Clinical Pharmacology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Keita Hirai
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Carlos Isaza
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Leonardo Beltrán
- Faculty of Heath Sciences, Laboratory of Medical Genetics, Universidad Tecnológica de Pereira, Pereira, Colombia
- Faculty of Heath Sciences, Unidad Central del Valle del Cauca, Valle del Cauca, Colombia
| | | | - Marisa Cañadas-Garre
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Alice Giontella
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Marianne K. Kringen
- Department of Pharmacology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Kari Bente Foss Haug
- Department of Medical Biochemistry, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Hye Sun Gwak
- Division of Life and Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, Korea
| | - Kyung Eun Lee
- College of Pharmacy, Chungbuk National University, Cheongju-si, Korea
| | - Pietro Minuz
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Ming Ta Michael Lee
- Genomic Medicine Institute, Geisinger Health System, Danville, Pennsylvania, USA
- National Center for Genome Medicine, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stuart Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Mazzaccara
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Lucia Sacchetti
- CEINGE–Biotecnologie Avanzate s.c.ar.l., Napoli, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Napoli, Italy
| | - Ece Genç
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Mahmut Özer
- Department of Pharmacology, Yeditepe University, Istanbul, Turkey
| | - Anil Pathare
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | | | - Andras Paldi
- Ecole Pratique des Hautes Etudes, UMRS_951, Genethon, Evry, France
| | - Virginie Siguret
- Sorbonne Paris Cité, INSERM, UMR-S-1140, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière, Service d’Hématologie Biologique, Paris, France
| | - Marie-Anne Loriot
- Sorbonne Paris Cité, INSERM, UMR-S-1147, Université Paris Descartes, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Biochimie UF Pharmacogénétique et Oncologie Moléculaire, Paris, France
| | - Vijay Kumar Kutala
- Department of Clinical Pharmacology & Therapeutics, Nizam’s Institute of Medical Sciences, Hyderabad, India
| | | | - Jamila Perini
- Research Laboratory of Pharmaceutical Sciences, West Zone State University-UEZO, Rio de Janeiro, Brazil
| | - Josh C. Denny
- Department of Medicine and Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrea H. Ramirez
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Balraj Mittal
- Department of Biotechnology, Babasaheb Bhimrao Ambedkar University, Lucknow, India
| | | | - Hersh Sagreiya
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Russ Altman
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Mohamed Hossam A. Shahin
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Sherief I. Khalifa
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Rivers
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aditi Shendre
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana, USA
| | - Chrisly Dillon
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ivet M. Suriapranata
- Mochtar Riady Institute for Nanotechnology, Universitas Pelita Harapan, Lippo Karawaci, Tangerang, Banten, Indonesia
| | - Hong-Hao Zhou
- Institute of Clinical Pharmacology, Central South University, Hunan Sheng, China
| | - Sheng-Lan Tan
- Department of Pharmacy, Xiangya Second Hospital, Central South University, Hunan Sheng, China
| | - Vacis Tatarunas
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaiva Lesauskaite
- Laboratory of Molecular Cardiology, Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yumao Zhang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke H. Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Talitha I. Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Monica Taljaard
- Clinica Epidemiology Program and Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jieying Eunice Zhang
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Cristiano Fava
- General Medicine and Hypertension Unit, Department of Medicine, University of Verona, Verona, Italy
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Dávila-Fajardo CL, Díaz-Villamarín X, Antúnez-Rodríguez A, Fernández-Gómez AE, García-Navas P, Martínez-González LJ, Dávila-Fajardo JA, Barrera JC. Pharmacogenetics in the Treatment of Cardiovascular Diseases and Its Current Progress Regarding Implementation in the Clinical Routine. Genes (Basel) 2019; 10:genes10040261. [PMID: 30939847 PMCID: PMC6523655 DOI: 10.3390/genes10040261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022] Open
Abstract
There is a special interest in the implementation of pharmacogenetics in clinical practice, although there are some barriers that are preventing this integration. A large part of these pharmacogenetic tests are focused on drugs used in oncology and psychiatry fields and for antiviral drugs. However, the scientific evidence is also high for other drugs used in other medical areas, for example, in cardiology. In this article, we discuss the evidence and guidelines currently available on pharmacogenetics for clopidogrel, warfarin, acenocoumarol, and simvastatin and its implementation in daily clinical practice.
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Affiliation(s)
- Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Alba Antúnez-Rodríguez
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | - Ana Estefanía Fernández-Gómez
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Paloma García-Navas
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
| | - Luis Javier Martínez-González
- Genomics Unit, Centro Pfizer-Universidad de Granada-Junta de Andalucía de Genómica e Investigación Oncológica (Genyo), 18016 Granada, Spain.
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, ibs.GRANADA, 18016 Granada, Spain.
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Cullell N, Carrera C, Muiño E, Torres N, Krupinski J, Fernandez-Cadenas I. Pharmacogenetic studies with oral anticoagulants. Genome-wide association studies in vitamin K antagonist and direct oral anticoagulants. Oncotarget 2018; 9:29238-29258. [PMID: 30018749 PMCID: PMC6044386 DOI: 10.18632/oncotarget.25579] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/28/2018] [Indexed: 12/17/2022] Open
Abstract
Oral anticoagulants (OAs) are the recommended drugs to prevent cardiovascular events and recurrence in patients with atrial fibrillation (AF) and cardioembolic stroke. We conducted a literature search to review the current state of OAs pharmacogenomics, focusing on Genome Wide Association Studies (GWAs) in patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). VKAs: Warfarin, acenocoumarol, fluindione and phenprocoumon have long been used, but their interindividual variability and narrow therapeutic/safety ratio makes their dosage difficult. GWAs have been useful in finding genetic variants associated with VKAs response. The main genes involved in VKAs pharmacogenetics are: VKORC1, CYP2C19 and CYP4F2. Variants in these genes have been included in pharmacogenetic algorithms to predict the VKAs dose individually in each patient depending on their genotype and clinical variables. DOACs: Dabigatran, apixaban, rivaroxaban and edoxaban have been approved for patients with AF. They have stable pharmacokinetics and do not require routine blood checks, thus avoiding most of the drawbacks of VKAs. Except for a GWAs performed in patients treated with dabigatran, there is no Genome Wide pharmacogenomics data for DOACs. Pharmacogenomics could be useful to predict the better clinical response and avoid adverse events in patients treated with anticoagulants, identifying the most appropriate anticoagulant drug for each patient. Current pharmacogenomics data show that the polymorphisms affecting VKAs or DOACs are different, concluding that personalized medicine based on pharmacogenomics could be possible. However, more studies are required to implement personalized medicine in clinical practice with OA and based on pharmacogenetics of DOACs.
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Affiliation(s)
- Natalia Cullell
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Caty Carrera
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.,Neurovascular Research Laboratory, Institut de Recerca, Universitat Autònoma de Barcelona, Hospital Vall d'Hebron, Barcelona, Spain
| | - Elena Muiño
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Nuria Torres
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Jerzy Krupinski
- Servicio de Neurología, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, Spain.,School of Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - Israel Fernandez-Cadenas
- Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútua Terrassa, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics, Institut de Recer ca Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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7
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Elkhazraji A, Bouaiti EA, Boulahyaoui H, Nahmtchougli CP, Zahid H, Bensaid M, Ibrahimi A, Messaoudi N. Effect of CYP2C9, VKORC1, CYP4F2, and GGCX gene variants and patient characteristics on acenocoumarol maintenance dose: Proposal for a dosing algorithm for Moroccan patients. Drug Discov Ther 2018; 12:68-76. [PMID: 29760340 DOI: 10.5582/ddt.2017.01063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the impact of non-genetics factors, and single nucleotide polymorphisms (SNPs) in VKORC1, CYP2C9, CYP4F2, and GGCX on acenocoumarol dosage in Moroccan adult's patients, in order to develop an algorithm to predict acenocoumarol dose for Moroccan patients. Our study consisted of 217 Moroccan patients taking a maintenance dose of acenocoumarol for various indications. The patients were genotyped for VKORC1 -1639 G>A, VKORC1 1173 C>T, CYP2C9*2, CYP2C9*3, CYP4F2 1347 G>A and GGCX 12970 C>G SNPs. The statistical analysis was performed using the SPSS software. The age and SNPs in VKORC1 and CYP2C9 were significantly associated with the weekly acenocoumarol dose requirement (p = 0.023, p = 0.0001 and p = 0.001 respectively). There was no association found between the weekly acenocoumarol dose and the CYP4F2 or GGCX variants (p-value > 0.05). Non-parametric analysis confirmed the accumulate effect of variant alleles at VKORC1 -1639 G>A, VKORC1 1173 C>T and CYP2C9 SNPs on the acenocoumarol dose requirement. With 90.24% less dose required for one patient carrying homozygote variant at VKORC1 -1173 (TT) and CYP2C9 *x/*x haplotype. The multiple linear regression analysis showed that mutation in VKORC1 -1639, VKORC1 1173 SNPs, or in CYP2C9 haplotype reduces the mean acenocoumarol weekly dose to 25.4%, 23.4% and 6.2%, respectively. The R2 for multiple regression analysis final model was found to be 35.9%. In this work we were able to establish the factors influencing interindividual sensitivity to the anticoagulant therapy that can help physicians to predict optimal dose requirement for long term therapy.
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Affiliation(s)
- Abdelhak Elkhazraji
- Laboratory of Medical Biotechnology (Med Biotech), Faculty of Medicine and Pharmacy, Mohamed V University
| | - El Arbi Bouaiti
- Epidemiological and Clinical Research Laboratory, Faculty of Medicine and Pharmacy, Mohamed V University
| | - Hassan Boulahyaoui
- Research Team in Molecular Virology and Onco-Biology, Faculty of Medicine and Pharmacy, Mohamed V University
| | | | - Hafid Zahid
- Hematology and Immuno-Hematology Service, Military Teaching Hospital Mohamed V, Rabat
| | - Mounia Bensaid
- Laboratory of Medical Biotechnology (Med Biotech), Faculty of Medicine and Pharmacy, Mohamed V University.,Military Teaching Hospital Mohamed V
| | - Azeddine Ibrahimi
- Laboratory of Medical Biotechnology (Med Biotech), Faculty of Medicine and Pharmacy, Mohamed V University
| | - Nezha Messaoudi
- Hematology and Immuno-Hematology Service, Military Teaching Hospital Mohamed V, Rabat
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8
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Ragia G, Karantza IM, Kelli-Kota E, Kolovou V, Kolovou G, Konstantinides S, Maltezos E, Tavridou A, Tziakas D, Maitland-van der Zee AH, Manolopoulos VG. Role of CYP4F2, CYP2C19, and CYP1A2 polymorphisms on acenocoumarol pharmacogenomic algorithm accuracy improvement in the Greek population: need for sub-phenotype analysis. Drug Metab Pers Ther 2017; 32:183-190. [PMID: 29252193 DOI: 10.1515/dmpt-2017-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND We have earlier developed a pharmacogenomic algorithm for acenocoumarol dose prediction in Greek patients that included CYP2C9/VKORC1 genetic information. This study aims at analyzing the potential effect of CYP4F2, CYP2C19, and CYP1A2 gene polymorphisms on acenocoumarol dose requirements and at further improving the Greek-specific pharmacogenomic algorithm. METHODS A total of 205 Greek patients taking acenocoumarol (140 who reached and 65 who did not reach stable dose), participants of acenocoumarol EU-PACT trial, were included in the study. CYP4F2, CYP2C19, and CYP1A2 polymorphisms were genotyped by use of the PCR-RFLP method. All patients were previously genotyped for CYP2C9/VKORC1 polymorphisms. RESULTS In the pooled sample, CYP4F2, CYP2C19, and CYP1A2 polymorphisms do not affect independently acenocoumarol dose requirements. For CYP4F2, significant effects were found on patients' ability to reach stable dose and on acenocoumarol dose requirements when CYP2C9/VKORC1 sub-phenotypes were analyzed. Specifically, when the patients were stratified according to their CYP2C9/VKORC1 functional bins, in sensitive responders, CYP4F2*3 allele carriers (CYP4F2 *1/*3 and *3/*3 genotypes) were more frequent in the patient group who reached stable dose (p=0.049). Additionally, in CYP2C9 intermediate metabolizers (IMs), after adjusting for age, weight, and VKORC1 genotypes, CYP4F2 genotypes were significantly associated with acenocoumarol stable dose (β: 0.07; 95% CI: 0.006-0.134; p=0.033). CONCLUSIONS CYP4F2 gene shows a prominent weak association with acenocoumarol dose requirements. Sub-phenotype analysis is potentially important in determining additional gene polymorphisms that are associated with acenocoumarol dose requirements.
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Affiliation(s)
- Georgia Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Dragana Campus, 68100 Alexandroupolis, Greece, Phone: +30 2551 030523, Fax: +30 2551 030523; and DNALEX S.A., Alexandroupolis, Greece
| | - Ioanna-Maria Karantza
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Eleni Kelli-Kota
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vana Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Konstantinides
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna Tavridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anke H Maitland-van der Zee
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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9
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Marín F, Vanessa R. The importance of excellence in the quality of anticoagulation control whilst taking vitamin K antagonists. Thromb Haemost 2017; 113:671-3. [DOI: 10.1160/th14-12-1087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 01/18/2015] [Indexed: 12/11/2022]
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10
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Cerezo-Manchado JJ, Roldán V, Corral J, Rosafalco M, Antón AI, Padilla J, González-Conejero R, Vicente V. Genotype-guided therapy improves initial acenocoumarol dosing. Thromb Haemost 2017; 115:117-25. [DOI: 10.1160/th14-09-0814] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 08/06/2015] [Indexed: 11/05/2022]
Abstract
SummaryA few trials so far have evaluated the effectiveness of algorithms designed to calculate doses in oral anticoagulant therapy, with negative or contradictory results. We compared a genotype-guided algorithm vs physician management for the initiation of acenocoumarol. In a twoarm, prospective, randomised study with patients with atrial fibrillation who started therapy, the first dose was administered to all patients according to the physician’s criteria. At 72 hours, the corresponding dose was calculated based on INR in the standard care group (SC, N=92), whereas genetic data (VKORC1, CYP2C9 and CYP4F2) were also considered for the genotype-guided dosing (pharmacogenetic) group (PGx, N=87) by using an algorithm previously validated in 2,683 patients. The primary outcomes were: patients with steady dose, the time needed to reach the same and the percentage of therapeutic INRs. After 90 days, 25 % of the SC and 39 % of the PGx patients reached the steady dose (p=0.038). Kaplan-Meier analysis showed that PGx group needed fewer days to reach therapeutic INR (p=0.033). Additionally, PGx had a higher percentage of therapeutic INRs than SC patients (50 % and 45 %, respectively) (p=0.046). After six months the proportion of steadily anticoagulated patients remained significantly higher in PGx (p=0.010). In conclusion, genotype-guided dosing was associated with a higher percentage of patients with steady dose than routine practice when starting oral anticoagulation with acenocoumarol.
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11
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Tong HY, Borobia AM, Martínez Ávila JC, Lubomirov R, Muñoz M, Blanco Bañares MJ, Hernández R, Fernández Capitán C, Ramírez E, Frías J, Carcas AJ. Influence of two variants of CYP450 oxidoreductase on the stable dose of acenocoumarol in a Spanish population. Pharmacogenomics 2017; 18:797-805. [PMID: 28592191 DOI: 10.2217/pgs-2017-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
AIM To evaluate the influence of two variants of P450 oxidoreductase (POR), rs2868177 and POR*28, on the stable dosage of acenocoumarol. PATIENTS & METHODS For this observational, cross-sectional study, patients were undergone stable anticoagulant treatment with acenocoumarol. Univariate and multiple regression analyses were performed to assess the influence of POR polymorphisms. RESULTS About 340 patients were enrolled. Multiple regression had a coefficient of determination (R2) of 51.5% and an Akaike information criterion of 234.22. The inclusion of POR*28 polymorphisms increased the R2 to 52.0% and reduced the Akaike information criteria to 230.58. The POR*28 heterozygote showed statistical significance in the algorithm. CONCLUSION The POR*28 heterozygote appears to be associated with the stable dose of acenocoumarol, but its clinical contribution to the prediction of the dosing of this drug is minimal.
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Affiliation(s)
- Hoi Y Tong
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Alberto M Borobia
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.,Pharmacology Department, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | | | - Rubin Lubomirov
- Pharmacology Department, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Mario Muñoz
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | | | - Rafael Hernández
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | | | - Elena Ramírez
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.,Pharmacology Department, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Jesús Frías
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.,Pharmacology Department, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.,Pharmacology Department, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
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12
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Baranova EV, Verhoef TI, Ragia G, le Cessie S, Asselbergs FW, de Boer A, Manolopoulos VG, Maitland-van der Zee AH. Dosing algorithms for vitamin K antagonists across VKORC1 and CYP2C9 genotypes. J Thromb Haemost 2017; 15:465-472. [PMID: 28063245 DOI: 10.1111/jth.13615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/15/2016] [Indexed: 11/27/2022]
Abstract
Essentials Prospective studies of pharmacogenetic-guided (PG) coumarin dosing produced varying results. EU-PACT acenocoumarol and phenprocoumon trials compared PG and non-PG dosing algorithms. Sub-analysis of EU-PACT identified differences between trial arms across VKORC1-CYP2C9 groups. Adjustment of the PG algorithm might lead to a higher benefit of genotyping. SUMMARY Background The multicenter, single-blind, randomized EU-PACT trial compared the safety and efficacy of genotype-guided and non-genetic dosing algorithms for acenocoumarol and phenprocoumon in patients with atrial fibrillation or deep vein thrombosis. The trial showed no differences in the primary outcome between the two dosing strategies. Objectives To explore possible reasons for the lack of differences between trial arms by performing a secondary analysis of EU-PACT data in order to evaluate the performance of both dosing algorithms across VKORC1-CYP2C9 genetic subgroups. Patients/Methods Anticoagulation control measured according to an International Normalized Ratio (INR) below (INR of < 2), within (INR of 2-3) and above (INR of > 3) the therapeutic range was compared across VKORC1-CYP2C9 subgroups. Owing to a low number of patients in each subgroup, trials for acenocoumarol and phenprocoumon were combined for analysis. Results Four weeks after therapy initiation, genotype-guided dosing increased the mean percentage of time in the therapeutic INR range (PTIR) in the VKORC1 GG-CYP2C9*1*1 subgroup as compared with the non-genetic dosing (difference of 14.68%, 95% confidence interval [CI] 5.38-23.98). For the VKORC1 AA-CYP2C9*1*1 subgroup, there was a higher risk of under-anticoagulation with the genotype-guided algorithm (difference of 19.9%; 95% CI 11.6-28.2). Twelve weeks after therapy initiation, no statistically significant differences in anticoagulation control between trial arms were noted across the VKORC1-CYP2C9 genetic subgroups. Conclusions EU-PACT genetic-guided dose initiation algorithms for acenocoumarol and phenprocoumon could have predicted the dose overcautiously in the VKORC1 AA-CYP2C9*1*1 subgroup. Adjustment of the genotype-guided algorithm could lead to a higher benefit of genotyping.
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Affiliation(s)
- E V Baranova
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - T I Verhoef
- Department of Applied Health Research, University College London, London, UK
| | - G Ragia
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - S le Cessie
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
- Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute, Utrecht, the Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - A de Boer
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - V G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - A H Maitland-van der Zee
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
- Department of Respiratory Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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13
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Ragia G, Kolovou V, Kolovou G, Konstantinides S, Maltezos E, Tavridou A, Tziakas D, Maitland-van der Zee AH, Manolopoulos VG. A novel acenocoumarol pharmacogenomic dosing algorithm for the Greek population of EU-PACT trial. Pharmacogenomics 2017; 18:23-34. [DOI: 10.2217/pgs-2016-0126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To generate and validate a pharmacogenomic-guided (PG) dosing algorithm for acenocoumarol in the Greek population. To compare its performance with other PG algorithms developed for the Greek population. Patients & methods: A total of 140 Greek patients participants of the EU-PACT trial for acenocoumarol, a randomized clinical trial that prospectively compared the effect of a PG dosing algorithm with a clinical dosing algorithm on the percentage of time within INR therapeutic range, who reached acenocoumarol stable dose were included in the study. Results: CYP2C9 and VKORC1 genotypes, age and weight affected acenocoumarol dose and predicted 53.9% of its variability. EU-PACT PG algorithm overestimated acenocoumarol dose across all different CYP2C9/VKORC1 functional phenotype bins (predicted dose vs stable dose in normal responders 2.31 vs 2.00 mg/day, p = 0.028, in sensitive responders 1.72 vs 1.50 mg/day, p = 0.003, in highly sensitive responders 1.39 vs 1.00 mg/day, p = 0.029). The PG algorithm previously developed for the Greek population overestimated the dose in normal responders (2.51 vs 2.00 mg/day, p < 0.001). Conclusion: Ethnic-specific dosing algorithm is suggested for better prediction of acenocoumarol dosage requirements in patients of Greek origin.
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Affiliation(s)
| | - Vana Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Genovefa Kolovou
- Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Konstantinides
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna Tavridou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Evros, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- University Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anke H Maitland-van der Zee
- Division of Pharmacoepidemiology & Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Clinical Pharmacology Unit, Academic General Hospital of Evros, Alexandroupolis, Greece
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14
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López I, Sangüesa E, Vancraenendonck Y, Zuriaga E, Ribate MP, García CB. Can pharmacogenetics help patients under chronic treatment with coumarin anticoagulants? Drug Metab Pers Ther 2016; 31:191-196. [PMID: 27740916 DOI: 10.1515/dmpt-2016-0026] [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: 06/16/2016] [Accepted: 09/02/2016] [Indexed: 11/15/2022]
Abstract
Vitamin K antagonists are highly effective antithrombotic drugs. However, appropriate dosing is difficult to establish owing to its narrow therapeutic window as well as widespread inter- and intra-individual variability in dosage. Compared with dosing solely based on clinical information, pharmacogenetics can help improve the therapy with coumarins by decreasing the time to reach a stable dose and reducing the risk of bleeding. Most of the studies about genotyping of patients using vitamin K antagonists have focused on predicting the stable dose. Two genes have been shown to have the most influence on dosing: VKORC1 and CYP2C9. Furthermore, genotyping of more genes, such as CYP4F2 and APOE, is also being included in some dosing algorithms. The role of genotype beyond the initial dose-titration phase is less clear. Thus, a proven genetically determined risk of unstable dose or bleeding could help with the selection of patients who require more frequent monitoring of dose. On the other hand, patients who have a genetically determined stable dose could self-monitor their international normalized ratio (INR), making the therapy less expensive and more convenient.
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15
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Tong HY, Dávila-Fajardo CL, Borobia AM, Martínez-González LJ, Lubomirov R, Perea León LM, Blanco Bañares MJ, Díaz-Villamarín X, Fernández-Capitán C, Cabeza Barrera J, Carcas AJ. A New Pharmacogenetic Algorithm to Predict the Most Appropriate Dosage of Acenocoumarol for Stable Anticoagulation in a Mixed Spanish Population. PLoS One 2016; 11:e0150456. [PMID: 26977927 PMCID: PMC4792430 DOI: 10.1371/journal.pone.0150456] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 02/15/2016] [Indexed: 12/25/2022] Open
Abstract
There is a strong association between genetic polymorphisms and the acenocoumarol dosage requirements. Genotyping the polymorphisms involved in the pharmacokinetics and pharmacodynamics of acenocoumarol before starting anticoagulant therapy would result in a better quality of life and a more efficient use of healthcare resources. The objective of this study is to develop a new algorithm that includes clinical and genetic variables to predict the most appropriate acenocoumarol dosage for stable anticoagulation in a wide range of patients. We recruited 685 patients from 2 Spanish hospitals and 1 primary healthcare center. We randomly chose 80% of the patients (n = 556), considering an equitable distribution of genotypes to form the generation cohort. The remaining 20% (n = 129) formed the validation cohort. Multiple linear regression was used to generate the algorithm using the acenocoumarol stable dosage as the dependent variable and the clinical and genotypic variables as the independent variables. The variables included in the algorithm were age, weight, amiodarone use, enzyme inducer status, international normalized ratio target range and the presence of CYP2C9*2 (rs1799853), CYP2C9*3 (rs1057910), VKORC1 (rs9923231) and CYP4F2 (rs2108622). The coefficient of determination (R2) explained by the algorithm was 52.8% in the generation cohort and 64% in the validation cohort. The following R2 values were evaluated by pathology: atrial fibrillation, 57.4%; valve replacement, 56.3%; and venous thromboembolic disease, 51.5%. When the patients were classified into 3 dosage groups according to the stable dosage (<11 mg/week, 11-21 mg/week, >21 mg/week), the percentage of correctly classified patients was higher in the intermediate group, whereas differences between pharmacogenetic and clinical algorithms increased in the extreme dosage groups. Our algorithm could improve acenocoumarol dosage selection for patients who will begin treatment with this drug, especially in extreme-dosage patients. The predictability of the pharmacogenetic algorithm did not vary significantly between diseases.
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Affiliation(s)
- Hoi Y. Tong
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Cristina Lucía Dávila-Fajardo
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Alberto M. Borobia
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
| | - Luis Javier Martínez-González
- Genomics Unit, Centre for Genomics and Oncological Research (GENYO), Pfizer-University of Granada-Andalusian Regional Government, Health Sciences Technology Park, PTS, Granada, Spain
| | - Rubin Lubomirov
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
| | - Laura María Perea León
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - Xando Díaz-Villamarín
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | | | - José Cabeza Barrera
- Department of Clinical Pharmacy, San Cecilio University Hospital, Institute for Biomedical Research, Ibs, Granada, Spain
| | - Antonio J. Carcas
- Department of Clinical Pharmacology, La Paz University Hospital, IdiPAZ, Madrid, Spain
- Department of Pharmacology, School of Medicine, Autonomous University of Madrid, IdiPAZ, Madrid, Spain
- * E-mail: (AJC); (AMB)
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16
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The SAMe-TT2R2 Score Predicts Poor Anticoagulation Control in AF Patients: A Prospective 'Real-world' Inception Cohort Study. Am J Med 2015; 128:1237-43. [PMID: 26087049 DOI: 10.1016/j.amjmed.2015.05.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 05/08/2015] [Accepted: 05/11/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES International guidelines recommend that an average individual time in therapeutic range should be >65% to 70% for optimal efficacy and safety outcomes while taking a vitamin K antagonist. The Sex, Age (<60 years); Medical history (at least 2 of the following: hypertension, diabetes, coronary artery disease/myocardial infarction, peripheral arterial disease, congestive heart failure, previous stroke, pulmonary disease, hepatic or renal disease); Treatment (interacting drugs, eg, amiodarone for rhythm control) [all 1 point]; and the current Tobacco use (2 points) and Race (non-Caucasian; 2 points) (SAMe-TT2R2) score would help decision making by identifying those patients with newly diagnosed atrial fibrillation who could do well on vitamin K antagonists. The study objective was to validate the predictive value of the SAMe-TT2R2 score for discriminating those who would achieve a high time in the therapeutic range (≥65%) in a prospective "real-world" cohort of patients with atrial fibrillation initiating oral anticoagulation therapy with vitamin K antagonists. METHODS We studied an inception cohort of consecutive patients with nonvalvular atrial fibrillation who initiated oral anticoagulation in our outpatient anticoagulation clinic. The baseline SAMe-TT2R2 score was calculated. At 6 months, we calculated the time in therapeutic range using a linear method. RESULTS We included 459 patients, of whom 222 (47%) were male. Their median age was 76 years (interquartile range, 70-82 years), median Cardiac failure or dysfunction, Hypertension, Age over 75 years [Doubled], Diabetes, Stroke [Doubled] - Vascular disease, Age between 65-74 and Sex category [Female] (CHA2DS2-VASc) score was 4 (3-5), and median Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score was 3 (2-3). The median SAME-TT2R2 score was 2 (1-2). At 6 months, the mean ± standard deviation time in therapeutic range was 64% ± 17% overall, and 248 patients (54%) had a time in therapeutic range value >65%. Patients with a SAME-TT2R2 score 0 to 1 had a mean time in therapeutic range of 67% ± 18%, whereas patients with a SAME-TT2R2 score ≥2 had a mean time in therapeutic range of 61% ± 16% (P < .001). The odds ratio for having a low time in therapeutic range value was 2.10 (95% confidence interval, 1.44-3.06; P < .001) for those patients with a SAME-TT2R2 score ≥2. CONCLUSIONS In a prospective "real-world" inception cohort of patients with atrial fibrillation initiating oral anticoagulation with acenocoumarol, we have validated the clinical value of the SAME-TT2R2 score for the identification of patients who would have poor-quality anticoagulation. Thus, rather than imposing a "trial of vitamin K antagonists" for such patients (and exposing such patients to thromboembolic risks), we can a priori identify those patients who can (not cannot) do well on a vitamin K antagonists. Such patients would benefit from additional strategies for improving anticoagulation control with vitamin K antagonists or alternative oral anticoagulant drugs.
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17
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Dimitrova-Karamfilova A, Tzveova R, Chilingirova N, Goranova T, Nachev G, Mitev V, Kaneva R. Acenocoumarol Pharmacogenetic Dosing Algorithms and Their Application in Two Bulgarian Patients with Low Anticoagulant Requirements. Biochem Genet 2015; 53:334-50. [PMID: 26377995 DOI: 10.1007/s10528-015-9695-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 09/05/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The anticoagulant therapy with acenocoumarol is generally associated with a high risk of bleeding and thromboembolic events. PURPOSE We applied eight already existing acenocoumarol dosing algorithms to Bulgarian patients with low acenocoumarol dose requirements and investigated which of these algorithms would predict most precisely the dose anticoagulant. MATERIALS AND METHODS Two patients with Bulgarian origin were referred to the outpatient clinical laboratory of "St. Ekaterina" University Hospital for Cardiovascular Surgery and Cardiology, Sofia, Bulgaria. After obtaining written informed consent, both patients were genotyped for polymorphisms in genes for Cytochrome P450 2C9 (CYP2C9), Vitamin K epoxide reductase (VKORC1), Apolipoprotein E (APOE), and Cytochrome P450 4F2 (CYP4F2). RESULTS All applied acenocoumarol dosing algorithms predicted relatively similar doses of coumarin anticoagulant in both patients. However, van Schie et al.'s algorithm allowed more accurate calculation of the optimal dose in our patients with extremely low acenocoumarol requirements. Genotyping of selected polymorphic variants in CYP2C9 and VKORC1 showed that both patients were compound heterozygotes for CYP2C9 (CYP2C9*2/*3) and homozygotes for both variants in VKORC1 (VKORC1 1173 T/T, and VKORC1-1639 A/A). This combination of genotypes suggested high sensitivity to acenocoumarol leading to the low anticoagulant dose requirements (0.25 and 1 mg/day, respectively) needed to reach the target International Normalized Ratio of 2.5-3.5. CONCLUSIONS The genotyping of polymorphic variants in VKORC1 and CYP2C9, together with clinical and demographic parameters, can serve for more precise definition of the individual starting and maintenance doses of coumarin derivatives in each patient.
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Affiliation(s)
- Antoaneta Dimitrova-Karamfilova
- Department of Clinical Laboratory, University Hospital of Cardiovascular Surgery and Cardiology "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., 1431, Sofia, Bulgaria
| | - Reni Tzveova
- Molecular Medicine Center, Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, 1431, Sofia, Bulgaria.
| | - Nezabravka Chilingirova
- Department of Clinical Laboratory, University Hospital of Cardiovascular Surgery and Cardiology "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., 1431, Sofia, Bulgaria
| | - Teodora Goranova
- Molecular Medicine Center, Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, 1431, Sofia, Bulgaria
| | - Gencho Nachev
- Department of Cardiovascular Surgery, University Hospital of Cardiovascular Surgery and Cardiology "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., 1431, Sofia, Bulgaria
| | - Vanio Mitev
- Molecular Medicine Center, Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, 1431, Sofia, Bulgaria
| | - Radka Kaneva
- Molecular Medicine Center, Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, 1431, Sofia, Bulgaria
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Jiménez-Varo E, Cañadas-Garre M, Garcés-Robles V, Gutiérrez-Pimentel MJ, Calleja-Hernández MÁ. Extrapolation of acenocoumarol pharmacogenetic algorithms. Vascul Pharmacol 2015; 74:151-157. [PMID: 26122664 DOI: 10.1016/j.vph.2015.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/01/2015] [Accepted: 06/23/2015] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Acenocoumarol (ACN) has a narrow therapeutic range that is especially difficult to control at the start of its administration. Various dosing pharmacogenetic-guided dosing algorithms have been developed, but further work on their external validation is required. The aim of this study was to evaluate the extrapolation of pharmacogenetic algorithms for ACN as an alternative to the development of a specific algorithm for a given population. MATERIAL AND METHODS The predictive performance, deviation, accuracy, and clinical significance of five pharmacogenetic algorithms (EU-PACT, Borobia, Rathore, Markatos, Krishna Kumar) were compared in 189 stable ACN patients representing all indications for anticoagulant treatment. RESULTS The correlation between the dose predictions of the five pharmacogenetic models ranged from 7.7 to 70.6% and the percentage of patients with a correct prediction (deviation ≤20% from actual ACN dose) ranged from 5.9 to 40.7%. EU-PACT and Borobia pharmacogenetic dosing algorithms were the most accurate in our setting and evidenced the best clinical performance. CONCLUSIONS Among the five models studied, the EU-PACT and Borobia pharmacogenetic dosing algorithms demonstrated the best potential for extrapolation.
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Affiliation(s)
- Enrique Jiménez-Varo
- Pharmacogenetics Unit, UGC Provincial de Farmacia de Granada, Instituto de Investigación Biosanitaria de Granada, Complejo Hospitalario Universitario de Granada, Avda. Fuerzas Armadas, 2, 18014 Granada, Spain.
| | - Marisa Cañadas-Garre
- Pharmacogenetics Unit, UGC Provincial de Farmacia de Granada, Instituto de Investigación Biosanitaria de Granada, Complejo Hospitalario Universitario de Granada, Avda. Fuerzas Armadas, 2, 18014 Granada, Spain.
| | - Víctor Garcés-Robles
- Pharmacogenetics Unit, UGC Provincial de Farmacia de Granada, Instituto de Investigación Biosanitaria de Granada, Complejo Hospitalario Universitario de Granada, Avda. Fuerzas Armadas, 2, 18014 Granada, Spain.
| | - María José Gutiérrez-Pimentel
- Haematology Department, Complejo Hospitalario Universitario de Granada, Avda. Fuerzas Armadas, 2, 18014 Granada, Spain.
| | - Miguel Ángel Calleja-Hernández
- Pharmacogenetics Unit, UGC Provincial de Farmacia de Granada, Instituto de Investigación Biosanitaria de Granada, Complejo Hospitalario Universitario de Granada, Avda. Fuerzas Armadas, 2, 18014 Granada, Spain.
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Tzveova R, Dimitrova-Karamfilova A, Saraeva R, Solarova T, Naydenova G, Petrova I, Hristova N, Popov I, Nachev G, Mitev V, Kaneva R. Estimation and validation of acenocoumarol dosing algorithms in Bulgarian patients with cardiovascular diseases. Per Med 2015; 12:209-220. [PMID: 29771648 DOI: 10.2217/pme.14.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim & Methods: A total of 169 Bulgarian patients were genotyped for CYP2C9*2,*3, VKORC1-1639G>A and VKORC11173C>T. The effect of genetic and nongenetic factors on acenocoumarol dose variability was tested in a derivation cohort of patients and the obtained algorithm was validated in a test cohort. RESULTS & DISCUSSION It was found that VKORC-1639G>A (25.5%), CYP2C9*2 (7.8%), CYP2C9*3 (6.1%), age (13.6%) and diagnosis (6.0%) significantly affected acenocoumarol dose variability in the derivation cohort. These factors with additional factors, such as sex (0.1%, p = 0.76), weight (2.6%, p = 0.14) and amiodarone use (3.0%, p = 0.059) accounted for 46.5% and 23.0% of the dose variability for genetic and clinical models, respectively. CONCLUSION Based on the results of this investigation, validated clinical and pharmacogenetic algorithms for the prediction of a stable anticoagulant dose were developed, specifically designed for the Bulgarian population.
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Affiliation(s)
- Reni Tzveova
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Antoaneta Dimitrova-Karamfilova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Radoslava Saraeva
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Tanya Solarova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Galya Naydenova
- Second Department of Cardiology, University NationalMulti-profile Active Treatment Hospital "Dr. G. Stansky"- Pleven, 8A Georgi Kochev str., Pleven 5800, Bulgaria
| | - Irina Petrova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Nataliya Hristova
- Department of Clinical Laboratory, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Ivan Popov
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Gencho Nachev
- Department of Cardiac Surgery, University National Multi-profile Active Treatment Hospital "St. Ekaterina"- Sofia, 52A Pencho Slaveykov bul., Sofia 1431, Bulgaria
| | - Vanio Mitev
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
| | - Radka Kaneva
- Molecular Medicine Center, Department of Medical Chemistry & Biochemistry, Medical Faculty, Medical University - Sofia, 2 Zdrave str, Sofia 1431, Bulgaria
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An acenocoumarol dosing algorithm exploiting clinical and genetic factors in South Indian (Dravidian) population. Eur J Clin Pharmacol 2014; 71:173-81. [PMID: 25519826 DOI: 10.1007/s00228-014-1791-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/03/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to determine the influence of CYP2C9, VKORC1, CYP4F2, and GGCX genetic polymorphisms on mean daily dose of acenocoumarol in South Indian patients and to develop a new pharmacogenetic algorithm based on clinical and genetic factors. METHODS Patients receiving acenocoumarol maintenance therapy (n = 230) were included in the study. Single nucleotide polymorphisms (SNP) of CYP2C9, VKORC1, CYP4F2, and GGCX were genotyped by real-time polymerase chain reaction (RT-PCR) method. RESULTS The mean daily acenocoumarol maintenance dose was found to be 3.7 ± 2.3 (SD) mg/day. The CYP2C9 *1*2, CYP2C9 *1*3, and CYP2C9 *2*3 variant genotypes significantly reduced the dose by 56.7 % (2.0 mg), 67.6 % (1.6 mg), and 70.3 % (1.5 mg) than wild-type carriers 4.1 mg, p < 0.0001. The genetic variants of CYP2C9 and GGCX (rs11676382) were found to be associated with lower acenocoumarol dose, whereas CYP4F2 (rs2108622) was associated with higher doses. Age, body mass index (BMI), variation of CYP2C9, VKORC1, CYP4F2, and GGCX were the major determinants of acenocoumarol maintenance dose, accounting for 61.8 % of its variability (adjusted r (2) = 0.615, p < 0.0001). Among the VKORC1 variants, rs9923231 alone contributed up to 28.6 % of the acenocoumarol dose variation. CONCLUSION VKORC1 rs9923231 polymorphism had the highest impact on acenocoumarol daily dose. A new pharmacogenetic algorithm was established to determine the acenocoumarol dose in South Indian population.
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Verhoef TI, Redekop WK, Daly AK, van Schie RMF, de Boer A, Maitland-van der Zee AH. Pharmacogenetic-guided dosing of coumarin anticoagulants: algorithms for warfarin, acenocoumarol and phenprocoumon. Br J Clin Pharmacol 2014; 77:626-41. [PMID: 23919835 DOI: 10.1111/bcp.12220] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/17/2013] [Indexed: 12/13/2022] Open
Abstract
Coumarin derivatives, such as warfarin, acenocoumarol and phenprocoumon are frequently prescribed oral anticoagulants to treat and prevent thromboembolism. Because there is a large inter-individual and intra-individual variability in dose-response and a small therapeutic window, treatment with coumarin derivatives is challenging. Certain polymorphisms in CYP2C9 and VKORC1 are associated with lower dose requirements and a higher risk of bleeding. In this review we describe the use of different coumarin derivatives, pharmacokinetic characteristics of these drugs and differences amongst the coumarins. We also describe the current clinical challenges and the role of pharmacogenetic factors. These genetic factors are used to develop dosing algorithms and can be used to predict the right coumarin dose. The effectiveness of this new dosing strategy is currently being investigated in clinical trials.
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Affiliation(s)
- Talitha I Verhoef
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht
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23
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Multiplex pyrosequencing method to determine CYP2C9*3, VKORC1*2, and CYP4F2*3 polymorphisms simultaneously: its application to a Korean population and comparisons with other ethnic groups. Mol Biol Rep 2014; 41:7305-12. [DOI: 10.1007/s11033-014-3617-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
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Wang X, Epstein MP, Tzeng JY. Analysis of gene-gene interactions using gene-trait similarity regression. Hum Hered 2014; 78:17-26. [PMID: 24969398 DOI: 10.1159/000360161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/30/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Gene-gene interactions (G×G) are important to study because of their extensiveness in biological systems and their potential in explaining missing heritability of complex traits. In this work, we propose a new similarity-based test to assess G×G at the gene level, which permits the study of epistasis at biologically functional units with amplified interaction signals. METHODS Under the framework of gene-trait similarity regression (SimReg), we propose a gene-based test for detecting G×G. SimReg uses a regression model to correlate trait similarity with genotypic similarity across a gene. Unlike existing gene-level methods based on leading principal components (PCs), SimReg summarizes all information on genotypic variation within a gene and can be used to assess the joint/interactive effects of two genes as well as the effect of one gene conditional on another. RESULTS Using simulations and a real data application to the Warfarin study, we show that the SimReg G×G tests have satisfactory power and robustness under different genetic architecture when compared to existing gene-based interaction tests such as PC analysis or partial least squares. A genome-wide association study with approx. 20,000 genes may be completed on a parallel computing system in 2 weeks.
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Affiliation(s)
- Xin Wang
- Bioinformatics Research Center, North Carolina State University, Raleigh, N.C., USA
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Cerezo-Manchado JJ, Roldan V, Rosafalco M, Anton AI, Arroyo AB, Garcia-Barbera N, Martínez AB, Padilla J, Corral J, Vicente V, Gonzalez-Conejero R. Effect of VKORC1, CYP2C9 and CYP4F2 genetic variants in early outcomes during acenocoumarol treatment. Pharmacogenomics 2014; 15:987-96. [DOI: 10.2217/pgs.13.232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: To analyze VKORC1, CYP2C9 and CYP4F2 polymorphisms in relation to the main outcomes in the first stages of acenocoumarol therapy. Patients & methods: Nine hundred and forty one patients who had started therapy and in whom time to stable dosage, time to over-anticoagulation and adverse events occurred during 3 first months were retrospectively analyzed. Results: VKORC1 AA patients needed fewer days to reach stable dosage (p = 0.017). International normalized ratio [INR] at 72 h, and VKORC1 and CYP2C9 genotypes conditioned INR values >2.5 (p < 0.001, p = 0.002 and p < 0.001, respectively), whereas CYP4F2 T carriers had a low risk of the same outcome (p = 0.009). In regards to combined genotypes, CYP4F2 had a significant effect on over-anticoagulation at the beginning of therapy except for the VKORC1 AA and CYP2C9*3 combination. Conclusion: In addition to VKORC1 and CYP2C9, CYP4F2 gene has a slight but significant role in reaching INR >2.5 during the first weeks of acenocoumarol therapy. Original submitted 22 July 2013; Revision submitted 14 November 2013
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Affiliation(s)
- Juan Jose Cerezo-Manchado
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Vanessa Roldan
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | | | - Ana Isabel Anton
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Ana Belen Arroyo
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Nuria Garcia-Barbera
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Ana Belen Martínez
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Jose Padilla
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Javier Corral
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Vicente Vicente
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
| | - Rocio Gonzalez-Conejero
- Hospital Universitario Morales Meseguer & Centro Regional de Hemodonacion, University of Murcia, Ronda de Garay s/n, 30003, IMIB, Murcia, Spain
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Siegbahn A, Verheugt FWA, Weitz JI. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110:1087-107. [PMID: 24226379 DOI: 10.1160/th13-06-0443] [Citation(s) in RCA: 277] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/19/2013] [Indexed: 12/27/2022]
Abstract
Oral anticoagulants are a mainstay of cardiovascular therapy, and for over 60 years vitamin K antagonists (VKAs) were the only available agents for long-term use. VKAs interfere with the cyclic inter-conversion of vitamin K and its 2,3 epoxide, thus inhibiting γ-carboxylation of glutamate residues at the amino-termini of vitamin K-dependent proteins, including the coagulation factors (F) II (prothrombin), VII, IX and X, as well as of the anticoagulant proteins C, S and Z. The overall effect of such interference is a dose-dependent anticoagulant effect, which has been therapeutically exploited in heart disease since the early 1950s. In this position paper, we review the mechanisms of action, pharmacological properties and side effects of VKAs, which are used in the management of cardiovascular diseases, including coronary heart disease (where their use is limited), stroke prevention in atrial fibrillation, heart valves and/or chronic heart failure. Using an evidence-based approach, we describe the results of completed clinical trials, highlight areas of uncertainty, and recommend therapeutic options for specific disorders. Although VKAs are being increasingly replaced in most patients with non-valvular atrial fibrillation by the new oral anticoagulants, which target either thrombin or FXa, the VKAs remain the agents of choice for patients with atrial fibrillation in the setting of rheumatic valvular disease and for those with mechanical heart valves.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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