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Pokushalov E, Ponomarenko A, Smith J, Johnson M, Garcia C, Pak I, Shrainer E, Kudlay D, Bayramova S, Miller R. Efficacy of AI-Guided (GenAIS TM) Dietary Supplement Prescriptions versus Traditional Methods for Lowering LDL Cholesterol: A Randomized Parallel-Group Pilot Study. Nutrients 2024; 16:2023. [PMID: 38999770 PMCID: PMC11243060 DOI: 10.3390/nu16132023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Emerging evidence suggests that personalized dietary supplement regimens can significantly influence lipid metabolism and cardiovascular risk. The efficacy of AI-guided dietary supplement prescriptions, compared with standard physician-guided prescriptions, remains underexplored. In a randomized, parallel-group pilot study, 70 patients aged 40-75 years with LDL-C levels between 70 and 190 mg/dL were enrolled. Participants were randomized to receive either AI-guided dietary supplement prescriptions or standard physician-guided prescriptions for 90 days. The primary endpoint was the percent change in LDL-C levels. Secondary endpoints included changes in total cholesterol, HDL-C, triglycerides, and hsCRP. Supplement adherence and side effects were monitored. Sixty-seven participants completed the study. The AI-guided group experienced a 25.3% reduction in LDL-C levels (95% CI: -28.7% to -21.9%), significantly greater than the 15.2% reduction in the physician-guided group (95% CI: -18.5% to -11.9%; p < 0.01). Total cholesterol decreased by 15.4% (95% CI: -19.1% to -11.7%) in the AI-guided group compared with 8.1% (95% CI: -11.5% to -4.7%) in the physician-guided group (p < 0.05). Triglycerides were reduced by 22.1% (95% CI: -27.2% to -17.0%) in the AI-guided group versus 12.3% (95% CI: -16.7% to -7.9%) in the physician-guided group (p < 0.01). HDL-C and hsCRP changes were not significantly different between groups. The AI-guided group received a broader variety of supplements, including plant sterols, omega-3 fatty acids, red yeast rice, coenzyme Q10, niacin, and fiber supplements. Side effects were minimal and comparable between groups. AI-guided dietary supplement prescriptions significantly reduce LDL-C and triglycerides more effectively than standard physician-guided prescriptions, highlighting the potential for AI-driven personalization in managing hypercholesterolemia.
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Affiliation(s)
- Evgeny Pokushalov
- Center for New Medical Technologies, 630090 Novosibirsk, Russia; (A.P.); (I.P.); (E.S.); (S.B.)
- Scientific Research Laboratory, Triangel Scientific, San Francisco, CA 94101, USA (C.G.)
| | - Andrey Ponomarenko
- Center for New Medical Technologies, 630090 Novosibirsk, Russia; (A.P.); (I.P.); (E.S.); (S.B.)
| | - John Smith
- Scientific Research Laboratory, Triangel Scientific, San Francisco, CA 94101, USA (C.G.)
| | - Michael Johnson
- Scientific Research Laboratory, Triangel Scientific, San Francisco, CA 94101, USA (C.G.)
| | - Claire Garcia
- Scientific Research Laboratory, Triangel Scientific, San Francisco, CA 94101, USA (C.G.)
| | - Inessa Pak
- Center for New Medical Technologies, 630090 Novosibirsk, Russia; (A.P.); (I.P.); (E.S.); (S.B.)
| | - Evgenya Shrainer
- Center for New Medical Technologies, 630090 Novosibirsk, Russia; (A.P.); (I.P.); (E.S.); (S.B.)
| | - Dmitry Kudlay
- Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia;
| | - Sevda Bayramova
- Center for New Medical Technologies, 630090 Novosibirsk, Russia; (A.P.); (I.P.); (E.S.); (S.B.)
| | - Richard Miller
- Scientific Research Laboratory, Triangel Scientific, San Francisco, CA 94101, USA (C.G.)
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Lawrence J. Step-down multiple testing procedures for the overall population and partitioning subgroups. J Biopharm Stat 2024; 34:240-250. [PMID: 36882961 DOI: 10.1080/10543406.2023.2187818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/01/2023] [Indexed: 03/09/2023]
Abstract
Multiple comparisons procedures are described for two-armed studies where there is a primary hypothesis and one or more ordered secondary hypotheses in the scenario where the objective is to test for an effect on the overall population and/or nonoverlapping subgroups that partition the population. This scenario arises when the subgroups are defined by disease etiology or by other patient characteristics such as genetic factors, age, sex, or race, and the treatment may have differential effects in the subgroups. The procedures described control the family-wise error rate in the strong sense at a specified level α.
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Affiliation(s)
- John Lawrence
- Office of Biostatistics, US Food and Drug Administration, Silver Spring, Maryland,USA
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Qureshi R, Basit SA, Shamsi JA, Fan X, Nawaz M, Yan H, Alam T. Machine learning based personalized drug response prediction for lung cancer patients. Sci Rep 2022; 12:18935. [PMID: 36344580 PMCID: PMC9640729 DOI: 10.1038/s41598-022-23649-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Lung cancers with a mutated epidermal growth factor receptor (EGFR) are a major contributor to cancer fatalities globally. Targeted tyrosine kinase inhibitors (TKIs) have been developed against EGFR and show encouraging results for survival rate and quality of life. However, drug resistance may affect treatment plans and treatment efficacy may be lost after about a year. Predicting the response to EGFR-TKIs for EGFR-mutated lung cancer patients is a key research area. In this study, we propose a personalized drug response prediction model (PDRP), based on molecular dynamics simulations and machine learning, to predict the response of first generation FDA-approved small molecule EGFR-TKIs, Gefitinib/Erlotinib, in lung cancer patients. The patient's mutation status is taken into consideration in molecular dynamics (MD) simulation. Each patient's unique mutation status was modeled considering MD simulation to extract molecular-level geometric features. Moreover, additional clinical features were incorporated into machine learning model for drug response prediction. The complete feature set includes demographic and clinical information (DCI), geometrical properties of the drug-target binding site, and the binding free energy of the drug-target complex from the MD simulation. PDRP incorporates an XGBoost classifier, which achieves state-of-the-art performance with 97.5% accuracy, 93% recall, 96.5% precision, and 94% F1-score, for a 4-class drug response prediction task. We found that modeling the geometry of the binding pocket combined with binding free energy is a good predictor for drug response. However, we observed that clinical information had a little impact on the performance of the model. The proposed model could be tested on other types of cancers. We believe PDRP will support the planning of effective treatment regimes based on clinical-genomic information. The source code and related files are available on GitHub at: https://github.com/rizwanqureshi123/PDRP/ .
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Affiliation(s)
- Rizwan Qureshi
- grid.452146.00000 0004 1789 3191College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar
| | - Syed Abdullah Basit
- FAST National University of Computer and Emerging Sciences, Karachi, Pakistan
| | - Jawwad A. Shamsi
- FAST National University of Computer and Emerging Sciences, Karachi, Pakistan
| | - Xinqi Fan
- grid.35030.350000 0004 1792 6846Department of Electrical Engineering, City University of Hong Kong, Kowloon, Hong Kong ,grid.35030.350000 0004 1792 6846Center for Intelligent Multidimensional Data Analysis (CIMDA), City University of Hong Kong, Kowloon, Hong Kong
| | - Mehmood Nawaz
- grid.10784.3a0000 0004 1937 0482Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR China
| | - Hong Yan
- grid.35030.350000 0004 1792 6846Department of Electrical Engineering, City University of Hong Kong, Kowloon, Hong Kong ,grid.35030.350000 0004 1792 6846Center for Intelligent Multidimensional Data Analysis (CIMDA), City University of Hong Kong, Kowloon, Hong Kong
| | - Tanvir Alam
- grid.452146.00000 0004 1789 3191College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar
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Limdi NA, Brown TM, Shendre A, Liu N, Hill CE, Beasley TM. Quality of anticoagulation control and hemorrhage risk among African American and European American warfarin users. Pharmacogenet Genomics 2018; 27:347-355. [PMID: 28806200 DOI: 10.1097/fpc.0000000000000298] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We evaluated whether percent time in target range (PTTR), risk of over-anticoagulation [international normalized ratio (INR)>4], and risk of hemorrhage differ by race. As PTTR is a strong predictor of hemorrhage risk, we also determined the influence of PTTR on the risk of hemorrhage by race. PARTICIPANTS AND METHODS Among 1326 warfarin users, PTTR was calculated as the percentage of interpolated INR values within the target range of 2.0-3.0. PTTR was also categorized as poor (PTTR<60%), good (60≤PTTR<70%), or excellent (PTTR≥70%) anticoagulation control. Over-anticoagulation was defined as INR more than 4 and major hemorrhages included serious, life-threatening, and fatal bleeding episodes. Logistic regression and survival analyses were carried out to evaluate the association of race with PTTR (≥60 vs. <60) and major hemorrhages, respectively. RESULTS Compared with African Americans, European Americans had higher PTTR (57.6 vs. 49.1%; P<0.0001) and were more likely to attain 60≤PTTR<70% (22.9 vs. 13.1%; P<0.001) or PTTR of at least 70% (26.9 vs. 18.2%; P=0.001). Older (>65 years) patients without venous thromboembolism indication and chronic kidney disease were more likely to attain PTTR of at least 60%. After accounting for clinical and genetic factors, and PTTR, African Americans had a higher risk of hemorrhage [hazard ratio (HR)=1.58; 95% confidence interval (CI): 1.04-2.41; P=0.034]. Patients with 60≤PTTR<70% (HR=0.62; 95% CI: 0.38-1.02; P=0.058) and PTTR of at least 70% (HR=0.27; 95% CI: 0.15-0.49; P<0.001) had a lower risk of hemorrhage compared with those with PTTR less than 60%. CONCLUSION Despite the provision of warfarin management through anticoagulation clinics, African Americans achieve a lower overall PTTR and have a significantly higher risk of hemorrhage. Personalized medicine interventions tailored to African American warfarin users need to be developed.
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Affiliation(s)
- Nita A Limdi
- aDepartment of Neurology bDepartment of Medicine, Division of Cardiovascular Diseases cDepartment of Epidemiology dDepartment of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA eDepartment of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
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Yang J, Gao L, Zhang Y, Wang H, Lu C, Zhao Y, Xu Q, Xu B, Zhang Y, Yin T. Estimation of the warfarin dose with a pharmacogenetic refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Thromb Haemost 2017; 108:1132-40. [DOI: 10.1160/th12-05-0362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/14/2012] [Indexed: 12/28/2022]
Abstract
SummaryPharmacogenetic (PG) dosing algorithms have been confirmed to predict warfarin therapeutic dose more accurately;however, most of them are based on standard intensity of warfarin anticoagulation, and their utility outside this range is limited. This study was designed to develop and validate a PG refinement algorithm in Chinese patients mainly under low-intensity warfarin anticoagulation. Consented Chinese-Han patients (n=310) under stable warfarin treatment were randomly divided into a derivation (n=207) and a validation cohort (n=103), with 83% and 80% of the patients under low-intensity anticoagulation, respectively. In the derivation cohort, a PG algorithm was constructed on the basis of genotypes (CYP2C9*3 and VKORC1–1639A/G) and clinical data. After integrating additional covariates of international normalised ratio (INR) values (INR on day 4 of therapy and target INR) and genotype of CYP4F2 (rs2108622), a PG refinement algorithm was established and explained 54% of warfarin dose variability. In the validation cohort, warfarin dose prediction was more accurate (p <0.01) with the PG refinement algorithm than with the PG algorithm and the fixed dose approach (3 mg/day). In the entire cohort, the PG refinement algorithm could accurately identify larger proportions of patients with lower dose requirement (≤2 mg/day) and higher dose requirement (≥4 mg/day) than did the PG algorithm. In conclusion, PG refinement algorithm integrating early INR response and three genotypes CYP2C9*3, VKORC1–1639A/G, CYP4F2 rs2108622) improves the accuracy of warfarin dose prediction in Chinese patients mainly under low-intensity anticoagulation.
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Biomarker-Guided Non-Adaptive Trial Designs in Phase II and Phase III: A Methodological Review. J Pers Med 2017; 7:jpm7010001. [PMID: 28125057 PMCID: PMC5374391 DOI: 10.3390/jpm7010001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/06/2016] [Accepted: 01/11/2017] [Indexed: 01/22/2023] Open
Abstract
Biomarker-guided treatment is a rapidly developing area of medicine, where treatment choice is personalised according to one or more of an individual’s biomarker measurements. A number of biomarker-guided trial designs have been proposed in the past decade, including both adaptive and non-adaptive trial designs which test the effectiveness of a biomarker-guided approach to treatment with the aim of improving patient health. A better understanding of them is needed as challenges occur both in terms of trial design and analysis. We have undertaken a comprehensive literature review based on an in-depth search strategy with a view to providing the research community with clarity in definition, methodology and terminology of the various biomarker-guided trial designs (both adaptive and non-adaptive designs) from a total of 211 included papers. In the present paper, we focus on non-adaptive biomarker-guided trial designs for which we have identified five distinct main types mentioned in 100 papers. We have graphically displayed each non-adaptive trial design and provided an in-depth overview of their key characteristics. Substantial variability has been observed in terms of how trial designs are described and particularly in the terminology used by different authors. Our comprehensive review provides guidance for those designing biomarker-guided trials.
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French B, Wang L, Gage BF, Horenstein RB, Limdi NA, Kimmel SE. A systematic analysis and comparison of warfarin initiation strategies. Pharmacogenet Genomics 2016; 26:445-52. [PMID: 27383664 PMCID: PMC5014593 DOI: 10.1097/fpc.0000000000000235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Randomized trials have reported inconsistent evidence on the effectiveness of algorithms that use genotypes to initiate warfarin therapy. The Clarification of Optimal Anticoagulation through Genetics (COAG) trial initiated therapy on the basis of predicted maintenance doses, with a pharmacogenetic-guided algorithm in one study group and a clinically guided algorithm in the other. The European Pharmacogenetics of Anticoagulant Therapy (EU-PACT) consortium initiated therapy on the basis of loading doses, with an algorithm-based prediction in one study group and a fixed-dose regimen in the other. To understand the differences between these trials, we compared the initial doses between alternative dosing algorithms (the pharmacogenetic-guided and clinically guided algorithms developed by Gage and colleagues and those developed by the International Warfarin Pharmacogenetics Consortium) and between the COAG and EU-PACT dose-initiation strategies. METHODS This was a secondary analysis of the COAG trial - a double-blind, randomized-controlled trial (2009-2013) - conducted at 18 clinical centers in the USA, which included 1010 adults initiating warfarin therapy, of whom 719 achieved maintenance dose. RESULTS Among COAG participants, the distribution of initial doses differed between algorithms, but showed similar prediction accuracy for maintenance dose. However, had the COAG trial implemented the EU-PACT strategy, the 3-day initial dose would have been 4.8 mg greater among participants randomized to pharmacogenetic-guided dosing, but only 2.5 mg greater among participants randomized to clinically guided dosing (P<0.001). CONCLUSION Compared with the COAG trial, the EU-PACT trial used systematically larger loading doses in the pharmacogenetic-guided group and might have inadequately adjusted for clinical variability in warfarin dose requirements in the fixed-dose group.
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Affiliation(s)
- Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Le Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian F. Gage
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | | | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen E. Kimmel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Kasner SE, Wang L, French B, Messé SR, Ellenberg J, Kimmel SE. Warfarin Dosing Algorithms and the Need for Human Intervention. Am J Med 2016; 129:431-7. [PMID: 26642907 PMCID: PMC4792751 DOI: 10.1016/j.amjmed.2015.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/05/2015] [Accepted: 11/05/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Dosing algorithms for warfarin incorporate clinical and genetic factors, but human intervention to overrule algorithm-based dosing may occasionally be required. The frequency and reasons for varying from algorithmic warfarin management have not been well studied. METHODS We analyzed a prospective cohort of 1015 participants from the Clarification of Optimal Anticoagulation through Genetics trial who were randomized to either pharmacogenetic- or clinically-guided warfarin dosing algorithms. Clinicians and participants were blinded to dose but not international normalized ratio (INR) during the first 28 days. If an issue arose that raised concern for clinicians but might not be adequately accounted for by the protocol, then clinicians contacted the unblinded medical monitor who could approve exceptions if clinically justified. All granted exceptions were logged and categorized. We analyzed the relationships between dosing exceptions and both baseline characteristics and the outcome of percentage of time in the therapeutic INR range during the first 4 weeks. RESULTS Sixteen percent of participants required at least one exception to the protocol-defined warfarin dose (15% in the genotype arm and 17% in the clinical arm). Ninety percent of dose exceptions occurred after the first 5 days of dosing. The only baseline characteristic associated with dose exceptions was congestive heart failure (odds ratio 2.12, 95% confidence interval, 1.49-3.02, P <.001). Neither study arm nor genotype was associated with dose exceptions. CONCLUSION Despite rigorous algorithms, human intervention is frequently employed in the early management of warfarin dosing. Congestive heart failure at baseline appears to predict early exceptions to standardized protocol management.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia.
| | - Le Wang
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Benjamin French
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Steven R Messé
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Jonas Ellenberg
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Stephen E Kimmel
- Department of Neurology and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
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Cloitre M, Petkova E, Su Z, Weiss B. Patient characteristics as a moderator of post-traumatic stress disorder treatment outcome: combining symptom burden and strengths. BJPsych Open 2016; 2:101-106. [PMID: 27703762 PMCID: PMC4995554 DOI: 10.1192/bjpo.bp.115.000745] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) psychotherapy research has failed to identify patient characteristics that consistently predict differential outcome. AIMS To identify patient characteristics associated with differential outcome via a statistically generated composite moderator among women with childhood abuse-related PTSD in a randomised controlled trial comparing exposure therapy, skills training and their combination. METHOD Six baseline patient characteristics were combined in a composite moderator of treatment effects for PTSD symptoms across the three treatment conditions through a 6-month follow-up. RESULTS The optimal moderator was the combined burden of all symptoms and emotion regulation strength. Those with high moderator scores, reflecting high symptom load relative to emotion regulation, did least well in exposure, moderately well in skills and best in the combination. CONCLUSIONS A clinically meaningful moderator, which combines patient symptom burden and strengths, was identified. Assessment at follow-up may provide a more accurate indicator of variability in outcome than that obtained immediately post-treatment. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Marylene Cloitre
- , PhD, National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA; NYU Langone Medical Center, New York, USA
| | - Eva Petkova
- , PhD, Department of Child & Adolescent Psychiatry, NYU Langone Medical Center; Nathan Kline Institute for Psychiatric Research, New York State Office of Mental HealthH, New York, New York, USA
| | - Zhe Su
- , MA, Department of Child & Adolescent Psychiatry, NYU Langone Medical Center, New York, New York, USA
| | - Brandon Weiss
- , PhD, National Center for PTSD Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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Kasner SE, Wang L, French B, Messe SR, Horenstein R, Mohler ER, Muldowney JAS, Ellenberg J, Kimmel SE. The Impact of Inpatient Versus Outpatient Initiation on Early Warfarin Dosing. Am J Cardiovasc Drugs 2015; 15:267-74. [PMID: 26037731 PMCID: PMC4508217 DOI: 10.1007/s40256-015-0126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Dosing algorithms for warfarin incorporate clinical and genetic factors but may not account for the numerous comorbidities affecting patients who start warfarin while hospitalized. We aimed to determine whether these algorithms perform differently when warfarin is initiated for inpatients compared with outpatients. PATIENTS AND METHODS We analyzed a prospective cohort of 1015 participants from the Clarification of Optimal Anticoagulation through Genetics (COAG) trial who were randomized to either pharmacogenetically or clinically guided warfarin dosing algorithms. Clinicians and participants were blinded to dose during the first 28 days. We compared groups, based on location at the time of the first warfarin dose request, in relation to the following outcomes: percentage of time in the therapeutic international normalized ratio (INR) range (PTTR) during the first 4 weeks, time to first therapeutic INR, time to maintenance dose, and the difference between predicted and observed maintenance doses. RESULTS A total of 527 participants started warfarin as inpatients and 488 as outpatients. There was no difference in PTTR based on location: 43.2 % for inpatient versus 47.4 % for outpatient initiation [mean adjusted difference -2.2 %; 95 % confidence interval (CI) -5.9 to 1.6]. Similarly, there were no differences in time to first therapeutic INR [hazard ratio (HR) 1.06; 95 % CI 0.91-1.24] or to maintenance dose (HR 0.96; 95 % CI 0.81-1.14). There was no evidence of interaction between study intervention (pharmacogenetically vs. clinically guided therapy) and location of initiation for these main outcomes. The difference between predicted and observed maintenance doses was similar for both locations. CONCLUSION The warfarin dosing algorithms performed similarly for subjects who initiated warfarin as inpatients and outpatients, regardless of whether dosing was pharmacogenetically or clinically guided.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania Medical Center, 3W Gates Bldg, 3400 Spruce Street, Philadelphia, PA, 19104, USA,
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Pharmacogenetics of Coumarin Anticoagulant Therapy. ADVANCES IN PREDICTIVE, PREVENTIVE AND PERSONALISED MEDICINE 2015. [DOI: 10.1007/978-3-319-15344-5_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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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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Heidari F, Vasudevan R, Mohd Ali SZ, Ismail P, Etemad A, Pishva SR, Othman F, Abu Bakar S. Association of insertion/deletion polymorphism of angiotensin-converting enzyme gene among Malay male hypertensive subjects in response to ACE inhibitors. J Renin Angiotensin Aldosterone Syst 2014; 16:872-9. [PMID: 25002132 DOI: 10.1177/1470320314538878] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Several studies show that the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene has been associated with hypertension in various populations. The present study sought to determine the association of the I/D gene polymorphism among Malay male essential hypertensive subjects in response to ACE inhibitors (enalapril and lisinopril). MATERIALS AND METHODS A total of 72 patients with newly diagnosed hypertension and 72 healthy subjects were recruited in this study. Blood pressure was recorded from 0 to 24 weeks of treatment with enalapril or lisinopril. Genotyping of the I/D polymorphism was carried out using a standard PCR method. RESULTS Statistically significant association of the D allele of the ACE gene was observed between the case and control subjects (p < 0.01). There was a decrease in blood pressure in the patients carrying the DD genotype (SBP=18.5±8.1 mmHg, DBP=15.29±7.1 mmHg) rather than the ID (SBP=4.1±3.3 mmHg, DBP=9.1±3.5 mmHg) and II genotypes (SBP= 3.0±0.2 mmHg, DBP 0.11±6.1 mmHg) of the ACE gene. CONCLUSION Patients carrying the DD genotype had higher blood pressure-lowering response when treated with ACE inhibitors enalapril or lisinopril than those carrying ID and II genotypes, suggesting that the D allele may be a possible genetic marker for essential hypertension among Malay male subjects.
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Affiliation(s)
- Farzad Heidari
- Genetic Research Group, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | | | | | - Patimah Ismail
- Genetic Research Group, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Ali Etemad
- Genetic Research Group, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Seyyed Reza Pishva
- Genetic Research Group, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Fauziah Othman
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - Suhaili Abu Bakar
- Genetic Research Group, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
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14
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Affiliation(s)
| | - Teri E. Klein
- Stanford University School of Medicine, Stanford, CA
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15
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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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16
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Johnson JA. Pharmacogenetics in clinical practice: how far have we come and where are we going? Pharmacogenomics 2014; 14:835-43. [PMID: 23651030 DOI: 10.2217/pgs.13.52] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Recent years have seen great advances in our understanding of genetic contributors to drug response. Drug discovery and development around targeted genetic (somatic) mutations has led to a number of new drugs with genetic indications, particularly for the treatment of cancers. Our knowledge of genetic contributors to variable drug response for existing drugs has also expanded dramatically, such that the evidence now supports clinical use of genetic data to guide treatment in some situations, and across a variety of therapeutic areas. Clinical implementation of pharmacogenetics has seen substantial growth in recent years and groups are working to identify the barriers and best practices for pharmacogenetic-guided treatment. The advances and challenges in these areas are described and predictions about future use of genetics in drug therapy are discussed.
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Affiliation(s)
- Julie A Johnson
- Department of Pharmacotherapy & Translational Research & Center for Pharmacogenomics, University of Florida, PO Box 100486, Gainesville, FL 32610-0486, USA.
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17
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Kimmel SE, French B, Kasner SE, Johnson JA, Anderson JL, Gage BF, Rosenberg YD, Eby CS, Madigan RA, McBane RB, Abdel-Rahman SZ, Stevens SM, Yale S, Mohler ER, Fang MC, Shah V, Horenstein RB, Limdi NA, Muldowney JAS, Gujral J, Delafontaine P, Desnick RJ, Ortel TL, Billett HH, Pendleton RC, Geller NL, Halperin JL, Goldhaber SZ, Caldwell MD, Califf RM, Ellenberg JH. A pharmacogenetic versus a clinical algorithm for warfarin dosing. N Engl J Med 2013; 369:2283-93. [PMID: 24251361 PMCID: PMC3942158 DOI: 10.1056/nejmoa1310669] [Citation(s) in RCA: 557] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The clinical utility of genotype-guided (pharmacogenetically based) dosing of warfarin has been tested only in small clinical trials or observational studies, with equivocal results. METHODS We randomly assigned 1015 patients to receive doses of warfarin during the first 5 days of therapy that were determined according to a dosing algorithm that included both clinical variables and genotype data or to one that included clinical variables only. All patients and clinicians were unaware of the dose of warfarin during the first 4 weeks of therapy. The primary outcome was the percentage of time that the international normalized ratio (INR) was in the therapeutic range from day 4 or 5 through day 28 of therapy. RESULTS At 4 weeks, the mean percentage of time in the therapeutic range was 45.2% in the genotype-guided group and 45.4% in the clinically guided group (adjusted mean difference, [genotype-guided group minus clinically guided group], -0.2; 95% confidence interval, -3.4 to 3.1; P=0.91). There also was no significant between-group difference among patients with a predicted dose difference between the two algorithms of 1 mg per day or more. There was, however, a significant interaction between dosing strategy and race (P=0.003). Among black patients, the mean percentage of time in the therapeutic range was less in the genotype-guided group than in the clinically guided group. The rates of the combined outcome of any INR of 4 or more, major bleeding, or thromboembolism did not differ significantly according to dosing strategy. CONCLUSIONS Genotype-guided dosing of warfarin did not improve anticoagulation control during the first 4 weeks of therapy. (Funded by the National Heart, Lung, and Blood Institute and others; COAG ClinicalTrials.gov number, NCT00839657.).
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Affiliation(s)
- Wolfgang Lieb
- Institute of Epidemiology, Christian Albrechts Universität Kiel, Niemannsweg 11, Kiel, Germany.
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Abstract
Variability in drug responsiveness is a sine qua non of modern therapeutics, and the contribution of genomic variation is increasingly recognized. Investigating the genomic basis for variable responses to cardiovascular therapies has been a model for pharmacogenomics in general and has established critical pathways and specific loci modulating therapeutic responses to commonly used drugs such as clopidogrel, warfarin, and statins. In addition, genomic approaches have defined mechanisms and genetic variants underlying important toxicities with these and other drugs. These findings have not only resulted in changes to the product labels but also have led to development of initial clinical guidelines that consider how to facilitate incorporating genetic information to the bedside. This review summarizes the state of knowledge in cardiovascular pharmacogenomics and considers how variants described to date might be deployed in clinical decision making.
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Abstract
PURPOSE OF REVIEW To review the most promising genetic markers associated with the variability in the safety or efficacy of warfarin and clopidogrel and highlight the verification and validation initiatives for translating clopidogrel and warfarin pharmacogenetic tests to clinical practice. RECENT FINDINGS Rapid advances in pharmacogenetics, continuous decrease in genotyping cost, development of point-of-care devices and the newly established clinical genotyping programs at several institutions hold the promise of individualizing clopidogrel and warfarin based on genotype. Guidelines have been established to assist clinicians in prescribing clopidogrel or warfarin dose based on genotype. However, the clinical utility of clopidogrel and warfarin is still limited. Accordingly, large randomized clinical trials are underway to define the role of clopidogrel and warfarin pharmacogenetics in clinical practice. SUMMARY Pharmacogenetics has offered compelling evidence toward the individualization of clopidogrel and warfarin therapies. The rapid advances in technology make the clinical implementation of clopidogrel and warfarin pharmacogenetics possible. The clinical genotyping programs and the ongoing clinical trials will help in overcoming some of the barriers facing the clinical implementation of clopidogrel and warfarin pharmacogenetics.
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Abstract
Interindividual heterogeneity in drug response is a central feature of all drug therapies. Studies in individual patients, families, and populations over the past several decades have identified variants in genes encoding drug elimination or drug target pathways that in some cases contribute substantially to variable efficacy and toxicity. Important associations of pharmacogenomics in cardiovascular medicine include clopidogrel and risk for in-stent thrombosis, steady-state warfarin dose, myotoxicity with simvastatin, and certain drug-induced arrhythmias. This review describes methods used to accumulate and validate these findings and points to approaches--now being put in place at some centers--to implementing them in clinical care.
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Affiliation(s)
- Peter Weeke
- Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee; ,
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22
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CYP2D6 genotype and adjuvant tamoxifen: meta-analysis of heterogeneous study populations. Clin Pharmacol Ther 2013; 95:216-27. [PMID: 24060820 PMCID: PMC3904554 DOI: 10.1038/clpt.2013.186] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/09/2013] [Indexed: 01/13/2023]
Abstract
The International Tamoxifen Pharmacogenomics Consortium was established to address the
controversy regarding cytochrome P450 2D6 (CYP2D6) status and clinical outcomes
in tamoxifen therapy. We performed a meta-analysis on data from 4,973 tamoxifen-treated
patients (12 globally distributed sites). Using strict eligibility requirements
(postmenopausal women with estrogen receptor–positive breast cancer, receiving
20 mg/day tamoxifen for 5 years, criterion 1); CYP2D6 poor metabolizer status
was associated with poorer invasive disease–free survival (IDFS: hazard ratio =
1.25; 95% confidence interval = 1.06, 1.47; P = 0.009). However,
CYP2D6 status was not statistically significant when tamoxifen duration,
menopausal status, and annual follow-up were not specified (criterion 2, n =
2,443; P = 0.25) or when no exclusions were applied (criterion 3, n
= 4,935; P = 0.38). Although CYP2D6 is a strong predictor of IDFS
using strict inclusion criteria, because the results are not robust to inclusion criteria
(these were not defined a priori), prospective studies are necessary to fully
establish the value of CYP2D6 genotyping in tamoxifen therapy.
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Kadian-Dodov DL, van der Zee SA, Scott SA, Peter I, Martis S, Doheny DO, Rothlauf EB, Lubitz SA, Desnick RJ, Halperin JL. Warfarin pharmacogenetics: A controlled dose–response study in healthy subjects. Vasc Med 2013; 18:290-7. [DOI: 10.1177/1358863x13503193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of this study was to determine how genetic variants contribute to warfarin dosing variability when non-genetic factors are controlled. Thirty healthy subjects were subjected to a warfarin dosing algorithm with daily international normalized ratio (INR) measurements to INR ≥ 2.0, then off warfarin to INR ≤ 1.2. The primary outcome was the cumulative dose required to achieve INR ≥ 2.0 for 2 consecutive days. CYP2C9 ( p=0.004) and VKORC1 ( p=0.02) variant carriers required lower cumulative doses, and CYP4F2 carriers required higher doses ( p=0.04). Subjects with variants in both CYP2C9 and VKORC1 required fewer days to reach INR ≥ 2.0 than wild-type subjects or those with variants in CYP2C9 or VKORC1 ( p=0.01). Genetic contribution to dose variability (~62%) was greater than previously reported, suggesting that uncontrolled clinical variables influence the effect of these variants. In conclusion, genotype-guided warfarin-dosing algorithms may rely more on genetic variables in healthier individuals than in patients with clinical confounders. ClinicalTrials.gov Identifier: NCT01520402
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Affiliation(s)
- Daniella L Kadian-Dodov
- Vascular Medicine Section, The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Inga Peter
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suparna Martis
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dana O Doheny
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth B Rothlauf
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan L Halperin
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Sorich MJ, Coory M. Interpreting the clinical utility of a pharmacogenomic marker based on observational association studies. THE PHARMACOGENOMICS JOURNAL 2013; 14:1-5. [DOI: 10.1038/tpj.2013.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/26/2013] [Accepted: 07/22/2013] [Indexed: 12/12/2022]
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Abstract
The use of genetic information to guide medication decisions holds great promise to improve therapeutic outcomes through increased efficacy and reduced adverse events. As in many areas of medicine, pediatric research and clinical implementation in pharmacogenetics lag behind corresponding adult discovery and clinical applications. In adults, genotype-guided clinical decision support for medications such as clopidogrel, warfarin and simvastatin are in use in some medical centers. However, research conducted in pediatric populations demonstrates that the models and practices developed in adults may be inaccurate in children, and some applications lack any pediatric research to guide clinical decisions. To account for additional factors introduced by developmental considerations in pediatric populations and provide pediatric patients with maximal benefit from genotype-guided therapy, the field will need to develop and employ creative solutions. In this article, we detail some concerns about research and clinical implementation of pharmacogenetics in pediatrics, and present potential mechanisms for addressing them.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University, 2200 Children's Way, Nashville, TN 37232, USA ; The Monroe Carell Jr Children's Hospital at Vanderbilt, 8232 DOT, 2200 Children's Way, Nashville, TN 37232, USA
| | - Tracy L McGregor
- Department of Pediatrics, Vanderbilt University, 2200 Children's Way, Nashville, TN 37232, USA ; The Monroe Carell Jr Children's Hospital at Vanderbilt, 8232 DOT, 2200 Children's Way, Nashville, TN 37232, USA ; The Center for Human Genetics Research, 519 Light Hall, 2215 Garland Avenue, Nashville, TN 37232-0700, USA
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26
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Kimmel SE, French B, Anderson JL, Gage BF, Johnson JA, Rosenberg YD, Geller NL, Kasner SE, Eby CS, Joo J, Caldwell MD, Goldhaber SZ, Hart RG, Cifelli D, Madigan R, Brensinger CM, Goldberg S, Califf RM, Ellenberg JH. Rationale and design of the Clarification of Optimal Anticoagulation through Genetics trial. Am Heart J 2013; 166:435-41. [PMID: 24016491 PMCID: PMC4415273 DOI: 10.1016/j.ahj.2013.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Current dosing practices for warfarin are empiric and result in the need for frequent dose changes as the international normalized ratio gets too high or too low. As a result, patients are put at increased risk for thromboembolism, bleeding, and premature discontinuation of anticoagulation therapy. Prior research has identified clinical and genetic factors that can alter warfarin dose requirements, but few randomized clinical trials have examined the utility of using clinical and genetic information to improve anticoagulation control or clinical outcomes among a large, diverse group of patients initiating warfarin. METHODS The COAG trial is a multicenter, double-blind, randomized trial comparing 2 approaches to guiding warfarin therapy initiation: initiation of warfarin therapy based on algorithms using clinical information plus an individual's genotype using genes known to influence warfarin response ("genotype-guided dosing") versus only clinical information ("clinical-guided dosing") (www.clinicaltrials.gov Identifier: NCT00839657). RESULTS The COAG trial design is described. The study hypothesis is that, among 1,022 enrolled patients, genotype-guided dosing relative to clinical-guided dosing during the initial dosing period will increase the percentage of time that patients spend in the therapeutic international normalized ratio range in the first 4 weeks of therapy. CONCLUSION The COAG will determine if genetic information provides added benefit above and beyond clinical information alone.
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Affiliation(s)
- Stephen E Kimmel
- Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA.
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Abstract
The use of genetic information to guide medication decisions holds great promise to improve therapeutic outcomes through increased efficacy and reduced adverse events. As in many areas of medicine, pediatric research and clinical implementation in pharmacogenetics lag behind corresponding adult discovery and clinical applications. In adults, genotype-guided clinical decision support for medications such as clopidogrel, warfarin and simvastatin are in use in some medical centers. However, research conducted in pediatric populations demonstrates that the models and practices developed in adults may be inaccurate in children, and some applications lack any pediatric research to guide clinical decisions. To account for additional factors introduced by developmental considerations in pediatric populations and provide pediatric patients with maximal benefit from genotype-guided therapy, the field will need to develop and employ creative solutions. In this article, we detail some concerns about research and clinical implementation of pharmacogenetics in pediatrics, and present potential mechanisms for addressing them.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University, 2200 Children’s Way, Nashville, TN 37232, USA
- The Monroe Carell Jr Children’s Hospital at Vanderbilt, 8232 DOT, 2200 Children’s Way, Nashville, TN 37232, USA
| | - Tracy L McGregor
- Department of Pediatrics, Vanderbilt University, 2200 Children’s Way, Nashville, TN 37232, USA
- The Monroe Carell Jr Children’s Hospital at Vanderbilt, 8232 DOT, 2200 Children’s Way, Nashville, TN 37232, USA
- The Center for Human Genetics Research, 519 Light Hall, 2215 Garland Avenue, Nashville, TN 37232-0700, USA
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Perera MA, Cavallari LH, Limdi NA, Gamazon ER, Konkashbaev A, Daneshjou R, Pluzhnikov A, Crawford DC, Wang J, Liu N, Tatonetti N, Bourgeois S, Takahashi H, Bradford Y, Burkley BM, Desnick RJ, Halperin JL, Khalifa SI, Langaee TY, Lubitz SA, Nutescu EA, Oetjens M, Shahin MH, Patel SR, Sagreiya H, Tector M, Weck KE, Rieder MJ, Scott SA, Wu AHB, Burmester JK, Wadelius M, Deloukas P, Wagner MJ, Mushiroda T, Kubo M, Roden DM, Cox NJ, Altman RB, Klein TE, Nakamura Y, Johnson JA. Genetic variants associated with warfarin dose in African-American individuals: a genome-wide association study. Lancet 2013; 382:790-6. [PMID: 23755828 PMCID: PMC3759580 DOI: 10.1016/s0140-6736(13)60681-9] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND VKORC1 and CYP2C9 are important contributors to warfarin dose variability, but explain less variability for individuals of African descent than for those of European or Asian descent. We aimed to identify additional variants contributing to warfarin dose requirements in African Americans. METHODS We did a genome-wide association study of discovery and replication cohorts. Samples from African-American adults (aged ≥18 years) who were taking a stable maintenance dose of warfarin were obtained at International Warfarin Pharmacogenetics Consortium (IWPC) sites and the University of Alabama at Birmingham (Birmingham, AL, USA). Patients enrolled at IWPC sites but who were not used for discovery made up the independent replication cohort. All participants were genotyped. We did a stepwise conditional analysis, conditioning first for VKORC1 -1639G→A, followed by the composite genotype of CYP2C9*2 and CYP2C9*3. We prespecified a genome-wide significance threshold of p<5×10(-8) in the discovery cohort and p<0·0038 in the replication cohort. FINDINGS The discovery cohort contained 533 participants and the replication cohort 432 participants. After the prespecified conditioning in the discovery cohort, we identified an association between a novel single nucleotide polymorphism in the CYP2C cluster on chromosome 10 (rs12777823) and warfarin dose requirement that reached genome-wide significance (p=1·51×10(-8)). This association was confirmed in the replication cohort (p=5·04×10(-5)); analysis of the two cohorts together produced a p value of 4·5×10(-12). Individuals heterozygous for the rs12777823 A allele need a dose reduction of 6·92 mg/week and those homozygous 9·34 mg/week. Regression analysis showed that the inclusion of rs12777823 significantly improves warfarin dose variability explained by the IWPC dosing algorithm (21% relative improvement). INTERPRETATION A novel CYP2C single nucleotide polymorphism exerts a clinically relevant effect on warfarin dose in African Americans, independent of CYP2C9*2 and CYP2C9*3. Incorporation of this variant into pharmacogenetic dosing algorithms could improve warfarin dose prediction in this population. FUNDING National Institutes of Health, American Heart Association, Howard Hughes Medical Institute, Wisconsin Network for Health Research, and the Wellcome Trust.
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Affiliation(s)
- Minoli A Perera
- Section of Genetic Medicine, Department of Medicine, University of Chicago, IL, USA
| | - Larisa H Cavallari
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Nita A Limdi
- Department of Neurology and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric R Gamazon
- Section of Genetic Medicine, Department of Medicine, University of Chicago, IL, USA
| | - Anuar Konkashbaev
- Section of Genetic Medicine, Department of Medicine, University of Chicago, IL, USA
| | - Roxana Daneshjou
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Anna Pluzhnikov
- Section of Genetic Medicine, Department of Medicine, University of Chicago, IL, USA
| | - Dana C Crawford
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN, USA
| | - Jelai Wang
- Section on Statistical Genetics, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nianjun Liu
- Section on Statistical Genetics, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Stephane Bourgeois
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, UK
| | - Harumi Takahashi
- Department of Biopharmaceutics, Meiji Pharmaceutical University, Tokyo, Japan
| | - Yukiko Bradford
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN, USA
| | - Benjamin M Burkley
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, USA
| | - Robert J Desnick
- Department of Genetics and Genomics Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Jonathan L Halperin
- The Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA
| | - Sherief I Khalifa
- Pharmaceutical Sciences Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Taimour Y Langaee
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, USA
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Matthew Oetjens
- Center for Human Genetics Research, Vanderbilt University, Nashville, TN, USA
| | - Mohamed H Shahin
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, USA
| | - Shitalben R Patel
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Hersh Sagreiya
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | | | - Karen E Weck
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
- Department of Genetics, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
| | - Mark J Rieder
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Stuart A Scott
- Department of Genetics and Genomics Sciences, Mount Sinai School of Medicine, New York, NY, USA
| | - Alan HB Wu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacology, Uppsala University, Uppsala, Sweden
| | - Panos Deloukas
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, UK
| | - Michael J Wagner
- School of Pharmacy, University of North Carolina at Chapel Hill; Chapel Hill, NC, USA
| | | | | | - Dan M Roden
- Department of Medicine and Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Nancy J Cox
- Section of Genetic Medicine, Department of Medicine, University of Chicago, IL, USA
| | - Russ B Altman
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Teri E Klein
- Department of Genetics, Stanford University, Stanford, CA, USA
| | | | - Julie A Johnson
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL, USA
- Correspondence to: Prof Julie A Johnson, Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Box 100486, Gainesville, FL 32610–0486, USA
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30
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Cavallari LH, Nutescu EA, Duarte JD. Personalized medicine in cardiology: the time for genotype-guided therapy is now. Future Cardiol 2013; 9:459-64. [DOI: 10.2217/fca.13.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacy Practice, University of Illinois at Chicago, 833 South Wood Street, Room 164, Chicago, IL 60612-7230, USA.
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago, 833 South Wood Street, Room 164, Chicago, IL 60612-7230, USA
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, 833 South Wood Street, Room 164, Chicago, IL 60612-7230, USA
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Tajik P, Zwinderman AH, Mol BW, Bossuyt PM. Trial Designs for Personalizing Cancer Care: A Systematic Review and Classification. Clin Cancer Res 2013; 19:4578-88. [DOI: 10.1158/1078-0432.ccr-12-3722] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Verhoef TI, Redekop WK, Veenstra DL, Thariani R, Beltman PA, van Schie RMF, de Boer A, Maitland-van der Zee AH. Cost–effectiveness of pharmacogenetic-guided dosing of phenprocoumon in atrial fibrillation. Pharmacogenomics 2013; 14:869-83. [DOI: 10.2217/pgs.13.74] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: To investigate the cost–effectiveness of pharmacogenetic-guided phenprocoumon dosing versus standard anticoagulation care in Dutch patients with atrial fibrillation. Materials & methods: Using a decision-analytic Markov model, cost–effectiveness of pharmacogenetic-guided therapy versus standard care was estimated. Results: Compared with standard care, the pharmacogenetic-guided dosing strategy increased quality-adjusted life-years (QALYs) only very slightly and increased costs by €15. The incremental cost–effectiveness ratio was €2658 per QALY gained. In sensitivity analyses, the cost of genotyping had the largest influence on the cost–effectiveness ratio. In a probabilistic sensitivity analysis, the incremental costs of genotype-guided dosing were less than €20,000 per QALY gained in 75.6% of the simulations. Conclusion: Pharmacogenetic-guided dosing of phenprocoumon has the potential to increase health slightly and may be able to achieve this in a cost-effective way. Owing to the many uncertainties it is too early to conclude whether or not patients starting phenprocoumon should be genotyped. Original submitted 20 December 2012; Revision submitted 8 April 2013
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Affiliation(s)
- Talitha I Verhoef
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, PO Box 80 082, 3508 TB Utrecht, The Netherlands.
| | - William K Redekop
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | - David L Veenstra
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Rahber Thariani
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Peter A Beltman
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, PO Box 80 082, 3508 TB Utrecht, The Netherlands
| | - Rianne MF van Schie
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, PO Box 80 082, 3508 TB Utrecht, The Netherlands
| | - Anthonius de Boer
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, PO Box 80 082, 3508 TB Utrecht, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, PO Box 80 082, 3508 TB Utrecht, The Netherlands
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Ramos AS, Seip RL, Rivera-Miranda G, Felici-Giovanini ME, Garcia-Berdecia R, Alejandro-Cowan Y, Kocherla M, Cruz I, Feliu JF, Cadilla CL, Renta JY, Gorowski K, Vergara C, Ruaño G, Duconge J. Development of a pharmacogenetic-guided warfarin dosing algorithm for Puerto Rican patients. Pharmacogenomics 2013; 13:1937-50. [PMID: 23215886 DOI: 10.2217/pgs.12.171] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AIM This study was aimed at developing a pharmacogenetic-driven warfarin-dosing algorithm in 163 admixed Puerto Rican patients on stable warfarin therapy. PATIENTS & METHODS A multiple linear-regression analysis was performed using log-transformed effective warfarin dose as the dependent variable, and combining CYP2C9 and VKORC1 genotyping with other relevant nongenetic clinical and demographic factors as independent predictors. RESULTS The model explained more than two-thirds of the observed variance in the warfarin dose among Puerto Ricans, and also produced significantly better 'ideal dose' estimates than two pharmacogenetic models and clinical algorithms published previously, with the greatest benefit seen in patients ultimately requiring <7 mg/day. We also assessed the clinical validity of the model using an independent validation cohort of 55 Puerto Rican patients from Hartford, CT, USA (R(2) = 51%). CONCLUSION Our findings provide the basis for planning prospective pharmacogenetic studies to demonstrate the clinical utility of genotyping warfarin-treated Puerto Rican patients.
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Affiliation(s)
- Alga S Ramos
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Puerto Rico, Room 420, PO Box 365067, San Juan, PR 00936-5067, USA
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Johnson JA, Cavallari LH. Pharmacogenetics and cardiovascular disease--implications for personalized medicine. Pharmacol Rev 2013; 65:987-1009. [PMID: 23686351 DOI: 10.1124/pr.112.007252] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The past decade has seen tremendous advances in our understanding of the genetic factors influencing response to a variety of drugs, including those targeted at treatment of cardiovascular diseases. In the case of clopidogrel, warfarin, and statins, the literature has become sufficiently strong that guidelines are now available describing the use of genetic information to guide treatment with these therapies, and some health centers are using this information in the care of their patients. There are many challenges in moving from research data to translation to practice; we discuss some of these barriers and the approaches some health systems are taking to overcome them. The body of literature that has led to the clinical implementation of CYP2C19 genotyping for clopidogrel, VKORC1, CYP2C9; and CYP4F2 for warfarin; and SLCO1B1 for statins is comprehensively described. We also provide clarity for other genes that have been extensively studied relative to these drugs, but for which the data are conflicting. Finally, we comment briefly on pharmacogenetics of other cardiovascular drugs and highlight β-blockers as the drug class with strong data that has not yet seen clinical implementation. It is anticipated that genetic information will increasingly be available on patients, and it is important to identify those examples where the evidence is sufficiently robust and predictive to use genetic information to guide clinical decisions. The review herein provides several examples of the accumulation of evidence and eventual clinical translation in cardiovascular pharmacogenetics.
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Affiliation(s)
- Julie A Johnson
- Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida, Box 100486, Gainesville, FL 32610-0486, USA.
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Verhoef TI, Redekop WK, van Schie RM, Bayat S, Daly AK, Geitona M, Haschke-Becher E, Hughes DA, Kamali F, Levin LÅ, Manolopoulos VG, Pirmohamed M, Siebert U, Stingl JC, Wadelius M, de Boer A, Maitland-van der Zee AH. Cost-effectiveness of pharmacogenetics in anticoagulation: international differences in healthcare systems and costs. Pharmacogenomics 2013; 13:1405-17. [PMID: 22966889 DOI: 10.2217/pgs.12.124] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Genotyping patients for CYP2C9 and VKORC1 polymorphisms can improve the accuracy of dosing during the initiation of anticoagulation with vitamin K antagonists (coumarin derivatives). The anticipated degree of improvement in the safety of anticoagulation with coumarins through genotyping may vary depending on the quality of patient care, which varies both with and among countries. The management and the cost of anticoagulant care can therefore influence the cost-effectiveness of genotyping within any given country. In this article, we provide an overview of the cost-effectiveness of pharmacogenetics-guided dosing of coumarin derivatives. We describe the organization of anticoagulant care in the UK, Sweden, The Netherlands, Greece, Germany and Austria, where a genotype-guided dosing algorithm is currently being investigated as part of the EU-PACT trial. We also explore the costs of anticoagulant care for the treatment of atrial fibrillation in these countries.
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Affiliation(s)
- Talitha I Verhoef
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
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Moaddeb J, Haga SB. Pharmacogenetic testing: Current Evidence of Clinical Utility. Ther Adv Drug Saf 2013; 4:155-169. [PMID: 24020014 DOI: 10.1177/2042098613485595] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Over the last decade, the number of clinical pharmacogenetic tests has steadily increased as understanding of the role of genes in drug response has grown. However, uptake of these tests has been slow, due in large part to the lack of robust evidence demonstrating clinical utility. We review the evidence behind four pharmacogenetic tests and discuss the barriers and facilitators to uptake: 1) warfarin (drug safety and efficacy); 2) clopidogrel (drug efficacy); 3) codeine (drug efficacy); and 4) abacavir (drug safety). Future efforts should be directed toward addressing these issues and considering additional approaches to generating evidence basis to support clinical use of pharmacogenetic tests.
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Affiliation(s)
- Jivan Moaddeb
- Duke Institute for Genome Sciences & Policy 304 Research Drive Box 90141 Durham, NC 27708 USA
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Hong H, Jawaid A, Wang J, Catalano J, Fox JC, Hawkins TB. Combining genetic variations in CYP2C9 and VKORC1 with clinical factors for warfarin dosing determination improved clinical effectiveness. Pharmacogenomics 2013; 14:459-60. [PMID: 23556443 DOI: 10.2217/pgs.13.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Huixiao Hong
- Division of Bioinformatics & Biostatistics, National Center for Toxicological Research, US FDA, 3900 NCTR Road, Jefferson, AR 72079, USA.
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The future of inpatient anticoagulation management. J Thromb Thrombolysis 2013; 35:375-86. [DOI: 10.1007/s11239-013-0892-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Genotyping of CYP2C9 and VKORC1 in the Arabic population of Al-Ahsa, Saudi Arabia. BIOMED RESEARCH INTERNATIONAL 2013; 2013:315980. [PMID: 23586031 PMCID: PMC3613048 DOI: 10.1155/2013/315980] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 01/17/2013] [Accepted: 02/03/2013] [Indexed: 11/17/2022]
Abstract
Polymorphisms in the genes encoding CYP2C9 enzyme and VKORC1 reductase significantly influence the dose variability of coumarinic oral anticoagulants (COAs). Substantial inter- and intraethnic variability exists in the frequencies of CYP2C9*2 and *3 and VKORC1 -1639A alleles. However, the prevalence of CYP2C9 and VKORC1 genetic variants is less characterized in Arab populations. A total of 131 healthy adult subjects from the Al-Ahsa region of Saudi Arabia were genotyped for the CYP2C9 *2 and *3 and VKORC1 -1639G>A polymorphisms by PCR-RFLP method. The frequencies of the CYP2C9 *2 and *3 and VKORC1 -1639A alleles were 13.3%, 2.3%, and 42.4%, respectively, with no subjects carrying 2 defective alleles. The frequencies of the CYP2C9 *3 and VKORC1 -1639A alleles were significantly lower than those reported in different Arabian populations. None of the subjects with the VKORC1 -1639AA genotype were carriers of CYP2C9 *1/*3 genotypes that lead to sensitivity to COAs therapy. The low frequency of the CYP2C9 *3 allele combined with the absence of subjects carrying 2 defective CYP2C9 alleles suggests that, in this specific population, pharmacogenetic COAs dosing may mostly rely upon VKORC1 genotyping.
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Daly AK. Optimal dosing of warfarin and other coumarin anticoagulants: the role of genetic polymorphisms. Arch Toxicol 2013; 87:407-20. [PMID: 23376975 DOI: 10.1007/s00204-013-1013-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 01/17/2013] [Indexed: 12/14/2022]
Abstract
Coumarin anticoagulants, which include warfarin, acenocoumarol and phenprocoumon, are among the most widely prescribed drugs worldwide. There is now a large body of published data showing that genotype for certain common polymorphisms in the genes encoding the target vitamin K epoxide reductase (G-1639A/C1173T) and the main metabolizing enzyme CYP2C9 (CYP2C9*2 and *3 alleles) are important determinants of the individual coumarin anticoagulant dose requirement. Additional less common polymorphisms in these genes together with polymorphisms in other genes relevant to blood coagulation such as the cytochrome P450 CYP4F2, gamma-glutamyl carboxylase, calumenin and cytochrome P450 oxidoreductase may also be significant predictors of dose, especially in ethnic groups such as Africans where there have been fewer genetic studies compared with European populations. Using relevant genotypes to calculate starting dose may improve safety during the initiation period. Various algorithms for dose calculation, which also take patient age and other characteristics into consideration, have been developed for all three widely used coumarin anticoagulants and are now being tested in ongoing large randomised clinical trials. One recently completed study has provided encouraging results suggesting that calculation of warfarin dose on the basis of individual patient genotype leads to few adverse events and a higher proportion of time within the therapeutic coagulation rate window, but these findings still need confirmation.
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Affiliation(s)
- Ann K Daly
- Institute of Cellular Medicine, Newcastle University Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
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Warfarin dose prediction in children using pharmacometric bridging--comparison with published pharmacogenetic dosing algorithms. Eur J Clin Pharmacol 2013; 69:1275-83. [PMID: 23307232 PMCID: PMC3651819 DOI: 10.1007/s00228-012-1466-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 12/18/2012] [Indexed: 11/16/2022]
Abstract
Purpose Numerous studies have investigated causes of warfarin dose variability in adults, whereas studies in children are limited both in numbers and size. Mechanism-based population modelling provides an opportunity to condense and propagate prior knowledge from one population to another. The main objectives with this study were to evaluate the predictive performance of a theoretically bridged adult warfarin model in children, and to compare accuracy in dose prediction relative to published warfarin algorithms for children. Method An adult population pharmacokinetic/pharmacodynamic (PK/PD) model for warfarin, with CYP2C9 and VKORC1 genotype, age and target international normalized ratio (INR) as dose predictors, was bridged to children using allometric scaling methods. Its predictive properties were evaluated in an external data set of children 0–18 years old, including comparison of dose prediction accuracy with three pharmacogenetics-based algorithms for children. Results Overall, the bridged model predicted INR response well in 64 warfarin-treated Swedish children (median age 4.3 years), but with a tendency to overpredict INR in children ≤2 years old. The bridged model predicted 20 of 49 children (41 %) within ± 20 % of actual maintenance dose (median age 7.2 years). In comparison, the published dosing algorithms predicted 33–41 % of the children within ±20 % of actual dose. Dose optimization with the bridged model based on up to three individual INR observations increased the proportion within ±20 % of actual dose to 70 %. Conclusion A mechanism-based population model developed on adult data provides a promising first step towards more individualized warfarin therapy in children. Electronic supplementary material The online version of this article (doi:10.1007/s00228-012-1466-4) contains supplementary material, which is available to authorized users.
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Roden DM. Cardiovascular pharmacogenomics: the future of cardiovascular therapeutics? Can J Cardiol 2013; 29:58-66. [PMID: 23200096 PMCID: PMC3529768 DOI: 10.1016/j.cjca.2012.07.845] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 07/17/2012] [Accepted: 07/31/2012] [Indexed: 01/08/2023] Open
Abstract
Responses to drug therapy vary from benefit to no effect to adverse effects which can be serious or occasionally fatal. Increasing evidence supports the idea that genetic variants can play a major role in this spectrum of responses. Well-studied examples in cardiovascular therapeutics include predictors of steady-state warfarin dosage, predictors of reduced efficacy among patients receiving clopidogrel for drug eluting stents, and predictors of some serious adverse drug effects. This review summarizes contemporary approaches to identifying and validating genetic predictors of variability in response to drug treatment. Approaches to incorporating this new knowledge into clinical care, and the barriers to this concept, are addressed.
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Affiliation(s)
- Dan M Roden
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Cavallari LH, Momary K. Pharmacogenetics in Cardiovascular Diseases. Pharmacogenomics 2013. [DOI: 10.1016/b978-0-12-391918-2.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Voora D. Building the evidentiary framework for pharmacogenetic testing: is it time to move beyond randomized controlled trials? Per Med 2013; 10:1-3. [DOI: 10.2217/pme.12.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Deepak Voora
- Center for Personalized Medicine, Duke University Medical Center, Durham, NC, USA
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Cavallari LH, Perera MA. The future of warfarin pharmacogenetics in under-represented minority groups. Future Cardiol 2012; 8:563-76. [PMID: 22871196 DOI: 10.2217/fca.12.31] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Genotype-based dosing recommendations are provided in the US FDA-approved warfarin labeling. However, data that informed these recommendations were from predominately Caucasian populations. Studies show that variants contributing to warfarin dose requirements in Caucasians provide similar contributions to dose requirements in US Hispanics, but significantly lesser contributions in African-Americans. Further data demonstrate that variants occurring commonly in individuals of African ancestry, but rarely in other racial groups, significantly influence dose requirements in African-Americans. These data suggest that it is important to consider variants specific for African-Americans when implementing genotype-guided warfarin dosing in this population.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, 833 South Wood Street, Chicago, IL 60612-7230, USA.
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Halperin JL, Goyette RE. Management of Atrial Fibrillation: Direct Factor IIa and Xa Inhibitors or “Warfarin Shotgun”? ACTA ACUST UNITED AC 2012; 79:705-20. [DOI: 10.1002/msj.21346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Verhoef TI, Redekop WK, Hegazy H, de Boer A, Maitland-van der Zee AH. Long-term anticoagulant effects of CYP2C9 and VKORC1 genotypes in phenprocoumon users. J Thromb Haemost 2012; 10:2610-2. [PMID: 23016521 DOI: 10.1111/jth.12007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Impact of the CYP4F2 p.V433M polymorphism on coumarin dose requirement: systematic review and meta-analysis. Clin Pharmacol Ther 2012; 92:746-56. [PMID: 23132553 DOI: 10.1038/clpt.2012.184] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A systematic review and a meta-analysis were performed to quantify the accumulated information from genetic association studies investigating the impact of the CYP4F2 rs2108622 (p.V433M) polymorphism on coumarin dose requirement. An additional aim was to explore the contribution of the CYP4F2 variant in comparison with, as well as after stratification for, the VKORC1 and CYP2C9 variants. Thirty studies involving 9,470 participants met prespecified inclusion criteria. As compared with CC-homozygotes, T-allele carriers required an 8.3% (95% confidence interval (CI): 5.6-11.1%; P < 0.0001) higher mean daily coumarin dose than CC homozygotes to reach a stable international normalized ratio (INR). There was no evidence of publication bias. Heterogeneity among studies was present (I(2) = 43%). Our results show that the CYP4F2 p.V433M polymorphism is associated with interindividual variability in response to coumarin drugs, but with a low effect size that is confirmed to be lower than those contributed by VKORC1 and CYP2C9 polymorphisms.
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Abstract
After a decade of clinical investigation, pharmacogenetic-guided initial dosing of warfarin is at a crossroads. Genotypes for two single nucleotide polymorphisms (SNPs) in the cytochrome P 450 2C9 gene, affecting warfarin metabolism, and one SNP in vitamin K reductase complex 1 gene, affecting warfarin sensitivity, account for approximately 30% of therapeutic warfarin dosing variability in whites and Asians. Incorporating this genetic information, along with patient's age, body size, and other clinical information improves the accuracy of initial warfarin dosing. Currently, there is insufficient evidence to support the clinical benefits and cost effectiveness of routine warfarin pharmacogenetics. Results from ongoing international randomized clinical trials should provide clarity about the place of warfarin pharmacogenetics in personalized medicine.
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Affiliation(s)
- Charles Eby
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USA.
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